EXHIBIT A – SCOPE OF SERVICES

THIRD PARTY ADMINISTRATOR (TPA) CONFLICT CLAIMS

1.0 BACKGROUND

Metro’s workforce of nearly 12,000 employees reports approximately 1,650 workers’ compensation claims annually. Metro self-insures and self-administers its Workers’

Compensation (WC) liability, which is administered by Metro’s Workers’ Compensation Division

(WCD) of the Risk, Safety and Asset Management (RSAM) Department. The WCD employs approximately 16 claims professionals and various clerical staff to administer benefits on approximately 2450 open WC files. Metro’s computerized workers’ compensation claims management system is the Riskonnect iVOS system. The WCD is dedicated to providing a high level of customer service, the best medical care, and all appropriate indemnity benefits to injured employees through quality and cost-efficient claims management.

2.0 PROJECT

The Los Angeles County Metropolitan Transportation Authority (Metro) is seeking a qualified third-party administrator (TPA) for claims administration of Metro’s Workers’ Compensation

Program (Conflict Claims). The contract is for comprehensive claims administration services to include managed care, computer hardware, and office supplies appropriate for the management of the Program. Metro requires a TPA partner with an innovative and effective claims management process that is streamlined and user-friendly, has a strong customer service focus, solid reporting capabilities, proactive and consistent management of employee occupational absences, competitive rates and fees, and the ability and willingness to comply with Metro’s performance standards. The Contractor’s staff should have proper licensing to perform claims administration services. The Contractor should have a strong regional presence in California, and depth of staff necessary to perform the claims administration services requested now and into the future.

3.0 INTENT

The Third‑Party Administrator (TPA) is required to deliver defined administrative, operational, and compliance‑related services on behalf of Metro for conflict claims. The TPA will provide these services in accordance with applicable laws, regulatory requirements, industry standards, and agreed‑upon performance metrics. The selected TPA will be required to provide the following services:

• Program Administration through day-to-day management of the benefit or claims program, including processing, tracking, and documentation for conflict claims.

• Claims Processing through intake, adjudication, validation, payment coordination, and appeals handling.

• Recordkeeping and Data Management through secure storage, updates, reconciliation, and reporting of participant and plan data.

• Regulatory Compliance by ensuring adherence to the Employee Retirement Income

Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), Internal Revenue Service (IRS), Department of Labor (DOL), state regulations, and required filings.

• Customer Service and Participant Support through call center operations, email support, issue resolution, and participant education.

• Financial Administration through payment processing and financial reconciliation.

• Data Security and Privacy through Safeguards for Protected Health Information (PHI)/

Personally Identifiable Information (PII), breach protocols, encryption, and access controls.

• Vendor Coordination by working with designated service providers.

• Ongoing Governance through Meetings, issue escalation, and continuous improvement.

4.0 CONTRACTOR REQUIREMENTS

1. General Qualification Requirements

The Contractor must:

• Demonstrate the specialized expertise, operational capacity, and regulatory compliance necessary to administer a public‑sector workers’ compensation program of conflict claims.

• Maintain all qualifications throughout the contract term and comply with all applicable

California workers’ compensation statutes, public‑entity procurement rules, and reporting requirements.

• Meet both contractual obligations and regulatory or statutory requirements to ensure compliance, quality service, and accountability during the performance period.

2. Compliance with Federal and Statutory Requirements

The Contractor must comply with:

• U.S. Constitution, applicable statutes, and regulations (e.g., anti-discrimination, environmental, public welfare protections).

• Performance measurement requirements: clear goals, objectives, timelines, reporting expectations, and data collection responsibilities.

• Equipment use and disposal rules if applicable: equipment must be used for authorized purposes, not encumbered without approval, and disposed of in compliance with laws and agency guidance.

3. Contractual and Service Standards

The Contractor must adhere to minimum performance standards:

• Caseload limits: Indemnity adjusters capped at 110–120 open claims (medical-only claims counted 2:1).

• Timely file setup: prepare claim files within 1 business day of receiving employer reports, with initial reserves documented within 5 business days.

• Reporting timelines: meet deadlines for physician contact (24-hour contact) and compensability determination within 90 days of claim reported.

• Conflict of interest: avoid situations that could compromise impartiality.

4. Operational and Administrative Duties

The Contractor must adhere to:

• Data accuracy and documentation: maintain complete, accessible claim files with all medical and factual information.

• Communication: provide timely updates to Metro and coordinate with agents and other stakeholders.

• Quality control: ensure claims are adjudicated consistently and in line with policy and legal standards.

5. Oversight and Accountability

• Performance measurement: Track and report on key performance indicators (KPIs) such as case resolution time, accuracy rates, and compliance with timelines.

• Audits and inspections: Be prepared for audits by the Federal agency, state regulators, or program administrators.

• Corrective action: Address deficiencies promptly and document improvements

6. Personnel Qualifications

The Contractor must employ:

• Licensed claims adjusters with workers’ compensation experience of at least 3 years.

• Supervisors with advanced credentials (e.g., Workers’ Compensation Claims

Administration (WCCA) and/or Workers’ Compensation Claims Professional (WCCP).

7. Operational Capacity

The Contractor must maintain:

• Sufficient staffing levels (one Claims Adjuster, one Claims Supervisor and one Claims

Assistant) to meet statutory deadlines and service‑level requirements.

• Quality assurance processes including file audits, supervisory reviews, and corrective‑action protocols.

8. Data Security & Privacy Controls

The Contractor must maintain:

• Encryption of data in transit and at rest.

• Public‑sector compliance with cybersecurity standards (e.g., NIST, SOC 2 preferred).

• Breach‑notification procedures aligned with state and public‑entity requirements.

• Compliance with public‑records laws while protecting PHI/PII.

9. Compliance, Security & Governance

The Contractor must provide:

• SOC2-aligned controls

• Role-based access

• Data privacy compliance

10. Customer Service & Stakeholder Support

The Contractor must maintain:

• Dedicated account management for the public entity.

• Clear communication protocols with Metro injured employees, supervisors, HR, and risk management.

• Multichannel support (phone, email, portal) with defined response times.

• Experience supporting unionized workforces and public‑safety departments.

11. Ongoing Qualification Maintenance

The Contractor must:

• Maintain required Certificate to Administer Claims issued by the California Office of Self-

Insured Plans and required insurance.

• Notify the public entity of any material changes affecting qualifications.

• Participate in periodic audits, performance reviews, and governance meetings.

5.0 CONTRACTOR RESPONSIBILITIES

The contractor shall provide:

A. Claims Intake & Initial Processing by receiving, documenting, and processing all First Reports of Injury within required statutory timeframes. The Contractor shall establish claim files promptly with complete documentation and notify the public entity of all new claims and significant incidents.

B. Compensability determinations in accordance with California workers’ compensation laws and public‑entity policies.

C. Claims Investigation and Management by conducting timely and thorough investigations, including interviews, statements, and evidence gathering. The Contractor should also coordinate with supervisors, HR, safety personnel, and union representatives as needed.

D. Maintenance of accurate, up‑to‑date claim notes and documentation and manage medical‑only, lost‑time, litigated, and catastrophic claims through closure.

E. Medical Management by coordinating medical treatment, ensuring compliance with state fee schedules and utilization review requirements. The Contractor shall also monitor treatment plans, medical progress, and return‑to‑work readiness, in addition to facilitating qualified medical evaluations or Agreed Medical Examiner (QMEs & AMEs) when appropriate, while ensuring timely and accurate payment of medical bills.

F. Indemnity and Benefit Administration by calculating and issuing indemnity payments in accordance with statutory requirements, maintaining accurate wage statements and benefit calculations with timely processing of temporary disability, permanent disability, and supplemental benefits. The Contractor shall also manage overpayments, offsets, and benefit adjustments.

G. Litigation and Legal Coordination by coordinating with approved defense counsel for litigated claims, providing complete claim files, documentation, and recommendations to counsel and participating in settlement evaluations, hearings, and mediations.

H. Return‑to‑Work and Modified Duty Coordination by collaborating with Metro to identify modified duty or transitional work opportunities, communicating regularly with injured employees, supervisors, and HR. The Contractor shall also track employee progress and readiness for full duty to support early and safe return‑to‑work strategies.

I. Subrogation and Recovery by identifying potential third‑party recovery opportunities, pursuing subrogation claims, liens, and reimbursements and maintaining documentation of recovery efforts and outcomes.

J. Reporting and Analytics services by providing monthly, quarterly, and annual reports, including loss runs and claim status summaries.

K. Support public‑entity reporting requirements, including open‑records requests.

L. Compliance and Regulatory Requirements by ensuring all claims activities comply with the California workers’ compensation statutes.

M. Public‑entity reporting requirements through HIPAA and data‑privacy laws. The

Contractor shall file all required Electronic Data Interchange (EDI) reports, state forms, and notices on time and maintain adjuster licensing and continuing education.

N. Customer Service and Stakeholder Communication through clear communication with injured employees, supervisors, and human resources by responding to inquiries within agreed‑upon service levels.

O. Data Security and Confidentiality through protection of all PHI/PII in accordance with public‑sector cybersecurity standards. The Contractor shall maintain secure systems with encryption, access controls, and audit trails and follow breach‑notification protocols consistent with state and public‑entity requirements.

6.0 DELIVERABLES

Contractors shall submit the deliverables to the Chief Risk, Corporate Safety, and Asset Management Officer in accordance with the Statement of Work and the schedule indicated below.

TASK

DELIVERABLE

DATE REQUIRED

REFERENCE

No.1 General Qualification Requirements Through the duration of the Contract

SOW: Item 4.1

No.2 Compliance with Federal and Statutory Requirements

Through the duration of the Contract

SOW: Item 4.2

No.3 Contractual and Service Standards

Through the duration of the Contract

SOW: Item 4.3

No.4 Operational and Administrative Duties

Through the duration of the Contract

SOW: Item 4.4

No.5 Oversight and Accountability Through the duration of the Contract

SOW: Item 4.5

No.6 Personnel Qualifications Through the duration of the Contract

SOW: Item 4.6

No.7 Operational Capacity Through the duration of the Contract

SOW: Item 4.7

No.8 Data Security & Privacy Controls and Compliance, Security &

Governance

As needed SOW: Item 4.8-4.9

No.9 Customer Service & Stakeholder Support and Ongoing Qualification

Maintenance

Within 90 days of RFP award

SOW: Item 4.10-4.11