Agmt04 Claims Management BCJPIA - Laserfiche WebLink

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The TP A shall maintain direct contact with medical service providers to ensure their reports are received in a timely manner. The TP A shall arrange medical evaluations when needed, reasonable, and/or requested in compliance with the current Labor Code. The TP A shall ensure that medical bills are reduced to the recommended rates established by the Administrative Director of Workers' Compensation. The use of a service contractor is acceptable provided the City's approval is first obtained. The City shall pay for the use and benefits of the services provided. The TPA shall provide, at the City's expense, utilization review and/or professional managed care services on an as-needed basis to injured employees, provided the member city and/or the City's approval is obtained prior to the provision of such service. 8. Medical Payments: Medical bills will be matched to the file, reviewed 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 TP A will notify the medical provider, on the appropriate form letter, within time limits established by Labor Code 4603.2. 9. 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 will be identified in the computer notepad. 10. Investigation: The TP A shall subscribe to the Index Bureau. The examiner shall request a report from the Index Bureau on all new indemnity claims. Subsequent requests should be made every six (6) to twelve (12) months thereafter on all active indemnity claims. 11. 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 documented in the file within three (3) working days of the receipt of the notification of the loss. Delay or denial of benefit letters shall be mailed in compliance with the Division ofIndustrial Relations' guidelines. The TPA shall notify the member city of delay or denial of any claim. In no case shall a final compensability decision be extended beyond ninety (90) days from the member city's knowledge of the claim. 12. Provision of Benefits: The TP A shall provide all compensation and medical benefits in a timely manner and in compliance with the statutory requirements of the California Labor Code. The TP A shall compute and pay temporary disability benefits to injured employees based upon earnings information and authorized disability periods. The TPA shall review, compute, and pay all informal ratings, death benefits, Findings and Awards, life pensions, or Compromise and Release settlements. City of Redwood City - Performance Standards Page 3 of8 July 1.2004 -- -H- ---,