Workers Compensation Claim Administration

A. Term of Agreement. 1. The initial contract term shall be for three (3) years, with the option to renew for two (2) additional years, in one (1) year increments, not to exceed five (5) years. The Contract term for services shall commence after the date of Council award, the execution of an Agreement for Professional Services and the issuance of a City of Pomona purchase order. Anticipated start date is June 1, 2022. This start date is subject to change.B. Program Administration1. Program Administration includes the providing of professional and technical staff to perform Workers’ Compensation claims adjusting services.2. Inform City staff of changes in the statutes, laws, rules and regulations that pertain to the City’s Workers’ Compensation claims program.3. Advise City staff of trends or problems areas that could result in an increase in workers’ compensation claims.4. Attend meetings and file reviews with City staff and provide updates on the City’s open cases; conduct seminars and training to City staff in the area of workers’ compensation claims and the state of the current law.5. Provide statistical reports on a monthly basis that depict the claims that have been opened and closed during the past month, the payments that have been issued and the pending workers’ compensation claims including current reserves.6. Complete the TPA portion of the Annual Report.7. Assume responsibility for the completion of OSHA 300 Log, 300A and 301 reports and provide copies of those reports to designated City staff.8. Respond to any requests the City’s excess pool, PRISM, may have with regard to the City’s workers compensation claims program as well as providing any reports the excess pool may request.C. Claim Administration1. Given the City’s current pending claim inventory, it is expected that at a minimum, the City will have 1 full time, fully qualified, certificated/dedicated claims adjuster as well as a claims assistant and separate clerical support assigned to the City’s claim program.2. The assigned claims adjuster shall be fully versed in Labor Code 4850 benefits and the providing of those benefits and shall also perform the following:a. Create and set up new files in the workers compensation claims software program no later than 48 hours after receipt of the notice of claim from the City;b. Conduct 3 point contact with the injured worker, employer and medical provider within 48 hours of receipt of claim;c. Review claim and doctor’s first report of injury to determine whether to recommend acceptance or delay of the claim that is filed against the City;d. Issue the appropriate notices to injured employees as required under the workers compensation provisions in the Labor Code;e. Monitor and pay all medical and legal expenses incurred on the City’s workers compensation files;f. Process all requests for medical treatment through the Utilization Review provider;g. Submit all incurred medical bills to the medical bill review process and recommend payment as necessary;h. Make recommendation to the City’s Risk Manager regarding settlement/disposition of workers compensation claims (all settlement authority rests with the City);i. Review medical reports to determine the extent of permanent disability, if any, that an injured City employee may be entitled to;j. Make recommendation to the City’s Risk Manager regarding the use of an investigator/surveillance;k. File and serve required documents with the Workers Compensation Appeals Board, if appropriate;l. If appropriate, appear before the Workers Compensation Appeals Board;m. Responsible for all CMS 111 reporting and Medicare set asides;n. Work with the City workers compensation defense counsel to achieve a reasonable resolution on all the City’s litigated workers compensation claims;o. If necessary, handle the subrogation aspect of a claim to recover workers compensation costs the City incurs due to the negligence of a third party;p. Report appropriate claim