Request For Proposal – Professional Services #RFP PS-27-0005 Title: Worker’s Compensation Third Party Administration (TPA) Claims Management Services

EXHIBIT A – SCOPE OF WORK

1. BACKGROUND

The City of Phoenix is a public agency with approximately 14,000 benefit eligible employees. Contractor agrees to do all things necessary to timely and properly provide all claims management and payment services necessary to provide benefits under the Workers' Compensation Program for City employees and in accordance with the Contract, including but not limited to those duties set out in this Scope of Work. All services performed hereunder shall be subject to performance guarantees.

2. FIRM AND STAFF REQUIREMENTS:

Failure to maintain and adequately staff an on-site facility shall be a material breach of the Contract and will be subject to penalty as outlined in the performance guarantees.

FIRM:

A. Contractor shall be licensed to conduct business and licensed to adjust workers' compensation claims in the State of Arizona and approved as a Third Party Administrator (TPA) by the Industrial Commission of Arizona by July 1, 2025 and maintain license current throughout the term of this agreement.

B. Contractor must have the capability and requisite experience to manage the Program on behalf of the City in accordance with the provisions and requirements of the Scope of Work.

STAFF:

C. Contractor must provide a sufficient number of qualified staff to provide services.

D. The employees assigned to work under the Contract shall have the appropriate license, experience and training at the Senior Adjuster level. All adjusters must have a workers' compensation adjusting license prior to adjusting any City claims. Adjusters assigned to occupational cancer claims must have prior experience processing occupational cancer claims.

E. Designated Account Manager/Operations Manager – Contractor must designate an Account Manager/Operations Manager who is responsible for ensuring the Contract requirements and service deliverables are consistently met by the Contractor.

• The designee shall be the single day-to-day contact for the City with the primary responsibilities of responding to all performance issues, coordinating the efforts of the Contractor’s staff to resolve issues, and overseeing all aspects of project management including, but not limited to, the initial implementation and ongoing program facilitation.

• The designee shall have a minimum of 5 years of experience with an organization similar to the City and direct experience with accounts of similar size and complexity as the City. The City retains the right to approve the assigned Account Manager/Operations Manager and to participate in any interview as needed.

• The designee must have appropriate authority to make reasonable decisions in response to the City’s Program needs.

F. Account Management Team – Contractor must provide an Account

Management Team that is experienced in providing services for similar entities, is accessible to the City, and has sufficient capacity and authority to respond to the City’s issues in a timely manner. Contractor agrees that all services performed pursuant to the Contract shall be rendered through its claims office on-site at City of Phoenix offices. Contractor shall maintain services for the duration of the Contract staffed by a dedicated unit consisting of, at a minimum:

a. One dedicated Account/Operating Manager

b. One (1) Claims Manager

c. Two - Three (2-3) on-site Supervisors

d. One (1) dedicated Senior Subrogation and Restitution Recovery

Adjuster

i. with one dedicated assistant to manage claims and recovery.

e. Senior/Indemnity Adjusters and Assistants:

i. One (1) assistant assigned per two (2) claims adjusters to assist and perform services required in the Contract.

ii. A sufficient number of senior/indemnity adjusters to maintain a caseload of 150 active claims

iii. A sufficient number of adjusters to maintain a caseload of 500 supportive care claims

iv. A sufficient number of adjusters for all claims as deemed necessary to perform the services required in the contract.

G. Contractor requirements

a. Contractor shall maintain a dedicated staff member(s) to review files and provide requested information for disability retirements using the City’s request process within 10 business days of the initial request.

b. City will provide an office/cubical space for the on-site staff and a fax machine.

c. Contractor may be required to provide other equipment, such as computers, work supplies, and other items as deemed necessary for the on-site staff to perform their duties.

H. On-site staffing requirements

a. A Supervisor shall be on site with the City daily.

b. Contractor shall have staff on-site Monday - Friday. See Teleworking for staffing requirements by job classification.

c. Contractor will provide computers, work supplies, and other items deemed necessary for the on-site staff to perform their duties.

d. All staff assigned to the City’s account must reside in the state of

Arizona.

I. Teleworking - Teleworking is allowed, provided, the on-site staffing requirements are met.

a. All Supervisors, adjusters and recovery specialists are required to work on site with the City one day per week (Tuesday, Wednesday or Thursday);

b. Assistants are required to work on site with the City three to four days per week.

c. Should claim issues arise, discussions regarding teleworking adjustments may be necessary on a case-by-case basis.

J. Personnel substitution

i. The resulting Agreement is predicated, in part and among other considerations, on the utilization of the specific individual(s) and/or personnel qualification(s) identified and/or described in Contractor’s Offer.

Therefore, no substitution of such designated personnel shall be made without prior written approval of the City.

ii. Key personnel changes: Proposed substitution of personnel under this Agreement shall be of equal experience and/or shall exceed the current incumbent’s experience and qualifications.

a. Resume: Provide a resume of the proposed personnel. Include relevant experience and qualifications specific to the Services outlined in this Agreement.

b. Organization chart: Provide a revised organizational chart to the City.

iii. Notice to City: The City requires an advance notice of fourteen (14) calendar days for all key personnel changes. For immediate staff changes where this timeframe is not possible, Contractor shall notify the City of staff changes immediately, or no later than forty-eight (48) hours after Contractor is notified by their staff.

iv. City’s Review: The City will review the proposed staff member’s resume and determine if the experience is equal to or exceeds. The City will provide a written response to Contractor within five (5) business days determining if the experience is equal to or exceeds. Any proposed staff member whose experience is not equal to or exceeds as determined by the city, shall not be assigned to the city’s account.

v. The City’s approval of a personnel substitution shall not be construed as an acceptance of the substitution’s performance potential. Contractor shall bear all transitional expenses incurred for any costs associated with removing or replacing Key Personnel who are performing work under the contract.

3. SCOPE OF SERVICES

A. To the extent the City makes appropriate funds available, Contractor covenants and represents that it will not delay the payment of any bill or benefit payable either under the Workers' Compensation Program or required by federal, state, or local law for any reason. Contractor shall make timely payments to all persons and entities supplying labor, materials, or equipment or services for the performance of the Agreement. Failure to make timely payments shall be a material breach of this Agreement and will be subject to penalty as outlined in the performance guarantees.

B. Contractor will follow claim procedures and settlement authority established by the City. The City retains the right to exclude all ancillary providers recommended by Contractor. The City further retains the right to agree or disagree with ancillary services recommended by Contractor, including but not limited to: pharmacy programs, durable medical equipment providers, defense attorneys, and surveillance companies at the City's discretion.

C. Contractor will investigate and evaluate all claims and make informed recommendations for future handling to the City Human Resources Department Worker’s Compensation Section to ensure the proper disposition and medical management of each claim. This will ensure that proper medical services are being performed and that injured employees are returning to work under transitional work programs.

D. Contractor will be involved with managing financial transactions on behalf of the City, to include issuance of payments.

4. GENERAL FILE MANAGEMENT

A. Claims will be set up by Contractor and at the adjuster's desk within one business day of receipt of legal notice of a new injury (either Form 102 or Form 101/407).

B. Adjusters will make three-point contact with the City, injured worker, and providers office on every claim within one business day of receipt of each claim on their desk.

C. Adjusters will return all phone calls from City employees or medical providers within one business day. If an adjuster is out of the office, phone calls will be returned by the Supervisor or designee within one business day. All attempts to return phone calls will be documented in the claim notes. If an adjuster is out of the office, an out of office auto-reply shall be put in place. This requirement may be subject to a performance guarantee.

D. Diaries will be placed on all files in order to obtain the information necessary to make a compensability determination within 14 business days from Contractor's receipt of the claim.

E. Adjusters will secure recorded interviews on all claims that require thorough background information. This includes but is not limited to: claims involving preexisting or underlying conditions, claims involving injuries that require specialist referral, injuries that are under investigation for any reason, and injuries that require detailed information regarding negligent third parties.

F. Adjusters will immediately request all prior medical records on all claims that are being investigated for compensability and/or are suspected, within the first seven days of the investigation, to potentially become lost time claims.

G. Within 14 calendar days from the date of file creation or the date of any employee's first day of lost time from work, adjusters will prepare any appropriate indemnity benefit payments per Arizona Revised Statutes (A.R.S.)

§ 23-1062 and communicate the dates and amounts in writing to the appropriate City Human Resources Department Worker’s Compensation

Section staff member. The adjuster will utilize a payment method (check, voucher, or other form if requested) and procedures agreed upon by the City.

Contractor must also establish procedures for recovering, tracking and follow-up to ensure that indemnity and medical benefit overpayments or duplicate payments are recovered within 30 days after Contractor has become aware of the discrepancies.

H. At the time an adjuster communicates either verbally or in writing to City Human Resources Department Worker’s Compensation Section staff that industrial time is either not approved or is denied, the adjuster is required to call the affected employee directly and advise or leave a message with detailed information regarding the non-approval of industrial time. This contact will include the adjuster's contact information as well as an invitation to the employee to call with any questions they may have. This telephonic contact must then be followed up with a letter sent via certified mail to the employee within one business day referencing the date of the telephonic message and its contents, along with an invitation to contact the adjuster with any questions or concerns. This item is subject to penalty as outlined in the performance guarantees.

I. Adjusters will initiate all appropriate medical payments within 30 days of receipt per A.R.S. § 23-1062.01. Contractor will utilize a payment method (check, voucher, or other form if requested) and procedures agreed upon by the City.

If a bill is received by Contractor and not paid within 30 days of receipt by Contractor, Contractor shall incur and pay at its sole cost any and all late charges, interest, fees, penalties and fines, and shall defend, indemnify, and hold harmless the City, its elected or appointed officials, agents, servants, and employees against any liability for nonpayment of said bill. This requirement is subject to performance guarantees.

J. Adjusters will meet with and notify, via e-mail, the Human Resources Department Worker’s Compensation Section staff within one business day upon receiving notice that an injured worker has been released to any form of light duty.

K. Adjusters will review each file to ensure that ICA notification has been received by the 30th day following receipt of a claim. If the adjuster notes that no ICA notification has been received on the 30th day following receipt of a new claim, the adjuster will supply a copy of the completed ICA Form 407 from the claim file to the Industrial Commission. This action will then be documented in the claim notes on the date the ICA Form 407 was copied to the Commission.

L. Adjusters will not issue any notices to the Industrial Commission until the ICA claim number has been received.

M. Adjusters will contact the City no later than seven calendar days prior to a potential claim denial due to the expiration of a 21-day notice from the Commission. The adjuster will work with City Human Resources Department Worker’s Compensation Section staff during that seven day period to gather any and all information possible to make a fair determination of compensability for every claim before the due date for the determination.

N. All calls from medical providers requesting first-fill prescription authorizations, physical therapy authorizations, or medical diagnostics authorizations for treatment being provided to a City employee under a new injury claim prior to the establishment of a claim file at Contractor's office will be routed to Contractor’s Supervisor. The Supervisor will then:

1. Obtain the employee information from the provider.

2. Contact City Human Resources Department Worker’s Compensation

Section staff for verification that the injured worker is a City of Phoenix employee with a new work-related injury.

3. At the Supervisor's discretion based on the information obtained, the adjuster will call the provider back and authorize the first fill prescription and medical diagnostics as needed, and up to the first three visits of physical therapy on an investigative basis pending Contractor's receipt of the claim from the City.

O. Upon acceptance of any previously denied claim or previously denied Petition to Reopen, adjusters will make immediate direct contact both by telephone and in writing with all associated medical providers who rendered medical services to a City of Phoenix employee during the period when the industrial claim or the active treatment was denied. All medical bills associated with payments that were processed through the employee's personal health plan must be immediately solicited by the adjuster and paid on the workers' compensation claim so that the employee's personal health plan can be reimbursed by the medical provider.

P. The adjuster will notify the City Human Resources Department Worker’s Compensation Section staff in writing of any recommendations for initial reserve or subsequent reserve increase that is in combined excess of $75,000. The reserve increase request will be accompanied with a written outline of the adjuster's evaluation of the claim and justification for the reserve increase. Reserves on indemnity medical claims will be reviewed by the adjuster no less than every ninety 90 days.

Q. Adjusters are required to appropriately classify and dispose of claims involving exposure to bodily fluids, airborne pathogens, and/or chemical exposures with the Industrial Commission, i.e., determine whether the exposure is with or without injury and issue the Notice of Claim Status.

R. Adjusters will comply with all federal and state laws as well as all City written guidelines regarding employee privacy/confidentiality. The City requires that the personal-identifying information of all City employees be protected from unnecessary public disclosure. City employee identification numbers will be provided and are to be utilized on all correspondence. City employee identification numbers must be entered into the claim system within seven days of receipt by Contractor.

S. Due to confidentiality concerns, the City reserves the right to direct how claims will be reported to the Index Bureau.

T. At no time will any City employee's Social Security Number (SSN) be published on any correspondence. This includes all notices issued to the Industrial Commission of Arizona. When claim information is requested by an outside party and prior to publication of that information, Contractor is responsible for ensuring that all personal identifying information of the employee is redacted, including all references to: SSN, employee identification number, date of birth, home address, and all personal phone numbers. This requirement is subject to performance guarantees.

U. All referrals to defense counsel shall be discussed with and approved in writing by the City Human Resources Department Worker’s Compensation Section staff prior to assignment.

V. All referrals for Independent Medical Examinations (IMEs) will be discussed with and approved in writing by the City Human Resources Department Worker’s Compensation Section staff prior to assignment. The written request will include the name of the Independent Medical Examiner (IME) company to be assigned and the IME physician to be utilized prior to assignment. Any change in IME physician must be communicated to and approved in writing by City Human Resources Department Worker’s Compensation staff.

W. All referrals to nurse case management will be discussed with City Human Resources Department Worker’s Compensation Section staff and approved in writing prior to assignment.

X. All referrals for surveillance investigations will be discussed with City Human Resources Department Worker’s Compensation Section staff and approved in writing prior to assignment.

Y. Adjusters will copy City Human Resources Department Worker’s Compensation Section staff on all correspondence between Contractor and defense counsel and on all IME reports. City Human Resources Department Worker’s Compensation Section staff reserves the right to be copied on any medical reports, nurse case management reports, subrogation correspondence, investigative reports, and video surveillance upon specific request.

Z. Adjusters or a designated representative for Contractor will immediately notify City Human Resources Department Worker’s Compensation Section staff upon receipt of any Worker's and Physician's Report of lnjury (ICA Form 102) for which there is no corresponding Employer's First Report of lnjury (ICA Form 101). No denial is to be issued on a City claim due solely to the absence of a completed Employer's First Report of Injury without the written approval of City Human Resources Department Worker’s Compensation Section staff.

AA. Adjusters are required to consult with City Human Resources Department Worker’s Compensation Section staff and to work directly with the injured worker and Copperpoint in assisting the injured worker with the reopening process when denials are being recommended because the injured worker has a prior industrial claim with the City through Copperpoint or the State Compensation Fund.

BB. Prior to mailing any denial, the adjuster will contact and personally advise or attempt to personally advise the employee (by leaving a voicemail message if unable to reach the employee directly) that a denial of their industrial claim is being issued. This message will include an invitation to the employee to call the adjuster back with any concerns or questions they have regarding the claim denial. The injured worker must be provided a contact number that will be answered by a live person during regular business hours.

CC. If necessary, adjusters will respond to specific claim inquiries from City Human

Resources Department Worker’s Compensation Section staff verbally within four hours and provide a written status report within 48 hours of such a request.

DD. Immediately upon receipt of a new claim, all adjusters handling City injury claims will review the claim for determination of possible relief from third parties, including charges under the provisions pertaining to handicapped employees and second injury funds unless the City agrees in writing that the pursuit is not cost-effective or necessary. Contractor will identify and place negligent third parties on notice of a workers' compensation lien within the first thirty (30) days after receipt of the new claim. Employee notification of a lien will be issued on the acceptance of claim date. This requirement is subject to a performance guarantees.

EE. Upon receipt of a new claim, all adjusters will actively initiate the process of identifying possible responsible third parties, including but not limited to auto liability insurance. Adjusters will also conduct immediate verification of liability subrogation investigations involving general liability, premises liability, and product liability coverage and pursue third party recoveries in all cases unless the City agrees in writing that the pursuit is not cost-effective or necessary.

These investigations will include verifying immediately if the injured worker filed an Incident Report or in any way placed the other party on notice at the time of the incident and advise the City of same.

FF. Upon receipt of a claim arising from a crime, all adjusters will seek restitution through the criminal court system to protect the City's recovery rights in criminal cases and will immediately identify responsible criminal suspects through contact with the injured worker. The adjuster will place the appropriate criminal court representative on notice of the City's interest in seeking restitution judgments against responsible criminal third parties. The adjuster will maintain contact with the criminal court representative and provide updates to the criminal court as requested by the representative.

GG. The City does not agree to any assumed levels of lien reduction to third parties or their attorneys. All requests for third party settlements or for reductions in the City's workers' compensation lien from attorneys representing City of Phoenix employees in bodily injury claims against third parties must be placed in writing by the third party attorney and addressed to both Contractor and City Human Resources Department Worker’s Compensation Section staff before any lien reduction will be considered. Contractor will provide claim summary details to the City for review during consideration.

HH. The adjuster will require third parties to complete all required forms when requesting a compromise of a City lien. All third party settlements must be approved by City Human Resources Department Worker’s Compensation Section staff in writing prior to disbursement of funds.

II. Adjusters will notify the City immediately of any third party claim denied by the adverse party or adverse carrier. The adjuster will not abandon subrogation without the written approval of City Human Resources Department Worker’s

Compensation Section staff.

JJ. Contractor’s Supervisor shall conduct file reviews on all open active claims on at least a quarterly basis. All supportive care awards (SCA) shall be reviewed by the Supervisor every six (6) months.

KK. Contractor’s Supervisor's reviews will include meaningful, claim-specific written recommendations to the adjuster for future handling, including management and disposition of the claim. The claim notes will reflect the adjuster's immediate response to the supervisor's recommendations. The supervisor's diary will be re-set at appropriate intervals to oversee the adjuster's responsiveness and adherence to the recommendations made.

LL. In the event of a catastrophic injury/claim, at the direction of City Human Resources Department Worker’s Compensation Section staff, if requested a field investigator will be sent to the site immediately to conduct an investigation. The adjuster will then participate in a conference call with all interested City personnel.

MM. The adjuster will include with the employee's copy of the Closing Notices a copy of the City's "How Are We Doing?" survey to be completed by the employee and returned directly to City Human Resources Department Worker’s Compensation Section.

NN. Contractor will notify City Human Resources Department Worker’s Compensation Section staff of any pending hearing, trials, or settlement conferences.

OO. Contractor will send written notice within one (1) business day to an employee via certified mail when the adjuster assigned to their claim changes unless otherwise agreed up with City Human Resources Department Worker’s Compensation Section staff on a case-by-case basis. This communication will include the name and contact information for the new adjuster.

PP. At the discretion of the City, City Human Resources Department Worker’s Compensation Section staff may take a random screen shot picture of adjuster caseloads to verify compliance. This requirement is subject to performance guarantees.

5. ADDITIONAL CLAIMS ADMINISTRATION REQUIREMENTS

A. The City retains the right to exclude all ancillary providers recommended by Contractor and to agree or disagree with ancillary services recommended by Contractor, including but not limited to pharmacy programs, durable medical equipment providers, IME companies, defense attorneys, and surveillance companies.

B. If the Contract is awarded under a per claim charge, Contractor will only charge a specified Per Incident rate for First Aid Only claims. This same rate will apply to all Exposure Claims that have no associated injury (i.e., saliva, incidental contact with blood-borne pathogens, or airborne contaminates).

C. The City requires Contractor to report all City claims that fall within the federal reporting guidelines to the Centers for Medicare and Medicaid Services (CMS) as required by the Medicare Secondary Payer (MSP) Act of 2007, effective July 1, 2009.

D. If a claim reported to CMS requires a Medicare Set-Aside (MSA) to be established, Contractor is responsible for immediately communicating in writing the amount and requirements of the MSA to City Human Resources Department Worker’s Compensation Section staff.

E. Contractor will utilize and disclose to the City a specified payment code that Contractor would utilize for payment from Contractor's funds for any statutory penalties assessed to the City as a result of Contractor's failure to comply with any local, state or federal statute.

F. Contractor will provide claim forms for the reporting of all occupational incidents, injuries, and diseases to the proper state regulatory agency and recommend procedures for prompt reporting.

G. Contractor will prepare and submit to the Industrial Commission of Arizona and other such regulatory agencies all required hard-copy and electronic reporting forms relating to workers' compensation claims.

H. Contractor will maintain complete records (hard copy and computerized) on all reported claims on behalf of and as custodian for the City.

I. At no additional cost to the City, Contractor will provide real-time access to claims data and provide the City with the means and training to create specific real time loss reports.

J. At no additional cost to the City, Contractor will work in conjunction with the City to streamline processes and create efficiencies where possible, including process improvement in case management, technological efficiencies, and recordkeeping.

K. When an employee with an existing open claim sustains a new injury, Contractor will assign the new injury claim to the adjuster handling the existing open claim(s).

L. Contractor will recommend attorneys to assist in any case where legal representation is desired and will consult with and furnish available claim information to any attorney chosen. The City will make final selection of attorneys.

M. At no additional cost to the City, Contractor will send a representative as required by the various criminal and/or civil court systems to present lien documentation and testify on behalf of the City in all cases where the restitution lien being sought is greater than $1000.

N. Contractor will report appropriate losses and details therein to the City's excess insurance carrier. The City will be copied on all correspondence between Contractor and the excess insurance carrier.

O. Contractor will meet quarterly with the City's designee(s) to review all open indemnity claims, and to discuss estimated liabilities and claim management strategies.

P. Contractor will meet annually with the City's designee(s) to review the reserve amounts posted on all claims that exceed $75,000.

Q. Contractor will cooperate with and make information available to City auditors, regulating agencies, or other designees upon request.

R. Contractor will consult with the City on matters pertaining to self-insurance as deemed necessary by the City.

S. If requested, Contractor will assist in the preparation and filing of self-insurance reports and forms required by the Industrial Commission of Arizona and any other regulatory agency.

T. At no additional cost to the City and if requested, Contractor will attend City Council meetings to provide information about the status of claims.

U. Contractor will ensure that any Acknowledgement of Summons and Complaint is immediately sent to City Human Resources Department Worker’s Compensation Section staff.

V. Contractor will discuss all proposed claim settlements with City Human Resources Department Worker’s Compensation Section staff prior to settlement. Claim settlements include all negotiated payments other than statutory medical and indemnity payments that result in the closing of the claim.

W. Contractor agrees that in the event of the termination of the Contract, Contractor will continue to provide ministerial services and administer any open claims provided that the City continues to make adequate funds available for the payment of such claims and the parties negotiate and agree to an additional fee for this service.

X. Upon termination of the contract and if requested by the City, Contractor must provide the City with complete and accurate electronic claims information, actual physical files of City claims in a format requested by the City, and any other claims information requested.

Y. Contractor shall provide the City’s Bill Review Contractor with an electronic copy of original bills for review and evaluation. It is the responsibility of the Bill Review Contractor to arrange for the electronic transmission bills and related documentation in a manner and frequency that is acceptable to the City.

Contractor shall work cooperatively with the Bill Review Contractor to ensure that bills are paid timely and accurately.

Z. Subcontracting services under this RFP is not allowed without the express written approval of City Human Resources Department Worker’s Compensation Section staff. Contractor may be authorized to use special consultants to provide technical services such as Independent Medical Examinations with the express approval of the City. Special consultant expenses that are authorized in writing prior to expenditure will be paid in addition to the per claimant adjustment fee.

AA. Contractor shall adhere to the City's core mission and values which can be found on the City's website at:

https://www.phoenix.gov/citymanager/vision-and-values

6. REPORTING/AUDITING REQUIREMENTS

Reporting A. At no additional cost, Contractor will provide an annual fiscal year (July 1 -

June 30) electronic report in a City-specified format by September 1 of each year. The report must outline significant claim trends and developments observed during the fiscal year; suggestions for mitigating the adverse impact of the trends and developments; the effectiveness and cost of Contractor-provided or subcontracted managed care contracts http://www.phoenix.gov/citymanager/vision-and-values

B. On a monthly basis and at no additional cost, Contractor will provide the City with an electronic report of the City's current claims data. The report will be in a City-specified format that allows City staff to manipulate the data and will include:

claim number, City-issued employee identification number, employee’s department and division name and number, employee's last name, employee's first name, date of injury, date of claim acceptance, adjuster name, claim type, and claim status. This information must be presented for the previous two-month period. Parameters that are not met are subject to performance guarantees.

C. On a monthly basis and at no additional cost, Contractor will provide the City with an electronic report in a City specified format that includes: a listing of all independent medical examinations completed in the previous thirty (30) day period, the name of the IME company, the name of the person who scheduled the IME, the name of the practitioner who performed the IME, the employee's name, the employee’s City-issued identification number, the employee’s department name and number, and the name of the adjuster.

D. Contractor will create and provide a monthly report that tracks, at a minimum, employee name, date of TPA ICA notification, ICA listed due date, and date the actual notice was issued. The City will review the report and monitor claim statutory requirements.

E. Contractor will provide a monthly report that includes all payments made on denied claims that month. HR Workers Compensation will review report and monitor for payment accuracy.

F. Contractor will provide a monthly report that includes claim count staffing by adjuster that includes claim type and number.

G. Contractor will provide any other one time or repeat reports requested by the City.

Auditing A. Contractor shall provide full disclosure of all its records upon notice from the City and/or the City-selected auditor. The Contractor shall cooperate with the auditors and waive any fees associated with obtaining access to the City’s data and/or records.

The City reserves the right to audit Contractor’s performance and records.

Contractor shall cooperate with the internal/external auditor(s) and shall provide records as requested at no additional fee to the City.

7. PERFORMANCE GUARANTEES/PENALTIES

A. Contractor shall timely report all qualifying city claims to the Centers for Medicare and Medicaid Services (CMS) in accordance with the guidelines of the Medicare Secondary Payer (MSP) Law. In the event that Contractor fails to do so, and the city is fined as a result, Contractor will be solely responsible for reimbursing the city for the entire cost of associated fines/penalties assessed to the city.

B. The city will assess a $200 per instance charge-back to Contractor's monthly statement for any City claim that Contractor denies due to exposure, but which also had/has an associated injury (i.e., needlestick, human bite, etc.).

C. The city will assess a $200 per instance charge-back to Contractor's monthly statement for any claim that is denied by Contractor solely because Contractor did not receive the Employer's Report of Injury (Form 101) prior to the due date for ICA notification.

D. The City will assess a $5,000 per instance charge-back to Contractor's monthly statement each time an employee's personal identifying information (PII) is published in writing or is not properly redacted from documents Contractor supplies to any outside source. Additionally, Contractor will be responsible for providing one year of credit monitoring service free of charge for any City employee whose PII is released by Contractor.

E. If an adjuster fails to timely notify an employee verbally or in writing of a denial or delay of industrial compensation, and if the City is required to pay compensation solely because the adjuster did not communicate with the employee in a timely manner, the amount of the compensation approved (that would not otherwise have been due to the employee) will be deducted from Contractor’s monthly invoice.

F. If a bill is received by Contractor and not paid per the requirements of A.R.S. § 23-1062.01, Contractor shall pay at its sole cost any and all late charges, interest, fees, penalties, and fines and shall defend, indemnify, and hold harmless the City, its elected or appointed officials, agents, servants, and employees against any liability for nonpayment of said bill.

G. If Contractor fails to obtain prior written approval of City Human Resources Department Worker’s Compensation staff and agrees to reduce a City lien or agrees to accept or process a payment from: (1) the third party, (2) the third party insurer, or (3) the third party attorney, Contractor will repay at its sole cost the amount of the reduction to the City within thirty (30) days. If payment is not received within thirty (30) days, a 10% fee will be assessed to the reduction amount for each additional thirty (30) day period until the reduction is repaid.

H. On a monthly basis and at no additional cost, Contractor will provide the City with an electronic report of the City's current claims data as referenced in paragraph 6(B). If required parameters are not met, a $1,000 fee will be deducted from Contractor’s monthly invoice for each instance per line item of unmet criteria.

I. If Contractor fails to maintain a sufficient number of adjusters to maintain a caseload of 150 active claims and 500 supportive care claims, and a sufficient number of assistants for all claims as deemed necessary to perform services required in the Contract, a $500 fee will be assessed for each file in excess of the caseload requirements. At the discretion of the City, Human Resources Department Worker’s Compensation Section staff or City Audit Staff will take a random screen shot picture of adjuster caseloads to verify compliance.

J. If Contractor fails to identify and notify negligent third parties of a Workers' Compensation lien within the first thirty (30) days after receipt of the new claim or fails to issue injured worker notification of the lien on the acceptance of claim date, a $500 fee will be assessed for each instance when notification was not provided. An additional $1,000 fee will be assessed for each additional thirty

(30) day period of nonnotification.

NOTE: City of Phoenix reserves the right to waive or enforce all performance guarantees/penalties at its sole discretion.

8. TECHNOLOGY / CLOUD APPLICATIONS

A. Contractor shall make all data available to the City via an SFTP site established during implementation. In addition, all schemata and file definitions shall be made available to the City upon request.

B. Contractor shall communicate through HIPAA-compliant electronic sites to exchange data between itself and any other required vendor as requested by the City and at no additional cost.

C. Contractor shall provide claim system functionality that shows individual medical bill payment and bill review fees matched together on the claim payment screen.

D. Contractor shall provide claim system functionality to send/receive file transmission from the City’s Worker’s Compensation section.

9. TRANSITION AND IMPLEMENTATION SERVICES

A. Contractor shall begin the implementation process within ten (10) business days of Contract award.

B. Contractor shall submit an implementation plan which shall include a detailed transition of claims. The plan must prioritize the transition of active claims that are receiving Temporary Partial Disability (TPD), Total Temporary Disability (TTD) or Permanent Partial Disability (PPD) – Compensation benefits first, followed by all remaining claims that are open for medical treatment, followed by closed claims.

C. Contractor shall facilitate and accept the transfer of all claims as requested by the City. The City estimates approximately 43,000 claims total. This includes approximately 2,500 open claims and 41,000 closed claims.

D. A designated transition and implementation manager shall support the City through completion of the implementation process and for a minimum of forty-five (45) calendar days after the implementation effective date (see paragraph 9A). Such support includes but is not limited to: weekly calls with the City and the designated account management team, maintenance of issue tracking logs, and issue resolution. This support must be provided as part of the base administrative fees with no additional cost to the City.

E. Contractor shall provide any necessary information, including records, data, claims or documentation related to transition when a member moves from one TPA to another, and upon termination of this Agreement.

F. Contractor shall have a procedure which describes how Contractor would administer and close claims that remain with Contractor if/when it is replaced by another firm.