TuolCo_WC_Performance_Standards.pdf

PERFORMANCE STANDARDS

The following performance standards establish the minimum requirements and level of service to be provided by the third-party claims administrator (TPA) in delivering claims adjusting services and related activities to the County. The TPA agrees that all duties and responsibilities contained within the performance standards will be provided to the County at no additional cost unless otherwise specifically noted herein and agreed to by both parties. The performance standards and expectations below shall be in conjunction with PRISM’s Addendum A Claims

Administration Standards, whichever is more stringent for each criterion.

1. Caseload

Each examiner shall have a caseload not to exceed one hundred and twenty-five (125) open indemnity claims, which includes future medical claims (weighted as 2:1). The supervisor shall not carry a caseload.

The TPA shall provide a computer-generated quarterly caseload report to the County

Administrator for all examiners handling County claims. The report shall include all clients and claims each examiner is handling and shall be provided to the County Administrator electronically within ten (10) business days of closure of the previous month.

2. Claim File Set Up

Upon receipt of the Employer’s Report of Occupational Injury or Illness or Application for

Adjudication of Claim, the TPA will prepare an individual claim file within one (1) business day for each claim. Preparation of the claim file shall include entering each new claim into the computer system and establishing appropriate initial reserves. Initial reserves will be set based on the facts known at the time the case is entered into the computer and reserve rationale clearly documented in the computer notepad. The file shall be available to the

County for inspection and contain all medical and information on each reported claim.

3. Coverage

The TPA shall verify coverage was provided by the County on the date of injury or illness in accordance with County program dates and governing documents. If applicable, the TPA shall exercise due diligence in joining applicable co-defendants. All activity to verify coverage and join co-defendants shall be clearly documented in the computer notepad.

4. Employer Contact

The TPA shall request the Employer’s Report of Occupational Injury or Illness form within one (1) business day when or if notification of any injury or illness by any source is received first.

If the DWC-1 form has not been received by the TPA within two (2) business days after receiving the Employer’s Report of Occupational Injury or Illness, the examiner will contact the County to ensure the DWC-1 form was given to the employee within one (1) business day of knowledge of the injury. If a DWC-1 form has not been given to the injured employee, the TPA shall immediately send the form directly to the employee.

The TPA shall contact the County within one (1) business day of receipt of notice of a claim by any source to conduct an initial and meaningful investigation. Such contact with the

County shall be clearly documented in the computer notepad.

When a claim reaches or exceeds $100,000 in total incurred value, the TPA shall report to the

County every ninety (90) calendar days regarding the status of the claim. A copy of the claim status report will be provided to the County. Such report shall include a current status of the claim, the examiner’s plan of action for the future handling of the claim, and the current paid to date and total incurred amounts listed by indemnity (broken down by TD and

PD), vocational rehabilitation, medical, and expense categories.

The examiner will provide quarterly file reviews and annual Stewardship reports.

Return phone calls to the County will be accomplished within one (1) business day.

5. Employee Contact

In all non-litigated, lost time cases, where the employee has not returned to work, telephone or personal contact will be established with the injured employee within one (1) business day of receipt of notice of claim. Such contact will continue as often as necessary, but at least monthly. Such contact with the employee shall be clearly documented in the computer notepad.

Return phone calls to employees will be accomplished within one (1) business day.

All correspondence from employees will be responded to within five (5) calendar days of receipt.

6. Compensability

The compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation) and the reasons for such determination will be made and clearly documented in the file within five (5) business days of the receipt of the notification of the loss. Delay of benefit notices shall be mailed in compliance with the

Division of Industrial Relations’ guidelines. Copies of benefit notices will be maintained in the applicable claim file. The TPA shall obtain authority from the County to delay or deny a claim. The County’s authorization shall be clearly documented in the applicable claim file or in the computer notepad.

In no case shall a final compensability decision be extended beyond seventy-five (75) calendar days for presumptive claims or ninety (90) calendar days from the County’s knowledge of the claim.

7. Investigations

The TPA shall promptly initiate investigation of issues identified as material to potential litigation. The County shall be alerted to the need for an outside investigation as soon as possible and the examiner shall appoint an investigator who is acceptable to the County. The

County shall be kept informed on the scope and results of all investigations. All activities shall be clearly documented in the computer notepad.

9. Reserves

Reserves shall be established based on the facts of the claim and the probable cost of each claim in accordance with OSIP Regulation §15300. A reserve rational for each reserve change shall be clearly documented in the file notes. All reserve categories shall be reviewed on a regular basis but not less than at least every thirty (30) calendar days. The use of a paper or electronic reserve worksheet is required on all claims and a hard copy shall be maintained in the applicable claim file.

10. Payments

The County has established a zero-balance account, which shall at all times contain sufficient funds to enable the TPA to make timely payments of claims, allocated loss expenses, and other amounts the TPA is authorized to make on behalf of County. To comply with the positive pay requirements, the TPA shall electronically submit the information required by the County with each check run. The submissions will be at no additional cost to the County.

11. Collections

All collections will be logged and posted to the file but will be sent to the County with accompanying support for deposit. The support will list the date the collection was posted to the claim file. No County refunds or other collections will be deposited by the TPA in any TPA or client accounts.

12. Provision of Benefits

The TPA shall provide all compensation and medical benefits in a timely manner and in compliance with the statutory requirements of the California Labor Code. The TPA shall compute and pay temporary disability benefits to injured employees based upon earnings information and authorized disability periods. Disability payment amounts must be reported to the County, along with the number of expected payments and the anticipated final payment date, within 1 day of the first payment being issued. This same information must be communicated to the County within 1 day anytime the payment amount changes. The TPA shall review, compute, and pay all informal ratings, death benefits, Findings and Awards, life pensions, or Compromise and Release settlements. All such benefits shall be paid from the

County’s established zero-balance account that will be linked to County’s “positive pay” account.

13. Initial Indemnity Payment

The initial indemnity payment or voucher will be issued and mailed to the injured employee together with a properly completed DWC benefit notices within fourteen (14) calendar days of the first day of disability. Copies of benefit notices will be provided to the County and

Late payments must include the self-imposed 10% penalty in accordance with Labor Code

Section 4650.

14. Subsequent Indemnity Payments

All indemnity payments or vouchers subsequent to the first payment will be verified, except for those payments where permanent disability is expected beyond ninety (90) calendar days in which case those payments will be verified in ninety (90) day increments. All disability payments will be issued in compliance with Labor Code Section 4651.

Late payments must include the self-imposed 10% penalty in accordance with Labor Code

Section 4650.

Copies of benefit notices issued with subsequent benefits will be provided to the County and

15. Medical Administration

The TPA, absent a Medical Provider Network (MPN), shall select a panel of general practitioners, specialists, hospitals, and emergency treatment facilities to which injured employees should be referred and regularly review and update the panel.

The physician’s office will be contacted within one (1) calendar days of notice of all new claims to conduct an initial investigation as to the medical aspects of the claim and discuss the County’s return-to-work goals. Such contact will continue as needed during the continuation of temporary disability to assure that treatment is related to a compensable claim and clearly documented in the computer notepad.

The TPA shall maintain contact with treating physicians to ensure employees receive proper medical treatment and are returned to full or modified employment at the earliest possible date. The TPA shall ensure that the injured employee continues to treat until a full discharge is received.

The TPA shall maintain direct contact with medical providers to ensure their reports are received in a timely manner.

The TPA shall arrange medical evaluations when needed, reasonable, and/or requested in compliance with the current California Labor Code.

The TPA shall ensure that medical bills are reduced to the Official Medical Fee Schedule

(OMFS) and recommended rates established by the Administrative Director of Workers’

Compensation. The use of a service contractor is acceptable provided approval is first obtained from the County. County shall pay for the use and benefits of the services provided; however, fees charged by the service contractor shall have been approved by the

County prior to the provision of and payment for services. The County will approve the service contractor’s fees on a monthly basis prior to payment by the TPA to the service provider. Such fees will be charged to the applicable claim file and will be paid from the medical category.

The TPA shall provide, at County’s expense, utilization review and/or professional managed care services on an as-needed basis to injured employees, provided County and/or the

County’s approval is obtained prior to the provision of such service. The use of a service contractor to provide this service is acceptable provided County’s approval is first obtained.

Such fees will be charged to the applicable claim file and will be paid from the medical category. Establishment of the UR referral criteria shall be approved by County prior to implementation and submission to the state as part of the County’s UR Plan.

The TPA will notify and ensure the County receives copies of all work status updates, with work restrictions listed, and all other medical status updates, such as Permanent and

Stationary determinations, within 1 day of receiving them.

16. Medical Payments

Medical bills will be reviewed by the assigned claims examiner, assistant, or supervisor for correctness, approved for payment, and paid within time limits established by Labor Code

Section 4603.2. If all or part of the bill is being disputed, the TPA will notify the medical provider, on the appropriate form letter, within time limits established by Labor Code Section

4603.2.

17. Transportation Expense

Transportation reimbursement will be mailed within five (5) calendar days of the receipt of the claim for reimbursement. Advance travel expense payments will be mailed to the injured employee at least ten (10) calendar days prior to the anticipated date of travel.

18. Return-to-Work

The TPA shall provide assistance to the County in coordinating return-to-work program information that is appropriate for injured employees while recovering and prior to their return to regular duties.

The TPA shall notify County immediately upon receipt of an employee’s permanent work restrictions so that the County can determine the availability of permanent modified or alternative work. The method of notification shall clearly be documented in the computer notepad within one (1) business day.

The TPA shall consult with the County on a bi-weekly basis in those cases where the injury residuals might involve work restrictions and assist the County in the provision of modified duty when appropriate.

Should County contract with a vendor to assist with return-to-work, the TPA shall cooperate with the assignment of cases or the provision of information in order to help facilitate a successful return-to-work program.

19. Permanent Disability

The TPA shall provide information and assistance to injured employees in completing the necessary forms to obtain a permanent disability rating.

The TPA shall determine the nature and extent of permanent disability and arrange for an informal disability rating whenever possible to avoid Workers’ Compensation Appeals Board

(WCAB) litigation. The TPA shall take advantage of any potential apportionment potential to prior claims, disabilities, and impairments. The TPA shall also advise the County of potential credits and penalties to permanent disability benefits should the County accommodate permanent/alternative work for at least twelve (12) months.

Permanent Disability benefits shall be provided in accordance with Labor Code Section

4658. All permanent disability benefit notices shall be sent to the employee as required by the California Labor Code. Copies of benefit notices will be maintained in the applicable claim file and provided to the County.

20. Vocational Rehabilitation

In accordance with all applicable California laws in place at the date of injury, the TPA shall:

A. Determine the Qualified Injured Worker/Non-Qualified Injured Worker status;

B. Advise the injured worker of his/her right to rehabilitation benefits;

C. Provide appropriate vocational rehabilitation benefits;

D. Control rehabilitation costs;

E. Attempt to secure the prompt conclusion of vocational rehabilitation benefits; and

F. Provide notification to the County should work restrictions require a permanent or modified accommodation.

21. Diary Review

All claim files shall be reviewed at least every thirty (30) calendar days for active claims and at least every three (3) months for claims that have settled but are open for the employee’s future medical care. The examiner shall distinguish the regular diary review from routine file documentation in the computer notepad. A plan of action will be included and separately labeled in the file notes during a diary review. The plan of action shall include, but not limited to, the employee’s current work status, medical status, review of reserves, and future activity to move the claim towards resolution. The TPA shall monitor the diary reviews by printing a “No Activity” report each month to identify any files that have fallen off the diary system. The TPA will provide to the County a copy of the “No Activity” report referenced in

Section 39, “Loss Runs”, of this document by the 10th calendar day of each month.

22. Plan of Action

Each claim file shall contain the examiner’s plan of action for the future handling of that claim. Such plan of action shall be clearly stated including the reasoning for the plan. The plan of action will be updated with each new work status, and at least every thirty (30) calendar days during the diary review if no work status is received, and clearly identified in the computer notepad. The initial plan of action will be clearly documented in the computer notepad within fourteen (14) calendar days of the initial claim set-up.

23. Claim Supervision

The TPA shall provide supervisory staff that will regularly review the work product of the examiners. The supervisor shall review each examiner’s caseload, indemnity every 120 days and future medical every 180 days, to ensure each examiner is following these performance standards. In addition, the supervisor shall conduct a regular quarterly review of all open indemnity claims with reserves in excess of $100,000 and all problem or complex claims.

Such reviews shall be labeled as “Supervisor Review” and clearly documented in the computer notepad.

24. Status Reports

Other than the reports identified in Section 5, (Employer Contact) and Section 39 (Loss

Runs) of this document, claim status reports requested by the County shall be provided by the

TPA to the County within ten (10) business days. Verbal status reports requested by the

County shall be provided by the TPA within two (2) business days. Computer generated loss data reports shall be provided within twenty (20) business days.

25. Claim Reconciliation

All claim files shall be reconciled to ensure all indemnity payments have been made correctly. The reconciliation should verify that payments were made in the correct amount and from the correct claim file. The physical file should be verified with the computer information. All open claim files shall be reconciled semi-annually and at the time of submission for closure. Proof of the reconciliation should remain in the claim file and clearly documented in computer notepad.

26. Settlements

The TPA shall obtain the County’s authorization on all settlements. The TPA or defense counsel shall forward settlement proposals to the County in a format approved by the

County’s Workers’ Compensation Administrator. All requests for settlement authority shall be clear and concise (easily understandable to the elected officials that sit on our Board of

Supervisors) and include a written claim analysis, estimate of permanent disability, and the defense counsel’s comments and recommendations.

27. Award Payment

Payments on Awards, computations, or Compromise and Release agreements will be issued within ten (10) business days or sooner, if necessary, to ensure payment within twenty (20) calendar days of the WCAB approval date, following receipt of the appropriate document.

28. Future Medical Claims

Claims that remain open to monitor future medical care shall remain open for two (2) years from the last payment of benefit in accordance with OSIP Regulations §15400.2. Reviews shall be documented in the claim notes to include settlement information, future medical care outline, last date and type of treatment, name of excess carrier, excess carrier reporting level, and excess carrier reporting history. Reserves for future medical treatment will be reviewed every six (6) months and adjusted for use over a three (3) year average and the injured employee’s life expectancy based on the latest version of the U.S. Life Table in accordance with OSIP Regulations §15300. The reason(s) and calculation(s) for the adjustment(s) shall be clearly documented in the computer notepad.

29. Subrogation

In all cases where a third party is responsible for the injury to the employee, the TPA will consult with the County to determine if subrogation should be pursued. The TPA will send a letter to the County indicating they will pursue subrogation unless instructed otherwise by the

County. When subrogation is to be pursued, the third party shall be contacted within ten (10) business days with notification of the County’s right to subrogation and the recovery of certain claim expenses. If the third party is a governmental agency, a claim shall be filed with the governing agency within six (6) months of the injury or notice of injury.

Periodic contact shall be made with the responsible third party and/or insurer to provide notification of the amount of the estimated recovery to which the County will be entitled.

If the injured worker brings a civil action against the party responsible for the injury, the

TPA shall consult with the County about the value of the subrogation claim and other considerations. If subrogation rights are waived, the TPA shall obtain written authority from the County. Upon the County’s authorization, subrogation counsel shall be assigned to file a

Lien or a Complaint in Intervention in the civil action. Upon assignment of the case to an authorized subrogation attorney, the TPA shall request a “not to exceed” estimate of fees for such representation. The fees shall be authorized by the County prior to commencement of work by counsel. Should the “not to exceed” fees be reached, the TPA shall be responsible for obtaining continuing authority prior to incurring additional costs. Such contact with the

County shall be documented in the computer notepad. Should the costs exceed the estimated fees without proper verbal authority from the County, the TPA may be responsible for reimbursement to County for the additional cost(s).

Whenever practical, the TPA should take advantage of any settlement in a civil action by attempting to settle the workers’ compensation claim by means of a Third Party Compromise and Release. If such attempt does not succeed, then every effort should be made through the

WCAB to offset claim expenses through a credit against the proceeds from the employee’s civil action.

30. Litigated Cases

TPA shall promptly initiate investigation of issues identified as material to potential litigation. The County shall be alerted to the need for an outside investigation as soon as possible and the examiner shall appoint an investigator who is acceptable to the County. The

County shall be kept informed on the scope and results of all investigations.

When defense counsel is not necessary, the TPA shall work closely with the applicant’s attorney in informal disposition of litigated cases. All assignments to outside counsel will be done with the County’s authorization and consent. The TPA shall prepare clear and concise litigation referrals to outside counsel outlining the issues of the claim and duties that will be handled by defense counsel. Such referral will be documented in the TPA’s computer notepad. In conjunction with the County, the TPA shall monitor the outside counsel’s progress. The TPA shall audit all defense counsel’s bills before payment is authorized.

Defense counsel shall provide to the TPA, with a copy to the County, an initial case analysis and a plan of action within ten (10) business days of the assignment.

All preparation for a trial shall involve the County so that all material evidence and witnesses are utilized to obtain a favorable result for the defense.

The manager, supervisor, or the examiner shall attend WCAB hearings, rehabilitation hearings, other court proceedings, meetings with defense counsel, and meetings with

County’s staff, departments, and employee groups as necessary and as requested to do so.

31. Fraudulent Claims

The TPA shall consult with the County regarding any claim believed to be fraudulent prior to referring to TPA’s in-house special investigation unit for further investigation and potential referral to the District Attorney. If TPA does not have an in-house special investigation unit, the claim will be referred to an investigator, with the County’s prior approval, to conduct further investigation.

32. Excess Insurance

Cases that have the potential to exceed County’s self-insured retention shall be reported in accordance with the reporting criteria established by the excess insurance policies. All cases that meet the established reporting criteria are to be reported within five (5) business days of the day on which it is known the criterion is met. A copy of the submission to the excess carrier shall be forwarded to the County until such time the TPA is instructed otherwise.

Any related excess reimbursements will be posted to the file and the payment will be forwarded to County for deposit.

33. Penalties

Late payment of all benefits must include the self-imposed penalty in accordance with

California law. The TPA will provide the County a quarterly listing of any administrative penalties paid the quarters ending March 31, June 30, September 30, and December 31, which were the responsibility of the TPA, and a check from the TPA payable to County for reimbursement. The check and report shall be submitted to the County by the 20th of the following month after the quarter ends. Evidence of the penalty reimbursement shall be noted within the claim file and posted within the payment detail as a recovery/ reimbursement.

34. Case Closure

The supervisor must review all medical only claims open beyond ninety (90) calendar days from the date of entry by the TPA for potential closure or conversion to indemnity claim status. All indemnity cases, where permanent disability is not an issue, will be closed within sixty (60) calendar days of the final financial transaction or final correspondence to the injured worker as required by law. All indemnity claims, where permanent disability is an issue but not settlement, will remain open for two (2) years from the last payment of benefit and then closed within sixty (60) calendar days of that date.

35. Forms

The TPA shall provide all forms necessary for the processing of benefits or claims information including the Employer’s Report of Occupational Injury or Illness, DWC-1, medical service orders, return-to-work slips, lost time information reports, vouchers, checks, and other related forms. The cost of providing these forms shall be included within the contract price set forth in this AGREEMENT.

36. Computer Access

The TPA shall provide online access to claims data at no additional charge to the County.

Such data shall be in a format accessible from County computers and will permit the County to print copies of the data on its printers. The TPA shall provide training for use of the system for County Staff. If the County, under the TPA’s guidance, is not able to maintain online interface with data maintained by the TPA, the TPA may be required to provide a digital copy of all data processed during the previous month by another means by the tenth

(10th) calendar day following month end.

37. Reporting Services and Record Retention

The TPA will provide, and train to interpret, the County with regular monthly and quarterly reports in the format and number requested. The reports may be provided in hard copy, excel, or via online access.

Such reports include, but may not be limited to, the following:

• Loss Experience Reports

• Location Report

• Growth Analysis and Loss Narrative Report

• Management Summary Reports

• Weekly Claims Register

• Monthly Claims Summary Reports

• Monthly Claims Register Reports

• Annual Report to the State

• Annual Tax Statements, including Federal Form 1099 and State form 599 as appropriate

• Large Loss Reports – Over $25,000 and $100,000

Additional reports and lists that must be available include:

• List of Providers –Including the data in the correct format for County to prepare the

IRS 1099s.

• Litigated Claims

• Investigated Claims

• Claims involving subrogation

• Vocational Rehabilitation Claims

• Medical Case Management Claims

• First Aid Claims

• Excess Insurance Claims

• Total Incurred for open and closed claims

Annual Report – Prepare the Public Entities Self-Insurer's Annual Report as required by the

Department of Industrial Relations Office of Self-Insurance Plans; and submit it to County no later than 30 days prior to the due date.

The TPA shall maintain all loss information as required by the Workers’ Compensation

Insurance Rating Bureau.

The TPA shall assist in the preparation of all reports that are now, or will be, required by the

State of California or other government agencies with respect to self-insurance programs.

The TPA will also assist in the preparation of all reports for other statistical database organizations or excess coverage provider as requested by the County.

38. Records Retention

All claim files shall be maintained in accordance with statutory time requirements and the

County’s Record Retention Policy. The County shall be notified prior to any destruction of files to determine if the County wishes to retain the claim file.

All records, products and all claim files shall be the property of the County. The TPA shall be responsible for providing records to the County upon request. The TPA shall make claim files available to the County upon request and shall be delivered to the County upon termination of the agreement at no additional charge.

39. Loss Runs

The TPA shall, at its expense, by the tenth (10th) calendar day of the following month, unless otherwise specified below:

A. Provide the following information monthly to the County:

i. A listing of all open claims showing the employee’s name, claim number, date of injury, paid amount, future liability, total incurred, and any amounts recovered;

ii. OSHA 300 and 300A logs or a listing of all information needed for the County to complete the OSHA 300 and 300A logs. The logs or report shall include claims where temporary disability benefits were paid during the applicable month showing the paid-to-date amounts, from and through dates of temporary disability benefits paid, claim number, and date of injury; and

iii. A summary listing by fiscal year to include, but not limited to, paid to date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim.

B. Provide the following information monthly to the County electronically in Excel format:

i. All open and closed claims run by fiscal year and then alphabetically, to include the employee’s name, claim number, date of injury, occupation, text description of the injury, number of days temporary disability benefits were paid, future liability or reserves separated by type, any amounts recovered for subrogation or excess insurance, free form text description of the claim and descriptions of cause, site, and nature;

ii. A summary listing run alphabetically and then by year showing paid to date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim;

iii. A summary listing run by year showing paid-to-date amounts, future liability or reserve amounts, total incurred amounts, number of open claims, number of closed claims, and average cost per claim;

iv. A check register, excluding vouchers, in check number order, including any voids, refunds, and recoveries received with a page showing the total payments for the month by fiscal year;

v. A check register, including all activity, in check number order, including any voids, refunds, and recoveries received with a page showing the total payments for the month to be run by department and then fiscal year;

vi. A voucher register run by fiscal year and then by department; and

vii. A “No Activity” report listing the claims that have had no activity during the previous six (6) months. The report components should include no reserve changes, no payments, no recoveries, no refunds, and/or no computer notepad activity.

C. Provide the following quarterly reports, in addition to the regular monthly reports electronically in Excel format:

i. A listing of any administrative penalties paid during the quarter that were the responsibility of the TPA.

D. Provide a fiscal year-end report. The report shall include all open and closed claims run by fiscal year and then alphabetically, to include the employees’ name, claim number, date of injury, occupation, text description of the injury, number of days temporary disability benefits were paid, future liability or reserves separated by type, and any amounts recovered for subrogation or excess insurance; and

E. Provide other special reports required by the County including, but not limited to, loss trend reports, claim abstract reports, reports required by actuaries, excess insurance carriers, etc., provided that such reports do not require data elements that have not previously been collected by the TPA on behalf of County. If new programming is required in order to provide such reports, the TPA shall pay at its own expense for new or special programming costs.

Any corrections to the loss runs shall be made within thirty (30) calendar days of the request for correction.

40. Availability of Personnel

The TPA shall maintain at all times, one (1) or more of the examiners assigned to the

County’s claims, or in their absence, the supervisor or management above the supervisory level, to be available by telephone for emergencies through a 24-hour emergency telephone number. The TPA shall provide a toll-free telephone number at no additional charge.

The TPA shall ensure at least one (1) or more examiners are available to the County every business day.

41. County Services

The TPA shall provide special on-site training services annually to County staff to ensure that workers’ compensation claims are being effectively processed and staff are carrying out the procedures required for a successful program.

The TPA shall require its examiners or other TPA personnel, as necessary, to attend County’s meetings, if requested, to report on the general state of the program since the last meeting and on any particular cases of interest to the County. The TPA may require the supervisor or other TPA personnel, as necessary, to attend County’s meetings to report on the general state of the program since the last meeting and on any particular cases of interest to County.

The TPA shall consult annually with the County on the establishment and coordination of necessary procedures and practices to meet the needs of the County with respect to the administration and processing of claims.

The TPA shall require one of the examiners or supervisory staff to meet with County personnel, at the County’s location, at least once annually to review program procedures regarding workers’ compensation reporting requirements and other program matters that require the timely participation of the County.

The TPA shall require an examiner to be available and readily respond to the County’s request for assistance with problem cases, including on-site visits to the County.

The TPA shall provide the County with information regarding statutes, proposed changes to statutes, and changes to the rules and regulations affecting County and its responsibility as a legally self-insured entity.

The TPA shall assist in developing and recommending policies and procedures in areas as required by County.

42. Employee Services

As required, the TPA will develop, for review by County, materials which will provide information and guidance to County employees regarding workers’ compensation and the self-insurance program.

As required, the TPA will meet with and assist injured employees in resolving problems that arise from injury or illness claims.

43. Examiner Training

The TPA shall annually certify to the County that each claims examiner handling the

County’s claims is in compliance with all legal and regulatory licensing and continuing educational requirements as presently or in the future shall be promulgated and required by the State of California. Such certification for the prior year shall be in the form of a letter to be received no later than April 1 of each year.

44. Right to Audit or Review

The County, or its designated representative, is authorized to visit the TPA’s processing and/or storage premises, for purpose of performing a claims audit or review. Additionally, the TPA will undergo claims audits by PRISM or their contracted auditor. Any assistance or service provided in response to a claims audit described above will be rendered at no additional cost to the County.

44. Legislative and Judicial Activity

The TPA shall keep the County informed as to recent changes or proposed changes in statutes, rules, laws and judicial decisions affecting the County’s responsibility and the responsibilities of its personnel under a self-insured Workers’ Compensation program.

45. Conflict of Interest

The TPA shall avoid all conflicts of interest or appearance of conflicts of interest. If, during any given year, the TPA receives compensation from any party for services included in its agreement with the County, such as bill review services, managed care, or investigations, the

TPA shall disclose total compensation received in prior year. Such disclosure shall be in the form of a letter and shall be received by the County no later than April 1 of each year.

These performance standards may be modified, or additions made prior to execution of a contract, and re-evaluated throughout the term of the contract. All claims handling services shall comply with statutory requirements.