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["CITY OF KNOXVILLE:  WC/AL/GL TPA RFP Questionnaire - DATE"]
[null,null,"TPA NAME:"]
["TPA MUST SUPPLY RESPONSE TO THE ITEMS BELOW.  PROVIDE EXPLANATION IF CANNOT COMPLY.  SEE ALSO CLIENT RFP DOCUMENT FOR CORRESPONDING QUESTION DETAIL."]
["Q#","Questions ","Response","Detail / Explanation"]
["5.1 CLAIM ADMININSTRATION:  TPA SERVICE & CONTROLS"]
["a.","External Claim Audit; agree to 1/year, a minimum of 50 files by coverage line."]
["b.","Claim Review; minimum 12/year (monthly)."]
["c. ","Staffing Proposal; TPA must supply a clear outline for dedicated/designated teams"]
[null,"Must list adjuster by claim level-type/coverage line, and jurisdiction (ID target caseload for each)"]
[null,"Must identify lead/supervisor for each team"]
[null,"Must identify claim manager for each team"]
[null,"Must include bios for team members where available"]
[null,"Must identify years of experience; industry, TPA, current position for each team member"]
["d. ","Staffing Changes (notice); in advance prior to implementing, within 24 hours when not in advance."]
["e. ","Staffing Changes (screen/approval); the City will be consulted prior to placement and/or assignment."]
["f. ","Account Management; must be a designated, senior level resource "]
[null,"Must include bio "]
[null,"Must disclose location  "]
[null,"Must identify years of experience; industry, TPA, current position"]
["g.","Additional Administration Requirements:"]
[null,"New Loss Intake"]
[null,"Web (primary), Phone (secondary); to include an option for WC 24/7 RN "]
[null,"Reserve Level; $10,000"]
[null,"Settlement Level; $10,000"]
[null,"Caseload"]
[null,"WC (IND/LT) - 126-150 (max)"]
[null,"WC (MED) - 200-225 (max)"]
[null,"LIAB (BI) - 101-125 (max)"]
[null,"LIAB (PD) - 126-150 (max)"]
[null,"TPA must disclose their proposed caseloads by position."]
[null,"Adjuster Experience"]
[null,"WC (IND/LT) - 3-5 years (min)"]
[null,"LIAB - 3 years (min for PD), 5 years (min for BI), 7  years (min for litigated)"]
[null,"TPA must disclose average adjuster experience"]
[null,"TPA must diclose current adjuster turn-over % "]
[null,"Denial; must be reviewed with and issued by the City"]
[null,"Recorded Statements; will be taken on all questionable claims, including witnesses when available"]
[null,"Medical Management; agree to obtain City approval of any referral to MCM"]
[null,"Litigation; provide immediate notice and agree to utilize the City preferred counsel"]
[null,"Surveillance; agree to obtain City approval prior to assignment or referral"]
[null,"Subrogation; agree to obtain City approval prior to the pursuit of any third-party recovery"]
[null,"Expert Opinions; agree to obtain City approval before using any third party experts/services"]
[null,"Outcome Metrics; agree to quarterly scorecard of program results, annual stewardship overall results "]
["5.2 MEDICAL BILL REVIEW, RE-PRICING, AND PAYMENT (WORKERS' COMPENSATION ONLY)"]
["a.","Review bills in accordance to State mandated timeframes, with applicable FS/UCR reductions"]
["b.","Ensure bill reductions, rejections, and/or denials are issued within State mandated timeframe"]
["c. ","Indentify and deny duplicate billings, at no ($0) charge"]
["d. ","Deny charges for non-compensable services, at no ($0) charge"]
["e. ","Review and apply discounts/credits to provider bills submitted for reconsideration"]
["f. ","Handle all incoming provider inquiries regarding bill reductions"]
["g.","Provide access to outcomes and/or evidenced based medical network"]
["h. ","Provide access to PBM to include effective opioid management resources"]
["i. ","Must agree to work with MyMatrixx for all pharmacy benefit management for the City"]
["j.","Must agree to work with the City of Knoxville's \"onsite medical center\" for occupational healthcare, and include the center on all postings for initial medical and rehabilitative care (i.e., physical therapy). "]
["k. ","Provide summary detail of savings/discounts, and resulting fees for service"]
["l.","Name all TPA perferred managed care providers, by their respective service, who may work with City"]
["m.","Agree to City's reservation of right to select of a non-preferred managed care provider"]
["5.3 CASE MANAGEMENT / UTILIZATION MANAGEMENT (WORKERS' COMPENSATION ONLY)"]
["a.","Must provide, maintain, and update \"medical provider\" listings (panels) by City department &/or location"]
["b.","Ensure immediate acces to a panel of medical providers by specialty for IME"]
[null,"Agree to customize IME panel based on input by the City"]
[null,"Agree to adopt specialized guidelines for IME preparation (scheduling, distribution of info, comm)."]
["c. ","Medical provider listings (panels) must be available in English and Spanish"]
["d. ","Provide analysis and metrics on medical provider outcomes to assist in selection "]
["e. ","TPA must supply &/or support options for 24/7 nurse call center (with bi-langual capabilities)"]
["f. ","Must provide an esclation process (email and text to risk@knoxvilletn.gov) for severe injury notice"]
[null,"Must provide an esclation process using City classification for severity designation"]
["g.","Agree to seek City approval of any/all referrals to TCM - FCM "]
["h. ","Must work to prevent minor injury claims from developing into high severity claims"]
[null,"TPA must describe their decision support and early identification process to alert adjusters "]
["i. ","Provide process to approve or disallow services within mandated State timeframes"]
["j.","Must ensure effective UR programs to determine appropriateness, frequency, and duration of care"]
["k.","All treatment denials through UR must be reviewed and pre-approved by City before treatment is denied"]
["l.","Provide aggressive medical management guidelines for high severity claims as determined by the City"]
["m.","Provide access to tele-health services (identify provider name) and identify cost/rate for same"]
["n.","Must agree to coordinate all medical management services with ancillary providers as necessary"]
["o.","Name all TPA preferred medical case management/utilization review providers"]
["p.","Agree to City's reservation of right to select of a non-preferred MCM/UR provider"]
["5.4 MEDICARE LIENS & SET-ASIDES; STRUCTURED SETTLEMENTS"]
["a.","Has systems/controls to provide reporting required under Medicare Section III at no cost to the City"]
["b.","Will adhere to City directoin regarding reserving within their deductibles and retentions"]
["c","Name all TPA preferred MSA service providers "]
["d. ","Agree to the City's reservation of right to select a non-preferred MSA service provider"]
["5.5 COMPLIANCE AND ADMINISTRATIVE CONSIDERATIONS"]
["a.","Provide they City with updates and training on changes in statute, rules, regulations that will affect claims program"]
["b.","Ensure all State filings are in place (EDI or hard copy)"]
[null,"Provide the City notice of any fees, taxes, or surcharges imposed for compliance with State requirements"]
["c. ","Must be fully licensed and approved to handle insured &/or self-insured claims in ALL States for CLIENT"]
["d. ","Must provide support for self-insured reporting in applicable States, as required by CLIENT"]
["e. ","Will comply with requests from CLIENT to provide necessary data/reports to vendors for various needs"]
["f. ","Must agree to prepare and present critical program results through annual stewardship"]
["g","Must agree to present an annual report to CLIENT to address major trends and highlight opportunities"]
["h. ","TPA must supply loss funding options, with escrow reimbursement on weekly and pre-fund >$100K"]
["i. ","Ensure that all claim information is protected in accordance with applicable State and Federal laws"]
["j.","Must partner with CLIENT approved consultants on any claim program initiatives"]
["k","Must agree to full responsibility for excess carrier notifications"]
["l.","Must provide detail and sampling of your current benchmarking capabilities"]
["m.","Must supply a copy of your current claim handling best pratices "]
["n.","Must highlight quality assurance controls for claims management (best practice & CLIENT specifications)"]
[null,"Must agree to supply CLIENT a quarterly report on internal quality results"]
["5.6 LITIGATION MANAGEMENT"]
[" ","Agree to work with the City of Knoxville's in-house counsel (City Attorney's office) for all WC matters and with John Lawhorn of Frantz, McConnell, and Seymour for all LIAB matters. "]
[null,"Agree to provide immediate notice of any/all legal matters (claims involving attorney representation, litigation, hearings, mediations, &/or arbitrations) to the City of Knoxville.  "]
[null,"Agree to collaborate with the City of Knoxville in-house counsel and external defense counsel to ensure appropriate litigation managemem plans, with understanding that ulitimate decision making authority and case strategy remaims with the City. "]
["a.","When requested by the City, arrange for appropriate medical/legal opinions on disputed cases"]
["b.","When directed by the City, promote claim resolution through direct negotiation, referring to the City's assigned counsel when appropriate."]
["c. ","Refer litigated claims to only City approved defense counsel, in a timely manner (i.e., in accordance to applicable law)."]
["d. ","Prepare and supply a summary of claim hsitory, issues, payments, records to counsel upon assignment"]
["e. ","Work closely with the City and approved legal, to provide coordinated preparation of litigated claims"]
["f. ","Ensure training is completed by adjusters who handle litigated claims, to meet all City required guidelines"]
["g.","Agree to monthly \"round-table\" participation with the City Attorney's office and City Risk Management for abridged review of litigated &/or contested claims."]
["5.7 CLAIMS MANAGEMENT SYSTEMS & DATA"]
["a.","Supply online access to view real time claim data/notes, and create reports, 7 days/week, 24 hours/day"]
["b.","Provide access to, and pricing for, access to TPA claims management system (up to 7 \"full access\" users)"]
["c. ","Supply quarterly user/usage reports to verify all access points and security levels for access to City data"]
["d. ","Store and manage all City of Knoxville claims that occur during the contract period"]
["e. ","Verify ability to manage the transfer and store all electronic claim files"]
["f. ","Must agree to supply the City with custom reports vital to its operations, existing (below) and future state"]
[null,"SAMPLE"]
[null,"SAMPLE"]
[null,"SAMPLE"]
[null,"SAMPLE"]
["g. ","TPA must supply a sample of their proposed scorecard for the City WC and LIAB programs"]
["h. ","Must be able to limit &/or allow access to PII and HIPAA protected information by user type/level."]
["i. ","Confirm predictive modeling capabilites for reserving, claim severity, fraud, and decision support"]
["j.","Must allow for the ability to download reports, images, notes and back up for MBR and litigation management."]
["k","Must provide a user-friendly interface to access claim data, through use of a menu driven system"]
["l.","Must provide training through implementation, and ongoing basis, on system capabilities"]
["m.","Must provide access to technical support through a help desk that is operational M-F, 8-5p ET"]
["n.","Describe system controls to manage accuracy and timeliness of indemnity payments"]
["o.","Describe your scanning process to digitize claim information, and the City's ability to access"]
["p.","Describe quality control features in place to ensure data integrity "]
["q.","Confirm the security features of your claim system, and your adjusters, used to protect data "]
["r.","What steps are taken to ensure the claim system remains compliant with regulatory changes"]
["s.","Decsribe your back-up procedure for access to claim information in the event of system outage"]
["t.","Verify your disaster recovery, business continuity, and incident response plan"]
["u.","Must be able to accept a data feed from the City's HR data source(s) (Peoplesoft & Unicorn HRO)"]
["v.","Provide monthly tracking of OSHA recordable data, and completion of annual BLS reports.  "]
["5.8 BUSINESS REFERENCES"]
["a.","Must list your current, active public entity (TN city government preferred) in response to this RFP (column D)."]
["b.","Identify 2-3 clients from your active public entity listing that can be contacted as business references (TN city government preferred). "]
["d. ","Additionally, provide 1-2 references from a recently terminated customer. "]
["5.9 PROPOSED ACCOUNT SERVICE TEAM"]
[" ","Must supply a clear outline for your proposed team (by position and responsibility); with bios."]
["5.10 TRANSITION PLAN"]
[" ","Provide detailed transition plan; to address activities for a new claim go live effective 12/1/22 followed by a conversion of legacy claims effective 2/1/23.  For conversion, please include your strategy to evaluate the City's open claims (triage timeframe) for early resolution and closure."]
["5.11 COST PROPOSAL"]
["a.","Provide pricing options for both life of contract and life of claim services based on forecasted claim counts (Section III)."]
["b.","Provide quote for legacy claim transfer on life of contract basis.  Please clearly specify if fees for legacy claim handling are a 1 time cost or if it will be reassessed annually for claims that continue to remain open at the end of each term."]
["c. ","Please provide pricing for claim intake services, based on the requirements expressed within RFP."]
["d. ","Provide fee schedule re-pricing on a cost per bill basis, with a percent-of-savings fee for reductions after fee schedule (PPO, out-of-network, negotiated, etc…). "]
["e. ","All percent-of-savings fees must be accompanied by a cap, or maximum fee allotment. "]
["f. ","Provide an alternative Medical Bill Review fee structure, that is a flat cost per bilil (for both FS/UC & all other savings). "]
["g. ","Itemize any pricing (if applicable) for Medicare Section 111 reporting."]
["h. ","List fees for Indexing of claims, and the parameters (timeframes) for issuance by claim"]
["i. ","Outline subrogation recovery costs, and how it will be managed.  TPA must confirm if their subrogation recovery fee will be capped (maximum fee of $10,000)."]
["j. ","Clearly address any costs associated with the provision of self-insured state reporting. "]
["k. ","Supply overview of OSHA services and the costs associated with each service level offered."]
["l.","The City of Knoxville will award the contract for a period of three (3) years with two (2) optional one-year renewals at the same terms and conditions.  TPAs must clearly outline any increase in pricing proposed for multi-year terms on this basis."]
["m.","Please outline your billing options (frequency and payment terms by # of days).  "]
["n.","Provide any non-renewal &/or contractual termination clauses (and adjoining costs, if any).  "]
["o.","Will agree to the City's defnitions for WC Medical Only and WC Indemnity as specified within this RFP."]
[null,"Will provide a minimum of 2 point contact on all WC claims (City reporting personnel and injured employee)."]
["5.12 PERFORMANCE GUARANTEE"]
[" ","The City requests that all TPAs submit a performance guarantee for service models proposed.  TPAs will be scored on their ability to reinforce their value proposition through a commitment to guarantee performance.  All ideas are strongly encouraged and can range from satisfaction measures, compliance with best practices, or measurement of critical KPI.  The TPA should build proposals around those areas they believe are the most significant way to showcase their ability to positively impact the business.   "]
["5.13 OUTCOME MEASURES"]
[" ","TPAs must complete Appendix 5.4 (FORM-TPA RFP METRICS)."]
[null,"Confirm what NAICS/SIC codes are used for completed metrics"]
[null,"Confirm the # of accounts/clients that make up completed metrics"]
[]
[]
[null,null,"Will comply (see detail)"]
[null,null,"Cannot comply (see explanation)"]