PROFESSIONAL SERVICES CONTRACT BETWEEN
THE CITY OF HUNTINGTON BEACH AND
INTERCARE HOLDINGS INSURANCE SERVICES
FOR
WORKERS' COMPENSATION THIRD PARTY
ADMINISTRATION AND UTILIZATION REVIEW SERVICES
THIS AGREEMENT ("Agreement") is made and entered into by and between the City of Huntington Beach, a municipal corporation of the State of California, hereinafter referred to as "CITY," and, INTERCARE HOLDINGS INSURANCE SERVICES., a hereinafter referred to as "CONSULTANT."
WHEREAS, CITY desires to engage the services of a consultant to perform Workers' Compensation Thid Party Claims Administration and Utilization Review Services; and
Pursuant to documentation on file in the office of the City Clerk, the provisions of the Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service contracts have been complied with; and CONSULTANT has been selected to perform these services, NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows:
SCOPE OF SERVICES
CONSULTANT shall provide all services as described in Exhibit "A," which is attached hereto and incorporated into this Agreement by this reference. These services shall sometimes hereinafter be referred to as the "PROJECT." CONSULTANT hereby designates Agnes Hoeberling, who shall represent it and be its sole contact and agent in all consultations with CITY during the performance of this Agreement.
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2. CITY STAFF ASSISTANCE
CITY shall assign a staff coordinator to work directly with CONSULTANT in the performance of this Agreement.
TERM; TIME OF PERFORMANCE
Time is of the essence of this Agreement. The services of CONSULTANT are to commence on November 1, 2026 (the "Commencement Date"). This Agreement shall automatically terminate three (3) years from the Commencement Date, unless extended or sooner terminated on October 31, 2029. All tasks specified in Exhibit "A" shall be completed no later than two (2) years from the Commencement Date. The time for performance of the tasks identified in Exhibit "A" are generally to be shown in Exhibit "A." This schedule may be amended to benefit the PROJECT if mutually agreed to in writing by CITY and CONSULTANT.
In the event the Commencement Date precedes the Effective Date, CONSULTANT shall be bound by all terms and conditions as provided herein.
4. COMPENSATION
In consideration of the performance of the services described herein, CITY agrees to pay CONSULTANT on a time and materials basis at the rates specified in Exhibit "B," which is attached hereto and incorporated by reference into this Agreement, a fee, including all costs and expenses, not to exceed Two Million Seven Hundred Thousand Dollars ($2,700,000.00).
EXTRA WORK
In the event CITY requires additional services not included in Exhibit "A" or changes in the scope of services described in Exhibit "A," CONSULTANT will undertake such work only after receiving written authorization from CITY. Additional 26-18785/426401 2 of 12
•
compensation for such extra work shall be allowed only if the prior written approval of CITY is obtained.
METHOD OF PAYMENT
CONSULTANT shall be paid pursuant to the terms of Exhibit "B."
DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS
CONSULTANT agrees that title to all materials prepared hereunder, including, without limitation, all original drawings, designs, reports, both field and office notices, calculations, computer code, language, data or programs, maps, memoranda, letters and other documents, shall belong to CITY, and CONSULTANT shall turn these materials over to CITY upon expiration or termination of this Agreement or upon PROJECT completion, whichever shall occur first. These materials may be used by CITY as it sees fit.
HOLD HARMLESS
A. CONSULTANT hereby agrees to protect, defend, indemnify and hold harmless CITY, its officers, elected or appointed officials, employees, agents and volunteers from and against any and all claims, damages, losses, expenses, judgments, demands and defense costs (including, without limitation, costs and fees of litigation of every nature or liability of any kind or nature arising out of or in connection with CONSULTANT's (or CONSULTANT's subcontractors, if any) negligent (or alleged negligent) performance of this Agreement or its failure to comply with any of its obligations contained in this Agreement by CONSULTANT, its officers, agents or employees except such loss or damage which was caused by the sole negligence or willful misconduct of CITY. CONSULTANT will conduct all defense at its sole cost and expense and CITY shall approve selection of CONSULTANT's counsel. This indemnity shall 26-18785/426401 3 of 12
apply to all claims and liability regardless of whether any insurance policies are applicable.
The policy limits do not act as limitation upon the amount of indemnification to be provided by CONSULTANT.
B. To the extent that CONSULTANT performs "Design Professional Services" within the meaning of Civil Code Section 2782.8, then the following Hold Harmless provision applies in place of subsection A above:
"CONSULTANT hereby agrees to protect, defend, indemnify and hold harmless CITY and its officers, elected or appointed officials, employees, agents and volunteers, from and against any and all claims, damages, losses, expenses, demands and defense costs (including, without limitation, costs and fees of litigation of every nature or liability of any kind or nature to the extent that the claims against CONSULTANT arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of CONSULTANT. In no event shall the cost to defend charged to CONSULTANT exceed CONSULTANT's proportionate percentage of fault. However, notwithstanding the previous sentence, in the event one or more other defendants to the claims and/or litigation is unable to pay its share of defense costs due to bankruptcy or dissolution of the business, CONSULTANT shall meet and confer with CITY and other defendants regarding unpaid defense costs. The duty to indemnify, including the duty and the cost to defend, is limited as provided in California Civil Code Section 2782.8.
C. Regardless of whether subparagraph A or B applies, CITY shall be reimbursed by CONSULTANT for all costs and attorney's fees incurred by CITY in enforcing this obligation. This indemnity shall apply to all claims and liability regardless of whether any insurance policies are applicable. The policy limits do not act as a limitation upon the amount of indemnification to be provided by CONSULTANT. 26-18785/426401 4 of 12
PROFESSIONAL LIABILITY INSURANCE
CONSULTANT shall obtain and furnish to CITY a professional liability insurance policy covering the work performed by it hereunder. This policy shall provide coverage for CONSULTANT's professional liability in an amount not less than One Million Dollars ($1,000,000.00) per occurrence and in the aggregate. The above- mentioned insurance shall not contain a self-insured retention without the express written consent of CITY; however an insurance policy "deductible" of Ten Thousand Dollars ($10,000.00) or less is permitted. A claims-made policy shall be acceptable if the policy further provides that:
A. The policy retroactive date coincides with or precedes the initiation of the scope of work (including subsequent policies purchased as renewals or replacements).
B. CONSULTANT shall notify CITY of circumstances or incidents that might give rise to future claims.
CONSULTANT will make every effort to maintain similar insurance during the required extended period of coverage following PROJECT completion. If insurance is terminated for any reason, CONSULTANT agrees to purchase an extended reporting provision of at least two (2) years to report claims arising from work performed in connection with this Agreement.
If CONSULTANT fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the CITY with required proof that insurance has been procured and is in force and paid for, the CITY shall have the right, at the CITY's election, to forthwith terminate this Agreement. Such termination shall not 26-18785/426401 5 of 12
effect Consultant's right to be paid for its time and materials expended prior to notification of termination. CONSULTANT waives the right to receive compensation and agrees to indemnify the CITY for any work performed prior to approval of insurance by the CITY.
10. CERTIFICATE OF INSURANCE
Prior to commencing performance of the work hereunder, CONSULTANT shall furnish to CITY a certificate of insurance subject to approval of the City Attorney evidencing the foregoing insurance coverage as required by this Agreement; the certificate shall:
A. provide the name and policy number of each carrier and policy; B. state that the policy is currently in force; and
C. shall promise that such policy shall not be suspended, voided or canceled by either party, reduced in coverage or in limits except after thirty (30) days' prior written notice; however, ten (10) days' prior written notice in the event of cancellation for nonpayment of premium.
CONSULTANT shall maintain the foregoing insurance coverage in force until the work under this Agreement is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverage shall not derogate from CONSULTANT's defense, hold harmless and indemnification obligations as set forth in this Agreement. CITY or its representative shall at all times have the right to demand the original or a copy of the policy of insurance. CONSULTANT shall pay, in a prompt and timely manner, the premiums on the insurance hereinabove required. 26-18785/426401 6 of 12
11. INDEPENDENT CONTRACTOR
CONSULTANT is, and shall be, acting at all times in the performance of this Agreement as an independent contractor herein and not as an employee of CITY.
CONSULTANT shall secure at its own cost and expense, and be responsible for any and all payment of all taxes, social security, state disability insurance compensation, unemployment compensation and other payroll deductions for CONSULTANT and its officers, agents and employees and all business licenses, if any, in connection with the PROJECT and/or the services to be performed hereunder.
12. TERMINATION OF AGREEMENT
All work required hereunder shall be performed in a good and workmanlike manner. CITY may terminate CONSULTANT's services hereunder at any time with or without cause, and whether or not the PROJECT is fully complete. Any termination of this Agreement by CITY shall be made in writing, notice of which shall be delivered to CONSULTANT as provided herein. In the event of termination, all finished and unfinished documents, exhibits, report, and evidence shall, at the option of CITY, become its property and shall be promptly delivered to it by CONSULTANT.
13. NASSIGNMENT AND DELEGATION
This Agreement is a personal service contract and the work hereunder shall not be assigned, delegated or subcontracted by CONSULTANT to any other person or entity without the prior express written consent of CITY. If an assignment, delegation or subcontract is approved, all approved assignees, delegates and subconsultants must satisfy the insurance requirements as set forth in Sections 9 and 10 hereinabove. 26-18785/426401 7 of 12
14. COPYRIGHTS/PATENTS
CITY shall own all rights to any patent or copyright on any work, item or material produced as a result of this Agreement.
15. CITY EMPLOYEES AND OFFICIALS
CONSULTANT shall employ no CITY official nor any regular CITY employee in the work performed pursuant to this Agreement. No officer or employee of CITY shall have any financial interest in this Agreement in violation of the applicable provisions of the California Government Code.
16. NOTICES
Any notices, certificates, or other communications hereunder shall be given either by personal delivery to CONSULTANT's agent (as designated in Section 1 hereinabove) or to CITY as the situation shall warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the same in the United States Postal Service, to the addresses specified below. CITY and CONSULTANT may designate different addresses to which subsequent notices, certificates or other communications will be sent by notifying the other party via personal delivery, a reputable overnight carrier or U.S. certified mail-return receipt requested:
TO CITY: TO CONSULTANT:
City of Huntington Beach Intercare Holding Insurance Services ATTN: Human Resources Director ATTN: Agnes Hoeberling, President 2000 Main Street 999 Town and Country Road
Huntington Beach, CA 92648 Orange, CA 92868
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17. CONSENT
When CITY's consent/approval is required under this Agreement, its consent/approval for one transaction or event shall not be deemed to be a consent/approval to any subsequent occurrence of the same or any other transaction or event.
18. MODIFICATION
No waiver or modification of any language in this Agreement shall be valid unless in writing and duly executed by both parties.
19. SECTION HEADINGS
The titles, captions, section, paragraph and subject headings, and descriptive phrases at the beginning of the various sections in this Agreement are merely descriptive and are included solely for convenience of reference only and are not representative of matters included or excluded from such provisions, and do not interpret, define, limit or describe, or construe the intent of the parties or affect the construction or interpretation of any provision of this Agreement.
20. INTERPRETATION OF THIS AGREEMENT
The language of all parts of this Agreement shall in all cases be construed as a whole, according to its fair meaning, and not strictly for or against any of the parties.
If any provision of this Agreement is held by an arbitrator of court of competent jurisdiction to be unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining covenants and provisions of this Agreement. No covenant or provision shall be deemed dependent upon any other unless so expressly provided here.
As used in this Agreement, the masculine or neuter gender and singular or plural number shall be deemed to include the other whenever the context so indicates or requires.
Nothing contained herein shall be construed so as to require the commission of any act 26-18785/426401 9 of 12
contrary to law, and wherever there is any conflict between any provision contained herein and any present or future statute, law, ordinance or regulation contrary to which the parties have no right to contract, then the latter shall prevail, and the provision of this Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to bring it within the requirements of the law.
21. DUPLICATE ORIGINAL
The original of this Agreement and one or more copies hereto have been prepared and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of the date of its execution and delivery, be deemed an original. Each duplicate original shall be deemed an original instrument as against any party who has signed it.
22. IMMIGRATION
CONSULTANT shall be responsible for full compliance with the immigration and naturalization laws of the United States and shall, in particular, comply with the provisions of the United States Code regarding employment verification.
23. LEGAL SERVICES SUBCONTRACTING PROHIBITED
CONSULTANT and CITY agree that CITY is not liable for payment of any subcontractor work involving legal services, and that such legal services are expressly outside the scope of services contemplated hereunder. CONSULTANT understands that pursuant to Huntington Beach City Charter Section 309, the City Attorney is the exclusive legal counsel for CITY; and CITY shall not be liable for payment of any legal services expenses incurred by CONSULTANT.
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24. ATTORNEY'S FEES
In the event suit is brought by either party to construe, interpret and/or enforce the terms and/or provisions of this Agreement or to secure the performance hereof, each party shall bear its own attorney's fees, such that the prevailing party shall not be entitled to recover its attorney's fees from the nonprevailing party.
25. SURVIVAL
Terms and conditions of this Agreement, which by their sense and context survive the expiration or termination of this Agreement, shall so survive.
26. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the laws of the State of California.
27. SIGNATORIES
Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully for any injuries or damages to CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn.
28. ENTIRETY
The parties acknowledge and agree that they are entering into this Agreement freely and voluntarily following extensive arm's length negotiation, and that each has had the opportunity to consult with legal counsel prior to executing this Agreement. The parties also acknowledge and agree that no representations, inducements, promises, agreements or warranties, oral or otherwise, have been made by that party or anyone acting on that party's behalf, which are not embodied in this Agreement, and that that party has not executed this Agreement in reliance on any representation, inducement, 26-18785/426401 11 of 12
promise, agreement, warranty, fact or circumstance not expressly set forth in this Agreement. This Agreement, and the attached exhibits, contain the entire agreement between the parties respecting the subject matter of this Agreement, and supersede all prior understandings and agreements whether oral or in writing between the parties respecting the subject matter hereof.
29. EFFECTIVE DATE
This Agreement shall be effective on the date of its approval by the City Attorney. This Agreement shall expire when terminated as provided herein.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized officers.
CONSULTANT, CITY OF HUNTINGTON BEACH,
INTERCARE HOLDINGS INSURANCE a municipal corporation of the State of SERVICES California
By:_
Mayor
print name
ITS: (circle one) Chairman/President/Vice President
City Clerk
AND
INITIATED AND APPROVED:
By:
Assistant City Manager
print name APPROVED AS TO FORM:
ITS: (circle one) Secretary/Chief Financial Officer/Asst.
Secretary - Treasurer Pesan
/ City Attorney
REVIEWED AND APPROVED:
City Manger
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promise, agreement, warranty, fact or circumstance not expressly set forth in this Agreement. This Agreement, and the attached exhibits, contain the entire agreement between the parties respecting the subject matter of this Agreement, and supersede all prior understandings and agreements whether oral or in writing between the parties respecting the subject matter hereof.
29. EFFECTIVE DATE
This Agreement shall be effective on the date of its approval by the City Attorney. This Agreement shall expire when terminated as provided herein.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized officers.
CONSULTANT, CITY OF HUNTINGTON BEACH,
INTERCARE HOLDINGS INSURANCE a municipal corporation of the State of SERVICES California
By:_ Lowell Hays
Lowell Hays, CEO Mayor
print name
ITS: (circle one) Chairman/President/Vice President
City Clerk
AND
INITIATED AND APPROVED:
By: Co. Hasi
Assistant City Manager
Agnes Hoeberling, CCO
print name APPROVED AS TO FORM:
ITS: (circle one) Secretary/Chief Financial Officer/Asst.
Secretary - Treasurer Pesan
/ City Attorney
REVIEWED AND APPROVED:
City Manger
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EXHIBIT "A"
A. STATEMENT OF WORK: (Narrative of work to be performed) Administer the City's claims for Workers' Compensation benefits in accordance with the requirements of the Workers' Compensation laws of the State of California; provide the City with cost effective claims administration while delivering value added services with measurable results and better outcomes.
B. CONSULTANT'S DUTIES AND RESPONSIBILITIES:
CONSULTANT'S duties and responsibilities shall follow provisions specified in the City of Huntington Beach Scope of Work shown in Exhibit A1. Detailed services shall include but is not limited to the Scope of Work in Exhibit Al.
C. CITY'S DUTIES AND RESPONSIBILITIES:
City shall collaborate with CONSULTANT to promote compliance with Scope of Work requirements; foster a high level of communication, trust, transparency, and commitment which is imperative to the success of the program.
D. WORK PROGRAM/PROJECT SCHEDULE:
Work program is required per the Scope of Services requested by the CITY.
EXHIBIT A
EXHIBIT A.1
SCOPE OF SERVICES
Claims Management Services
• Administer Workers' Compensation benefits in full compliance with the California Labor Code.
• Make initial contact with the injured employee and establish a claim file within twenty-four (24) hours of receipt of the Employer's First Report of Injury for the City.
• Maintain claim files that are available for review by the city at any time during the TPA's regular business hours.
• Resolve City-identified issues immediately and to the City's satisfaction, which may include reassignment of claims examiner staff when necessary. • Make and document compensability determinations (acceptance, denial, or delay pending investigation), including the rationale for each determination. • Provide guidance and information regarding Workers' Compensation benefits to City employees.
• Respond to City staff inquiries within twenty-four (24) hours and address critical issues on the same business day.
• Monitor medical treatment programs to ensure injured employees receive appropriate care and to prevent excessive or unnecessary treatment. • Establish initial claim reserves and continuously review and adjust reserves throughout the life of each claim to reflect current exposure. • Identify and pursue suspected abuse of the Workers' Compensation system or potential fraud
• Investigate questionable claims and, with the City's consent and coordination, recommend and facilitate independent outside investigations. • Obtain prior authorization from the city for all claim settlements. • Notify the City of all penalties incurred due to the TPA's failure to comply with statutory requirements or reimbursement obligations. Such penalties shall be the sole responsibility of the TPA and reimbursed to the City on a quarterly basis. • Identify subrogation opportunities and, in consultation with the City's Risk Management division, pursue subrogation when appropriate. • Conduct file and claims review at the discretion of the City of Huntington Beach. • Assist with ongoing development, administration, and continuous improvement of ADR carve-out programs in compliance with California Labor Code requirements..
Claims Management Software
• The claims management software should provide a claim description, financial data, and ad hoc reports on claims using criteria such as reserves, paid, indemnity, etc. • The claims management system must be read-only accessible to City of Huntington Beach Risk Management with licensing allowing a minimum of three (3) individual computers to access claim information simultaneously.
EXHIBIT A
• The selected firm will be required to provide training to Risk Management staff on report generation and the use of software.
Reporting
• Reports generated by the TPA should be furnished to the city in paper or electronic form as requested.
• Provide customized reports as needed upon reasonable request. • Provide a monthly administrative report in Excel format, including information such as:
• Number of claims, medical only, indemnity and reporting only • Number of closed claims
• Number of active files assigned to each claims adjuster • Indemnity paid in 4850 benefits, TD, PD, Death and Rehabilitation Benefits • Expenses paid
• Cases assigned to counsel, investigators, and nurse advocate • Amounts recovered in apportionment or subrogation
Number of litigated cases
List of cases settled during the month, indicating the amount of the settlement and method/type of settlement
• Summary and detailed bill review reports outlining bill review activity, savings and cost, and other reports at the City's discretion • Provide the following annual reports for Risk Management:
• Assemble and submit data as required for State reports, including the self- insurance report to Industrial Relations
• Assemble and submit data needed for actuarial studies performed on the City's Workers' Compensation Program
• OSHA 300 Logs of Work-Related Injuries and Illnesses; and OSHA 300A Summary of Work-Related Injuries and Illnesses
• The annual carve our report for the ADR program as required by the State of California
• Annual Stewardship Report with pertinent statistics for benchmarking and ADR program, measuring the City of Huntington Beach's workers' compensation program
Banking, Tax Reporting & Financial Needs
• City of Huntington Beach will establish and maintain a bank account from which TPA will issue checks for payment of services and benefits. • The TPA will provide weekly to City of Huntington Beach's Risk Management and Finance departments a check register indicating date, check number, payee, reason for payment and amount paid, in Excel/spreadsheet format. • The City of Huntington Beach Finance department will reconcile bank account statements against check registers provided by the TPA.
EXHIBIT A
• Invoices for replenishment of the City's trust account shall be submitted to City weekly on Thursday. The invoices submitted will replenish the fund expenditures from the previous week.
• Monthly reconciliation invoices will be submitted at the end of any given month.
These invoices will replenish any other funds in the account not covered under the weekly invoices.
• Provide any other written documentation to support any changes to the trust account balance.
Utilization Review (UR) Services
• Establish a UR program in compliance with all California workers' compensation statutes and regulations. The program plan shall include the development of utilization review policies, procedures, and processes. The plan shall be customized for the City of Huntington Beach and shall include provisions for the oversight of the UR authorization process. UR decisions shall be coordinated in the bill review platform to ensure consistency in the medical approval and payment processes. • Consultant shall demonstrate the ability to utilize industry standard best practices, nationally accepted medical criteria and the MTUS adopted by the State of California to accurately assess the request for medical services in timeframes mandated by the State of California.
• Consultant shall utilize a California based Medical Director and Reviewer/Expert Reviewer panel to delay, modify, or deny requests for authorization of medical treatment that does not meet medical criteria establishing medical necessity to cure or relieve the effects of the industrial injury.
• Physician Reviewer means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed in the State of California, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the individual's scope of practice.
• Medical Director is the physician and surgeon licensed by the Medical Board of California or Osteopathic Board of California who holds an unrestricted license to practice medicine in the State of California. The Medical Director is responsible for all decisions made in the utilization review.
• Consultant must be URAC certified.
EXHIBIT A
EXHIBIT "B"
Payment Schedule (Hourly Payment)
A. Hourly Rate
CONSULTANT'S fees for such services shall be based upon the following hourly rate and cost schedule:
SEE ATTACHED EXHIBIT B.1 - FIXED FEE PAYMENT SCHEDULE
B. Travel. Charges for time during travel are not reimbursable C. Billing
1. All billing shall be done monthly in fifteen (15) minute increments and matched to an appropriate breakdown of the time that was taken to perform that work and who performed it.
2. Each month's bill should include a total to date. That total should provide, at a glance, the total fees and costs incurred to date for the project.
A copy of memoranda, letters, reports, calculations and other documentation prepared by CONSULTANT may be required to be submitted to CITY to demonstrate progress toward completion of tasks. In the event CITY rejects or has comments on any such product, CITY shall identify specific requirements for satisfactory completion.
4. CONSULTANT shall submit to CITY an invoice for each monthly payment due.
Such invoice shall:
A) Reference this Agreement;
B) Describe the services performed;
C) Show the total amount of the payment due;
D) Include a certification by a principal member of CONSULTANT's firm that the work has been performed in accordance with the provisions of this Agreement; and
E) For all payments include an estimate of the percentage of work completed.
Upon submission of any such invoice, if CITY is satisfied that CONSULTANT is making satisfactory progress toward completion of tasks in accordance with this Agreement, CITY shall approve the invoice, in which event payment shall be made within thirty (30) days of receipt of the invoice by CITY. Such approval shall not be unreasonably withheld. If CITY does not approve an invoice, CITY shall notify CONSULTANT in writing of the reasons for non-approval and the schedule of performance set forth in Exhibit "A" may at the option of CITY be suspended until the parties agree that past performance by CONSULTANT is in, or has been brought into compliance, or until this Agreement has expired or is terminated as provided herein.
Any billings for extra work or additional services authorized in advance and in writing by CITY shall be invoiced separately to CITY. Such invoice shall contain all of the information required above, and in addition shall list the hours expended and hourly rate charged for such time. Such invoices shall be approved by CITY if the work performed is in accordance with the extra work or additional services requested, and if CITY is satisfied that the statement of hours worked and costs incurred is accurate. Such approval shall not be unreasonably withheld. dispute between the parties concerning payment of such an invoice shall be treated as separate and apart from the ongoing performance of the remainder of this Agreement.
EXHIBIT B.1
FIXED FEE
PAYMENT
Contract Years | FY 26/27 FY 27/28 | FY 28/29
THIRD PARTY ADMINISTRATION(a)
Partially Bundled(b) | $800,000 $830,000 $860,000
Rate per claim fee: In excess of claim volume noted in RFP Indemnity Claim $185 ] $198
Medical Only Claim | $1,100 $1,139 $1,178
Administrative Fees
Account $2,500 $2,588 | $2,678
Management
UTILIZATION REVIEW Rate
Non-Physician Review $90.00/hour
Physician Review $200.00/hour
Expert Physician Review $350.00/hour
Medical Director Review $200.00/hour
Other: Adjust Authorization $15.00 (waived)
CASE MANAGEMENT Rate
Telephonic Case Management $95.00 per hour
Field Case Management $125.00 per hour
(a) Fees for claims administration is based on the following staffing model:
• Caseload: 150 per adjuster. This is a blended model using a 2 FM and 2 MO claim ratio to 1 Indemnity. Based on the claim volume, will dedicate 3 adjusters and 1 assistant to the program. The Supervisor will be designated.
Claim volume is up to 675 open tail claims and approximately 200 new claims per year. Claims reported over the threshold are subjcet to the additional per claim fee.
(b) Reflect COLA increases and increases in benefit premiums for our staff to ensure retention. A bundled program creates efficiencies for the claim staff and helps with employee retention, amplifies claims adjudication, reduces administrative burden for both the City and our claims team, and supports communication, and strengthens the City's relationships with the injured worker by demonstrating proactive treatment authorization.