Agmt04 Claims Management Inc - Laserfiche WebLink

Browse Search

25. Penalties: Late payment of all benefits must include the self-imposed penalty in accordance with California law. The AUTHORITY will be provided a listing of any administrative penalties paid during the quarter, which were the responsibility of the TP A, and a check from the TP A payable to the AUTHORITY for reimbursement. 26. Case Closure: The supervisor must review all Medical Only claims open beyond ninety (90) days from the date of entry by the TP A, for potential closure or conversion to Indemnity claim status. Claims with $3,000 (three thousand dollars) or more paid to date and any claim open beyond one hundred eighty days from date of entry must be converted to Indemnity status and a reasonable, precautionary indemnity reserve placed on the claim(s). All indemnity cases where permanent disability is not an issue will be closed within sixty (60) days of the final financial transaction or final correspondence to the injured worker as required by law. All indemnity claims where permanent disability is an issue will remain open for two (2) years from the last payment of benefit and then closed within sixty (60) days of that date. The TPA will monitor stipulated cases with future medical provisions. Reserves for future medical will be reviewed semi-annually and adjusted according to use. 27. Status Reports: Special claim status reports requested by member cities outside the regular 90- day status reports shall be provided by the TP A to the respective city within ten (10) business days. Verbal status reports requested by member cities shall be provided by the TP A to the respective city within two (2) business days. Special computer generated loss data reports requested by member cities shall be provided within twenty (20) business days. 28. Claims Reporting: The TPA shall maintain all loss information as required by the Workers' Compensation Insurance Rating Bureau. The TP A shall assist in the preparation of all reports that are now, or will be required by the State of California or other government agencies with respect to self-insurance programs. The TP A will also assist in the preparation of all reports or databases required by the California Institute for Public Risk Analysis (CIPRA) or other statistical database organizations as requested by the AUTHORITY. 29. Record Retention: All claim files shall be maintained in accordance with statutory time requirements and the AUTHORITY's Record Retention Policy. 30. Claim Supervision: The TP A shall provide supervisory staff that will regularly review the work product of the claims examiners. The supervisor shall review at least ten percent (10%) of each examiner's case load each month to ensure each examiner is following the performance standards outlined in this document. In addition, the supervisor shall conduct a regular quarterly review of all open indemnity claims with reserves in excess of $100,000 and all problem or complex claims. 31. Availability of Personnel: The TPA shall ensure at least one (I) or more of the examiners assigned to the AUTHORITY are on-site and available to the AUTHORITY and its member cities every business day throughout the term of the approved contract between the AUTHORITY and the TPA. BCJPIA PWCP Performance Standards Page 6 of 7 February 11, 2004 --'".-