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OIIIINAL Exhibit A BAY CITIES JOINT POWERS INSURANCE AUTHORITY POOLED WORKERS' COMPENSATION PROGRAM PERFORMANCE STANDARDS The following Claims Administration Performance Standards have been adopted by the Bay Cities Joint Powers Insurance Authority (AUTHORITY) Executive Committee: l. Caseload: Each examiner shall have a caseload not to exceed 175 open indemnity claims. Each claims assistant shall have a caseload not to exceed 300 open medical only claims. The supervisor shall have a case load not to exceed 30 open indemnity claims. 2. Forms: The TP A shall provide all forms necessary for the processing of benefits or claims information including the Employer's Report of Injury, DWC Form I, return to work slips, vouchers, checks, and other related forms. The cost of providing these forms shall be included within the contract price. 3. Claim File Set Up and Diary Review: Upon receipt of the Employer's Report oflnjury, the TPA will prepare an individual claim file within two (2) working days for each claim. All claim files shall be reviewed at least every forty-five (45) calendar days for active claims and at least every six (6) 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. The supervisor shall monitor the diary reviews by printing a "No Activity" report each month to identify any files that have fallen off the diary system. 4. Employer Contact: The TPA shall request the Employer's Report of Injury form when or if notification of an injury or incident by any source is received first (i.e., Application of Adjudication, notice oflegal representation, Doctor's First Report ofInjury, etc.). The TPA will confirm the DWC Form 1 was given to the employee within one (1) working day of knowledge of the injury. Ifthere is no evidence the form was provided, the TPA will provide the form with the initial contact letter to the employee within three (3) business days of receiving the claim. The TP A shall contact the member city within one (1) working day of receipt of notice of a lost time claim by any source. Such contact with the member city shall be documented in the computer notepad after the claim has been created in the system. When a claim reaches or exceeds one half of the member city's SIR in total incurred value, the TPA shall report to the member city, with a copy to the Workers' Compensation Program Manager, every ninety (90) days regarding the status of the claim. Such report shall include the examiner's plan of action for the future handling of the claim. The examiner will provide on-site file reviews quarterly if requested by the member city. Other periodic on-site file reviews will be scheduled based upon the needs of the member city. BCJPIA PWCP Performance Standards Page 1 of 7 February 11, 2004 .~ _.~"..