BHRA Workers Comp TPA RFP 10.8.26.pdf

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STATE OF SOUTH DAKOTA

INFORMATION TECHNOLOGY (IT) RFP

Bureau of Human Resources and Administration 523 East Capitol Ave, Pierre, South Dakota 57501-3182

South Dakota State TPA Workers’ Compensation

PROPOSALS ARE DUE NO LATER THAN November 25, 2026 at 5:00 p.m.

RFP #: 26RFP19880 STATE POC: State of South EMAIL: Peggy.Canter@state.sd.us Dakota, Bureau of Human Resources and Administration Peggy Canter

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FIRM NAME: AUTHORIZED SIGNATURE:

ADDRESS: TYPE OR PRINT NAME:

CITY/STATE: TELEPHONE NO:

ZIP (9 DIGITS): FAX NO:

E-MAIL:

PRIMARY CONTACT INFORMATION

CONTACT NAME: Peggy Canter

TELEPHONE NO: 605.773.4099

FAX NO: E-MAIL: Peggy.Canter@state.sd.us

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1. General Information

1.1. Purpose of Request for Proposal (RFP)

1.1.1 Background: The State of South Dakota, Bureau of Human Resources and Administration (“State”) is seeking a licensed and qualified business partner to provide Third Party Claims Administration for the State’s Workers’ Compensation Program. The selected vendor will be required to provide Medical Case Management, Medical Bill Review, and Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) reporting

1.1.2 Goals and Objectives:

• Ensure timely, accurate, and consistent administration of workers’ compensation claims in accordance with applicable laws, regulations and State policies.

• Implement cost-containment strategies that reduce claim duration and overall program costs while ensuring injured employees receive appropriate medical care and benefits.

• Provide guidance and recommendations to assist the State in mitigating risk and improving workplace safety.

• Delivering meaningful reporting, analytics, and benchmarking that enables the State to monitor program performance in real time, identify trends, and make informed decisions.

• Serve as a strategic partner with the State to identify opportunities to improve claim outcomes, employee experience, return-to-work efforts, and overall program effectiveness.

• Provide specialized expertise and proactive management of complex workers’ compensation claims.

1.1.3 Description of Components or Phases:

The contract is for three (3) periods, each with one twelve (12) month period.

1.1.4 Scope of Components or Phases:

• Fiscal Year 1 will be July 1, 2027 to June 30, 2028

• Fiscal Year 2 will be July 1, 2028 to June 30, 2029

• Fiscal Year 3 will be July 1, 2029 to June 30, 2030

1.2. Issuing Office and RFP Reference Number

The Bureau of Human Resources and Administration (“Agency”) is the issuing office for this document and all subsequent addenda relating to it, on behalf of the State of South Dakota (“State”). The reference number for this transaction is RFP#26RFP19880. This reference number must be referred to on all proposals, correspondence, and documentation relating to this RFP. For purposes of this RFP, the State’s centralized IT agency, the Bureau of Information and Technology (“BIT”), must approve all IT related purchases.

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1.3. Schedule of Activities (Subject to Change)

All deadlines in the Schedule of Activities are due by 11:59 p.m. CST. The Schedule of Activities for this RFP are as follows:

RFP Publication ............................................................................... October 15, 2026 Deadline for Submission of Written Inquires ..................................... October 30, 2026 Deadline for responses to Offeror Questions .................................. November 9, 2026 Evaluation of Proposals to Determine Short List (if required) ........ November 25, 2026 Discussions/Technical Review ....................................................... December 9, 2026 Demonstrations and Presentations (if required) .................. November 30-Dec 4, 2026 Proposal Revisions (if required) .................................................... December 21, 2026 Anticipated Award Decision/Contract Negotiation ......................... December 29, 2026

1.4. Submitting a Proposal

All proposals must be completed and received by the Agency by the date and time indicated in Section 1.3 Schedule of Activities.

Proposals received after the Deadline for Proposal Submission will be late and ineligible for consideration.

All proposals must be signed, in ink or electronically, by a representative of the offeror who is legally authorized to bind the offeror to the proposal. Proposals that are not properly signed may be rejected. The offeror’s proposal must be prepared pursuant to the requirements of Section 6 Proposal Submission Requirements of this RFP.

The State will only accept electronic proposals via email.

Each offeror must provide an electronic version of the proposal. The electronic version should be provided in MS Word or in PDF format to Peggy.Canter@state.sd.us. The email, including attachments, must be limited to 20MB in size.

No proposal will be accepted from, or no contract or purchase order will be awarded to, any person, firm, or corporation that is in arrears upon any obligations to the State of South Dakota, or that otherwise may be deemed irresponsible or unreliable by the State of South Dakota.

1.5. Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary

Exclusion – Lower Tier Covered Transactions

By signing and submitting this proposal, the offeror certifies that neither its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation, by any Federal department or agency, from transactions involving the use of Federal funds. Where the offeror is unable to certify any of the statements in this certification, the offeror shall attach an explanation to its offer.

1.6. Non-Discrimination Statement

The State of South Dakota requires that all contractors, vendors, and suppliers do mailto:Peggy.Canter@state.sd.us

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business with any State agency, department, or institution, provide a statement of non-discrimination. By signing and submitting their proposal, the offeror certifies they do not discriminate in their employment practices regarding race, color, creed, religion, age, sex, ancestry, national origin, or disability.

1.7. Restriction of Boycott of Israel

For contractors, vendors, suppliers, or subcontractors with five (5) or more employees who enter into a contract with the State of South Dakota that involves the expenditure of one hundred thousand dollars ($100,000) or more, by submitting a response to this solicitation or agreeing to contract with the State, the bidder or offeror certifies and agrees that the following information is correct:

The bidder or offeror, in preparing its response or offer or in considering proposals submitted from qualified, potential vendors, suppliers, and subcontractors, or in the solicitation, selection, or commercial treatment of any vendor, supplier, or subcontractor, has not refused to transact business activities, has not terminated business activities, and has not taken other similar actions intended to limit its commercial relations, related to the subject matter of the bid or offer, with a person or entity on the basis of Israeli national origin, or residence or incorporation in Israel or its territories, with the specific intent to accomplish a boycott or divestment of Israel in a discriminatory manner. It is understood and agreed that, if this certification is false, such false certification will constitute grounds for the State to reject the bid or response submitted by the bidder or offeror on this project and terminate any contract awarded based on the bid or response. The successful bidder or offeror further agrees to provide immediate written notice to the contracting executive branch agency if during the term of the contract it no longer complies with this certification and agrees such noncompliance may be grounds for contract termination.

1.8. Certification Relating to Prohibited Entity

For contractors, vendors, suppliers, or subcontractors who enter into a contract with the State of South Dakota by submitting a response to this solicitation or agreeing to contract with the State, the bidder or offeror certifies and agrees that the following information is correct:

The bidder or offeror, in preparing its response or offer or in considering proposals submitted from qualified, potential vendors, suppliers, and subcontractors, or in the solicitation, selection, or commercial treatment of any vendor, supplier, or subcontractor, is not a prohibited entity, regardless of its principal place of business, that is ultimately owned or controlled, directly or indirectly, by a foreign national, a foreign parent entity, or foreign government from China, Iran, North Korea, Russia, Cuba, or Venezuela, as defined by South Dakota Codified Law § 5-18A. It is understood and agreed that, if this certification is false, such false certification will constitute grounds for the State to reject the bid or response submitted by the bidder or offeror on this project and terminate any contract awarded based on the bid or response. The successful bidder or offeror further agrees to provide immediate written notice to the contracting executive branch agency if during the term of the contract it no longer complies with this certification and agrees such noncompliance may be grounds for contract termination and would be cause to suspend and debar a business under SDCL § 5-18D-12.

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1.9. Modification or Withdrawal of Proposals

Proposals may be modified or withdrawn by the offeror prior to the established due date and time.

No oral, telephonic, telegraphic or facsimile responses or modifications to informal, formal bids, or Request for Proposals will be considered.

1.10. Questions Regarding RFP

All written questions should be sent to: SD RFP Project Peggy.Canter@state.sd.us, only emailed questions will be accepted.

Each offeror may submit questions via email concerning this RFP to obtain clarification of requirements. No questions will be accepted after the date and time indicated in the above schedule of activities. Email questions to the email address listed above with the subject line “RFP#26RFP19880”. The questions and their answers will be sent to all offerors that submitted Letters of Intent, submitted questions, or requested the questions and answers via email before the proposal submittal date and will be sent by the date and time indicated in the above calendar of events. Offeror may not rely on any other statements, either of a written or oral nature, that alter any specification or other term or condition of this RFP that have not originated from the SD RFP Project Contact. Offerors will be notified in the same manner as indicated above regarding any modifications to this RFP. Offerors and their agents may not contact any state employee other than the Primary Contact regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and exclusion from specific procurements.

1.11. Prohibition on Solely AI-Generated Submissions

All questions, responses, and proposals submitted in response to this RFP must be thoroughly vetted, verified, and validated by the vendor's human staff. Submissions that are solely generated by Artificial Intelligence (AI) without substantive human review and oversight are strictly prohibited and may result in the disqualification of the proposal or rejection of the submitted questions.

1.12. Proprietary Information

The proposal of the successful offeror(s) becomes public information. Proprietary information can be protected under limited circumstances such as client lists and non-public financial statements. An entire proposal may not be marked as proprietary.

Offerors must clearly identify in the Executive Summary and mark in the body of the proposal any specific proprietary information they are requesting to be protected. The Executive Summary must contain specific justification explaining why the information is to be protected. Proposals may be reviewed and evaluated by any person at the discretion of the State. All materials submitted become the property of the State of South Dakota and may be returned only at the State's option.

1.13. Length of Contract

The length of the contract will be for a term of three (3) years. The State will have the mailto:Peggy.Canter@state.sd.us

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opportunity to renew the contract annually for up to two (2) one-year time extensions. The extension(s) will not be automatic.

1.14. Governing Law

This RFP will be governed by and construed in accordance with the laws of the State of South Dakota. Any lawsuit pertaining to or affecting this RFP will be venued in Circuit Court, Sixth Judicial Circuit, Hughes County, South Dakota.

1.15. Site Visit

If site visits are required, they will be scheduled before the submission of the proposal.

Site visits will be made at the offeror’s expense.

1.16. Presentations/Demonstrations

At the State’s discretion, the State may require a presentation or demonstration by an offeror to clarify a proposal. However, the State may award a contract based on the initial proposals received without a presentation or demonstration by the offeror. If presentations or demonstrations are required, they will be scheduled after the submission of proposals. Presentations and demonstrations will be held at the offeror’s expense.

1.17. Discussions

At the State’s discretion, the offeror may or may not be invited to have discussions with the State. The discussions can be before or after the RFP has been submitted.

Discussions will be made at the offeror’s expense.

1.18. Technical Review

At the State’s discretion, the State may require a technical review of the offeror based on the offeror’s proposal and response to the Security and Vendor Questionnaire.

1.19. Negotiations

This process is a Request for Proposal/Competitive Negotiation process. Each proposal will be evaluated, and each respondent will be available for negotiation meetings at the State’s request. The State reserves the right to negotiate on any component of every proposal submitted. From the time the proposals are submitted until the formal award of a contract, each proposal is considered a working document and as such, will be kept confidential. The negotiation discussions will also be held as confidential until such time as the award is completed.

2. Standard Contract Terms and Conditions

Any contract or agreement resulting from this RFP will include the State’s standard terms and conditions as listed below, the State’s standard Information Technology (“IT”) contract terms listed in Exhibit G, and any additional terms and conditions as negotiated by the parties. The offeror must indicate in its response any issue it has with specific contract terms. If the offeror does not indicate that there is an issue with a specific contract term, then the offeror will be

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deemed to have accepted the contract terms as written.

2.1. The Contractor will perform those services described in the Scope of Work, attached hereto as Section 3 of the RFP and by this reference incorporated herein.

2.2. The Contractor’s services under this Agreement will start on July 1, 2027, and end on

June 30, 2030, unless terminated sooner pursuant to the terms of the Agreement.

2.3. The Contractor will not use State equipment, supplies, or facilities. The Contractor will provide the State with its Employer Identification Number, Federal Tax Identification Number, or Social Security Number upon execution of this Agreement.

2.4. The State will make payment for services upon satisfactory completion of the services.

The TOTAL CONTRACT AMOUNT is an amount not to exceed $ . The State will not pay Contractor's expenses as a separate item. Payment will be made pursuant to itemized invoices submitted with a signed state voucher. Payment will be made consistent with SDCL chapter 5-26.

2.5. The Contractor agrees to indemnify the State of South Dakota, its officers, agents, and employees, from and against all claims or proceedings for actions, suits, damages, liabilities, other losses or equitable relief that may arise at least in part as a result of an act or omission in performing services under this Agreement. The Contractor will defend the State of South Dakota, its officers, agents, and employees against any claim, including any claim, action, suit, or other proceeding related to the claim. The Contractor’s obligation to indemnify includes the payment of attorney fees and other costs of defense.

In defending the State of South Dakota, its officers, agents, and employees, the Contractor will engage other professionals, subject to the written approval of the State which will not be unreasonably withheld. Notwithstanding the foregoing, the State may, in its sole discretion and at the expense of the Contractor, engage attorneys and other professionals to defend the State of South Dakota, its officers, agents, and employees, or to assist the Contractor in the defense. This section does not require the Contractor to be responsible for or defend against claims or proceedings for damages, liabilities, losses, or equitable relief arising solely from errors or omissions of the State, its officers, agents, or employees.

2.6. During the term of this Agreement, the Contractor will obtain and maintain in force insurance coverage of the types and with the limits as follows:

2.6.1 Commercial General Liability Insurance:

The Contractor will maintain occurrence based commercial general liability insurance or equivalent form with a limit of not less than $1 million for each occurrence. If such insurance contains a general aggregate limit it will apply separately to this Agreement or be no less than two times the occurrence limit.

The insurance policy will name the State of South Dakota, its officers and employees, as additional insureds, but liability coverage is limited to claims not barred by sovereign immunity. The State of South Dakota, its officers and employees do not hereby waive sovereign immunity for discretionary conduct as provided by law.

2.6.2 Professional Liability Insurance or Miscellaneous Professional Liability Insurance:

The Contractor will procure and maintain professional liability insurance or

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miscellaneous professional liability insurance with a limit of not less than $1 million.

2.6.3 Business Automobile Liability Insurance:

The Contractor will maintain business automobile liability insurance or equivalent form with a limit of not less than $1 million for each accident. Such insurance will include coverage for owned, hired, and non-owned vehicles.

2.6.4 Workers’ Compensation Insurance:

The Contractor will procure and maintain workers’ compensation and employers’ liability insurance as required by South Dakota or federal law.

Before beginning work under this Agreement, Contractor will furnish the State with properly executed Certificates of Insurance which will clearly evidence all insurance required in this Agreement. In the event of a substantial change in insurance, issuance of a new policy, cancellation, or nonrenewal of the policy, the Contractor agrees to provide immediate notice to the State and provide a new certificate of insurance showing continuous coverage in the amounts required. Contractor will furnish copies of insurance policies if requested by the State.

2.7. While performing services under this Agreement, the Contractor is an independent contractor and not an officer, agent, or employee of the State of South Dakota.

2.8. The Contractor agrees to report to the State any event encountered during performance of this Agreement which results in injury to the person or property of third parties, or which may otherwise subject Contractor or the State to liability. The Contractor will report any such event to the State immediately upon discovery.

The Contractor's obligation under this section will only be to report the occurrence of any event to the State and to make any other report provided for by their duties or applicable law. The Contractor’s obligation to report will not require disclosure of any information subject to privilege or confidentiality under law (e.g., attorney-client communications).

Reporting to the State under this section will not excuse or satisfy any obligation of the Contractor to report any event to law enforcement or other entities under the requirements of any applicable law.

2.9. This Agreement may be terminated by either party hereto upon thirty (30) days’ written notice. In the event the Contractor breaches any of the terms or conditions of this Agreement, this Agreement may be terminated by the State at any time with or without notice. If termination for a breach is affected by the State, any payments due to the Contractor at the time of termination may be adjusted to cover any additional costs to the State because of the Contractor's breach. Upon termination the State may take over the work and may award another party an agreement to complete the work under this Agreement. If after the State terminates a breach by the Contractor it is determined that the Contractor was not at fault, then the Contractor will be paid for eligible services rendered and expenses incurred up to the date of termination.

2.10. This Agreement depends upon the continued availability of appropriated funds and expenditure authority from the Legislature for this purpose. If for any reason the Legislature fails to appropriate funds or grant expenditure authority, or funds become unavailable by operation of law or federal funds reductions, this Agreement will be

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terminated by the State upon five (5) business days’ written notice. The Contractor agrees that termination for any of these reasons is not a default by the State nor does it give rise to a claim against the State or any officer, agent, or employee of the State, and the Contractor waives any claim against the same.

2.11. This Agreement may not be assigned without the express prior written consent of the

State. This Agreement may not be amended except in writing, which writing will be expressly identified as a part of this Agreement and be signed by an authorized representative of each of the parties to this Agreement.

2.12. This Agreement will be governed by and construed in accordance with the laws of the

State of South Dakota, without regard to any conflicts of law principles, decisional law, or statutory provision which would require or permit the application of another jurisdiction’s substantive law. Venue for any lawsuit pertaining to or affecting this Agreement will be in Circuit Court, Sixth Judicial Circuit, Hughes County, South Dakota.

2.13. The Contractor will comply with all federal, tribal, state, and local laws, regulations, ordinances, guidelines, permits, requirements, and other standards applicable to providing services pursuant to this Agreement and will be solely responsible for obtaining current information on such requirements. Nothing herein will constitute a waiver by the State to any defense to jurisdiction nor will anything under this Agreement constitute an acknowledgement by the State that any tribe has or exercises any jurisdiction over this Agreement or the parties.

2.14. The Contractor may not use subcontractors to perform the services described in this

Agreement without the express prior written consent of the State. The Contractor will include provisions in its subcontracts requiring its subcontractors to comply with the applicable provisions of this Agreement, to indemnify the State, and to provide insurance coverage for the benefit of the State in a manner consistent with this Agreement. The Contractor will cause its subcontractors, agents, and employees to comply with applicable federal, tribal, state, and local laws, regulations, ordinances, guidelines, permits, and other standards and will adopt such review and inspection procedures as are necessary to assure such compliance. The State, at its option, may require the vetting of any subcontractors. The Contractor will assist in the vetting process.

2.15. The State reserves the right to reject any person from performing services under this

Agreement who the State believes would be detrimental to the services, presents insufficient skills, presents inappropriate behavior, or is considered by the State to be a security risk.

2.16. The Contractor hereby acknowledges and agrees that all reports, plans, specifications, technical data, miscellaneous drawings, software system programs and documentation, procedures, or files, operating instructions and procedures, source code(s) and documentation, including those necessary to upgrade and maintain the software program, and all information contained therein provided to the State by the Contractor in connection with its performance of services under this Agreement will belong to and is the property of the State and will not be used in any way by the Contractor without the written consent of the State. Papers, reports, forms, software programs, source code(s), and other material which are a part of the work under this Agreement will not be copyrighted without written approval of the State.

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2.17. The Contractor certifies that neither Contractor nor its principals are presently debarred, suspended, proposed for debarment or suspension, or declared ineligible from participating in transactions by the federal government or any state or local government department or agency. Contractor further agrees that it will immediately notify the State if during the term of this Agreement Contractor or its principals become subject to debarment, suspension, or ineligibility from participating in transactions by the federal government, or by any state or local government department or agency.

2.18. By signing this Agreement, the Contractor certifies and agrees that is has not refused to transact business activities, have not terminated business activities, and have not taken other similar actions intended to limit its commercial relations, related to the subject matter of this Agreement, with a person or entity that is either the State of Israel, or a company doing business in or with Israel or authorized by, licensed by, or organized under the laws of the State of Israel to do business, or doing business in the State of Israel, with the specific intent to accomplish a boycott or divestment of Israel in a discriminatory manner. It is understood and agreed that, if this certification is false, such false certification will constitute grounds for the State to terminate this Agreement. During the term of this Agreement, if the Contractor no longer complies with this certification, the Contractor agrees to provide immediate written notice to the State and agrees such noncompliance may be grounds for termination of this Agreement.

2.19. Pursuant to South Dakota Codified Law § 5-18A, by entering into this Agreement with the

State of South Dakota, the Contractor certifies and warrants that the Contractor is not a prohibited entity, regardless of its principal place of business, that is ultimately owned or controlled, directly or indirectly, by a foreign national, a foreign parent entity, or foreign government from China, Iran, North Korea, Russia, Cuba, or Venezuela, as defined by South Dakota Codified Law § 5-18A.

The Contractor agrees that if this certification is false, the State may terminate this Agreement with no further liability to the State. The Contractor further agrees to provide immediate written notice to the State if during the term of the contract it no longer complies with this certification, and the Contractor agrees such noncompliance may be grounds for contract termination and would be cause to suspend and debar a business under SDCL § 5-18D-12.

2.20. Any notice or other communication required under this Agreement will be in writing and sent to the address set forth above. Notices will be given by and to on behalf of the State, and by and to , on behalf of the Contractor, or such authorized designees as either party may from time to time designate in writing. Notices or communications to or between the parties will be deemed to have been delivered when mailed by first class mail, provided that notice of default or termination will be sent by registered or certified mail, or, if personally delivered, when received by such party.

2.21. In the event that any court of competent jurisdiction will hold any provision of this

Agreement unenforceable or invalid, such holding will not invalidate or render unenforceable any other provision of this Agreement.

2.22. All other prior discussions, communications, and representations concerning the subject matter of this Agreement are superseded by the terms of this Agreement, and except as specifically provided in this Agreement, this Agreement constitutes the entire agreement with respect to the subject matter.

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2.23. The waiver by either party of a breach or violation of any provisions of this Agreement will not operate as, or be construed to be, a waiver of any subsequent breach of the same or other provision of this Agreement.

2.24. Nothing in this Agreement is intended to constitute a waiver of sovereign immunity by or on behalf of the State of South Dakota, its agencies, officers, or employees.

2.25. Neither party will disclose the contents of the Agreement except as required by applicable law or as necessary to carry out the terms of the Agreement or to enforce that party’s rights under this Agreement. The Contractor acknowledges that the State of South Dakota and its agencies are public entities and thus are bound by South Dakota open meetings and open records laws. It is therefore not a breach of this Agreement for the State to take any action that the State reasonably believes is necessary to comply with the South Dakota open records or open meetings laws, including, without limitation, posting this Agreement on the website pursuant to SDCL § 1-27-46.

3. Scope of Work

3.1. Overview

The State of South Dakota Workers’ Compensation Program is self-funded, and the Bureau of Human Resources and Administration is seeking a Third-Party Administrator (TPA) to administer all aspects of the Workers’ Compensation Program. The State has approximately 18,300 full-time equivalent employees (FTEs). Employees are located throughout the State of South Dakota and other sites within the U.S.

The Third-Party Administrator will evaluate, and process payment of claims submitted pursuant to the South Dakota Workers' Compensation statutes, applicable administrative rules and regulations and relevant case law. Further, the TPA is responsible for investigating and/or defending workers' compensation claims as determined by administrative rules and state statutes.

The State is requesting all TPA proposals be inclusive of Medical Case Management, Bill Review, and MMSEA Reporting for the Workers’ Compensation Program.

3.2. General Requirements

1. The TPA must provide injury reporting and response 24/7.

2. The TPA must be accessible to the State at 8 AM and 5 PM Central Time to the for consultation and information.

3. Responses to questions and requests must be timely depending on complexity as determined at the time of the request.

4. The TPA will meet with the State or others as deemed necessary by the State.

5. The TPA will be expected to provide suggested cost savings methods, applications, and/or programs to the State and support the implementation of changes.

6. The TPA must have secured email for the transmittal of personal health information

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(PHI).

7. The TPAs shall work with the subrogation services provider for the State.

8. No additional fees or expenses shall be paid to the TPA to meet these general requirements.

9. Exhibits

Exhibit Document Response Required

Exhibit A FY27 Benefits Guide N/A

Exhibit C BHRA Business Associates Agreement

Bidders must review and indicate on Exhibit C if they cannot agree to anything in the BAA

Exhibit D Summary Plan Description

(SPD)

N/A

Exhibit F BIT Security and Vendor Questionnaire

Bidders must complete

Exhibit G BIT Standard State Technology Contract Terms

Bidder must review and indicate on Exhibit G if they cannot agree to any standards.

Exhibit H BIT Security Acknowledgement Form

Bidders must complete and sign

Exhibit I Information Technology Security Policy – Contractor

Bidders must review and indicate on Exhibit I if they cannot agree to any standards.

3.3 Third Party Claims Administration (TPA)

1. The TPA is responsible for the intake and management of every State of South

Dakota employee injury and illness or disease claim submitted by an employee or the employer on behalf of the employee. To include, but not limited to: Electronic Payments, Monthly Payment Report (Report 107) to DOL, Reporting Form 101 (FROI) to DOLR, initial claimant letters, requesting medical information to determine compensability and necessary medical records for ongoing management of the Workers’ Compensation claim and 1099 reporting.

2. Describe organizational structure and provide a flow chart indicating the flow of claims through their system (i.e. FROI input).

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3. Describe availability to access TPA’s claim system.

4. Describe databases and software capabilities in detail, including claim notes lookup, Records Management Information System (“RMIS”) for standardized and ad hoc reports. dashboards, real-time reporting data, and text to employee capabilities.

5. Describe how claims payment information is made available, to whom, and at what intervals. Provide screen shots or samples of dashboards, reports, and on-demand information.

6. Provide examples of the following that would be available to the State: financial data, reserves, paid amounts and claims notes.

7. Describe dashboard access for the Human Resources team.

8. The TPA must have expertise in the requirements of the South Dakota Workers’ Compensation statutes.

9. Describe your disaster recovery plan for both office operations and data administration.

10. The TPA shall maintain complete electronic records of all reported claims on behalf of and as custodian for the State.

11. The TPA shall be responsible for payment of all appropriate medical bills in a timely manner while eliminating wasteful, excessive, inappropriate, and duplicate medical payments.

12. The TPA or their bill review company may be required to develop and maintain a comprehensive Preferred Provider Organization (PPO) network that will provide the State with the greatest possible opportunity for discounts as provided by State statutes for Workers’ Compensation injuries.

13. Should the PPO network be required, the TPA or their bill review company must assure providers in the PPO network do not arbitrarily inflate billings under the PPO agreement prior to application of the specified discounts, in addition to assuring that all bills are re-priced in accordance with State mandated medical fee schedule and usual and customary charges. Further, the TPA would be required to insure all PPO discounts are applied.

14. The TPA is responsible for responding to disputes with providers in accordance with all appropriate laws and regulations.

15. The TPA or their bill review company shall review, re-price the bills, and negotiate costs when necessary.

16. Provide list of approved litigation management/Legal counsel firms.

17. A Description of the TPA’s qualifications for this Scope of Services and previous experience on similar or related work performed for comparable agencies like the State of South Dakota. This description must include a summary of work performed, UPDATED APRIL 13, 2026 V5.4 14 the period over which the work was completed, and detail on how the TPA’s work assisted in the overall reduction of their cost of risk.

18. Describe your firm’s capacity to dedicate personnel to the State’s account and identify the personnel who would be assigned. Describe the specific roles and responsibilities of the personnel, and (1) their current caseload, and

(2) how they differentiate your firm from your competitors.

19. Provide data conversion rate per transfer of claim files for the initial term of the anticipated agreement, and for each claim type for runoff claims. The selected TPA will accept an electronic transfer of data for existing claims including payment and reserve transactions, claims activity notes and claims data. The integrity of this data must be assured during the transfer process, and the ability to report historical evaluations must be preserved.

3.4 TPA - Medical Case Management

1. The TPA or their management care company shall contact the State within twenty-four (24) hours of assignment to the file.

2. The TPA or their managed care company shall forward any Return-to-Work documentation within twenty-four (24) hours of receipt.

3. Updates following attendance at an appointment shall be provided with twenty-four

(24) hours.

4. Case Management Contractors must include in proposal Sample Progress/Case Management Report.

5. Describe Organization structure and provide a flow chart indicating the flow of managing a case.

6. Based on the loss data provided, please outline recommendations for managed care services. Please be specific with respect to medical severity reviews, when case management will review the files, the assignment process for case management, etc.

7. Describe your Pharmacy Management Services and provide your Preferred Pharmacy Management provider.

8. Describe your Nurse Triage and Return to Work Management/Transitional work placement processes.

3.5 Bill Review

1. The TPA or their bill review company will review duplicate bills, bills for excessive treatment, and bills for treatment unrelated to the compensable injuries and coordinate the process and communication for refunds or subrogation accordingly.

2. The TPA or their bill review company will respond to all challenges by medical providers for determinations of re-pricing in accordance with the South Dakota Workers’ Compensation Laws and Administrative Rules.

3. Bills are re-priced in accordance with the State mandated Workers’ Compensation

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medical fee schedule and usual and customary charges.

4. The TPA or their bill review company is responsible for responding to disputes with providers in accordance with all appropriate laws and regulations.

5. Please indicate all applicable PPO discounts and networks for the state of South

Dakota.

3.5.5.1 What are your average discounts in South Dakota?

3.6 MMSEA Reporting

1. The TPA is responsible for the MMSEA reporting and will provide the electronic reporting as required under the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) laws and regulations for the State of South Dakota, Bureau of Human Resources and Administration Workers’ Compensation Program.

2. The TPA will provide to the Centers for Medicare and Medicaid Services (CMS) all monthly and quarterly reporting as required under the MMSEA laws and regulations.

3. The TPA must adhere to file requirements: Medicare Secondary Payer, Query Only, and Non-Medicare Secondary Payer.

4. The TPA may be Responsible for financial penalties for failing to report claims, as described in Section 111 of the Medicare, Medicaid and SCHIP Extension Act.

5. The TPA will assist in submitting Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) proposals to the Centers for Medicare & Medicaid Services (CMS) for review.

4. Proposal Requirements and Company Qualifications

4.1. The offeror is cautioned that it is the offeror’s sole responsibility to submit information related to the evaluation categories and that the State is under no obligation to solicit such information if it is not included in the proposal. The offeror's failure to submit such information may have an adverse impact on the evaluation of the proposal and may result in the proposal being excluded as non-responsive.

4.2. Offeror’s Contacts: Offerors and their agents (including subcontractors, employees, consultants, or anyone else acting on their behalf) must direct all questions or comments regarding the RFP, the evaluation, etc. to the Primary Contact indicated on the first page of this RFP. Offerors and their agents may not contact any state employee other than the Primary Contact record regarding any of these matters during the solicitation and evaluation process. Inappropriate contacts are grounds for suspension and/or exclusion from specific procurements. Offerors and their agents who have questions regarding this matter should contact Primary Contact.

4.3. The offeror must submit a copy of their most recently audited financial statements upon the

State’s request.

4.4. The offeror must provide the following information related to at least three (3) previous and current service/contracts, performed by the offeror’s organization, which are similar to the requirements of this RFP. The offeror shall provide this information for any service/contract

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that has been terminated, expired or not renewed in the past three (3) years:

a. Name, address and telephone number of client/contracting agency and a representative of that agency who may be contacted for verification of all information submitted;

b. Dates of the service/contract; and

c. A brief, written description of the specific prior services performed and requirements thereof.

4.5. List staff members, qualifications, and experience.

4.6. Include three (3) references of employers who are currently under contract for services.

4.7. Include three (3) references of employers who were but are no longer under contract for services.

4.8. Proposals must include performance guarantees to ensure the offeror completes the obligations of its proposal. Performance guarantees must be provided in each of the following areas:

a. Implementation/Onboarding;

b. Quarterly Claims administration

c. Quarterly Customer Service reviews to include employee surveys; and

d. Reporting.

4.9. The offeror must thoroughly review the South Dakota Bureau of Information and

Technology (“BIT”) standard contract terms and conditions pertaining to IT security, which are attached as Exhibit G - BIT Standard State Technology Contract Terms.

The offeror must indicate in their response if there are any standard IT security terms that are not acceptable to the offeror. The offeror must include in their response reasons why the IT terms are unacceptable. The State will consider any IT contract term that was not indicated as unacceptable as being acceptable by the offeror.

4.10 No Broker Submission

For the purposes of this RFP, the State will not accept proposals from brokers on behalf of service providers that they represent. The State will receive proposals directly from service providers only. In addition, costs proposed for services cannot include fees, commissions or revenue sharing (e.g. percentage of discount savings, etc.) with any broker or consultant.

5. Proposal Response Format

5.1. The offer must provide one (1) copy of their entire proposal, including all attachments, in

Microsoft Word, EXCEL or PDF electronic format by email to Peggy.Canter@state.sd.us.

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Additionally, an original and five (5) identical copies of the proposal along with any attachments shall be submitted in hardcopy format.

5.2. The proposal should be page numbered and should have an index and/or a table of contents referring to the appropriate page number.

5.3. The offeror’s proposal should refrain from using the State of South Dakota State Seal in its proposal. Offerors are cautioned that use of the State Seal in any of its documents is illegal as per South Dakota Codified Law § 1-6-3.1. Use of seal or facsimile without authorization prohibited--Violation as misdemeanor. No person may reproduce, duplicate, or otherwise use the official seal of the State of South Dakota, or its facsimile, adopted and described in §§ 1-6-1 and 1-6-2 for any for-profit, commercial purpose without specific authorization from the secretary of state. A violation of this section is a Class 1 misdemeanor.

5.4. All proposals must be organized and tabbed with labels for the following headings:

5.4.1 RFP Form. The State’s Request for Proposal form (see page 1 of this RFP) completed and signed.

5.4.2 Executive Summary. The one (1) or two (2) page executive summary is to briefly describe the offeror’s proposal. This summary should highlight the major features of the proposal. It must indicate any requirements that cannot be met by the offeror. The reader should be able to determine the essence of the proposal by reading the executive summary. Proprietary information requests should be identified in this section.

5.4.3 Detailed Response. This section should constitute the major portion of the proposal and must contain at least the following information:

1. A complete narrative of the offeror’s assessment of the work to be performed, the offeror’s ability and approach, and the resources necessary to fulfill the requirements. This should demonstrate the offeror’s understanding of the desired overall performance expectations.

2. A specific point-by-point response, in the order listed to each requirement described in Section 3.0: Scope of Work and Section 4.0: Proposal Requirements and Company Qualifications of the RFP. The response should identify each requirement being addressed as enumerated in the

RFP.

3. A clear description of any options or alternatives proposed.

5.5 IT Requirements

The offeror’s proposal must highlight any requirement in Section 8 that the offeror’s proposed deliverables cannot comply with, and the offeror must provide any suggested “work-around” to the requirement in question or a future date that the offeror will be able to comply with the requirement.

5.5.1 Required Diagrams

1. System Diagram. The offeror’s proposal must include a system diagram which must provide specific details so that the State can understand the components, the system flow, and system requirements. The offeror must provide a system diagram for each hosting option. It is preferred that the diagram be provided as a

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separate document or attachment. The file must be named “(Your Name) System Diagram and Requirements.” If the offeror elects to make the diagram part of the proposal, then the location of the diagram must be clearly indicated in the Table of Contents.

2. Solution Diagram. The offeror’s proposal must include a solution diagram which must provide specific details on how the offeror’s proposed deliverables will meet the requirements of this RFP. The solution diagram must include integration with the State’s infrastructure; existing systems that will integrate with the proposed deliverables; how data would flow between systems; all components, tools, and products the proposed deliverables will utilize, the technology stack of the proposed deliverables including any dependencies; and include, but not be limited to, user onboarding/provisioning and SSO.

5.6 Background Investigations

The offeror must include the following statement in its proposal:

(Company name here) acknowledges and affirms that it understands that the (company name here) employees who have access to production Personally Identifiable Information (PII), data protected under the Family Educational Rights and Privacy Act (FERPA), Protected Health Information (PHI), Federal Tax Information (FTI), any information defined under state or federal statute as confidential or have access to secure facilities will have fingerprint-based background investigations. These background investigations will be used to check the criminal history records of the State as well as the Federal Bureau of Investigation’s records. (Company name here) acknowledges and affirms that this requirement will extend to include any subcontractors, agents, assigns, and affiliated entities.

5.7 Security and Vendor Questionnaire

The offeror must submit a completed Security and Vendor Questionnaire, which is attached to this RFP as Appendix B, for each proposed deliverable. The offeror must complete a Security and Vendor Questionnaire for each hosting option proposal. The Security and Vendor Questionnaire will be used in the proposal evaluation. The offeror must complete the Security and Vendor Questionnaire in the Microsoft Word format as it is provided to the offeror.

6. Proposal Evaluation and Award Process

6.1. After determining that a proposal satisfies the mandatory requirements stated in the

Request for Proposal, the evaluator(s) shall use subjective judgment in conducting a comparative assessment of the proposal by considering each of the following criteria, on a 500-point scale.

Description Points

Specialized expertise, capabilities, and technical competence as demonstrated by the proposed approach and methodology to meet the project requirements;

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Resources available to perform the work, including any specialized services, within the specified time limits for the project;

Record of past performance, including price and cost data from previous projects, quality of work, ability to meet schedules, cost control, and contract administration;

Availability and familiarity to project locale

Claims Management Information Systems – Data, Reporting and Analytics Risk Management and cost containment methods

Implementation – to include Account Management Team

Cost Proposal

6.2. Experience and reliability of the offeror’s organization are considered subjectively in the evaluation process. Therefore, the offeror is advised to submit any information which documents successful and reliable experience in past performances, especially those performances related to the requirements of this RFP.

6.3. The qualifications of the personnel proposed by the offeror to perform the requirements of this RFP, whether from the offeror’s organization or from a proposed…