attachment_3__minimum_qualifications_certification.pdf

RFP 27-3001 Attachment 3 California Department of Social Services Page 1 of 4

Minimum Qualifications Certification

As required in the Request for Proposal (RFP) 27-3001, section D, Proposal Requirements and Information, Proposer must complete and return this Certification, along with written evidence of how each qualification is met. All required fields must be completed to satisfy this requirement. Additional rows may be added, if necessary.

Evidence of Minimum Qualifications:

A. Provide evidence of satisfaction of Minimum Qualification C.1 by completing the table below OR selecting the appropriate check box as applicable. All requested fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer, as a TPA for California public entities, must have a minimum of five (5) years of experience, during the last eight (8) years, in administering workers’ compensation claims in accordance with the workers’ compensation laws, regulations and final non-appealable judicial decisions of the State of California. The Proposer must provide three (3) references for workers’ compensation claims administration services from three (3) large public entities located in California, as described in Section D, Item 5,b,2,c., Record of Performance. Large accounts are those with the number of claimants substantially similar to or larger than those identified on pages 6, 7, and 8 of this

RFP.

Name(s) of Entity to

Whom Services Were Provided

Brief Description of Service

Years of Experience

(MM/YY – MM/YY)

MM/YY - MM/YY

MM/YY - MM/YY

MM/YY - MM/YY

California Department of Social Services Page 2 of 4

Not applicable; Proposer is a governmental entity.

B. Provide evidence of satisfaction of Minimum Qualification C.2 by completing the appropriate check box below and completing the table below as applicable. All applicable fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer must have the appropriate business licenses to conduct business within the State of California.

Proposer certifies that it is a legal business entity authorized to do business in the State of California and has submitted the business license from the city/county in which the Proposer’s California based office(s) are located.

State of California Business License Number

Issue Date Date of Expiration

MM/YY

Proposer certifies that it is a legal business entity authorized to do business in the State of California, is based in an unincorporated area, and has submitted signed proof of “exempted” business license status from the city or county, if applicable.

C. Provide evidence of satisfaction of Minimum Qualification C.3 by completing the appropriate check box below. All requested fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer must have an office located within the state of California with assigned staff dedicated to the administration of States workers’ compensation claims during the term of any agreement awarded pursuant to this RFP to meet the business need for in-person meetings. Costs related to items such as travel and per diem are costs of the Proposer and will not be paid as part of the resulting agreements.

Proposer certifies that it has at least one (1) California office, and will provide services through this location.

California Office Address

Or, prior to execution of the awarded agreement, Proposer certifies that it will establish and maintain at least one (1) California office, and will provide services through this location.

California Department of Social Services Page 3 of 4

D. Provide evidence of satisfaction of Minimum Qualification C.4 by completing the appropriate check box below and completing the table below as applicable. All applicable fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer’s Claims/Risk Management System must be a paperless claim file system with online access provided to the State and ORIM.

Proposer certifies that the Claims/Risk Management System shall be a paperless claim file system with online access provided to the State and

ORIM.

E. Provide evidence of satisfaction of Minimum Qualification C.5 by completing the table below. All requested fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer must have the ability to fully comply with the State’s and the SCO’s Payment process as required in the Payments Provision of the Scope of Work.

Proposer certifies that they shall comply with the State's and the SCO's

Payment process as required in the Payments Provision of the Scope of Work.

F. Provide evidence of satisfaction of Minimum Qualification C.6 by completing the appropriate check box below. All requested fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer must have a California Workers’ Compensation Self-Insurance

Administrator Certificate to provide workers’ compensation claims administration services as a TPA in the State of California.

Proposer certifies that they have a California Workers' Compensation Self-

Insurance Administrator Certificate to provide workers' compensation claims administration services as a TPA in the State of California.

G. Provide evidence of satisfaction of Minimum Qualification C.7 by completing the appropriate check box below. All applicable fields must be completed in order to satisfy this Minimum Qualification.

1. The Proposer shall have an operating system with the capability to enable a successful data transfer and uninterrupted transition of the State’s claims data in the current TPA’s system, currently Claims Connect and Focus, to the Proposer’s system for all open and closed claims for each of the four (4) programs prior to December 1, 2027.

Proposer certifies that they have an operating system with the capability to enable a successful data transfer and uninterrupted transition of the State's claims data in the current TPA's system, currently Claims Connect

California Department of Social Services Page 4 of 4 and Focus, to the Proposer's system for all open and closed claims for each of the four (4) programs prior to December 1, 2027.

H. Provide evidence of satisfaction of Minimum Qualification C.8 by completing the appropriate check box below. All applicable fields must be completed in order to satisfy this Minimum Qualification.

1. Proposer’s corporation must be in good standing and qualified to conduct business in California as verified by the Secretary of State’s website:

http://www.sos.ca.gov/.

SOS Entity File Number SOS Status

Not applicable; Proposer is a governmental entity.

Proposer certifies this response fulfills the Minimum Qualifications outlined by signing below.

Authorized Signature

Name of Firm

Name and Title (Please Print)

Date