Common use of Claims Handling Services Clause in Contracts

Claims Handling Services. ADMINISTRATOR shall perform the following services: A. In conjunction with the SCHOOL BOARD, maintain a criteria-based model of workers’ compensation program administration. B. Prepare and follow service instructions that have been approved by the SCHOOL BOARD in the handling of the SCHOOL BOARD claims and catastrophic claims. C. Receive, examine and adjust on behalf of the SCHOOL BOARD all reports of employee injury. D. Provide initial clinical triage supported by predetermined criteria, appropriate deployment of resources including telephonic case management, field case management using staff knowledgeable in the criteria, protocols and appropriate utilization of internal and external medical management resources. E. Contact injured worker, employer and witnesses, either in writing or orally, within 24 hours of ADMINISTRATOR’s receipt of claim report. F. Conduct such investigation as in the exercise of professional judgment would seem necessary. Enhanced efforts shall be taken to identify possible fraudulent claims, including recorded statements and discussions from injured workers, witnesses and supervisors. G. Subject to applicable workers’ compensation law and the exercise of professional judgment, accept and adjust, settle or deny (settlements and denials need prior approval by the SCHOOL BOARD Administrative Agent) each reported claim of employee injury. The final decision to settle or deny shall rest solely with the SCHOOL BOARD. H. Report claims to SCHOOL BOARD excess insurer(s) in accordance with the requirements of the excess insurer(s) policies. I. Up to a discretionary limit of $10,000 and subject to the foregoing provisions, review and, if appropriate, pay in a timely fashion; and in conformity with legally imposed medical and surgical fee schedules, network discounts and/or contracted fees, all on- going claims and expenses pertaining thereto. ADMINISTRATOR shall request approval from SCHOOL BOARD Administrative Agent prior to issuance of medical or expense payments in excess of $10,000. The final decision to accept, deny or settle any claims shall rest with the SCHOOL BOARD. J. Consult with SCHOOL BOARD on the selection and referral to outside professionals such as surveillance personnel, expert witnesses and field adjusters/nurses to assist in the investigation, adjustment and medical management of claims. ADMINISTRATOR will review all bills for such services for reasonableness and conformity to pre-established rates or fees and have the ability to adhere to any set pricing schedules. K. Validate and pay in a timely manner, any and all indemnity benefits due to injured employees. L. Review all medical bills and bills for other services for which a claim is being made for reasonableness and conformity to rules, regulations and legally imposed medical and surgical fee schedules. M. Prepare and maintain files necessary for legal defense of claims and/or other litigation or other proceedings, such as actions for subrogation, contribution or indemnity. All Legal filings must be approved by the SCHOOL BOARD Administrative Agent prior to response. N. Attend hearings, depositions, mediations and other proceedings as necessary. O. At the request of the SCHOOL BOARD, provide a complete copy of all files involving litigation, potential or actual subrogation or potential or actual recovery from special or second injury funds. P. Aggressively pursue all possibilities of subrogation, excess insurance reimbursement, third party liens, contribution or indemnity and/or recovery from special or second injury funds on behalf of the SCHOOL BOARD. Q. Perform timely, periodic review of all open cases to establish the status of disabled employees in order to assist in the appropriate action to be taken. The ADMINISTRATOR shall meet with SCHOOL BOARD staff periodically to review any claims or overall program performance as requested. R. Provide assistance in implementing rehabilitation for injured employees, in consultation, retraining or reassignment of employees with limited physical performance arising from compensable injuries. S. Assist SCHOOL BOARD in the maintenance and development of its Stay at Work program, including identification of stay at work opportunities, communication of individual case strategies among key parties and managing the stay at work plan for each case, including appropriate use of outside vendors if appropriate. T. Provide access to a health care clinician network practicing criteria-based medical care. U. Provide full disclosure to the SCHOOL BOARD regarding clinician contracting and credentialing. V. Develop and follow appropriate written policies when the injured employee requests a one-time change or medical treatment is questioned. W. Assist in the scheduling of independent medical evaluations. X. Follow all provisions of Florida Statutes in regard to indemnity and medical benefit entitlement and administration. Y. Advise and consult with the SCHOOL BOARD with respect to safety program planning, implementation and analysis;

Claims Handling Services. ADMINISTRATOR The Consultant shall perform provide the following claims handling services: A. In conjunction with the SCHOOL BOARD, maintain a criteria-based model of workers’ compensation program administration. B. 4.1 Prepare and follow service instructions that have been approved by the SCHOOL BOARD District in the handling of the SCHOOL BOARD District's claims and catastrophic claims. C. 4.2 Receive, examine and adjust on behalf of the SCHOOL BOARD District all reports of employee injury. D. 4.3 Provide initial clinical triage supported by predetermined criteria, appropriate deployment of resources including telephonic case management, field case management using staff knowledgeable in the criteria, protocols and appropriate utilization of internal and external medical management resources. E. 4.4 Contact injured worker, employer and witnesses, either in writing or orally, within 24 hours of ADMINISTRATORConsultant’s receipt of claim report. F. 4.5 Conduct such investigation as in the exercise of professional judgment would seem necessary. Enhanced efforts shall be taken to identify possible fraudulent claims, including recorded statements and discussions from injured workers, witnesses and supervisors. G. 4.6 Subject to applicable workers’ compensation law and the exercise of professional judgment, accept and adjust, settle or deny (settlements and denials need prior approval by the SCHOOL BOARD Administrative AgentRisk Manager or its designee and District Attorney's Office) each reported claim of employee injury. The final decision to settle or deny shall rest solely with the SCHOOL BOARD. H. 4.7 Report claims to SCHOOL BOARD District's excess insurer(s) in accordance with the requirements of the excess insurer(s) policies. I. 4.8 Advise the District and obtain prior approval on claim reserve increases in excess of $25,000. 4.9 Up to a discretionary limit of $10,000 determined by the District and subject to the foregoing provisions, review and, if appropriate, pay in a timely fashion; and in conformity with legally imposed medical and surgical fee schedules, JECO network discounts and/or contracted fees, all on- going claims and expenses pertaining thereto. ADMINISTRATOR shall request approval from SCHOOL BOARD Administrative Agent prior to issuance of medical or expense payments in excess of $10,000. The final decision to accept, deny or settle any claims shall rest with the SCHOOL BOARDDistrict. J. 4.10 Fees, interest and civil penalties required due to late payments or adjuster mishandling shall be paid by the Consultant unless the error is solely caused by later reporting or misreporting of information by the District. Any such payments made by the Consultant shall be reimbursed to the District within 60 days of the payment. 4.11 Consult with SCHOOL BOARD District on the selection and referral to outside professionals such as surveillance personnel, expert witnesses and field adjusters/nurses to assist in the investigation, adjustment and medical management of claims. ADMINISTRATOR Consultant will review all bills for such services for reasonableness and conformity to pre-established rates or fees and have the ability to adhere to any set pricing schedules. K. 4.12 Validate and pay in a timely manner, any and all indemnity benefits due to injured employees. L. 4.13 Review all medical bills and bills for other services for which a claim is being made for reasonableness and conformity to rules, regulations and legally imposed medical and surgical fee schedules. M. 4.14 Prepare and maintain files necessary for legal defense of claims and/or other litigation or other proceedings, such as actions for subrogation, contribution or indemnity. All Legal filings must be approved by the SCHOOL BOARD Administrative Agent District's Legal Counsel prior to response. Defense of all claims will be handled by the District preferred defense counsel unless otherwise approved by the District. N. 4.15 Attend hearings, depositions, mediations and other proceedings as necessary. O. 4.16 At the request of the SCHOOL BOARDDistrict, provide a complete copy of all files involving litigation, potential or actual subrogation or potential or actual recovery from special or second injury funds. P. 4.17 Aggressively pursue all possibilities of subrogation, excess insurance reimbursement, third party liens, contribution or indemnity and/or recovery from special or second injury funds on behalf of the SCHOOL BOARDDistrict. Q. 4.18 Perform timely, periodic review of all open cases to establish the status of disabled employees in order to assist in the appropriate action to be taken. The ADMINISTRATOR Consultant shall meet with SCHOOL BOARD District staff periodically to review any claims or overall program performance as requested. R. 4.19 Provide assistance in implementing rehabilitation for injured employees, in consultation, retraining or reassignment of employees with limited physical performance arising from compensable injuries. S. 4.20 Assist SCHOOL BOARD District in the maintenance and development of its Stay at Work program, including identification of stay at work opportunities, communication of individual case strategies among key parties and managing the stay at work plan for each case, including appropriate use of outside vendors if appropriate. T. 4.21 Provide access to a local health care clinician network practicing criteria-criteria- based medical care. U. 4.22 Provide full disclosure to the SCHOOL BOARD District regarding clinician contracting and credentialing. V. 4.23 Develop and follow appropriate written policies when the injured employee requests a one-time change or medical treatment is questioned. W. 4.24 Assist in the scheduling of independent medical evaluations. X. 4.25 Follow all provisions of Florida Statutes in regard to indemnity and medical benefit entitlement and administration. Y. Advise and consult with the SCHOOL BOARD with respect to safety program planning, implementation and analysis;.