MB-10472 - USA (California) - Third Party Workers’ Compensation Claims Administration and Managed Care Services - Deadline October 14,2026

(1) Vendor needs to provide third party workers’ compensation claims administration and managed care services.• Claims AdministrationA. Determine liability for claimed injuries and illnesses on a timely basis and in accordance with the California Labor Code;B. Determine eligibility for and authorize payment of medical and indemnity benefits on a timely basis;C. Review, compute, and, after approval by the City, pay all informal ratings, findings and awards, and settlements; arrange for informal disability ratings whenever possible to avoid unnecessary litigation;D. Pay any and all penalties due in accordance with the agency.Such penalties shall be paid by the claims administrator with liability for the action determined by the record unless such penalties were incurred as a result of the City’s action or inaction;E. Establish files containing medical and factual information on each reported claim, together with complete accounting records and maintain in accordance with statutory time requirements;• Bill ReviewA. Review all bills in a timely manner for compliance with applicable fee schedules and reduce accordingly, including those that fall outside of a fee schedule or agency network;B. Identify and reduce all duplicate billings;C. Deny charges for all items not required for injury described;D. Identify all unauthorized charges to insure billing does not exceed parameters of injured workers’ treatment plan;• Utilization ReviewA. Approve or disallow service requests within the applicable time standards and provide medical advice as warranted;B. Provide timely reports to the City outlining utilization review requests, approvals, denials and costs/savings;C. Recommend, for City approval, panels of medical professionals, specialists, and treatment facilities to which injured employees should be referred for long– term or specialized treatment;• Nurse Case ManagementA. Provide telephonic and field case management nurses;B. Maintain close liaison with selected doctors and ensure maximum efficiency in the management of claims by practicing proactive case management and aggressive return–to–duty when clinically feasible– Claim Review and Documentation• Documentation should reflect any significant developments in the file. Each file will contain a current plan of action.