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<br />Exhibit A <br /> <br /> <br />The following Claims Administration Performance Standards have been adopted by the City of Redwood <br />City. <br /> <br />n------I~-n----f'.-m;elnad' . Each examinersitallhavea-caseload noHoex-ceed 150 open-Îndemnityue-laÏms. Eaeh <br />claims assistant shall have a case load not to exceed 300 open medical only claims. The <br />supervisor shall have a case load not to exceed 30 open indemnity claims. <br /> <br />2. <br /> <br />Forms' The TPA shall provide all forms necessary for the processing of benefits or claims <br />information including the Employer's Report of Injury, DWC Form 1, return to work slips, <br />vouchers, checks, and other related forms. The cost of providing these forms shall be included <br />within the contract price. <br /> <br />3. <br /> <br />Claim File Set TIp and Diary Review' Upon receipt of the Employer's Report ofInjury, the TPA <br />will prepare an individual claim file within two (2) working days for each claim. All claim files <br />shall be reviewed at least every forty-five (45) calendar days for active claims and at least every <br />six (6) months for claims that have settled but are open for the employee's future medical care. <br />The examiner shall distinguish the regular diary review from routine file documentation in the <br />computer notepad. The supervisor shall monitor the diary reviews by printing a "No Activity" <br />report each month to identify any files that have fallen off the diary system. <br /> <br />4. <br /> <br />Employer Contact. The TPA shall request the Employer's Report of Injury form when or if <br />notification of an injury or incident by any source is received first (i.e., Application of <br />Adjudication, notice oflegal representation, Doctor's First Report ofInjury, etc.). <br /> <br />The TPA will confirm the DWC Form 1 was given to the employee within one (1) working day <br />of knowledge of the injury. Ifthere is no evidence the form was provided, the TPA will provide <br />the form with the initial contact letter to the employee within three (3) business days of receiving <br />the claim. <br /> <br />The TP A shall contact the City within one (1) working day of receipt of notice of a lost time <br />claim by any source. Such contact with the City shall be documented in the computer notepad <br />after the claim has been created in the system. <br /> <br />When a claim reaches or exceeds one half of the City's SIR in total incurred value, the TP A shall <br />report to the City, with a copy to the Workers' Compensation Program Manager, every ninety <br />(90) days regarding the status of the claim. Such report shall include the examiner's plan of <br />action for the future handling of the claim. <br /> <br />The examiner will provide on-site file reviews quarterly if requested by the City. Other periodic <br />on-site file reviews will be scheduled based upon the needs of the City. <br /> <br />City of Redwood City Performance Standards <br /> <br />Page 1 of7 <br /> <br />April 28, 2006 <br />