EXHIBIT "A"
SCOPE OF SERVICES
1. Claims Management Services
ADMINISTRATOR shall:
a. Make initial contact with claimant and establish a numbered claim file within 24 hours of receipt of the Employers' First Report of Injury from CITY. (CITY prefers to transfer this form electronically.) These files shall be available for review by CITY at anytime during ADMINISTRATOR's regular business hours, preferably electronically through a remote access terminal with viewing capability.
b. Administer the provision of entitlements of workers' compensation benefits under State Labor Code in a timely and accurate manner. Any and all penalties incurred as a result of the failure of ADMINISTRATOR to comply with statutory laws and/or administrative regulations shall be the sole responsibility of ADMINISTRATOR. The only exception will be those requests made to ADMINISTRATOR in writing by CITY for specific action on a file.
c. Discuss any unusual claims promptly with Risk and Insurance Division staff and make any necessary contact with the injured employee and his or her manager or supervisor if additional information regarding the claim is required. (CITY is placing increased responsibility on the role of the manager and supervisor in each department in occupational injuries.)
d. Maintain accurate and timely loss runs and occupational injury data, using a format and system acceptable to CITY, and establish adequate reserves and post indemnity, 4850, 5850, medical, vocational rehabilitation benefits and loss adjustment expenses. Each of these records shall be individually itemized on any loss information reports.
e. Reduce all medical bills, other than medical legal expenses, to the Relative Value Schedule (RVS) and recommended rates set by the Administrative Director, Division of Workers' Compensation. CITY will make any selection of the vendor used.
f. Upon request, provide input to CITY which CITY may use to select defense and subrogation counsel. CITY currently uses the services of several local workers’ compensation law firms.
g. Proceed against all responsible persons and/or agencies in subrogation actions in an effort to recover losses suffered by CITY due to injuries or illnesses inflicted on its employees and volunteers. Such actions can be referred to specific legal counsel or alternative claims agency, if agreed to by CITY.
h. Investigate all questionable claims with the coordination and assistance of Risk and Insurance Division staff. Provide advance notice and explanation to the Risk and Insurance Division of any claim which may be denied by the claims examiner. Denial and acceptance of claims decisions is a joint process under the law involving ADMINISTRATOR and CITY.
2. Closing of Claims
ADMINISTRATOR shall process and close claims expediously, such that CITY's claim examiner does not have a caseload of open indemnity files at any one time that exceeds 150 files.
All closed files shall remain the property of CITY and shall not be disposed of without CITY's prior authorization. CITY shall have the option of relocate such files from ADMINISTRATOR's storage location to CITY. CITY will not pay costs or fees associated with the transfer of closed files to CITY or its agent.
ADMINISTRATOR shall:
a. Close claims for which all medical and indemnity payments within ninety days of the last benefit payment, whenever possible.
b. Maintain closed files pursuant to State Labor Code provisions.
c. Meet on a regular or quarterly basis with CITY staff to discuss closing of claims.
3. Additional Services
a. Upon request by CITY, ADMINISTRATOR's claims examiner shall attend selected Workers' Compensation Appeals Board hearings, status conferences and trials along with depositions, conferences with legal defense counsel, and meetings with CITY staff, departments and employee groups.
b. Prompt and responsive written, oral and in person communication by the claims examiner with CITY staff is required. Communications with CITY employees is of particular concern to CITY. ADMINISTRATOR may communicate with CITY employees via e-mail but copies of messages to employees shall be sent to CITY's Risk and Insurance Division.
c. At ADMINISTRATOR's expense, ADMINISTRATOR shall provide all forms, posters, and pamphlets required by the State Labor Code and the Administrative Director for the processing of claims and benefits information. ADMINISTRATOR shall prepare and file the Public Entities Self-Insured Annual Report.
d. ADMINISTRATOR shall report immediately to CITY's excess insurance carrier any claim that meets immediate reporting criteria as established by the excess insurance carrier, with a copy to CITY. ADMINISTRATOR shall provide all requested information to CITY's excess insurer and submit requests for reimbursements on behalf of CITY.
e. ADMINISTRATOR will fully cooperate with, provide requested information to, and respond to recommendations and findings of CITY and the excess carrier audit and actuary consultants.
f. ADMINISTRATOR shall complete and provide to CITY all required Cal/OSHA logs and Summary of Occupational Injuries and Illness reports. ADMINISTRATOR shall meet with and liase with CITY Loss Control and Occupational Health and Safety Analyst to identify potential loss problems or trends. Automated reporting in this area is important to CITY.
g. ADMINISTRATOR shall comply with CITY's Best Practices Plan, where applicable, and shall make recommendations to CITY for plan improvements and enhancements on an ongoing basis.
4. Medical Cost Control
a. ADMINISTRATOR shall provide details of medical service cost savings resulting from ADMINISTRATOR-maintained Preferred Provider Network, if applicable, on a quarterly basis. ADMINISTRATOR shall provide details of medical facility cost savings resulting from any ADMINISTRATOR-maintained Preferred Provider Network. ADMINISTRATOR shall also provide details of cost savings resulting from ADMINISTRATOR operated/contracted bill review activities.
b. Medical control on litigated claims shall remain with ADMINISTRATOR but with full communication to CITY. Mutual agreements with CITY will have to be made on the use of any Agreed Medical Examiners (AME) on individual or case- by-case basis.
5. Litigation
a. ADMINISTRATOR shall closely monitor litigation efforts and make regular reports to CITY. CITY's Risk and Insurance Manager shall authorize, in adance, any and all depositions, investigative and subrosa activities.
b. CITY's Risk and Insurance Manager or the Director of the Department of Human Resources shall approve any settlement of a litigated claim at least fourteen days in advance of its being presented or negotiated with claimant's attorney.
c. Prior to any settlement conference, ADMINISTRATOR and/or defense counsel, whichever is appropriate, shall provide a written analysis of the case, including options and recommendations for settlement. All permanent disability rating shall be defined in dollars and degree of disability. ADMINISTRATOR shall inform CITY of all settlement offers received from the claimant or claimant's attorney. Sunnyvale City Council approval is required for all settlements over $50,000.
d. ADMINISTRATOR shall inform CITY within twenty-four hours of receipt of any hearing, conference, or trial dates set by the Workers' Compensation Appeals Board. When an application for adjudication has been filed, an effort will be made by ADMINISTRATOR to settle the claim without assigning it to defense counsel.
e. ADMINISTRATOR shall establish controls and procedures to manage and contain the cost of defense.
6. Financial Matters/Accounting
a. A trust fund or account in the name of CITY and/or ADMINISTRATOR will be maintained for the purpose of paying benefits and entitlements that may be due on claims presented.
ADMINISTRATOR shall draw from that account or fund to make payments due on accounts payable and to make benefit payments; or a payment request process may be used to initiate payment, as appropriate, by CITY. Additionally, ADMINISTRATOR may be asked to open an account at a Union Bank as designated by CITY and maintain a zero balance account which will be funded by a wire transfer, as needed.
ADMINISTRATOR shall meet with CITY's Accounting Officer, or her designee, and CITY's Risk and Insurance Manager to determine all processes and procedures relative to this account. All agreed-upon processes and procedures shall be confirmed in writing.
b. ADMINISTRATOR shall provide to CITY's Risk and Insurance Manager a monthly check/voucher payment register of all transactions made for the period and a copy of all check vouchers or warrants drawn by ADMINISTRATOR to pay benefits and entitlements. CITY reserves the right to conduct an annual financial audit of the trust account to ensure the integrity of the account.
7. Data Processing/Loss Reporting
a. ADMINISTRATOR shall convert and/or establish loss run data base and transfer files from previous ADMINISTRATOR
b. ADMINISTRATOR shall provide a computer-generated loss run analysis/summary report for each month throughout the contract term covering activity on all newly reported, open and newly closed claims for the period. This report shall be customized to meet CITY needs and shall, at a minimum, provide the following information by claim year:
c. All records, files, transcripts, and computer tapes, including loss run data base files and other materials related to the management and administration of CITY's workers' compensation claims, are the property of CITY and shall be relinquished in good order and condition upon termination of the contract with ADMINISTRATOR.