ESBD_396153_1739478408421_Requirements-Questions-Tables.xlsx
XLSX spreadsheet 62 KB Posted
- Solicitation number
- RFP2025-008
- Issued by
- Texas
About this file
This is a requirements document from the City of Waco, Texas detailing specifications for Third Party Administrator (TPA) services to manage workers' compensation claims. The document outlines comprehensive requirements for claims handling, financial procedures, information systems, reporting, and administrative services beginning October 1, 2025. The TPA must provide dedicated claims handling staff licensed in Texas, including an indemnity/medical adjuster, supervisor, and support staff. Key requirements include managing both new and existing workers' compensation claims, maintaining contact with injured workers, processing payments, coordinating with medical providers, and handling all required state filings and documentation. The TPA must also provide an online claims management system with access for at least six City users.
The pricing structure allows proposers to submit either a flat annual fee or a per-claim fee schedule with separate rates for indemnity claims, medical-only claims, and record-only claims. Additional fees must be clearly specified for services such as data conversion, system maintenance, Medicare reporting, subrogation, field investigations, and medical cost containment services. The TPA must maintain claim loads within specified limits (100 for indemnity claims, 250 for medical-only claims, or 350 for combined claims) and provide regular financial and performance reporting. The selected TPA will be required to establish a loss fund account funded by the City for claim payments and must implement sufficient internal controls to protect against financial loss.
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Requirements
| REQUIREMENTS | ||
| Req. # | Requirement | Vendor Response |
Please respond to ALL items listed below.
| R1.0 | GENERAL | |
| R1.1 | TPA shall proactively manage all workers’ compensation claims submitted by the City adhering to the professional standards of the Firm and the City’s requirements, while serving as the City's representative in matters related to Texas workers' compensation laws. A copy of the TPA’s professional standards, including turnaround-time benchmarks, must be included with your proposal. | |
| R1.2 | TPA shall provide recommendations for improving the City’s claims processes and procedures. | |
| R1.3 | TPA shall fully cooperate with the City, the City’s Risk Consultant, and the adjusters/attorneys of the excess insurance carrier. TPA shall respond to inquiries within one business day. | |
| R1.4 | The TPA shall provide dedicated claims handling staff licensed in the State of Texas, including one dedicated indemnity/medical adjuster, a supervisor, and support staff. The supervisor and support staff need not be dedicated but must be sufficient to address City claims’ volume and customer service standards. | |
| R1.5 | At no additional cost to the City, the TPA agrees to collaborate with the City regarding language used in standard letters, filings, and documents. | |
| R1.6 | At no additional cost to the City, the TPA agrees that the City shall have reasonable access to all claim files, where "reasonable" is defined as access during normal business hours and within a timeframe that allows the City to efficiently review and manage the claims. | |
| R1.7 | At no additional cost to the City, the TPA agrees that the City shall have access to, and ownership of, all claim data, statistics, electronic media, and claim files including associated managed care information generated during the handling of the account. At the sole discretion of the City, and upon providing ten (10) working days’ notice, the TPA shall return these materials to the City in a format that is acceptable to the City. | |
| R1.8 | TPA shall designate at least one individual as the primary contact for matters not directly related to specific claims. Additionally, the TPA shall ensure that secondary contacts are available in the event the primary contact is unavailable. | |
| R1.9 | At no additional cost to the City, the TPA shall provide access to and cooperate with independent claims and/or financial auditors hired by the City, as well as provide any information requested under the Texas Open Records Act. | |
| R1.10 | The TPA shall provide a list of all potential servicing personnel, along with a current resume for each designated adjuster(s) assigned to handle City claims. The minimum qualifications for personnel handling City claims are as follows: | Account Manager: A minimum of five (5) years of experience in workers' compensation, including handling public entity claims preferred, unless otherwise approved by the City. |
| R1.11 | adjuster - Workers' Compensation: A minimum of four (4) years of experience handling workers' compensation claims, preferably for Texas public entities preferred, unless otherwise approved by the City. | |
| R1.12 | The TPA shall offer bilingual adjusting services with proficiency in both English and Spanish. | |
| R1.13 | Manage workers' compensation claims throughout the contract term, including but not limited to investigation, reserving, payment processing, and filing reports. | |
| R1.14 | At no additional cost to the City, the TPA shall provide on-call staff information for emergencies. This contact shall be available to the City at all times, including non-business hours. | |
| R1.15 | The claim load for each adjuster shall not exceed the following limits: |
Workers' Compensation Indemnity: No more than 100 claims Workers' Compensation Medical Only: No more than 250 claims Workers' Compensation Combined Indemnity and Medical Only: No more than 350 claims
| R1.16 | TPA shall provide notification to all employees and providers of services of the change in workers' compensation administration by City. This notification shall include a statement indicating that all billing of City claims for all injuries subsequent to the Contract date should be submitted to the new TPA for processing. |
| R1.17 | Subject to periodic claims audits conducted by internal City staff and/or an independent firm, at the City’s discretion. |
| R1.18 | The TPA shall provide copies of all licenses and permits required to administer claims in Texas. |
| R1.19 | The TPA shall disclose any affiliations with other companies, including ownership and financial arrangements with ancillary service providers proposed. If applicable, describe the nature of the "affiliated relationship." |
"Affiliated" refers to being owned by another company, sharing a common controller, shareholder, or interest, or being interconnected by contract to the extent that one is under the dominion or influence of another.
| R2.0 | CLAIMS HANDLING/PROCESSING |
| R2.1 | The TPA shall review all First Report of Injury (DWC 1) forms for compensability within seven (7) days of receipt and make the required filings accordingly. |
| R2.2 | Timely documentation of the 3-point contact (injured worker, medical provider, and City) within 48 hours for lost time claims and 72 hours for medical-only claims. |
| R2.3 | Initiating weekly benefits within the required statutory time limits. |
| R2.4 | Maintaining and documenting weekly contact with injured workers on active Temporary Income Benefits (TIBs) claims. |
| R2.5 | Provide procedures for tracking return-to-work cases and the payment of TIBs for employees transitioning from being off work to limited duty with a reduced pre-injury average weekly wage (AWW) and/or intermittent return to work within a single pay period. |
| R2.6 | Maintaining and documenting regular communication with treating physicians or specialists. If contact is not made, the reason for the lack of communication must be documented. |
| R2.7 | Identifying, implementing, and documenting medical management strategies, such as obtaining treatment plans and disputing or questioning unrelated, unreasonable, or unnecessary treatment protocols based on the reported injury, medical necessity, and treatment guidelines. |
| R2.8 | Adhere to statutory requirements for state filings related to administrative, medical, and indemnity payments. |
| R2.9 | The TPA shall, at no additional cost, conduct Index Bureau checks on all indemnity files with reserves of $2,500.00 or higher. |
| R2.10 | The TPA shall cooperate with any medical cost containment, case management, risk management, investigations, law firm, or other organization designated by the City. |
| R2.11 | The TPA shall not add any fees, charges, or premiums to the actual cost incurred for subcontracted or vendor services. |
| R2.12 | For subcontracted services, the TPA shall act as the managing TPA. The TPA shall disclose any financial arrangements related to subcontractors and/or vendors providing the services requested herein. The TPA should also highlight any internal profit centers established. |
| R2.13 | Medical Cost Containment services may be provided by the TPA or outsourced to a Medical Cost Containment provider. Include cost in the Other Services section of the Proposers Pricing-Fee Schedule. |
| R2.14 | Prescription Benefit Management (PBM) services may be provided by the TPA or outsourced. Details regarding PBM services, including access, should be included in the in the Other Services section of the Proposers Pricing-Fee Schedule. |
| R2.15 | At no additional cost to the City, the TPA shall routinely pursue Designated Doctor (DD), Independent Medical Exam (IME), and/or Required Medical Exam (RME) and establish a process within claims handling to ensure the examiner receives sufficient information to support their medical opinion. |
| R2.16 | The TPA shall pursue Peer Reviews regularly but judiciously and create a process within claims handling to provide the reviewer with sufficient information to form their medical opinion. Outcomes or reports will be communicated to the City timely. |
| R2.17 | Private Investigations may be integrated into the broader scope of claims management and cost containment strategies. However, any such investigations must be conducted with the City’s prior knowledge and approval. |
| R2.18 | At no additional cost to the City, the TPA shall assist the City in identifying and reporting claims to the City’s Excess Workers' Compensation carriers as required. The TPA will also promptly notify the City and/or its designee of any claims reported. |
| R2.19 | Files will be created and assigned within one (1) business day of receiving the initial report. |
| R2.20 | Contact with the claimant and the City will occur within two (2) business days of receiving the initial report for all claims. If this timeframe is not met due to no response, the documentation will reflect this accordingly. |
| R2.21 | All indemnity files will include reserve worksheets explaining how the current reserves are calculated and monitored. A copy of the reserve worksheet will be placed in the file. |
| R2.22 | All file activity, including telephone conversations, personal meetings, and diary reviews, will be promptly and clearly documented in the file notes. |
| R2.23 | Specific instructions for the investigation and handling of all indemnity claims will be established within five (5) business days of the initial report and clearly documented in the file notes. |
| R2.24 | The adjuster's rationale for accepting or denying compensability will be clearly documented in the file notes. The City of Waco must be notified immediately upon the decision to deny a claim or treatment. The adjuster must contact the employee by phone and follow up with written notice regarding the denial of a claim or treatment. |
| R2.25 | Upon learning of a catastrophic claim, notification will be made immediately by phone to the City, followed by an email. These claims will be managed by senior personnel. Catastrophic claims include, but are not limited to: fatalities, amputations, serious burns, brain injuries, cancer, post traumatic stress disorder (PTSD), mental trauma/stress, and multiple injuries. |
| R2.26 | Diaries will be established, monitored, and maintained to ensure that every open claim is reviewed and that claimant contact is made at least once every 30 days by the adjuster. |
| R2.27 | A supervisory file review will be conducted at least once every 30 days for all open indemnity claims. |
| R2.28 | Prepare and maintain files required for the legal defense of claims and/or litigation. |
| R2.29 | The TPA or an outside agency approved by the City will audit medical bills to assess the causal relationship and reasonableness of charges. |
| R2.30 | Medical-only claims will be reviewed for possible closure no less frequently than every 30 days. |
| R2.31 | All City of Waco locations participate in a return-to-work program. The City will provide written bona fide offers of transitional duty to the City employee, with a copy sent to the WC adjuster. The adjuster is responsible for documenting these offers and reporting on subsequent return-to-work activity and status updates. |
| R2.32 | The adjuster may request a Peer Review, RME, or DD at any time, but must first consult with the City and document this in the file notes. |
| R2.33 | The adjuster will attend hearings, depositions, mediations, and other proceedings. The City will not cover expenses for attending hearings; such costs must be included in the proposed fee. |
| R2.34 | The TPA will aggressively pursue all opportunities for subrogation, excess insurance reimbursement, and third-party liens. |
| R2.35 | The adjuster will secure a Maximum Medical Improvement (DWC 69) form for all claims, except for first aid and medical-only claims. |
| R3.0 | RESERVING |
| R3.1 | Reserving will be estimated and managed based on the most likely final cost. |
| R3.2 | Reserves will be set and reviewed every 30 days. |
| R3.3 | The rationale for the initial reserve and any subsequent reserve adjustments will be clearly documented for each file. |
| R3.4 | The adjuster will notify the City via email of any claim requiring an aggregate reserve of $25,000 or more, with the appropriate documentation entered. |
| R4.0 | FILE DOCUMENTATION |
| R4.1 | A completed reserve analysis will be included in all indemnity files. |
| R4.2 | All file activity, including telephone conversations, personal meetings, and diary reviews, will be thoroughly documented to include the date, individuals involved, discussion content, and the planned course of action. |
| R4.3 | The TPA’s rationale for acceptance or denial will be clearly documented. Before a denial is made, the adjuster must consult with the City to reach a mutual agreement on the decision. |
| R5.0 | INVESTIGATION AND CASE MANAGEMENT |
| R5.1 | Initial contact with the indemnity claimant will be made or attempted before the initial compensation payment, unless the claimant has returned to work. |
| R5.2 | Audio-recorded statements from the injured employee or claimant must be obtained for all indemnity claims to document the accident details, affected body parts, and major or questionable medical claims. |
| R5.3 | The claims adjuster will reach out to injured employees within a reasonable time frame, both prior to and following surgeries or hospital stays, with "timely" defined as within five (5) days before and after. |
| R5.4 | Before making any initial temporary income benefits payments, unless a medical report has already been received, the medical provider or facility will be contacted to verify the extent of the injury, its causal relationship to the alleged incident, and the estimated return-to-work date. |
| R5.5 | For all questionable workers' compensation cases, informative statements will be obtained from the claimant, supervisor, witnesses, other relevant parties, and the City’s Human Resources. |
| R5.6 | Any workers' compensation claim that the TPA intends to contest must be submitted to the City in a captioned report for review. |
| R5.7 | Medical reports will be obtained as necessary to verify the ongoing need for indemnity payments. |
| R5.8 | Before each indemnity payment, the TPA will confirm the continued disability with the City, provide status updates, and discuss the availability of modified duty or part-time work. |
| R5.9 | Since the City pays supplemental salary to all employees, the City may choose to use a PLN-6 form instead of TIBS, and the TPA will need to complete the PLN-6. |
| R5.10 | Telephone or personal contact will be maintained with temporarily disabled employees and their supervisors or other City-designated individuals to maintain rapport, monitor medical progress, track return-to-work status, and discuss modified duties. |
| R5.11 | Outside investigation services will be utilized only when necessary and with the City's approval. |
| R5.12 | Independent medical examinations will be scheduled with qualified physicians in cases where treatment, disability duration, or the extent of permanent impairment is in question. Appointment letters will include copies of all relevant medical reports, case information, job details, and a description of the opinions being requested, including coordination with the case manager. |
| R5.13 | Ensure that any documentation required for completing a Required Medical Examination (RME) is delivered personally, at no additional cost to the City. |
| R5.14 | Pertinent past medical records will be obtained, and apportionment will be addressed in all cases before final resolution of permanent partial disability, Impairment Income Benefits, or Supplemental Income Benefits. |
| R5.15 | Vocational rehabilitation will be provided as approved by the City. |
| R5.16 | Benefit payments will comply with the maximum medical improvement and impairment/supplemental income benefits guidelines as per the Texas Department of Insurance statutes. |
| R5.17 | Case management will be assigned based on criteria established by the City and TPA, with associated costs charged to the file. |
| R5.18 | Case management costs will be tracked, and a quarterly report will be provided to the City by the TPA. |
| R6.0 | AUDITS |
| R6.1 | Monthly DWC-3 Audits for all new claims where indemnity payments were initiated in the previous month, or claims that were upgraded to indemnity status within the last month. |
| R6.2 | Monthly Bill Review Service Quality Audit conducted in collaboration with the City, focusing on bills selected at random. This audit is included in the Performance Measure Report. |
| R6.3 | SAS 70, Type II Audit is required at the TPA’s own expense, conducted annually by a certified and licensed auditing firm. This audit will assess internal controls related to all contracted or subcontracted work covered by this proposal. The audit will be performed in accordance with the American Institute of Certified Public Accountants (AICPA) Statement on Auditing Standards No. 70, which addresses reports on transaction processing by service organizations. While the audit is not specific to the City of Waco, it must cover the vendor’s account service provider environment. Final audit reports must be submitted to the City by December 1st each year, starting in 2025. The SAS Audit provides a thorough review of internal claims control objectives and activities. It is performed at the vendor's expense but must be reported to the City. |
| R6.4 | Annual Claims Administration Audit may be requested by the City. The City will coordinate and notify the TPA about the onsite audit to be conducted by a qualified auditing firm. The TPA is required to allow access to any ancillary services used in the program. The City will not incur any charges or expenses for the work required of the TPA during this audit. |
| R6.5 | DWC-6 Forms & General Claim File Activity Audits shall be provided electronically with all DWC-6 forms, general claim file activity audits, and all PLNs issued for the previous month by the 10th of the following month. This requirement ensures compliance with state regulations and provides the City with timely and necessary information regarding workers' compensation claims. |
| R6.6 | SSAE 18 conducted annually in accordance with American Institute of Certified Public Accountants (AICPA) standards by a certified auditing firm at the TPA's own cost. The audit does not have to be specific to City but of the vendor’s Account Service Provider environment. Final audit reports shall be delivered to the City by November 1st of each year. |
| R6.7 | Random Audits - The City reserves the right to audit all work products, including but not limited to claim files to ensure compliance with Texas administrative guidelines and other standards outlined in this proposal. The TPA shall respond within five (5) business days unless the situation's urgency requires a more immediate response. Please specify if the TPA has undergone an external independent party or parent corporation audit. |
| R7.0 | FINANCIAL PROCEDURES AND CLAIM PAYMENTS |
| R7.1 | Workers’ Compensation payments will be made promptly and in full compliance with the Workers' Compensation Statute. |
| R7.2 | Invoices for vendor or subcontractor services will be paid if the services were provided within sixty (60) days prior to the invoice date. Any invoices received that are over 60 days old will be reported to the City for further review. |
| R7.3 | A loss fund account will be established by the TPA, with an initial deposit made by the City. The City will make monthly wire transfers to the trust fund to reimburse claims as they arise. |
| R7.4 | The TPA will issue checks from the loss fund account, which is funded by the City. Checks will be issued on a weekly basis, with the TPA providing a weekly check register and a monthly invoice to the City for recordkeeping. |
| R7.5 | The TPA will pay compensation, medical expenses, and allocated loss expenses using funds provided by the City and will issue checks, drafts, or other forms of payment from their office. |
| R7.6 | TPA shall describe procedure for issuing payments, including but not limited to the location, frequency, and financial safeguards such as access to check-writing functions, electronic signatures, handling of returned checks, and other relevant measures. Additionally, outline your procedures for voiding checks, stop payments, and correcting payments. |
| R7.7 | TPA shall specify whether it is the intent to issue medical and indemnity payments on a daily basis. If not, indicate the payment interval and describe your procedures for issuing off-cycle checks. Additionally, outline the financial safeguards in place to prevent duplicate or excessive indemnity and medical payments. |
| R7.8 | The TPA must ensure that the check system provides details such as check number, payee, claim number, entity charged, date, amount, and type of payment. Can your system provide this information? Please attach a sample. |
| R7.9 | The TPA is responsible for monitoring and collecting all recoveries due to the City. |
| R7.10 | The TPA will prepare and submit IRS Form 1099 for all vendors and mail the forms to the vendors. The TPA will also submit IRS 1099 data electronically to the City no later than January 15th each year. |
| R7.11 | The TPA must implement sufficient internal control procedures to protect the City from financial loss. Any payments made solely in error by the TPA will be the TPA’s responsibility. The TPA shall reimburse the City for any unrecovered payments resulting from errors or negligence by the TPA or a service partner. |
| R7.12 | The TPA will be responsible for any fines or interest resulting from non-compliance with Texas administrative or regulatory bodies, as long as the responsibility falls within the TPA's duties or those of its subcontractors. This includes fines from Texas administrative office audits identifying non-compliance with required standards, throughout the life of all claims managed by the TPA. However, the TPA will not be held accountable for fines arising solely from the City’s errors or delays. |
| R7.13 | The City will disclose any DWC or other Texas administrative audit activities that have occurred or are pending. The TPA will be required to implement any corrective actions identified in the audit. The TPA will bear financial responsibility for any failure to address past audit findings, where such failure leads to fines being levied or added to current fines in the same category. |
1. As of the date of this document there are no outstanding audits or exposures.
2.As of the date of this document there are no notices of Texas administrative TPA audits to be performed.
3.The City of Waco’s performance-based oversight results may be made available after the official results are released by the DWC.
| R7.14 | The successful TPA will submit a Business Continuity Plan detailing how they will recover and maintain critical operations in the event of disruptions, such as system failures, natural disasters, human actions, or other unforeseen events. |
| R7.15 | Provide a detailed description of your policies and procedures for preventing and detecting internal fraud. Additionally, outline your policies and procedures for preventing and detecting external fraud from providers and injured workers. |
| R8.0 | FINANCIAL OVERSIGHT |
| R8.1 | At no additional cost to the City, the TPA shall cooperate with the City in identifying duplicate and overpayments made by the TPA. If the duplicate or overpayment results from the TPA’s failure to adhere to generally accepted standards, the TPA shall report this to the City and arrange to reconcile any overpayments against anticipated fees. |
| R8.2 | The TPA shall set reserves within a reasonable timeframe after receipt, considering factors such as the injury, available medical information, anticipated income benefit exposure, and other allocated loss adjustment expenses related to the claims handling services. Provide information on how allocated expenses are monitored and adjusted. |
| R8.3 | At no additional cost to the City, the TPA shall provide periodic information and cooperate with the City’s actuarial service and/or loss forecasting evaluations. |
| R8.4 | At no additional cost to the City, the TPA shall identify, document, and pursue contribution and subrogation as needed. |
| R9.0 | INFORMATION MANAGEMENT SYSTEM |
| System Overview and Capabilities | |
| R9.1 | The TPA shall provide the City with access to an internet-based claims system through an online portal for at least six (6) users at no additional cost, including the necessary training and support. |
| R9.2 | The system shall allow the City to initiate claims, check claim statuses, view pending actions, and generate both pre-scheduled and ad hoc reports. |
| R9.3 | The system shall support notifications via SMS and/or email to the City and injured employees when certain actions are taken in the portal. |
| R9.4 | The system shall enable the City to create custom reports, access a standard package of system reports, and allow for remote access and ad hoc reporting capabilities. Reports should be viewable prior to printing. |
| R9.5 | The TPA shall ensure all required document filings and electronic submissions to meet City, State, and Federal requirements, mandates, and laws at no additional cost. This includes handling Electronic Data Interface (EDI) requirements, manual filings, and intermediary filings related to the City’s self-insured status, DWC Austin Representative, and 1099 forms. |
| R9.6 | The TPA will indemnify and protect the City from errors or omissions committed by the TPA. The TPA agrees to hold the City harmless and to indemnify the City for any losses arising from claims alleging errors or omissions in the services provided by the TPA. |
| R9.7 | The system shall allow real-time access for reporting claims, completing required forms, reviewing adjuster and supervisor claim notes, generating loss runs, and creating custom loss management/claim reports. |
| R9.8 | Provide IS technical support for questions, problems or development of customized reporting. |
| R9.9 | The system shall support the importation of prior loss data into a single database. |
| R9.10 | Full compliance with MMSEA Section 111 reporting requirements, including disclosure of any associated fees and the names of any third parties used for this reporting service. |
| R9.11 | The system shall provide scheduled loss reports to the City electronically on a monthly, quarterly, or as requested basis. Sample reports must be included in the proposal. |
| R9.12 | Training for City staff on the use of the IS, with any associated fees to be included in the Pricing/Fee Schedule. |
| R9.13 | The City will retain all rights, title, interest, and ownership to all loss statistics and claim files created through the services provided by the TPA. Upon termination of services, the TPA will provide the City with computer media containing all claim data, in a format compatible with commonly recognized claims administration databases. |
| R9.14 | The TPA shall notify the City of any security incident within 24 hours of becoming aware, and contact the City’s Information Technology Security team at 254-750-5700 and cybersecurity@wacotx.gov. |
| System Reporting and Data Tracking | |
| R9.15 | The system must be capable of generating claim severity reports by medical procedure, and tracking dormant claims based on medical payments or adjuster and supervisory notes. |
| R9.16 | The system shall track the length of disability, including intermittent lost time, with internal prompts or human interaction, as required. |
| R9.17 | The system must offer loss control fields and support tracking and reporting payments by payment type and subdivisions of payment types. |
| R9.18 | The system must provide pre-check and check registers to the City and support data mining capabilities for comprehensive reporting and analysis. |
| R9.19 | The system must track and report healthcare provider treatment patterns and treatment outcomes across claims, with access for the City to run these reports. |
| R9.20 | The system shall capture and input Benefit Review Conference and Contested Case Hearing results, and provide processes for accessing this data. |
| R9.21 | The system shall track and report denials and disputes, and provide methods for inputting and accessing this information. |
| R9.22 | The system must store payment data in a manner that allows for loss development analysis and communicate multiple claims for an injured worker to the adjuster. |
| R9.23 | The system must implement integrity and security controls for checks and differentiate allocated loss adjustment expenses. |
| R9.24 | The system shall track DWC-69’s and DWC-6’s on a per-claim basis, with clear procedures for input and access. |
| R9.25 | The system must provide an overview of the standard package of reports available and track claims and payments by provider and treatment, including trends and history. |
| R9.26 | The system must support data exports to various file formats including Word, Excel, PDF, etc. |
| System Infrastructure and Security | |
| R9.27 | The system shall support the ability to generate reports on timeliness of contacts, promptness of payments, currency of diaries, assignments, closing ratios, and pending inventory. |
| R9.28 | The system shall be provided as an online subscription. It must be TX-RAMP or FedRamp certified. |
| R9.29 | The system must clearly define where data is stored (cloud or otherwise), and detail the types of data stored (e.g., HIPAA, CJIS, PII). |
| R9.30 | The TPA must provide a SOC report if the system handles HIPAA, CJIS, or PII data and specify who has access to encryption keys or unencrypted data. |
| R9.31 | Specify data ownership if the City discontinues payments for the service and disclose the locations of the data centers used for the hosted system. |
| R9.32 | The system must support Single Sign-On (SSO) integration (e.g., Azure or OneLogin), with clear information on whether there is a cost for SSO setup. |
| R9.33 | The system must support Multi-Factor Authentication (MFA). Specify the authentication methods used. |
| R10.0 | REPORTS |
| R10.1 | Administrative Office of the Division of Workers’ Compensation and reporting results of monthly required audits. |
| R10.2 | The TPA shall, at a minimum, be required to produce the following reports: |
Weekly Void Check Register report listing the checks voided or stop paid in the system that week.
The report shall be provided weekly and contain the claimants name, claim number, check dates and check number that was voided.
| R10.3 | Weekly and Monthly Check Register consisting of indemnity payments disbursed weekly, stub notes that include the reason for the payment (i.e., waiting period, no duty status, partial duty status, limited duty status, for claimant’s attorney, or wage garnishment) Voided checks or stop payments shall also be noted on the register. |
| R10.4 | End of Month Pay/Type Category Report indicating the types of payments made during the month by claimant showing work performed and the allocated expenses made to the claim files for designated timeframes; supporting documentation may be required. |
| R10.5 | Executive Summary consisting of Account Management data and statistics. |
| R10.6 | End of Month Reports that support the data included in the contract. |
| R10.7 | End of Month Overpayment Report listing the injured employee name, claim number, type of indemnity payment error, reason for error, error date, and amount due, check number, recovery activity and reimbursement date. |
| R10.8 | Monthly DWC-1, DWC-3, and DWC-6 Reports listing all new claims in the previous month, including the date the DWC-1 and DWC-3 was received, the date of knowledge by the City and calculations of the timely criteria for receipt. |
| R10.9 | Quarterly Reserve Change Report listing all reserve changes to claim files in the past quarter. |
| R10.10 | Monthly Financial Reports required by the City’s Finance department . |
| R10.11 | Monthly Certified Case Manager Report identifying the medical status/return to work status and other data as specified by Risk Management for all active cases reviewed by the Case Manager. |
| R10.12 | Monthly Field Case Management Active Cases Report of active cases for telephonic, field management, or vocational rehabilitation, the date assigned, and confirmation that criteria and objectives are being met. A quarterly closure report shall be generated with date of closure, reason for closure, and total days for the assignment. Initial and Closure reports shall be submitted within ten (10) business days of assignment; interim case updates shall be provided by e-mail to the adjuster and City Risk Management within two (2) business days of attending a doctor’s appointment with an employee. |
| R10.13 | Pre-Authorization and Utilization Review (RUR) Reporting |
Monthly Report: The Contractor shall provide a monthly report detailing the utilization review activity received and processed for each claimant within that month.
Merged Reports: The Contractor shall also compile and deliver merged reports summarizing the utilization review activity on a quarterly, semi-annual, and annual basis. These reports should consolidate the monthly data to provide a comprehensive overview of trends and patterns in utilization review activity.
| R10.14 | Quarterly Subrogation Report identifying the employee, claim number, amount subrogated, and amount tracked as processed and date a PLN was issued. | |
| R10.15 | Performance Log identifying contractor performance based on key industry performance indicators. | |
| R10.16 | Quarterly Active Claims Count to include prior years active claim open at the beginning of the fiscal year, new claim reported for the quarter, and prior year’s claims closed at the beginning of the fiscal year but re-opened during the quarter. | |
| R10.17 | Investigation and Surveillance Report as required listing the claims referred for private investigation, time frame for the investigation, hours billed and the quality of the report and timeliness of the investigation. | |
| R10.18 | Monthly & Annual Fiscal Year Reports—Fund Agency & Loss Run Reports including all loss development data required by the actuary to produce an actuary report for the City. | |
| R10.19 | Financial Analysis Report showing total amounts of payments made under each pay category by Fiscal Year and by claim year and # of claims paid on in that year. A separate pivot table is required that carves out medical expenses and lists medical costs of claims by claim year and # of payments that were made. | |
| R10.20 | Pharmacy Benefit Manager (PBM) Report should include both paper bills and e-bills, detailing the number of e-bills received, the number rejected, reasons for rejection, and the total number of paper and e-bills processed. These reports must be submitted at intervals agreed upon with the City. | |
| R10.21 | Monthly Medical Bill Reports showing medical bill pending payment activity, duplicate/irregular payments, detail and summary reports by provider type, ANSI code, claimant and other specific reporting elements to be agreed upon. | |
| R10.22 | Bill Review Service Reports providing system reports monthly verifying transmissions of all medical bills are timely and accurately submitted to the appropriate Texas | |
| R10.23 | Excess Reports to the excess insurer will include updates on the status of all files that meet the criteria set by the policy provider(s). This reporting will be contingent upon the City providing all necessary coverage details and reporting requirements. | |
| R11.0 | TRANSITION/IMPLEMENTATION | |
| R11.1 | By responding to this RFP, the TPA agrees to manage all claims and related services starting from 10/1/2025. Additionally, the TPA agrees to include the handling of all claims dated prior to 10/1/2025 within its fee structure. | |
| R11.2 | If awarded this contract, the TPA will assume responsibility for managing all open and closed claims under the City's control. | |
| R11.3 | The TPA is required to create a transition plan to facilitate the seamless coordination and implementation of this program. This plan must be developed and approved by the City before it is executed. The plan should include, at a minimum, the following elements: a detailed timeline covering all phases of the transition, a list of project team members involved in the process along with their qualifications, a procedure for transferring plan data, and a communications strategy outlining how the new TPA, outgoing TPA, City project team, and employees will collaborate and exchange information throughout the transition. | |
| R11.4 | The TPA will retain all existing claim numbers, including those for both open and closed claims. For any new claims initiated after the commencement of this contract, claim numbers will follow the TPA’s established numbering format. | |
| R11.5 | The TPA shall promptly notify all affected participants and product providers about the change in TPAs. | |
| R12.0 | MEETINGS | |
| R12.1 | TPA shall be required to have relevent key staff participate in the following meetings and others as required: | Monthly Operations Meeting with Risk Management to review account issues, including bill review, pre-authorization and progress reports of issues tracked in an issue and resolution log, a summary of business transacted in the previous month, identification of trends, claim issues and concerns, staffing, opportunities for improvements, resolution of issues, performance of the DWC Carrier Scorecard, timely payment of income, death and medical benefits, timely reauthorization, reconsideration requests, and other topics appropriate for an operations meeting. |
| R12.2 | Claim Review Meetings with City departments and Risk Management will be held to discuss open claims and other relevant claim management issues. These meetings, coordinated by the TPA, may be scheduled as recurring sessions on a quarterly basis. | |
| R12.3 | Account Management Meeting as needed, to review status of issues and project chart, outstanding concerns. TPA's Account Manager is required to attend as well as other relevant personnel based on the agenda. | |
| R12.4 | Quarterly Claims Meetings with the City’s HR, Safety, Legal, Excess Carrier and Risk Consultant to discuss the status and management of all open claims, as well as any other matters deemed necessary by the City. | |
| R12.5 | Annual Stewardship Meeting will be conducted. |
Questionnaire
| QUESTIONNAIRE | ||
| Question # | Question | Vendor Response |
Please respond to ALL items listed below.
| Q1.0 | GENERAL QUESTIONS |
| Q1.1 | Are the fees proposed in Fee Schedule for life of this claim or for life of Contract pricing? Explain. |
| Q1.2 | Do you include the cost for Electronic Data Interchange (EDI) reports to the Texas Department of Insurance (TDI) in your claims fee? |
If not, what is your charge(s) and how is it charged? Per claim? Per filing?
If per filing, based on similar accounts, how many average filings do you do per claim? Expected cost per claim?
| Q1.3 | Is Insurance Services Office (ISO) Claim Search included in the claim fee? Indicate if there are separate fees for filing the request and receiving/forwarding the report. |
| Q1.4 | Do you charge separately for subrogation? How are the charges based? |
| Q1.5 | Is there a set-up fee for the Benefit Review Conference (BRC)? |
| Q1.6 | Are there separate fees for managing litigated files? |
| Q1.7 | Answer the following question regarding Pharmacy Benefit Management (PBM) |
| Q1.7.1 | a) Does the TPA charge the City a percentage of savings? If yes, how much? |
| Q1.7.2 | b) Does the TPA charge a fee for each bill processed? If yes, how much? |
| Q1.8 | Answer the following questions regarding Bill Review Fees: |
| Q1.8.1 | Does your stated bill review fee include a comparison to the Official Disability Guidelines (ODG) for compliance? |
| Q1.8.2 | Are there other charges beyond the base bill review fee for nurse reviews, hospital bills, or complicated bills? |
| Q1.9 | Do you charge additional fees for the processing of Complex Claims? How do you define a Complex Claim? |
| Q1.10 | On what basis will a “Medical Only” or “Record Only” change category for which you will charge an extra fee? |
What will the notification be to the City?
| 2.0 | PROPOSER'S QUALIFICATIONS QUESTIONNAIRE | |
| Q2.1 | Will your proposal comply with the coverage, services, and provisions outlined in the Scope of Work and Requirements Section of this RFP? (Yes/No) | |
| Q2.1.1 | If NO, give full details: | |
| Q2.2 | Proposer's Official/Legal Name | |
| Q2.3 | Legal Address | |
| Q2.4 | Local Address | |
| Q2.5 | Provide the following for the individual designated as the proposer's point of contact for this RFP. | |
| Q2.5.1 | Name | |
| Q2.5.2 | Title | |
| Q2.5.3 | Phone Number | |
| Q2.5.4 | Address | |
| Q2.6 | Is the proposer owned or controlled by a parent company? (Yes/No) | |
| Q2.7 | If the proposer is owned or controlled by a parent company, provide the following: | |
| Q2.7.1 | Parent Company's Official/Legal Name | |
| Q2.7.2 | Parent Company's Legal Address | |
| Q2.8 | The proposer represents that it operates as this type of business organization: | Please select |
| Q2.8.1 | If Joint venture, provide a list of joint ventures OR If a Corporation, you were incorporated under the laws of: | |
| Q2.8.2 | List the names, business addresses, titles, and telephone numbers of the following people; if a corporation, of the president, executive officers, and any other officers directly responsible for this proposal; if a partnership, of the partners directly responsible for this proposal; or, if another form of business entity, of the principals directly responsible for this proposal. | |
| Q2.9 | How long has the Proposer been in business? | |
| Q2.10 | Provide the Proposer's financial references, for example, financial statements and/or bank references. | |
| Q2.11 | Identify any contractual obligations that could impact the Proposer’s ability to perform the work/services required by this RFP. If there are no such obligations, state "None". | |
| Q2.12 | How many claims processing locations does your firm have in Texas? | |
| Q2.13 | Please provide the following information for the designated claims processing location that will manage the City's account: | |
| Q2.13.1 | Number of accounts served | |
| Q2.13.2 | Average number of claims opened per month | |
| Q2.13.3 | Average number of claims handled by an adjuster each month | |
| Q2.13.4 | Average number of claims processed per month | |
| Q2.13.5 | Number of public entities managed by this office | |
| Q2.13.6 | Three-year client retention rate | |
| Q2.13.7 | Five-year client retention rate | |
| Q2.14 | Will any of the claims team work remotely? If so, please provide the number of days per week that the staff will work remotely and the city and state where staff is located. Also identify the staff positions that will work remotely | |
| Q2.15 | Specify your standards for claims assignment and workload for each adjuster. | |
| Q2.16 | Provide the following statistics regarding your operation as of December 31, 2021: | |
| Q2.16.1 | Claims on hand | |
| Q2.16.2 | Claims requiring medical-only payments | |
| Q2.16.3 | Total claims requiring compensation payments | |
| Q2.16.4 | Open/active claims | |
| Q2.16.5 | Number of claims opened each month | |
| Q2.16.6 | Number of claims closed each month | |
| Q2.16.7 | Number of TDI hearings each month. | |
| Q2.17 | Provide a description of the firm's qualifications to perform the proposed work, limited to no more than 2 pages. | |
| Q2.18 | Proposer's Certification |
A Proposer will not be considered for contract award under this RFP unless they have submitted the Certification regarding Debarment, which will be incorporated into the resulting contract.
| Q2.18.1 | Name |
| Q2.18.2 | Title |
| Q2.18.3 | Signature |
| Q2.18.4 | Date |
| Q2.19 | Has a Fidelity Bond or Errors and Omissions insurance ever been cancelled or non-renewed? If so, please provide an explanation. |
| Q2.20 | To your knowledge, has any principal or employee ever been convicted of mishandling or misappropriating funds? If yes, please provide details. Additionally, confirm that the Respondent will notify the City in writing if any changes to this response arise. |
| Q2.21 | Has any principal or employee been convicted of a felony related to securities or been subject to any regulatory disciplinary action? |
| Q2.22 | Has your firm, its affiliates or parent company ever faced regulatory disciplinary action? |
| Q2.23 | Have you or any anticipated subcontractors been involved in litigation with a client in the past five (5) years regarding the performance of Workers' Compensation TPA programs? If yes, please provide a full explanation. |
| Q2.24 | Are there any planned mergers, ownership transfers, sales, reorganizations, or departures of key personnel within the next two (2) years that could impact your ability to perform? |
| Q2.25 | Has the Department of Insurance Division of Workers' Compensation Compliance and Practices Division audited your company’s claims administration in the past five (5) years? If so, please describe the findings, including any violations and penalties paid. Please provide redacted DWC correspondence to support your response. |
| Q2.26 | Has your company had any non-audit violation referrals to the DWC in the past five (5) years? If yes, specify the number of violations and the penalty amount paid for each violation. Please provide redacted DWC correspondence to support your response. |
| Q2.27 | Has your company received any complaints filed with the Texas Department of Insurance or any other state insurance oversight body regarding claims you have handled? If yes, provide the total number of complaints and the outcomes. |
| Q2.28 | Describe your customer satisfaction program and the process for addressing and resolving concerns. |
| Q2.29 | Explain your staffing backup plan in cases where assigned staff is unavailable. |
| Q2.30 | Provide information on any ongoing training required for employees servicing this account. Indicate if City personnel may attend this training and any associated costs. |
| Q3.0 | CLAIMS HANDLING |
| Q3.1 | What policies and/or procedures do you have in place to ensure claims are handled in accordance with reasonable customer service standards, fair claims practices, and internal guidelines? |
| Q3.2 | How and how frequently are these policies and procedures communicated to staff? |
| Q3.3 | To what extent do you intend to utilize staff field investigations, included but not be limited to check delivery, statement gathering, and accident-related claims investigation? |
| Q3.4 | Please describe how you will provide the following services: |
| Q3.4.1 | BRC Representation and Attendance |
| Q3.4.2 | CCH Representation and Attendance |
| Q3.4.3 | Medical Bill Auditing and Review |
| Q3.4.4 | Coordination and Facilitation of Required Medical Examinations and Designated Doctor Examinations |
| Q3.4.5 | Review of Notice of Possible Administrative Violations |
| Q3.4.6 | Appeals Panel Filing of Briefs and Answers |
| Q3.4.7 | Coordination and Facilitation of Peer Reviews |
| Q3.4.8 | Impairment Rating Reviews |
| Q3.4.9 | DWC Compliance Audits |
| Q3.4.10 | DWC Austin Representation |
| Q3.4.11 | Private investigations |
| Q3.4.12 | Loss Control Services |
| Q3.4.13 | Nurse Case Management Services |
| Q3.4.14 | Medical Provider Network |
| Q3.4.15 | Legal Services |
| Q3.5 | Please describe the method and the positions involved that will provide support to the claims handling staff to furnish regular access to professional medical opinion as it pertains to disability management and medical relatedness. |
| Q3.6 | Describe the workflow of claims presented by City for handling. |
| Q3.7 | If the caseload for an adjuster is greater than the total required by City, as defined in the Scope of Work and Requirements Section, would your firm reduce the number to no more than the total active files per adjuster as defined? (Yes/No) |
| Q3.7.1 | If yes, how would this be accomplished? |
| Q3.8 | Describe your screening and follow-up system for the following: |
| Q3.8.1 | Review of usual, customary and reasonable medical charges |
| Q3.8.2 | Duplicate billings and duplicate payments |
| Q3.8.3 | Duplicate claims filed against employer's major medical plan or other insurance carriers. |
| Q3.8.4 | Selection of physician for independent medical exam |
| Q3.8.5 | Peer review or other means of reporting suspected medical malpractice. |
| Q3.8.6 | Overpayment of benefits |
| Q3.9 | Describe your claim audit program for the claim’s office. Include the frequency of the audits, who performs them, what percentage of claims is audited, and corrective action on areas in need of improvement. |
| Q3.10 | How frequently does your diary system allow claims supervisory personnel to review open claims? |
| Q3.11 | Provide details regarding TPA’s affiliations with a Workers’ Compensation Health Care Networks (HCN) OR 504 Provider Network to include: |
| Q3.11.1 | Current availability in Waco and/or the surrounding area |
| Q3.11.2 | The process used to select medical providers and rank them in the order of preference. |
| Q3.11.3 | How is the medical plan management addressed as to the removal of medical providers? |
| Q3.11.4 | Describe the method proposed to provide employee access to the provider lists. |
| Q3.11.5 | Describe the approach to treatment guidelines. |
| Q3.12 | What is the percentage of time that supervisory personnel will devote to the City's account? |
| Q4.0 | INFORMATION MANGEMENT SYSTEM |
| Q4.1 | How long have you used your proposed information management system (IS) in handling and managing workers’ compensation claims in Texas? |
| Q4.2 | Do you own the claims management system to be used on the account? If not, who is the owner and how much time remains on the lease? |
| Q4.3 | Please describe the system to include the operating platform, remote access capabilities, data field or table customization, loss control components, adjuster and supervisor diary, etc. |
| Q4.4 | Please describe the system's capability to provide a client secure diary capability. |
| Q4.5 | Does your system offer any capability to support client-based and maintained Return to Work program tracking and reporting? |
| Q4.6 | Who provides your programming and technical support for the system? Where are they located? What is their availability? |
| Q4.7 | Is a client version available and how does it differ from the claims management system used by your company? |
| Q4.8 | Who will provide training to City staff? At what location will this be provided? Please describe the training component, timeline, and any cost associated thereto. |
| Q4.9 | How many users can have access to the IS and at what cost? |
| Q4.10 | Please describe the process to correct errors on the system and identify who has the authority and capability. |
| Q4.11 | Please describe and provide an example of your system’s capability of providing claim severity reports by medical procedure. |
| Q4.12 | Does the system identify claims that have been dormant for variable periods regarding medical payments and/or adjuster and supervisory notes? If so, how is this feature reported? |
| Q4.13 | Please describe how the system tracks length of disability, to include intermittent lost time and whether there are systemic internal prompts or whether it is based on human interaction. |
| Q4.14 | Please describe in detail the loss control fields available in the system to include insight into how the categories/classifications are discerned, and by what position in your organization has the authority to do so. |
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