RFP_5800_SLW3033_0600_v1.xlsx
XLSX spreadsheet 47 KB Posted
- Solicitation number
- RFP 5800 SLW3033
- Issued by
- Texas
About this file
This is a Request for Proposal (RFP) workbook issued by the City of Austin for Workers Compensation Third Party Claims Administration and Related Services (RFP #5800 SLW3033). The procurement seeks qualified third-party administrator (TPA) firms to manage workers' compensation claims administration services for the City of Austin. The RFP requires vendors to demonstrate compliance with comprehensive general requirements, transition procedures, overpayment and late payment management, financial reporting standards, and management information systems capabilities. Vendors must agree to detailed scope of work requirements spanning sixteen distinct operational categories or provide documented exceptions. The proposal submission requires completion of multiple tabs covering performance guarantees, vendor experience, technical services capabilities, extended services pricing, surveillance and legal services partnerships, and MIS infrastructure. Specific staff positions must be identified or marked as "to be determined," including dedicated claims supervisors, adjusters for catastrophic, indemnity, medical-only, medical management, and hearing loss claims, along with claims associates and account management personnel.
The RFP establishes detailed performance guarantees with associated liquidated damages tied to specific metrics including Performance Based Oversight (PBO) ratings of 95 percent or higher, annual audit compliance, timely and accurate report delivery, quarterly performance logs, monthly financial reporting, claim review procedures, staffing vacancy fill times, recorded statement requirements, compensability determination timelines, claimant contact protocols, and response time standards. Vendors must submit pricing on Tab 10 as a "Not to Exceed" fee covering all claims administration services, MIS services, DWC carrier representative fees, and any additional charges not directly charged to individual claim files. The RFP requires vendors to provide references from similar Texas public sector entities where they served as the TPA within the past five years, along with information about clients who did not renew their contracts within the last three years. Vendors must demonstrate compliance with City of Austin artificial intelligence policies prohibiting AI use in human decision-making related to claims and medical determinations, with violations subject to penalties up to fifty thousand dollars per verified incident. The contract includes detailed specifications for claims system capabilities, employee portal access, form submission systems, report generation and delivery, Medicare Secondary Payer compliance, surveillance services partnerships, and legal services relationships.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP_5800_SLW3033_ATT_4_v1.docx | DOCX document | |
| CSP_6100_CLMB344_BID_DOC_5_v1.pdf | ||
| RFP_5800_SLW3033_ATT_9_v1.pdf | ||
| RFP_5800_SLW3033_ATT_3_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_PAC2_v1.docx | DOCX document | |
| RFP_5800_SLW3033_ATT_10_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_12_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_6_v1.xls | XLS spreadsheet | |
| RFP_5800_SLW3033_ATT_11_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_2_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_5_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ADD_1_v1.pdf | ||
| RFP_5800_SLW3033_ATT_7_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_ATT_1_v1.docx | DOCX document | |
| RFP_5800_SLW3033_PAC1_v2.pdf | ||
| RFP_5800_SLW3033_PAC1_v1.pdf | ||
| RFP_5800_SLW3033_ATT_8_v1.xlsx | XLSX spreadsheet | |
| RFP_5800_SLW3033_0600_v2.xlsx | XLSX spreadsheet |
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Text version
Cover
| The City of Austin |
| Request for Proposal # 5800 SLW3033 |
| for |
| Workers Compensation Third Party Claims Administration and Related Services |
Tab 1
| Requirements: General, Transition , Overpayments/Leakage, Late Payments, Financial , and MIS | ||
| All vendors must complete this section. | ||
| PROPOSAL SPECIFICATIONS | ||
| # | Specification | Agree/ Disagree |
| 1 | Vendor has read Scope of Work Section IV. A 1-16 General Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 2 | Vendor has read Scope of Work Section IV B. 1-4 Transition Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 3 | Vendor has read Scope of Work Section IV C. 1-4 Overpayments/Leakage, Late Payments, Reimbursement Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 4 | Vendor has read Scope of Work Section IV D. 1-9 Financial Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 5 | Vendor has read Scope of Work Section IV E. 1 - 11 Management Information Systems Requirements and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 6 | Vendor has completed the Performance Guarantees section of this Workbook, Tab 3 noting any deviations on Tab 2. | |
| 7 | The Respondent shall disclose any regulatory investigations, audits, enforcement actions, consent orders, administrative violations, fines, penalties, sanctions, corrective action plans, or other disciplinary actions issued by the Texas Department of Insurance, Division of Workers’ Compensation (TDI-DWC), or any other state or federal regulatory agency within the past five years. Failure to disclose regulatory actions that are later identified through the City's due diligence process may result in disqualification of the proposal. |
Tab 2
| Exceptions/Comments to Scope of Work Requirements | ||
| If you have any Deviations to the Proposal Requirements and Specifications, OR need to add additional commentary on any item in the Workbook Tabs, please include this here. | ||
| Proposal Requirements and Specifications | ||
| # | Specification | Deviation/Commentary |
Tab 3
| Claims Administration Performance Guarantees | |||||
| All vendors must complete this section. | |||||
| # | Performance Measure | Acceptable Performance | Liquidated Damage | Calculation | Agree Yes/No |
| 1 | Performance Based Oversight (PBO) as calculated by DWC. PBO is performed every 2 years. | 95% or higher PBO overall tier rating | Every 2 Years: $10,000 for an overall rating below 95% | PBO - results provided by DWC every 2 years. | |
| 2 | Annual Audit of Workers’ Compensation Claims Management & Subrogation, Preauthorization and Bill Review | Audit results for any categories audited are responded to by the TPA within 10 business days of receipt and action plans implemented within 30 calendar days to improve in any areas below 90%. | Annual: $5,000 for each category where the audit result is below 90%. The 3 categories are: 1. Claims Management 2. Pre-authorization 3. Bill Review. | Annual Audit – final audit results as provided by external audit company | |
| 3 | End of Fiscal Year Reports delivered to the City by the 15th of October each year. 1. Annual FY End Loss Run Report 2. Annual FY End Fund Agency Report. #. Three Year Average Claim Paid Report. | Each report must be delivered accurately and timely by the 15th of October. Timely is defined as receipt by 11:59 p.m. on the 15th of October. If the 15th falls on a weekend or holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of a report inaccuracy by the City to produce an accurate report. | Annual: $5,000 per business day penalty for each report that is inaccurate or late. Not to Exceed $15,000 annually. | Timeliness and accuracy are as defined under Acceptable Performance when calculating potential annual fines. | |
| 4 | Performance Log Results for 3 categories: 1. Claims Management 2. Utilization Management/Bill Review. 3. EDI | Quarterly average for each category must be a minimum of 95%. Each report must be delivered accurately and timely by the 10th of the month following each quarter. Timely is defined as receipt by 11:59 p.m. on the 10th of the month following each quarter. If the 10th falls on a weekend or holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of a report inaccuracy by the City to produce an accurate report. | Quarterly: $2,500 for each category that is below a 95% average score. Not to Exceed $15,000 annually. | Contract Quarters are October thru December/Jan thru March/April thru June/July thru September. | |
| 5 | End of Month Reports delivered to the City by the 15th of each month: 1. Bank Reconciliations 2. Executive Summary 3. Financial Analysis 4. Pay Type/Category Report 5. Check Register 6. Dedicated Nurse Report 7. Indemnity Report 8. New Claims Report 9. Overpayment Report | Each Report must be delivered accurately and timely by the 15th of following month. Timely is defined as receipt by 11:59 p.m. on the 15th of the month. If the 15th falls on a weekend or holiday the report is due on the next business day by 11:59 p.m. The TPA shall have one business day after notification of a report inaccuracy by the City to produce an accurate report | Monthly: $1,000 per business day penalty for each report (10 reports in total each month) that is inaccurate of late, not to exceed $10,000 per month. | Timeliness and accuracy are as defined under Acceptable Performance when calculating potential annual fines | |
| 6 | Send Claim Review Reports to City at least two (2) business days prior to the date of Claim Review. Action items resulting from the claims review shall be completed timely as agreed upon with the City. | Each Report must be delivered timely two (2) business days prior to the date of the Claim Review. Timely is defined as receipt by 11:59 pm two business days prior to the date of the Claim Review, Action items discussed and agreed upon by all parties must be completed within the time frame agreed upon by the TPA and City. | $100 per business day penalty for each report not received two business days prior to the Claim Review. $500 per business day penalty for actions items not completed within the time frame agreed to by the TPA and City not to exceed $5,000 per month. | Timeliness and accuracy are as defined under Performance Measure and Acceptable Performance when calculating penalty amount. | |
| 7 | Fill dedicated Claims Administration staff positions within 30 days after vacancy with a temporary employee and within 90 days with a permanent employee. | Dedicated staff positions must be filled within 30 calendar days after vacancy by 11:59 pm with a temporary employee and within 90 calendar days by 11:59 pm with a permanent employee. Example, if the position becomes vacant on 3/1/2024, the position must be filled with a temporary by 11:59 pm on 3/31/2024 at 11:59pm. The vacant position must be filled with a permanent employee by 11:59pm on May 30, 2024. | Monthly: $500 per business day penalty for each day that each individual position is vacant not to exceed $7,500 per month. | Timeliness and accuracy are as defined under Performance Measure and Acceptable Performance when calculating penalty amount. | |
| 8 | Recorded statements shall be taken on all claims |
defined in the contract as Indemnity Claims and
| Catastrophic Claims. | Recorded statements shall be taken on all Indemnity Claims and Catastrophic Claims within 2 business days of assignment as required in Scope of Work Section K.9 with the recorded statement available in the claim file. Indemnity claims and Cat Claims are defined in Scope of Work Section IV.H 2 and 3. If a medical only claims converts to an indemnity claim the 2 day window begins for the required recorded statement. | $1,000 for each missing Recorded | |||
| Statement. | Adherence to this requirement will be determined by the City. Exceptions will be made for employees who are incapacitated or on approved non-work related leave from the City. | ||||
| 9 | Claim Compensability shall be established by the 15th day from the date the loss was recevied by the Third Party Administrator. | TPA shall act on determining compensability within 15 days after receipt of the claim, excluding first responder presumption claims as DWC allows 60 days for a compensability determination. | $5,000 per claim that doesn't meet | ||
| acceptable performance. | Adherence to this requirement will be as determined by the City based on review of claim data maintained by the TPA. | ||||
| 10 | Maintain ongoing contact with COA employees on No Duty or Limited Duty status. | Employees on No Duty Status shall be contacted by Adjuster no less than every 15 days while the employee is on No Duty or Limited Duty status as required by Scope of Work Section K.5. | $500 per verified incident. | Verified service failure due to lack of documentation in the claim file through a screen shot or call log that contact was attempted at least twice and then an email sent to the department WC rep indicating contact was unsuccessful. | |
| 11 | Response to emails and phone calls within 1 | ||||
| business day | A response to City employee generated phone calls or emails is communicated back to the City employee within one business day of the inquiry; an acceptable response can be acknowledgement of receipt of the inquiry and an indication that it is being worked on. Follow-up responses shall be made within 1 business day. | $500 per verified incident. | Verified service failure due to lack of response through a screen shot or call log. | ||
| 12 | Adherence to Claim Caps per Adjuster Position as defined in Scope of Work Section I.1 | Claim caps by adjuster position are not exceeded for 2 consecutive months in a row as established by the claims caps indicated in the minimum staffing requirements in section I.1. | $5,000 per adjuster position above the | ||
| allowable cap for 2 months. If the same adjuster position exceeds the cap following the initial 2 month assessment, subsequent months for the same position will incur an additional $5,000 per month in liquidated damages until the allowable cap is acheived. | Claim Cap data by adjuster position from the Executive Summary shall be utilized to determine whether claims caps have been exceeded. Example: May Executive Summary data shall be used to compare April and March Claim Caps by adjuster position to determine if caps have been exceeded. | ||||
| 13 | Ensure compliance with Texas Labor Code § 409.0231 for the timely issuance of benefit payments by electronic funds transfer. | TPA shall timely issue benefit payments to claimants who elect payment by electronic funds transfer. This means of payment shall be in effect at the effective date of the contract through term of term of the contract. | $500 per verified individual instance where a claimant who elected payment by electronic funds transfer, did not receive such payment on or before the benefit payment due date. | Adherence to this requirement will be determined by the City. | |
| 14 | Contractor and/or it's subcontractors shall not to utilize Artificial Inteligence (AI) for any human decision making related to claims and medical determinations involving City claimant data. | Compliance by Contractors to the City's AI Policy is mandatory. The Chief Information Officer (CIO) will work with Department Directors to ensure compliance with the policy. Non-compliance may result in department leaders imposing disciplinary action, restriction of access, or more severe penalties up to and including termination of employment or vendor contract. Violations by contractors/vendors/partners may be considered breach of contract and may result in removal from assignment. Any AI-related activities which appear to violate applicable laws/regulations | |||
| will be reported to external law enforcement and/or regulatory agency. | $50,000 per verified incident. | Adherence to this requirement will be determined by the City. | |||
| 15 | Supporting documentation must be noted in the claim file by the claims examiner when approving treatment that was denied by utilization review. | UR denails shall not be auto-approved by the claims examiner without supporting documentation noted in the claim file. | $500 per verified incident. | Adherence to this requirement will be determined by the City. | |
| 16 | Rush payments shall not be approved by the claims examiner without sending the medical bills to bill review. | Clams examiners shall not approve rush payments for medical bills sent/received late by the medical provider. All medical bills must be sent to bill review for the appropriate review prior to approving payment. | $500 per verified incident. | Adherence to this requirement will be determined by the City. |
Tab 4
| Claims Administration Vendor Experience, Account Team, Resumes, and Scope of Work Requirements | ||
| All vendors must complete this section. | ||
| PROPOSAL SPECIFICATIONS | ||
| # | Specification | Vendor Response |
| 1 | Provide, in 3 pages or less, your firm's history, mission, organizational stability, dedicated resources, and experience as a TPA and in self-inured Claims Administration Services. | ATTACH TO PROPOSAL |
| 2 | Agree that you will confer with the City before hiring any staff that are currently working on the City of Austin account. | |
| 3 | Identify the Account Manager for the City of Austin and provide the percentage of time this position will be dedicated to the City of Austin Account. Identify the other accounts this manager will also be handling while working on the City of Austin account. | |
| 4 | Provide the resume/bio for the Account Manager. If the Account Manager is not currently employed, provide your minimum qualifications for the position. | ATTACH TO PROPOSAL |
| 5 | Identify the 100% dedicated Claims Supervisor for the City of Austin account. If this person has not been identified, indicate TBD. | EITHER TBD OR NAME |
| 6 | Provide the resume/bio for the Claims Supervisor. If the Claims Supervisor is not currently employed, provide your minimum qualifications for the position. | ATTACH TO PROPOSAL |
| 7 | Identify the 100% dedicated Assistant Supervisor for the City of Austin account. If this person has not been identied, indicate TBD. | EITHER TBD OR NAME |
| 8 | Provide the resume/bio for the Assistant Supervisor for the City of Austin account. If the Asst. Supervisor is not currently employed, provide your minimum qualifications for this position. | ATTACH TO PROPOSAL |
| 9 | Identify the 100% dedicated Catastrophic Claims Adjuster for the City of Austin account. If this person has not been identified, indicate TBD. | EITHER TBD OR NAME |
| 10 | Attach the resume/bio for the Cat Claims Adjuster. If you indicated TBD to question 11 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H 1. | ATTACH OR VERIFY |
| 11 | Identify the 3 100% dedicated Indemnity Adjusters for the City of Austin account. If these people have not been identified, indicate TBD. | EITHER TBD OR NAMES |
| 12 | Provide the resume/bio for the Indemnity Adjusters. If you indicated TBD to question 13 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H.1. | ATTACH OR VERIFY |
| 13 | Identify the 2 100% dedicated Medical Only Adjusters for the City of Austin account. If these people have not been identified, indicate TBD. | EITHER TBD OR NAMES |
| 14 | Provide the resume/bio for the Medical Only Adjusters. If you indicated TBD to question 15 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H.1 | ATTACH OR VERIFY |
| 15 | Identify the 100% dedicated Medical Management Adjuster for the City of Austin account. If this person has not been identified, indicate TBD. | EITHER TBD OR NAME |
| 16 | Provide the resume/bio for the Medical Management Adjuster. If you indicated TBD to question 17 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H.1 | ATTACH OR VERIFY |
| 17 | Identify the 100% dedicated Hearing Loss adjuster for the City of Austin Account. If this person has not been identified, indicate TBD. | EITHER TBD OR NAME |
| 18 | Provide the resume/bio for the Hearing Loss adjuster. If you indicated TBD to question 19 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H.1 | ATTACH OR VERIFY |
| 19 | Identify the 100% dedicated Claims Associate for the City of Austin Account. If this person has not been identified, indicate TBD. | EITHER TBD OR NAME |
| 20 | Provide the resume/bio for the Claims Associate. If you indicated TBD to question 21 above, verify that you will comply with the minimum experience required for this position in Scope of Work Section IV.H.1. | ATTACH OR VERIFY |
| 21 | Identify other executives that may be involved in the City of Austin Account when an escalation of an issue may arise, and briefly describe their background and expertise in resolving account challenges. | ATTACH TO PROPOSAL |
| 22 | Verify that you agree to work with the City if claims counts stay consistently below or above the claim caps to adjust staff and the administration fee. | |
| 23 | Verify you have read Scope of Work Section IV. F. 1-3 Business Hours and Availability and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 24 | Verify that you have read Scope of Work Section IV. I. 1-2 Training and agree to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 25 | Vendor has read Scope of Work Section IV. J 1- 32 Claim File Adjusting and agree to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 26 | Verify the costs for the Account Manager, Claims Supervisor, Assistant Supervisor, Cat Claims Adjuster, Indemnity Adjusters, Medical Only Adjusters, Medical Management Adjusters, Hearing Loss Adjusters, Claims Associate have been included in your Not to Exceed Claims Administration Fee on Tab 10 of this proposal. |
Tab 5
| Claims Administration Services Reference Information | |||
| List Texas political subdivisions with operations similar in size to the City of Austin where you were the Third-Party Administrator for Workers Compensation Claims Administration within the last 5 years. | |||
| NAME OF ENTITY | CONTACT NAME/TELEPHONE #/EMAIL ADDRESS | CONTRACT START/END DATES | LAST PBO RATING AND YEAR |
These references may be contacted as part of the evaluation process.
| Provide a list of the 3 most recent Texas public entity clients that did not renew their workers' compensation claims administration contract for your services within the last 3 years. | |||
| NAME OF ENTITY | CONTACT NAME/TELEPHONE #/EMAIL ADDRESS | CONTRACT START/END DATES | LAST PBO RATING AND YEAR |
Tab 6
| Claims Administration Technical Services Questions | ||
| All vendors must complete this section. | ||
| PROPOSAL Questions | ||
| # | Claims Administration Questions | Vendor Response |
| 1 | Provide a detailed implementation plan to include a specific timeline for transitioning the claims administration services to include milestones with dates. If you are the incumbent, include a list of transition steps your firm uses to transition accounts. | ATTACH TO PROPOSAL |
| 2 | List the functions that the Client Services /Account Manager position will perform for the City of Austin. | ATTACH TO PROPOSAL |
| 3 | List the claims positions that the Claims Supervisor will have directly reporting to them and list the functions and types of data and reports that the Claims Supervisor utilizes in order to ensure that the adjusting staff is completing their work. | ATTACH TO PROPOSAL |
| 4 | List the claims positions that the Claims Asst. Supervisor will have directly reporting to them and list the functions and types of data and reports the Claims Asst. Supervisor utilizes in order to ensure that the adjusting staff is completing their work. | ATTACH TO PROPOSAL |
| 5 | Will the adjusters on the COA account work remotely 100% of the time unless a client requires them to be located on site at their premises? | |
| 6 | Identify the financial threshold for Managers and claims adjusting staff for setting reserves and issuing checks. | |
| 7 | In 2 pages or less, detail your firm's solution to Medicare Secondary Payer compliance and include information regarding Medicare reporting, Medicare liens, and Medicare set-asides. Identify the benefits the City will receive by using your MSP process. | ATTACH TO PROPOSAL |
| 8 | Some City of Austin employees can be hard to reach by phone due to their work shifts or the type of position they hold. When the adjuster contacts our injured employee by phone, is your firm name identified as the caller? If not, are there plans to implement this function? If so, when would this be implemented in Texas and for the City of Austin? | |
| 9 | Does your firm have the capability of "tracking" incoming phone calls to a specific adjuster and determining if the adjuster has returned the phone calls? Explain the method, if any, you currently have in place to do this. | |
| 10 | Where are indemnity checks printed and how often are they printed? | |
| 11 | Can pay stubs on checks be customized if necessary? | |
| 12 | If an employee transitions from No Duty to Limited Duty in the middle of a week, will the employee receive one TIBs check that includes the payment for both statuses, or will your firm issue the employee two separate TIBs checks? | |
| 13 | Detail the process and timelines associated with a DWC form that is attached to an email and sent to an adjuster. When is the form considered received and when is the form uploaded into the claims system? | |
| 14 | The City sometimes reorganizes departments and merges them. Can your firm "move" claims in the system to a different department if the original department no longer exists? If so, describe the timeline for moving the claims. | |
| 15 | Identify the types of training and continuing education your firm provides to your adjusting staff. | |
| 16 | When a claims adjuster requests a peer review, RME or DD to address disputed issues, do you have a quality control process in place to ensure that all the medical and other information has been included with the request? |
Tab 7
| EXTENDED SERVICES ALLOCATED EXPENSES | ||
| ALL PROPOSERS MUST COMPLETE THIS TAB SHOWING CLAIM FILE CHARGES. THE "COA SERVICE ESTIMATE" COLUMN HAS BEEN PROVIDED FOR COA EVALUATORS TO INDICATE ESTIMATED WORK LOAD FOR TOTAL COSTS. | ||
| IF YOUR FIRM CHARGES HOURLY; SHOW THE HOURLY CHARGES ONLY; A TOTAL BY CONTRACT YEAR DOES NOT HAVE TO BE COMPLETED. | ||
| ALL CLAIM FILE CHARGES EXCEPT LEGAL FEES ESTABLISHED BY DWC ARE REQUIRED TO BE SHOWN IN THIS CHART. | ||
| TYPE OF ALLOCATED CHARGE | ANNUAL ALLOCATED ESTIMATED EXTENDED SERVICE CLAIM FILE CHARGES BASED ON COA ESTIMATE IN COLUMN C | |
| TPA CHARGES FOR MEDICAL COST CONTAINMENT | ||
| TPA CHARGES FOR OTHER SERVICES | ||
| Private Investigation Surveillance (per hour) | 2 | |
| Private Investigation Social Media checks | 10 | |
| Index Bureau Records | 1,886 | |
| EDI Claims (FROI/SROI) per submission | 1308/1411 | |
| MEDICARE | ||
| Medicare Claims Reported | 342 | |
| Medicare Querys- reporting Fee (indicate 1 time fee or ongoing) | 7,631 | |
| Conditional Pay Request (indicate per referral or per hour) | 5 | |
| Conditional Pay Dispute Resolution (per hour or inquiry) | 5 | |
| Medicare & Medicaid Investigations (per inquiry or per hour) | 5 | |
| TPA LEGAL CHARGES THAT ARE NOT FEES MANDATED BY DWC | ||
| PROPOSERS DO NOT NEED TO LIST ALL LEGAL FEES CHARGED TO THE CLAIM FILE THAT ARE MANDATED FEE AMOUNTS ESTABLISHED BY DWC | ||
| Attorney/Partner Fee Per hour | ||
| Associate Fee per hour | ||
| Paralegal Fee per hour | ||
| Charge to File a BRC or CCH Appeal | ||
| Charges for a BRC Set Notice change |
PROPOSER FOOTNOTE SECTION
Tab 8
| Claims Administration - Surveillance, VOC Rehab and Legal Services | ||
| All vendors must complete this section. | ||
| PROPOSAL Questions | ||
| # | Surveillance Services | Vendor Response |
| 1 | What legal entity will be providing Surveillance services as required in this scope of work? | |
| 2 | Verify you have read Scope of Work Section IV. R. 1-6 Investigation, Field Adjusting, Survellance and other External Services and agreesto all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 3 | For each separate legal entity identified in #'s 1 -4 above, provide, in 2 pages or less, the firm's history, mission, organizational stability, dedicated resources, and experience in the implementation and management of the services they will be providing. | ATTACH TO PROPOSAL |
| 4 | For each separate legal entity idenfitied in #'s 1 - 4 above, provide the resumes/bios of key individuals that will be performing work for the City of Austin account. | ATTACH TO PROPOSAL |
| # | Legal Services | Vendor Response |
| 5 | What law firm will be providing legal services as required in this scope of work? | |
| 6 | Vendor has read Scope of Work Section IV. K. 1-10 Legal Services and agrees to all the requirements in this section of the Scope of Work; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 7 | Provide, in 2 pages or less, the firm's history, mission, organizational stability, dedicated resources, and experience in the legal services they will be providing. | ATTACH TO PROPOSAL |
| 8 | Provide the resumes/bios of key lawyers and staff that will be assigned to perform legal services for the City of Austin account. | ATTACH TO PROPOSAL |
| 9 | Describe the types of legal serivces and types of support the law firm will provide to adjusters and the City. | ATTACH TO PROPOSAL |
| 10 | Provide the law firm's procedures for resolving disputes prior to a BRC or CCH, developing cases and attending dispute resolution proceedings at the DWC. |
Tab 9
| Claims Administration - MIS and Required Reports and Meetings | ||
| All vendors must complete this section. | ||
| PROPOSAL Questions | ||
| # | MIS Questions for Claims Administrator Internal Database | Vendor Response |
| 1 | Is your adjuster/internal claims system leased or proprietary? | |
| 2 | Briefly describe your system support and the maintenance and security controls that are in place. | ATTACH TO PROPOSAL |
| 3 | Is your data backed up every night? | |
| 4 | Do you have offsite storage of data and if so where is this located? | |
| 5 | If the City wants additional data captured in a separate field, how long will this take to customize and what will the cost be? | ATTACH TO PROPOSAL |
| 6 | What specific future technological enhancements to the internal adjuster claims system are planned to be implemented in calendar year 2026? | |
| 7 | List the alerts that your system has built in to help adjusters efficiently and accurately handle claims. | ATTACH TO PROPOSAL |
| 8 | Does your claims system "count" lost days per claim by calendar days lost or work days lost? (Example one week of lost time is 7 days or 5 work days) | |
| 9 | Does your claims system "count" restricted duty days per claim? Indicate how restricted duty days are counted. (Example one week of restricted days is 7 days or 5 work days) | |
| 10 | Describe what actions the adjusters take to "turn on" the lost and restricted duty day counter and if there are any Quality assurance controls that are in place to ensure lost and restricted duty days are counted. | |
| 11 | Does your system have the capability of establishing recurring indemnity payment cycles? | |
| 12 | Does your system have the capability of calculating interest due on late payments based on the date the payment was due and the date the payment was actually made? | |
| 13 | Does your claims and bill review systems have mechanisms for identifying duplicate claims and medical bills? If so, please briefly describe. | ATTACH TO PROPOSAL |
| 14 | How long does it take to void an indemnity check that has been issued? Do you have to have the original check before you can void it? | |
| 15 | How long does it take to place a stop payment on an indemnity check that has been issued? | |
| # | MIS Questions for the Client Access Claims Database | Vendor Response |
| 16 | Indicate the name of the Client accessible database that COA employees will use. | |
| 17 | Is the claims client facing system proprietary or leased? | |
| 18 | If City employees have trouble accessing the system, how will this be reported? | |
| 19 | Briefly describe how training will be provided to City personnel on the use of the system. | |
| 20 | Will City personnel be able to view, download, and print all images, forms, medical bills, EOBs, DD's, DWC and legal documents as well as adjuster notes? | |
| 21 | If your answer to the question above was no, please list information that City personnel will not have access to view. | |
| 22 | Can access be restricted by department? Example: Police Dept personnel can only see Police Dept claims information. | |
| 23 | Can City personnel viewing a claim in the client facing system submit an email to the claims adjuster by clicking on their name or another feature while in the system? | |
| # | MIS Questions for the Completion and Submission of Forms and Reports, Meetings and Audits | Vendor Response |
| 24 | Indicate the name of the Forms submission system that COA employees will use. | |
| 25 | Is this system proprietary or leased? | |
| 26 | If City employees have trouble accessing the system, how will this be reported? | |
| 27 | Can you provide statistics of how often and the length of time that your forms submission system has been down in the past year? | |
| 28 | Describe your experience pre-populating employee data in DWC 1, 3, and 6 forms. | ATTACH TO PROPOSAL |
| 29 | Indicate the lag time from the time a DWC-1 is entered into your system and the time a claim number is generated. | |
| 30 | Indicate the lag time from the time a DWC-1 is entered into your system and the time that DWC-3 and DWC-6 forms can be entered. | |
| 31 | After a form is entered into your system, will the City employee receive some type of notification that the form was successfully submitted? | |
| 32 | Describe your system capability for generating reports and data to include any advanced analytics that are available. | ATTACH TO PROPOSAL |
| 33 | Describe all standard reports available to the city and provide sample reports. Include, at a minimum: claim inventory, new and closed, litigation reports, performance quarantee & compliance reports, financial reserve reports, medical only & indemnity reports. | ATTACH TO PROPOSAL |
| 34 | What type of platform or technology will you be providing for the City to receive all the required reports? | |
| 35 | Verify that you have reviewed Section IV.S.1 # a-r Reports and that you have the capability to generate all the required reports; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| 36 | Verify that you have reviewed Section IV.S 2. a-f Meetings and Section IV S.3.a-e Audits and will be in compliance; any provisions that vendor disagrees with have been identified in Tab 2 of this workbook. | |
| # | Communication with the Injured Employee | Vendor Response |
| 36 | In 2 pages or less, describe any mobile apps, IT portals, or websites that are currently available that the injured employee will have access to and the type of information that can be communicated back and forth between the TPA and the claimant. | ATTACH TO PROPOSAL |
Tab 10
| Claims Admin Services Not To Exceed Fee | |||||
| All vendors must complete this section. Failure to complete a Not To Exceed Fee shall result in the rejection of your proposal. | |||||
| All costs that are not directly charged to a claim file are required to be shown here and included in the Not to Exceed Fee. | |||||
| Use the blanks in the chart below to add any charges or fees that are not specifically listed. | |||||
| Any costs that are one-time charges should be shown in the accurate contract year and leave the other year's blank. | |||||
| SERVICE ITEM | CONTRACT YEAR 1 | CONTRACT YEAR 2 | CONTRACT YEAR 3 | CONTRACT YEAR 4 | CONTRACT YEAR 5 |
| Claims Administration Services -- to include all positions required fromScope of Work Section I.1. |
| MIS |
| DWC Carrier Rep Fee |
TOTAL NOT TO EXCEED FEE
File details come from the government source that posted it. Updated .