74BAI-S2953 Scope of Work.docx

SCOPE OF WORK

The uninsured claims third-party administrator (Awarded Vendor) shall, during the term of this contract, render the services set forth below for the State of Nevada, DIR:

The Awarded Vendor shall provide goods and services specific to the needs and requirements of the Uninsured Employers Claim Account (UECA), including claims administration, claim investigation, case preparation for litigation purposes; case management; and bill review, processing and payment of all claim-related benefits.

VENDOR SERVICES

All uninsured workers’ compensation claims will be reported to the Awarded Vendor by email as a zip file from the Workers’ Compensation Section (WCS) Enforcement Unit. The Awarded Vendor shall provide the following services:

Notify providers of medical treatment and other services given to injured workers of the Awarded Vendor’s location and the method by which other vendors will report.

Inform employers and injured employees of their rights and benefits under Nevada Revised Statutes (NRS Chapters 616A-D and 617) and Nevada Administrative Codes (NAC Chapters 616A-D and 617) and communicate with the injured worker on a regular basis throughout the duration of the claim.

Assign a dedicated licensed senior claims adjuster having a minimum of five (5) years of experience administrating Nevada workers’ compensation claims to handle the UECA workers’ compensation claims. This experience must include medical only, complex indemnity claims and catastrophic claims. Adjuster trainees and claim assistants are not acceptable for handling UECA workers’ compensation claims.

Notify the UECA claims coordinator immediately of changes in the assigned adjuster.

Assume the complete handling of all open claims as well as new claims originating from the effective date of this contract. It is required that claims data and any and all other documentation (open and closed) associated with all current and prior claims be converted into the Awarded Vendor’s electronic claims system to ensure future DIR loss runs will contain a complete history of all claim years.

PROGRAM DEVELOPMENT

Within thirty (30) calendar days of the award of the contract, with input and agreement of the DIR, the Awarded Vendor shall develop a Claims Handling Protocol document delineating handling of claims in the following areas: processing UECA claims to ensure coordination in investigations and follow up of all industrial injuries and occupational diseases; issuing timely claim determinations; managing medical treatment; providing litigation support; establishing and maintaining reserves; maintaining accurate and timely payment of bills to ensure no duplicate payments; and providing timely payment of any and all workers’ compensation benefits. The document should also include contact information of staff, expectations and process descriptions.

Periodically, or upon request, meet with DIR personnel who may need to review procedures or may require updates regarding procedures.

Ensure the Awarded Vendor’s electronic claims system is accessible by designated DIR personnel upon the effective date of the contract.

MEDICAL COST CONTROL

It shall be the responsibility of the Awarded Vendor to maximize the potential cost savings to the DIR through the use of cost containment services and strategies.

The Awarded Vendor will select health care providers from DIR’s workers’ compensation treating panel and will work with these providers to ensure adequate and prompt treatment of workers’ compensation claimants, and timely initial and progress reporting.

All medical bills will be reviewed to ensure they have been submitted timely and include the required medical report. Any questionable items will be returned to the health care provider for clarification.

All timely and complete medical bills will be reviewed to ensure that they have been reduced to the Nevada Medical Fee Schedule and a managed care discount has been applied where applicable. The bills will be further reviewed to ensure that the charges are only for treatment required for the accepted industrial injury or occupational disease and will then be processed for payment.

The Awarded Vendor will promptly pay all medical bills in accordance with NRS 616C.136.

The Awarded Vendor shall identify and reduce all duplicate billing.

Any questionable and/or late bill submissions recommended for payment must be approved by the UECA claims coordinator prior to submission to the State for payment. The Awarded Vendor must provide the rationale and supporting documents to substantiate payment for the bill.

Request for all outside case management services utilized, including, but not limited to, nurse case management and special investigation services, must be discussed with and approved by the UECA claims coordinator in advance.

CLAIM PROCESSING

The Awarded Vendor will review and process all claims for workers’ compensation benefits in accordance with requirements of Nevada law. Uninsured Claims to this RFP is claim loss information of all claims supplied by the current Uninsured Claims Third Party Administrator (Sierra Nevada Administrators) and claims administrated by the previous Uninsured Claims Third Party Administrator (Nevada Alternative Solutions, Inc.). In processing administration claims, the Awarded Vendor will:

Assume the complete handling of all open claims as well as new claims originating from the effective date of this contract. It is required that claims data and any and all other documentation (open and closed) associated with all current and prior claims be transferred into the Awarded Vendor’s electronic claims system to ensure future DIR loss runs will contain a complete history of all claim years. Transfer of all claims data, information, or files must occur within the first 30 days of contract start date.

Assume responsibility for the transfer from the previous vendor of all open and closed claims, while maintaining claim file completeness, coherence and integrity.

Assume the responsibility for management of all open claims. DIR will be responsible for the storage of all closed claims files.

Assume the responsibility for the administration of all claims assigned by DIR to the UECA after the effective date of the contract.

Promptly review, compute and timely pay all benefits, rating awards, life medical and life pensions, in accordance with Nevada law.

Arrange and supervise rehabilitation programs, assigning rehabilitation service vendors when appropriate.

Manage medical and vocational rehabilitation cases, in accordance with sound claims, medical practices and the American College of Occupational and Environmental Medicine (ACOEM) guidelines.

Provide an acknowledgement email to the UECA claim coordinator upon the receipt of each claim. The acknowledgement shall include the following: claim number, claimant’s name, employer’s name and date of loss.

Submit all required D-38 Claims Indexing data for individual claims via the DIR’s web portal or in bulk via flat file All claims are to be indexed in the WCS Claims and Regulatory Data System (CARDS) within 30 days of the initial claim determination and within 30 days of any of the following: benefit start date, end date or type change (Total Temporary Disability (TTD), Temporary Partial Disability (TPD), Permanent Partial Disability (PPD), Vocational Rehabilitation (VR), Permanent Total Disability (PTD)); change in claim determination (denial to acceptance or vice versa); claim type change (medical only to lost time/indemnity); change to/from catastrophic claim status; finalized PPD rating and award offer; claim reopening; injured employee death; any correction to or update of the injured employee’s information including name, gender, birthdate, SSN, employer, etc.; any correction to and/or update of the claim information including claim number, date of injury, nature of injury, cause of injury, type of loss, body parts involved, etc.; and claim closure.

INVESTIGATIONS

All claims, including medical only and lost time claims, shall be thoroughly investigated to determine compensability and include contact with the employer, injured employee, witnesses and treating physician. The Awarded Vendor shall address issues affecting compensability, possibility of subrogation, and the extent of injuries and benefits in order to assist in litigated cases.

Upon receipt of the claim, the Awarded Vendor shall make contact or make reasonable attempts to contact the following individuals within the following parameters:

The Awarded Vendor shall conduct three-point contacts by telephone completed by the senior adjuster to the employer, injured employee and legal representation, (if represented by an attorney) and medical provider on all new claims within three (3) working days of receiving the claim but no later than five (5) working days.

When contacting the employer, the Awarded Vendor shall obtain the facts of the accident, identify and obtain information of any witnesses, discuss with the employer the potential for subrogation, inquire whether the employer has knowledge of any prior claims, verify and address the disability status of the employee, have the employer provide a description of the employee’s job duties, confirm the availability of modified duty and request wage history.

When contacting the injured employee and their legal representative (if represented by an attorney), the Awarded Vendor shall obtain the facts of the accident, identify and obtain information of any witnesses, discuss with the employee the potential for subrogation, inquire whether the employee had any prior injuries diseases and/or pre-existing conditions, verify and address disability status of the employee and gather information regarding treatment and prognosis.

Contact current medical provider(s) to obtain information regarding treatment, prognosis and work status.

Obtain current medical records and past medical records if the employee has a history of prior injury claims or prior medical conditions.

Obtain consent for release of personal medical records and retrieve those records.

Obtain police report, if applicable.

Provide facts to support possible subrogation.

Obtain information on any responsible third parties when subrogation is possible.

Obtain any other information that will have an impact on the outcome of the claim.

A summary of all the information obtained during the claim investigation must be included in the claim notes.

The DIR shall be kept informed on the scope and results of all investigations. All activities shall be clearly documented in the claim file.

All actual and attempted contacts shall be documented in the claim notes by the Awarded Vendor.

The Awarded Vendor shall request a report from the Index Bureau, the successor to the State Industrial Insurance System and/or another comprehensive all-claims database and system for claims process and fraud detection on all new claims at the initial set up of a claim. Subsequent requests should be made every six (6) to twelve (12) months thereafter on all active indemnity claims. A copy of the report and all records received will be retained within the claim file.

The Awarded Vendor shall request claims history information from CARDS. A copy of the report shall be retained within the claim file.

Information received back from the WCS CARDS Claims Index, the Index Bureau and all other comprehensive all-claim database systems shall be followed up on promptly by requesting medical records and claim files.

FILE DOCUMENTATION

The claim file must speak for itself. Proper file documentation benefits DIR by providing clear and concise information regarding the current status of a claim. Successful resolution of a claim is more likely if the file is properly documented. Information to be documented in the UECA claim files, includes:

All claim activities, events, and actions and claim facts.

Initial Action Plan must be clearly documented in the claim notes within 14 days from receipt of the claim.

In the activity notes, the Awarded Vendor shall document and confirm all communications accurately and include to whom the Awarded Vendor communicated and that party’s title and their relationship to the claim. Detail the issues discussed and any decisions or agreements reached between the Awarded Vendor and the other party.

Any letter, documents, telephone calls that prompt action must have a corresponding note.

All claim files must contain written Action Plans to be updated every 90 days or sooner as needed. All Action Plans must be comprehensive and list specific steps to bring each claim to closure as expeditiously as possible at the lowest possible cost.

Summarize relevant reports such as Independent Medical Examinations (IME), PPD Impairment Ratings and Functional Capacity Evaluations (FCE) and investigations.

Document every action and event, no matter how insignificant it may seem.

Claim notes shall clearly outline how the indemnity benefits were calculated.

Temporary modified/light duty must be documented in the claim notes and should include medical diagnosis, physical work restriction(s) and estimated duration of restriction(s), if a light duty job is available.

TTD, TPD, VR maintenance and PTD payments must be documented in the claim notes and indicate estimated duration of benefits.

All overpayments and underpayments must be clearly documented and addressed in claim notes.

Any questionable and/or late bill submissions approved for payment, must include rationale in the claim notes and supporting documents in the claim file to substantiate payment for the bill.

The Awarded Vendor must address and clearly document whether subrogation is applicable or not in all claim files.

CLAIM COMPENSABILITY

The Awarded Vendor shall conduct a complete and timely investigation to determine claim compensability, nature and extent of injuries, apportionment issues and subrogation potential.

Upon receipt of the C-4 (Claim for Compensation Form) from DIR, the Awarded Vendor will initiate claim investigation to determine claim compensability.

Promptly review and determine the compensability of claims and appropriate benefits, in accordance with Nevada law.

Prior to the denial of compensability of any claim, the adjuster must discuss the case with the UECA claims coordinator.

The compensability determination and the reasons for such determination will be made and clearly documented in the claim notes.

Provide copies of all compensability determination letters to the Department of Business and Industry Fiscal Unit and the UECA claims coordinator that are sent to injured employees on the same day the original is sent to the injured employee.

Prior to reopening any previously closed claims, the adjuster must discuss and provide the rationale with the UECA claims coordinator.

When a previously closed claim is reopened, the Awarded Vendor shall send a copy of the reopening notice to the Department of Business and Industry Fiscal Unit and the UECA claims coordinator at the same time at which the notice is delivered to the injured employee.

SUBROGATION

Investigate the causes of injury or illness, and recommend subrogation, with recommendation notification to DIR legal and the UECA claims coordinator.

Review every claim for subrogation potential and identify claims with opportunities for subrogation against liable third parties to protect the UECA fund.

Identify and document possible third-party interests or involvement relative to the accident, injury or loss in question.

Obtain photographs, diagrams, documents or observations, which support third party involvement.

Interview claimants, employers, insureds, witnesses, or other persons able to provide third party information relative to the accident, injury or loss in question.

Acquire and secure for further analysis, items of evidence as appropriate.

The Awarded Vendor will promptly give notice to DIR legal and the UECA claims coordinator for each case indicating a potential for subrogation.

The Awarded Vendor will put the relevant parties on notice of the intent to subrogate.

The Awarded Vendor shall notify DIR legal of any third-party litigation filed on behalf of claimant upon receipt. DIR legal shall file lien notices in pending litigation to protect the DIR’s interests in rights of recovery from third-party tortfeasors.

Any and all potential recovery shall be documented in the claim notes.

RESERVES

Promptly establish reserves on claims based upon medical and factual reporting, anticipated medical treatment, anticipated length of temporary disability, expected permanent residual impairment, age and occupation of the worker, anticipated and pension or survivors’ benefits, and Nevada law.

Reserves shall be established based upon the potential cost of each claim.

Any changes to reserves shall include an explanation for the change.

All reserves categories shall be reviewed on a regular basis but at least every ninety (90) days. Such reserves shall be indicated in the claim notes.

LITIGATION

The Awarded Vendor shall prepare files and submit documentation in the media format DIR requires, and vigorously represent the DIR at Department of Administration Hearing Officer hearings and cooperate with DIR in preparation at Department of Administration Appeals Officer hearings.

The Awarded Vendor shall ensure that all cases are properly prepared prior to hearing.

The Awarded Vendor shall email copies of all Notice of Hearings, Notice of Appeals and Decision and Orders to Department of Business and Industry Fiscal Unit and the UECA claims coordinator.

Without first obtaining the approval of DIR legal and the UECA claims coordinator, the Awarded Vendor is prohibited from entering into any agreements to bypass hearings.

The Awarded Vendor shall notify the UECA claims coordinator in writing of all hearing outcomes, through a written report and make recommendations regarding the merits of appealing outcomes at no additional charge to the DIR.

When the Awarded Vendor is recommending an appeal of a Hearing Officer’s Decision and Order, vendor shall notify the UECA claims coordinator via email to request assignment to DIR legal and provide the rationale for the recommendations to appeal the Hearing Officer’s Decision and Order. The UECA claims coordinator will forward the request to DIR legal with recommendations and DIR legal will make the determination if they will the accept the assignment or not.

The Awarded Vendor shall provide DIR legal counsel with an electronic copy of the complete case file in question when assignment is approved by DIR.

Timely provide all requested assistance to DIR legal counsel on cases requiring action before the Department of Administration, Hearing Division, Appeals Officer level in the State of Nevada and subsequent appeals. In the event legal counsel other than DIR counsel is utilized, attorney fees will be charged as an administrative expense which is allocated to the claim. The Awarded Vendor will not utilize legal counsel other than DIR counsel unless DIR Legal approves the utilization in writing, in advance.

COST AND CLAIM ANALYSIS REPORTS

To assist DIR with data needed to discharge obligations DIR may have in the area of assessments, and surety bonds, the Awarded Vendor will:

Prepare and submit Monthly Claims Activity Reports showing all claims activity for the month. These reports shall be in Excel format and shall have the capability to search, sort and filter data. The reports should include the following:

Claimant’s name Loss Date Claim number Compensation, including medical expenses, paid during the month and cumulatively to date Reserves Claim status information: Open Date, Closed Date and Reopened Date Claim Type Financial Activity Number of new claims for the month Number of closed claims for the month Number of reopened claims for the month Number of Indemnity claims Number of Medical only claims End of Period: Ending Open claims and Ending Closed claims

Prepare and submit Monthly Financial Reconciliation reports to Department of Business and Industry Fiscal Unit and the UECA claims coordinator. These reports shall be in Excel format and shall have the capability to search, sort and filter data. The reports should include the following:

Total disbursements which cleared, by date and claimant/payee;

Payment Details to include: check number, check date, type of payment, payee name;

Claim Details to include: claim number, claimant name;

Totals: Amount paid;

Total number of payments, reversals, reinstatements, refunds, reversed refunds; and Net Amount

All monthly reports will be emailed to the UECA claims coordinator within three (3) business days of the month following the close of the reporting month.

Prepare and provide an alphabetized Quarterly Master Claims Listing report to Department of Business and Industry Fiscal Unit and the UECA claims coordinator, which includes the name and address of the claimant’s employer, name of injured employee, date of injury, claim number and claim status.

Prepare and provide the following Quarterly reports to the UECA claims coordinator:

Claim Status Summary Reports with Narratives on all Indemnity and Litigated claims; and Loss Run Report

All quarterly reports will be emailed to the UECA claims coordinator within three (3) business days of the month following the close of the reporting quarter.

Reporting quarters end on the last date of the following months:

Prepare an electronic weekly Check Register and Payment Distribution report and email it to the UECA claims coordinator weekly.

Prepare the Fiscal Year Claims Activity reports annually and Occupational Disease Claims (OD-8) data as required and submit the reports and data in the manner prescribed by DIR on or before their established due dates.

Prepare annual loss run reports and email them to the UECA claims coordinator on the first Monday of July.

Prepare and deliver to the Internal Revenue Service an annual Miscellaneous Information Tax Form, 1099-MISC, on behalf of DIR.

The Awarded Vendor shall be responsible for generating and mailing Form 1099s to vendors and providers.

On behalf of the State and DIR, provide all reporting data to the Coordination of Benefits Contractor for the Center for Medicare and Medicaid Services as required by Section 111 of the Medicare, Medicaid and State Children’s’ Health Insurance Program (SCHIP) Extension Act of 2007.

File all reports, and data calls as required by the Department of Business and Industry, DIR, Division of Insurance (DOI) and its respective subsidiary agencies.

CLAIMS MANAGEMENT INFORMATION SYSTEM

A claims management system is an integral part of the Workers’ Compensation program, access to adjuster file notes and all documents related the claim of the injured employee is required. The Awarded Vendor’s electronic claims system must have the following abilities:

The Awarded Vendor will be required to maintain all claim files in an electronic format. Electronic access will be provided at no additional charge to DIR.

The Awarded Vendor shall electronically maintain imaged claim documents, in chronological order, to include all correspondence, written determinations, DIR/WCS mandated forms, all litigation documents; medical reports, medical bills and explanations of benefits that were created when bills were paid in chronological order.

Imaged claim documents shall be clearly and consistently labeled in easily identifiable and searchable categories.

Provide six (6) designated DIR staff users remote access to the claim files in a manner that allows real-time access to data, documents and information available to adjusters.

The Awarded Vendor shall ensure that required data, documentation, and payments are posted to each claim file in an accurate and timely manner.

The Awarded Vendor shall produce an electronic copy of the claim file at the request of the DIR.

The Awarded Vendor must provide claim data in real-time or upload every 24 hours.

System must be able to generate monthly, quarterly, annual and ad-hoc reports and should be able to provide the data necessary for submitting D-38 Claims Indexing data for individual claims via CARDS.

The Awarded Vendor will be required to import and convert all the historical data, documents and financial elements of all the UECA workers’ compensation claim files open or closed into its electronic claims system.

The Awarded Vendor shall provide training to DIR for use of the computer system at no additional charge.

All refinements, updates and modifications to the claims management information system will be at the expense of the Awarded Vendor.

FILE MAINTEANCE

Complete records of fact and cost data will be maintained by the Awarded Vendor’s office located closest to DIR’s Las Vegas or Carson City office.

Claim files will be available for review during normal business hours in the appropriate Awarded Vendor office or provided electronically.

Establish claim files containing complete claims documentation, in accordance with Nevada law and NAC 616C.088.

Ensure that uninsured claims files are kept and managed by a qualified and competent administrator located in the State of Nevada which has a valid certificate issued by the Commissioner of Insurance pursuant to NRS 683A.085.

GENERAL

The Division has appointed the UECA claims coordinator to coordinate the activities related to this project. The UECA claims coordinator will provide on-going direction and oversight to the Awarded Vendor. The UECA claims coordinator coordinates all funding requests related to the UECA claims and oversees the management of the claims by the TPA to ensure that injured employees receive accurate and timely delivery of all workers’ compensation benefits to which they are entitled.

The Awarded Vendor shall make all medical appointments to ensure that all necessary medical reports are provided in chronological order based on date of service to treating physician, rating physician, independent medical examination or consulting physician.

When a UECA claim is closed, the Awarded Vendor shall send a copy of or deliver by electronic transmission the closure notice to the Department of Business and Industry Fiscal Unit and the UECA claims coordinator at the same time at which the notice is delivered to the injured employee.

In the event of termination or nonrenewal of this contract, the Awarded Vendor shall provide DIR or its new vendor the necessary assistance to complete a smooth transition. The Awarded Vendor will provide the DIR or its new vendor, final computerized reports in a format which is usable and agreed upon by the DIR, providing claims listings, total amounts spent, and other loss information as required. In addition, Awarded Vendor will comply with all applicable regulations pertaining to insurer, third-party administrator claims file transfer obligations.

In collaboration with the State Treasurer, the Awarded Vendor will be responsible to set up a State checking account out of which all claim payments will be made. This account will be funded by the Department of Business & Industry on an as needed basis. These funds will be deposited only after the UECA claims coordinator and the Department of Business and Industry Fiscal Unit has reviewed and approved a preliminary check register provided by the Awarded Vendor. The Department of Business and Industry Fiscal Unit will process funding requests within three (3) working days of receipt. A mutually agreed upon method of fund transfer shall be established upon selection of the vendor of uninsured claims administrative services.

Currently there is no excess insurance in place for uninsured claims. However, in the event the DIR purchases excess insurance coverage, the Awarded Vendor will comply with excess carrier requirements on behalf of the DIR.

The Awarded Vendor shall provide initial and follow-up training to DIR personnel on the Awarded Vendor’s database and other electronic systems as requested by DIR.

The Awarded Vendor shall obtain DIR’s authorization on all settlements, including permanent partial disability, vocational rehabilitation lump sum buyouts or permanent total disability as well as any future medical benefits.

The Awarded Vendor shall provide DIR with direct access to a claims adjuster in the Awarded Vendor’s office who is responsible for the administration of the uninsured claims.

The Awarded Vendor will perform other advisor and administrative duties to assist the DIR in the administration of the uninsured claims.

The Awarded Vendor shall submit monthly invoices within fifteen (15) days of the end of the month.