Richmond City Council
December 6, 2022

Paid Incurred
As Of 07/31/2019
Open Total Avg. Paid Max. Paid Reserves Claims Paid IncurredLoss Type Avg. DaysLostRest.

Days
Confidential & Proprietary DAVID
Temp. Total or Part. Dis. (0.00% PD)
FM Minor permanent partial 24.999% or <
Closed Death Claim, C&R AOECOE/denial
Minor permanent partial 24.999% or <
FM Major permanent partial 25% or >
Frequency Analysis - Loss Type
Medical Only
Indemnity
NEVER USE<Not Assigned>
Major permanent partial 25% or >
Death
First Aid (CA)
Information Only
% of Insured's Total
All Insureds
Loss Dates: 01/01/1900 - 07/31/2019
Totals
Report Run:08/27/2019 Data Date: 08/27/2019 Page 1 of 3

15 30,578 212
August 27, 2019
11:48AM
174 5,922,095.54 2,092 23,486,292.41 17,564,196.87 8,395.89 511,163.39

Paid Incurred
As Of 07/31/2019
Open Total Avg. Paid Max. Paid Reserves Claims Paid IncurredLoss Type Avg. DaysLostRest.

Days
GRAND TOTALS 100.0 100.0 100.0
Confidential & Proprietary DAVID
Frequency Analysis - Loss Type
% of Insured's Total
Loss Dates: 01/01/1900 - 07/31/2019
Totals
Report Run:08/27/2019 Data Date: 08/27/2019 Page 2 of 3

Sample Dashboard Screenshots
3 Sample Dashboard Screenshots

4Sample Dashboard Screenshots

Sample Claim Status Report

CLAIM STATUS REPORT
Claim Overview Claimant: John Doe1005
Loss Date: 06/13/2005 Claim Number: 05138028
Dept.: 0900/1000 Public Safety Job Title: Police Dispatch Hire Date: 06/04/2004 LDW: 06/13/2005
Age at Injury: 25 Age: 35
Birthdate: 10/18/1979 RTW: TBD
Medicare Eligible: No
Claim Coding
Examiner: Dee Poser Loss Type: Indemnity
Accident Description: Nature of accident: REPETITIVE MOTION Nature of injury: CARPAL TUNNEL SYNDROME Body part: WRIST, RIGHT Incident type: REPETITIVE MOTION/TYPING Nurse Case Manager: Flora Nightingale TTD Rate:$0.00
Legal
Defense Counsel:

Applicant Attorney:

Case Resolution:

Financial Detail
Reserve Category Incurred Paid Outstanding
Indemnity

$ 5,965.43 $ 5,438.96 $ 526.47
Temporary Disability $1,345.43 $ 5,438.96 $ 526.47
Permanent Disability $4,620.00 $ 4,620.00 $ 0.00
Medical $ 9,687.77 $ 912.84 $ 8,774.93
Legal $ 0.00 $ 0.00 $ 0.00
Other $ 1,470.91 $ 390.57 $ 1,080.34
Total
Last TD Paid: Last PD Paid:

Plan of Action/Status
Disability status:

Current Issues:

Medical Status:

Plan of Action:

Dated: November 24, 2019

Key Metrics by Location
0 10
20 30
40 50
60 City Clerk City Corp Environmental
Resources
Facilities
Maintenance
Fire Dept Fleet Services Human Resources Human Services Info Only 0 0 0 0 0 0 0 0
First Aid 0 0 2 1 1 4 0 1
Med Only 0 1 10 0 30 3 0 0
Indemnity 1 0 18 2 23 4 2 0
Claims Count
Claims Count by Department
Fi
scal Year 2016/2017

0 20
40 60
80 100
120
Leisure And Recreation Police Dept Public Works Wastewater Department Water Department Info Only 0 0 0 0 0
First Aid 0 0 0 0 0
Med Only 1 52 2 3 0
Indemnity 1 49 1 5 1
Claims Count
Claims Count by Department
Fi
scal Year 2016/2017

Claims Administration Fees
and Claim Payments
9 0
0 1
0 11,894.47

0.00 0.00
-96.41

0.00 11,798.06
TotalCount
Payments:

Reversals:

Reinstatements:

Refunds:

Reversed Refunds:

Net Amount
Bank Account: Emerald City
AA-ACME-WC Demo / 0900/1000 Public Safety
06/17/2011 Check 06/17/2011 I8 2030026 Doe890 , John 1,456.00 16772 06/17/2011 Voucher 06/17/2011 I40 ME110079 Doe940 , John 1,680.00 16773 06/17/2011 Voucher 06/17/2011 I94 ME110079 Doe940 , John 840.00 16774 06/17/2011 Voucher 06/17/2011 I40 ME110064 Doe344 , John 1,552.03 16777 06/17/2011 Voucher 06/17/2011 I94 ME110064 Doe344 , John 776.10 16778 06/17/2011 Voucher 06/17/2011 I40 ME110087 Doe1028 , John 697.26 16779 06/17/2011 Voucher 06/17/2011 I40 08220491 Doe945 , John 1,946.48 16781 06/17/2011 Voucher 06/17/2011 I94 08220491 Doe945 , John 973.22 16782 06/17/2011 Voucher 06/17/2011 I40 06174393 Doe159 , John 1,973.38 16783 06/23/2011 Refund 06/23/2011 M47 8600505 Doe165 , John -96.41 0 1 6/17/20
3:09:38PM
Page Number:

Date Report Run:

Time Report Run:Activity Period:

Check No Effective Trans Type Check Date Type Payee Name Claim No Claimant Name Amount Totals for AA-ACME-WC Demo / 0900/1000 Public Safety
* = Break in check number sequence or duplicate check number(s) Financial Activity Ledger
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted
Redacted

4 0
0 0
0 4,872.45

0.00 0.00

0.00 0.00
4,872.45
TotalCount
Payments:

Reversals:

Reinstatements:

Refunds:

Reversed Refunds:

Net Amount
AA-ACME-WC Demo / 1100 Public Works Operations
06/17/2011 Voucher 06/17/2011 I40 ME100056 Doe1828 , John 1,147.39 16775 06/17/2011 Voucher 06/17/2011 I40 ME100005 Doe1835 , John 1,205.44 16776 06/17/2011 Voucher 06/17/2011 I40 ME110075 Doe1559 , John 1,321.23 16780 06/17/2011 Voucher 06/17/2011 I40 ME090023 Doe1359 , John 1,198.39 16784 2 6/17/20
3:09:38PM
Page Number:

Date Report Run:

Time Report Run:Activity Period: 6/17/11 - 6/23/11
Check No Effective Trans Type Check Date Type Payee Name Claim No Claimant Name Amount Totals for AA-ACME-WC Demo / 1100 Public Works Operations * = Break in check number sequence or duplicate check number(s) Financial Activity Ledger
Redacted
Redacted
Redacted
Redacted

Sample Reconciliation Report
Pay
Check No Date Amount Type Type Payee Claim No Claimant
79139 √ 11/03/2014 720.38 Payment I1 Dolores Machtolff 00200308 Machtolff, Dolores 79140 √ 11/03/2014 352.50 Payment M25 Allied Managed Care, Inc. 01201848 Poplawski, Evelyn 79141 √ 11/03/2014 648.00 Payment M3 ECONOMY TRANSPORT LLC 01201848 Poplawski, Evelyn 79142 √ 11/03/2014 1,200.00 Payment M44 myMatrixx 00200341 Alcaraz, Raleigh 79143 √ 11/04/2014 340.00 Payment I2 Arnulfo Velasco 01200654 Velasco, Arnulfo 79144 √ 11/05/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79145 √ 11/05/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79146 √ 11/05/2014 396.00 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79147 √ 11/05/2014 412.50 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79148 √ 11/05/2014 506.80 Payment L1 LAW OFFICES OF VILEISIS, BRUSH A150000282 Robinson, Ladonna 79149 √ 11/05/2014 564.39 Payment M37 One Call Care Transport & Translate 02000336 Hall, Stephen 79150 √ 11/06/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79151 √ 11/06/2014 799.24 Payment I2 Evelyn Poplawski 01201848 Poplawski, Evelyn 79152 √ 11/06/2014 355.20 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79153 √ 11/06/2014 589.86 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79154 √ 11/06/2014 140.00 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79155 √ 11/06/2014 14.56 Payment M33 Stephen W Hall 02000336 Hall, Stephen 79156 √ 11/06/2014 8,211.92 Payment L1 Floyd, Skeren, & Kelly, LLP 00200341 Alcaraz, Raleigh 79157 √ 11/06/2014 1,127.45 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L04000276 Perez, Naborina 79158 √ 11/06/2014 80.30 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L03000126 Maya, Nina 79159 √ 11/06/2014 155.60 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01200647 Rodriguez, Francisco 79160 √ 11/06/2014 105.00 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01201848 Poplawski, Evelyn 79161 √ 11/06/2014 2,232.78 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L02000362 Romo, Maria 79162 √ 11/06/2014 752.60 Payment L1 LAW OFFICES OF BRADFORD & BARTHEL, L L01200810 Ryan, Claudia 79163 √ 11/07/2014 .00 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79164 √ 11/07/2014 54.99 Payment M44 Coastal Express Pharmacy 03000126 Maya, Nina 79165 √ 11/07/2014 264.36 Payment M44 Coastal Express Pharmacy 00200341 Alcaraz, Raleigh 79166 √ 11/07/2014 159.02 Payment M46 DAVID TORREZ PHD MFT A COUNSEL 01200647 Rodriguez, Francisco 79167 √ 11/07/2014 .00 Payment M54 Diogenes Anesthesia Medical Gr 00200341 Alcaraz, Raleigh 79168 √ 11/07/2014 .00 Payment M54 Diogenes Anesthesia Medical Gr 00200341 Alcaraz, Raleigh 79169 √ 11/07/2014 353.29 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79170 √ 11/07/2014 137.05 Payment M47 Isaac Schmidt, MD 00200341 Alcaraz, Raleigh 79171 √ 11/07/2014 125.14 Payment M47 Joshua Prager MD MS 01201848 Poplawski, Evelyn 79172 √ 11/07/2014 719.56 Payment M47 Joshua Prager MD MS 01201848 Poplawski, Evelyn 79173 √ 11/07/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79174 √ 11/07/2014 120.86 Payment M44 MICHAEL`S PHARMACY 01200989 Velasco, Arnulfo 79175 √ 11/07/2014 74.60 Payment M47 P.R.I.M.E. PAIN MEDICINE INSTI 02000114 Lyle, James 79176 √ 11/07/2014 474.56 Payment I2 Maria Tapia 00200217 Tapia, Maria 79177 11/10/2014 616.96 Payment I2 Nina Maya 03000126 Maya, Nina 79178 √ 11/10/2014 305.54 Payment I14 Raleigh Alcaraz 00200341 Alcaraz, Raleigh 79179 √ 11/10/2014 431.14 Payment I2 Richard Menendez 02000102 Menendez, Richard 79180 √ 11/11/2014 124.78 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79181 √ 11/11/2014 124.78 Payment M47 BAY AREA PAIN & WELLNESS CENTE 01201464 Adame, Kathryn 79182 √ 11/11/2014 .00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79183 √ 11/11/2014 465.00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79184 √ 11/11/2014 .00 Payment M28 MSC GROUP INC 00200217 Tapia, Maria 79185 √ 11/11/2014 .00 Payment M28 MSC Group, Inc. 00200217 Tapia, Maria 79186 √ 11/11/2014 .00 Payment M28 MSC Group, Inc. 00200217 Tapia, Maria 79187 √ 11/12/2014 180.00 Payment O6 DocCentral 02000102 Menendez, Richard 79188 √ 11/12/2014 182.30 Payment O6 DocCentral 02000102 Menendez, Richard 79189 11/12/2014 128.00 Payment L1 Altman, Lunche & Blitstein A250002778 Pillot, Mary 79190 √ 11/12/2014 168.35 Payment L6 DocCentral 02000102 Menendez, Richard 79191 11/12/2014 240.00 Payment L1 LAW OFFICES OF MARGARET R. STE 01201377 Sharp, Marsanna 79192 √ 11/12/2014 115.50 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 02000543 Macias, Rafael 79193 √ 11/12/2014 132.00 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 01201049 Molina, Francisco 79194 √ 11/12/2014 1,480.03 Payment L1 LAW OFFICES OF ROBERT WHEATLEY 02000543 Macias, Rafael 79195 √ 11/12/2014 360.00 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria 79196 11/12/2014 300.25 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria Sample Client Reconciliation Check Register
November 1 - 30, 2014

Pay
Check No Date Amount Type Type Payee Claim No Claimant
79197 √ 11/12/2014 540.50 Payment L1 LOUIE & STETTLER, A LAW CORPOR 00200217 Tapia, Maria 79198 √ 11/14/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 79199 √ 11/14/2014 352.50 Payment O34 Allied Managed Care 00200217 Tapia, Maria 79200 √ 11/14/2014 352.50 Payment O34 Allied Managed Care, Inc. 02000102 Menendez, Richard 79201 √ 11/14/2014 549.13 Payment M25 CASE MANAGEMENT SOLUTIONS 02000336 Hall, Stephen 79202 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79203 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79204 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79205 √ 11/14/2014 728.00 Payment M37 CENTURY PACIFIC MEDICAL INC 03000126 Maya, Nina 79206 √ 11/14/2014 194.95 Payment M44 Coastal Express Pharmacy 01201049 Molina, Francisco 79207 √ 11/14/2014 270.00 Payment M30 COSSIOS INTERNATIONAL LINGUIST 00200217 Tapia, Maria 79208 √ 11/14/2014 .00 Payment M47 DARREL H. BURNSTEIN, M.D. A ME 02000102 Menendez, Richard 79209 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79210 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79211 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79212 √ 11/14/2014 137.05 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79213 √ 11/14/2014 411.15 Payment M47 DAVID FUCHS M.D., INC. 02000102 Menendez, Richard 79214 √ 11/14/2014 30.79 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79215 √ 11/14/2014 188.99 Payment M44 Express Scripts Inc 01201464 Adame, Kathryn 79216 √ 11/14/2014 388.96 Payment M47 Grabow Medical Group Inc. 00200217 Tapia, Maria 79217 √ 11/14/2014 130.19 Payment M47 HAIDER SPINE CENTER MEDICAL GR 01201049 Molina, Francisco 79218 √ 11/14/2014 197.12 Payment M47 Hamlin Psyche Center 02000102 Menendez, Richard 79219 √ 11/14/2014 125.14 Payment M47 Joshua Prager MD MS 02000102 Menendez, Richard 79220 √ 11/14/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79221 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79222 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79223 √ 11/14/2014 120.00 Payment M3 Maid Pro 00200217 Tapia, Maria 79224 √ 11/14/2014 120.86 Payment M44 MICHAEL`S PHARMACY 01200989 Velasco, Arnulfo 79225 √ 11/14/2014 .00 Payment M46 MIRFAK ASSOCIATES, INC. 02000114 Lyle, James 79226 √ 11/14/2014 1,864.90 Payment M44 myMatrixx 02000336 Hall, Stephen 79227 √ 11/14/2014 101.13 Payment M44 myMatrixx 01201117 Diaz, Rosa 79228 √ 11/14/2014 112.21 Payment M44 myMatrixx 01201117 Diaz, Rosa 79229 √ 11/14/2014 74.60 Payment M47 P.R.I.M.E. PAIN MEDICINE INSTI 02000114 Lyle, James 79230 √ 11/14/2014 187.39 Payment M28 Priority Care Solutions LLC 00200217 Tapia, Maria 79231 √ 11/14/2014
.00 Payment M18 Priority Care Solutions LLC 00200217 Tapia, Maria 79232 √ 11/14/2014 40.00 Payment M28 RS MEDICAL 00200217 Tapia, Maria 79233 √ 11/14/2014 40.00 Payment M28 RS MEDICAL 00200217 Tapia, Maria 79234 √ 11/14/2014 152.21 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79235 √ 11/14/2014 289.22 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79236 √ 11/14/2014 203.79 Payment M47 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79237 √ 11/14/2014 45.16 Payment M44 STONERIVER PHARMACY SOLUTIONS 01201848 Poplawski, Evelyn 79238 √ 11/14/2014 1,353.11 Payment M44 STONERIVER PHARMACY SOLUTIONS 01201848 Poplawski, Evelyn 79239 √ 11/14/2014 202.44 Payment M44 Stoneriver Pharmacy Solutions 00200217 Tapia, Maria 79240 √ 11/14/2014 270.46 Payment M44 TMESYS, INC 00200217 Tapia, Maria 79241 √ 11/14/2014 44.15 Payment M44 TMESYS, INC 00200217 Tapia, Maria 79242 √ 11/17/2014 720.38 Payment I1 Dolores Machtolff 00200308 Machtolff, Dolores 79243 √ 11/18/2014 340.00 Payment I2 Arnulfo Velasco 01200654 Velasco, Arnulfo 79244 √ 11/20/2014 799.24 Payment I2 Evelyn Poplawski 01201848 Poplawski, Evelyn 79245 √ 11/21/2014 474.56 Payment I2 Maria Tapia 00200217 Tapia, Maria 79246 11/21/2014 180.00 Payment O6 DocCentral 02000102 Menendez, Richard 79247 11/21/2014 223.40 Payment M36 FRANCISCO MOLINA 01201049 Molina, Francisco 79248 11/21/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79249 11/21/2014 120.00 Payment M8 Maid Pro 00200217 Tapia, Maria 79250 √ 11/21/2014 970.07 Payment L1 SOUTHLAND SPINE AND REHABILITA 00200090 Gonzalez, Ana Rosa 79251 11/24/2014 304.54 Payment I14 Raleigh Alcaraz 00200341 Alcaraz, Raleigh 79252 √ 11/24/2014 431.14 Payment I2 Richard Menendez 02000102 Menendez, Richard 79253 11/25/2014 616.96 Payment I2 Nina Maya 03000126 Maya, Nina 79254 11/26/2014 833.00 Payment I14 Kathryn Adame 01201464 Adame, Kathryn 78616 √ 11/03/2014 -35.99 Reversal M33 Francisco J. Rodriguez 01200647 Rodriguez, Francisco 79068 √ 11/17/2014 -833.00 Reversal I14 Kathryn Adame 01201464 Adame, Kathryn

EXHIBIT 14 –
Certificate of Insurance

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT
NAME:

FAXPHONE
(A/C, No):(A/C, No, Ext):

E-MAIL
ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

AUTHORIZED REPRESENTATIVE
INSURER(S) AFFORDING COVERAGE NAIC #
Y / N
N / A
(Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
EACH OCCURRENCE $
DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $
$
PRO-
OTHER:

LOCJECT

COMBINED SINGLE LIMIT
$(Ea accident)
BODILY INJURY (Per person) $ANY AUTO
OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY
HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
$
OCCUR EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
DED RETENTION $ $

PER OTH-

STATUTE ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION
© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE
National Fire Ins of Hartford
The Continental Insurance Company
State Compensation Ins. Fund
Landmark American Ins. Co.

Valley Forge Insurance Co
Houston Casualty Co.
12/17/2021
Edgewood Partners Ins Center
One California Street, Suite 400
Lic#0B29370 (415)356-3900
San Francisco, CA 94111
Laurie Martin
-
[email protected]
Acclamation Insurance Management
10445 Old Placerville Road
Sacramento, CA 95827
20478
35289
35076
33138
20508
42374
A X
X
X
6056760864 01/01/2022 01/01/2023 1,000,000
1,000,000
15,000
1,000,000
2,000,000
2,000,000
E
X
X X
6056760850 01/01/2022 01/01/2023 1,000,000
B X X
X 10000
6056760878 01/01/2022 01/01/2023 10,000,000
10,000,000
C
N
908337922 01/01/2022 01/01/2023 X
1,000,000
1,000,000
1,000,000
D
F
Professional Liab
Privacy Liability
LHR843573
H21NGP20937501
07/11/2021
07/11/2021
07/11/2022
07/11/2022
$5,000,000 agg E&O
$5,000,000 agg Cyber
$25,000 SIR E&O & Cyber
Claims administration services including Nurse Case Management and Bill Review.

Named insured includes: Acclamation Insurance Management Services, Inc.; Allied Managed Care, Inc.; LJR Holdings, Inc.; LJR Properties, LLC; CarivaCare, Inc. (See Attached Descriptions)
City of Richmond ATTN: Risk
Manager
450 Civic Center Plaza 3rd Floor
Richmond, CA 94804-0000
1 of 2
#S3022525/M3022241
ACCLINSUClient#: 6105
LMA4
SAGITTA 25.3 (2016/03)
DESCRIPTIONS (Continued from Page 1)
Thirty day notice of cancellation will be provided to the certificate holder but 10 days for non-payment of premium.

EMPLOYEE DISHONESTY / CRIME COVERAGE: Travelers Property & Casualty Insurance Company. #107196186 EFF: 1/1/22 EXP: 1/1/23 DISHONESTY LIMIT: $2,000,000 $20,000 DEDUCTIBLE Claims administration services and cost containment contract.

The City of Richmond, its officers, officials, employees, agents and volunteers are listed as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract, where required by written contract. General Liability insurance is primary and non-contributory with certificate holder's insurance. Workers Compensation Waiver of Subrogation endorsement is attached to the Workers Compensation policy. 2 of 2
#S3022525/M3022241

CNA PARAMOUNT
FinancialServices- GeneralLiability
ExtensionEndorsement
It is understoodand agreedthat this endorsementamendsthe COMMERCIALGENERALLIABILITYCOVERAGEPART as follows. If any other endorsementattached to this policy amends any provision also amended by this endorsement, then that other endorsementcontrols with respect to such provision, and the changes made by this endorsementwith respectto such provisiondo not apply.

TABLEOF CONTENTS

1. AdditionalInsureds

2. AdditionalInsured- PrimaryAnd Non-ContributoryTo AdditionalInsured’sInsurance

3. BodilyInjury– ExpandedDefinition

4. BroadKnowledgeof Occurrence/Noticeof Occurrence

5. BroadNamedInsured

6. Estates,LegalRepresentativesand Spouses

7. ExpectedOr IntendedInjury– Exceptionfor ReasonableForce

8. In Rem Actions

9. IncidentalHealthCare MalpracticeCoverage

10. JointVentures/Partnership/LimitedLiabilityCompanies

11. LegalLiability– DamageTo Premises

12. MedicalPayments

13. Non-ownedAircraftCoverage

14. Non-ownedWatercraft

15. PersonalAnd AdvertisingInjury– Discriminationor Humiliation

16. PersonalAnd AdvertisingInjury- LimitedContractualLiability

17. PropertyDamage- Elevators

18. SupplementaryPayments

19. UnintentionalFailureTo DiscloseHazards

20. Waiverof Subrogation– Blanket
6056760864CNA75102XX(1-15) PolicyNo:
6Page1 of 14 EndorsementNo:

Nat'l Fire Ins Co of Hartford 01/01/2022EffectiveDate:

ACCLAMATION INSURANCE MANAGEMENT SERVICES, INCInsuredName:

CopyrightCNA All Rights Reserved. Includes copyrightedmaterialof Insurance ServicesOffice, Inc., with its permission. 00020006460567608648327

CNA PARAMOUNT
FinancialServices- GeneralLiability
ExtensionEndorsement

1. ADDITIONALINSUREDS
a. WHO IS AN INSUREDis amendedto includeas an Insuredany personor organizationdescribedin paragraphs A. throughK. below whom a Named Insuredis required to add as an additionalinsured on this CoveragePart undera writtencontractor writtenagreement,providedsuch contractor agreement:
(1) is currentlyin effect or becomeseffectiveduringthe term of this CoveragePart; and (2) was executedprior to:
(a) the bodilyinjuryor propertydamage; or
(b) the offensethat causedthe personaland advertisinginjury, for which such additionalinsuredseeks coverage.
b. However,subject always to the terms and conditionsof this policy, including the limits of insurance,the Insurer will not providesuch additionalinsuredwith:
(1) a higherlimit of insurancethan requiredby such contractor agreement;or (2) coveragebroaderthan requiredby such contractor agreement,and in no event broader than that described by the applicableparagraphA. throughK. below.

Any coveragegrantedby this endorsementshall apply only to the extentpermissibleby law.

A. ControllingInterest
Any personor organizationwith a controllinginterestin a NamedInsured, but only with respectto such personor organization’sliabilityfor bodilyinjury, propertydamageor personaland advertisinginjuryarisingout of:

1. such personor organization’sfinancialcontrolof a NamedInsured; or

2. premises such person or organization owns, maintains or controls while a Named Insured leases or occupiessuch premises;
providedthat the coveragegrantedby this paragraphdoes not apply to structuralalterations,new constructionor demolitionoperationsperformedby, on behalfof, or for such additionalinsured.

B. Co-ownerof InsuredPremises
A co-ownerof a premisesco-ownedby a NamedInsuredand coveredunder this insurancebut only with respect to such co-owner’sliability for bodily injury, propertydamageor personaland advertisinginjury as co-owner of such premises.

C. Grantorof Franchise
Any person or organization that has granted a franchise to a Named Insured, but only with respect to such person or organization’sliability for bodily injury, property damage or personal and advertising injury as grantorof a franchiseto the NamedInsured.

D. Lessorof Equipment
Any person or organizationfrom whom a Named Insuredleases equipment,but only with respect to liability for bodily injury, propertydamageor personaland advertisinginjury caused,in whole or in part, by the Named Insured’smaintenance,operation or use of such equipment,provided that the occurrencegiving rise to such bodily injury, propertydamageor the offense giving rise to such personaland advertisinginjury takes place prior to the terminationof such lease.
6056760864CNA75102XX(1-15) PolicyNo:
6Page2 of 14 EndorsementNo:

Nat'l Fire Ins Co of Hartford 01/01/2022EffectiveDate:

ACCLAMATION INSURANCE MANAGEMENT SERVICES, INCInsuredName:

CopyrightCNA All Rights Reserved. Includes copyrightedmaterialof Insurance ServicesOffice, Inc., with its permission.

EXHIBIT 15 –
Proposer Qualifications

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Exhibit 15 – PROPOSER QUALIFICATIONS

Proposer Qualifications
Claims Administration
A. Firm’s s: Describe the firm and provide a statement of qualifications for performing the requested scope of services as outlined in Scope of Services- Claims Administration Services. Identify the firm’s primary service office for the City’s account. Provide a company-wide organizational chart with reference to the proposed service office and proposed service team.

Please see the main body of our proposal Firm Description and attached Exhibit of AIMS Organization Charts.

B. Service Team Qualifications: Provide an organizational chart outlining your proposed service team including names, titles, and length of service in your organization. For each proposed team member, provide a summary of qualifications including claims handling experience, indemnity case load, experience working with public entity self- insured entities, education, and any professional designations and awards. Include full resumes for each member of your proposed service team. If you have not designed staff to service the City’s account, provide the selection qualifications for any staff necessary to service the City’s account.

See attached Exhibit of AIMS Organization Charts and Team Resumes.

C. Claims Administrative Services: Describe your firm’s claims administration policies, procedures, and best practices that ensure superior service to City employees while maintaining economic and administrative control over claims costs. Discuss your claims reserving philosophy and indicate the maximum number of indemnity files handled by your proposed claims examiners.

Policies and Practices: AIMS has customized all procedures to meet the Scope of Work requirements of the City. AIMS administers our California Clients’ self-insurance plans in full compliance with all laws, rules and regulations governing the administration of self - insurance pursuant to Sections 3700 et seq . of the Labor Code and the California Administrative Procedure Act as set forth in Government Code, Title 2, Div. 3. Part I, Chapter 4 and 5 in effect at the time of submission of our response to this RFP as amended during the period that any contract wit h the Client is in effect and any other laws, rules, and regulations that govern the handling of California Workers’ Compensation claims.

A true partnership between the Client and the administrator is imperative to the successful management of a workers’ compensation program. This relationship takes a high level of communication, trust and a lot of work. Our hands -on team approach is what has led to the development of many strong partnerships over the years. This has involved partnering with the City to ass ess specific needs and then developing a customized claims

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
management program designed to combat claim exposures and costs for the City. The key elements of the program are:

Define - Learn and evaluate needs of the customer

Perform - Deliver and be accountable to expectations

Measure - Analyze effectiveness

Report – Present hard data

Recommend – Suggest proactive strategies to improve results Superior Client Service to City employees: As a Client -driven organization, AIMS delivers measurable financial results to our Clients through our intelligent use of innovative technology and a flexible, yet disciplined, approach to service delivery with fiscal accountability. We nurture long -term relationships by providing our Clients with technically competent, experienced, and dedicated staff, acting with integrity in all that we do.

Our commitment to great Client servi ce is the same at every level of our organization - from our front line employees to our senior managers. Clients evaluate our performance based on the responsiveness of our employees. When we consistently meet our commitments with enthusiasm and timelines s, the entire organization benefits, and our Clients becomes our advocates.

It is every employee’s responsibility to:
 Listen for understanding
 Show empathy
 Find solutions
 Anticipate needs
 Follow through on commitments
“Serving Clients is our purpose. Client service is our passion.”  Client Service Initiative: Seven years ago we launched a Client Service initiative directed at improving and providing a higher level of Client service for our current and future Clients. In the initial phase of the progra m we focused specifically on training and investing in our managers and staff bringing them on board with our goals and initiatives. Our training efforts have continued regularly since that time with an ultimate objective: to better understand, from our Client's perspective, how we at AIMS interact with you on a day to day basis.
 Client Relations Director: AIMS has implemented the second phase of our Client service program by establishing a Client Relations role within AIMS. We felt it was vitally important to have a position solely focused on maintaining and improving client satisfaction. Therefore, we have established and assigned the position of Director of Client Relations. This individual is in charge of developing a better understanding of how we wo rk together and how we at AIMS can provide even better service. Our Director of Client Relations contacts Client staff that interacts with us on day to day basis and asks questions concerning Client experiences with AIMS, both good and bad. This informati on is then provided to AIMS senior management for review and issue resolution responsibility.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Meetings, Training, Stewardship Reporting: AIMS prides itself on providing the kind of pro-active Client service seldom seen in our industry. From in-person Client meetings to completing specialized data reports on the program development, we will always go the extra step. Our management staff is responsible for our in -service training. When requested, training sessions on proper reporting, new case law or chan ges in the methodology the State expects the delivery of workers’ compensation services to be accomplished is an integral part of our value-added partnership. These training sessions may be held at our offices, Client locations or other specific areas des igned to accommodate a number of our local Clients who share the same need for up -to-date status on the ever changing climate of workers’ compensation in California.

As part of our philosophy with regard to continual and seamless communication with the City, we expect there will be times when agency or department heads will inquire about specific cases and the strategy for disposition. On those occasions and with the City’s permission, we will schedule file reviews or in-person meetings to inform the department of progress on a specific claim(s). AIMS provides the City regular face -to-face meetings with the Examiner(s) at the City’s desired location. Pre-meeting status reports are developed and any issue that is allowed to be discussed will be placed on an agenda.

Privacy issues will be protected from those employees who are not authorized to discuss those topics.

Economic and Administrative Control Over Claims Costs : Our approach to the management of our Clients’ claims and programs centers on quality, service and results.

We are committed to a constant focus on these key elements of our Loss Portfolio Management® approach. Our Clients are not just the employers but also the employees who have sustained industrial injuries or illnesses while working within the course and scope of their employment. We focus upon promptly providing these employees the benefits due them and maintaining open and on -going communication with them during the course of their claims. Programs that provide this positive approach will produce lower overall workers’ compensation costs, including significantly reduced litigation rates.

Loss Portfolio Management®: Our “Loss Portfolio Management®” approach ensures that we are always focused on identifying key issues that have a large financial impact on the overall claim and to proactively utilize all available internal and external cost containment resources to address and resolve these issues in an expedient fashi on.

AIMS management and staff have a singular objective: assist the City to be productive and profitable while providing compassionate care of its injured employees. We work in partnership with our Clients to achieve optimal results from their self-insured workers’ compensation program. AIMS goes beyond ordinary third party administration services, to offer our Clients a customized, flexible loss management program and services designed to generate lower claims costs and better outcomes.

Quality Assurance: AIMS asserts a strong Quality Control Program, in which we consistently monitor, measure performance, and review the quality of the services being provided to ensure superior customer service and cost saving results for our Clients. In addition to the standard supervisory audit, our Internal Audit Unit, headed by Cheryl Agee (Vice President Workers’ Compensation), conducts audits against our best practice standards as well as the Client’s Special Handling Instructions. The Audit Unit’s p rocess

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
involves notification that an audit is to be conducted in the Branch or local office. The Manager makes available all requested information, claim files, logs, contracts, etc. In addition, the Manager participates in the actual audit itself. All fi les with deficiencies and/or recommendations are immediately returned to the Claims Examiner for corrective action. The Claims Managers review the file for compliance at each diary date. The Supervisors carry independent diaries for this purpose. Audit scores are incorporated into Performance Evaluations conducted annually for each employee. The audit conducted by our internal audit unit is comprehensive and takes into consideration all facets of claim file handling.

Diary System: The key to good claims management, avoiding penalties and keeping deadlines, is an effective diary system that enables the Claims Examiner to properly manage each claim in an expedient manner. Claims Examiners are required to review open Indemnity claims at least every 45 days. Our computer system has an automated diary system that is utilized by all of our staff. A detailed list of diaries is displayed each time a user logs onto the computer. At a minimum the claims unit supervisors are required to review open Indemnity claims within 10 days of a new claim filing and thereafter every 120 days. Our knowledgeable, dedicated managers and supervisors provide strong supervisory oversight. AIMS internal audit team reviews claims to assure legal and regulat ory compliance, as well as conformity to best practices and Client -specific performance standards.

We employ a “supervisor’s overview” of the daily diary to monitor when a file is due to be reviewed and whether or not the Examiner has conducted the diary. This is one of the key components of our internal audit process.

In addition to the standard supervisory audit, our own Internal Audit Unit (headed by the Vice President of Workers’ Compensation), conducts audits against our established procedures as well as the Client’s Special Handling Instructions. The Audit Unit’s process involves notification that an audit is to be conducted in the Branch or local office. The Manager shall make available all requested information, claim files, logs, contracts, etc.

In addition, the Manager shall participate in the actual audit itself. All files with deficiencies/recommendations are immediately returned to the Claims Examiner for corrective action. The Claims Managers review the file for compliance at each diary date.

The Supervisors carry independent diaries for this purpose. Audit scores are incorporated into Performance Evaluations conducted annually for each employee. The audit conducted by our internal audit unit is comprehensive and takes into consideration all facets of claim file handling.

The following Time Performance Standards are part of our Best Practices audit standards, which are used to help keep claims on track for prompt resolution.

TASK TIMEFRAME
Claim set up in Computer Within one (1) working day of date of receipt Initial Claimant Contact Within one (1) working day of date of receipt

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services

TASK TIMEFRAME
Subsequent Claimant Contact Every 14-days of continued disability – or every thirty (30) days if on modified duty
Initial Client Contact Within one (1) working day of date of receipt Initial Medical Provider Contact Within one (1) working day of date of receipt Initial Payment of Disability Within fourteen (14) days of first day of disability Investigation Within five (5) days of knowledge of condition requiring investigation & approval by Client
Investigation Reports Within fifteen (15) days of assignment – subsequent reports maximum of every thirty (30) days
DWC Benefit Notices Within fourteen (14) days of the event causing the need for notice Penalty Report Form To be completed within 72 hours of notice of penalty -Form to home office within 5 working days
Penalty Payments Self-imposed penalty to accompany delayed benefit Auto Pay Schedules Not to be authorized for more than seven (7) periodic payments (84) days
Advance Travel Expense At least ten (10) days before examination date Transportation Reimbursement Approval for payment within fifteen (15) working days of request for reimbursement
Medical Treatment Billings Approval for payment within ten (10) calendar days of receipt of bill
Payment of electronic bills Within fifteen (15) days of electronic receipt Contested medical bills Notice to provider within twenty (30) calendar days that bill is contested, denied or incomplete
Payment of Awards, C & R ’s,
stipulations
Approval for payment within fourteen (14) calendar days of receipt or Statutory Requirements.

Litigation Referral to defense council no more than ten (10) days from date of decision to refer (sooner if impending court date or other deadline)
Initial status report from defense
counsel
Maximum of fifteen (15) days from date of referral
Subsequent reports Maximum of thirty (30) days from last report Subrogation Notification/Contact with negligent third party within thirty (30) days of determination of existence of subrogation
Balancing of Claim File Every 180 days or end of benefit, whichever occurs first

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services

TASK TIMEFRAME
Excess
Reporting/Reimbursement
Initial reporting —within ten (10) working days of date of knowledge that any reporting Criterion has been met
Requests for reimbursement Maximum of every ninety (90) days Case Closure Within thirty (30) days of the final payment, notice, or as provided by law
Telephone Inquires Return Calls —within one (1) working day of original telephone inquiry
Plan of Action Review Every ninety (90) days a full plan of action update is noted in the system
Return Correspondence Written answer completed and returned within five (5) working days of receipt
Supplemental Job Displacement
Vouchers (Potential Notice)
Within 10 days of last payment of temporary disability
Conversion of Medical Only to
Indemnity
Within one (1) day of knowledge that file needs to be converted and reviewed/approved by Supervisor
Reserves At initial file setup
Within seven (7) days for any event that triggers the need for a reserve change
Reserve reviews required at a maximum of every ninety (90) days Status Reports Every ninety (90) days created and provided to Client Examiner File Review No less than every forty-five (45) days – documented by notepad activity under “Examiner review”
Supervisory File Reviews At a maximum of every one-hundred and twenty (120) days

AIMS will customize these response times if the Client has specific requests and these will also be reflected in the Client Special Handling Instructions. These instructions will incorporate AIMS Best Practices (AIMS4Excellence), Case Review Details, and assertive quality control measures that include all Client specified timelines.

All of these standards and procedures, along with our hands-on proactive involvement in the claims, ensure cases continually move toward a timely and cost effective closure without jeopardizing necessary high quality of care for the injured worker.

AIMS Supervisors are focused on providing continuous oversight of the claims and Client programs. A monthly review is conducted on a percentage (minimum 10%) of each Examiner’s files to ascertain that the Claims Examiner is performing up to our standard as well as the agreed upon standards of the Client. The Supervisor subsequently reviews claims at regularly timed intervals (not less than every 120 days) or when specific events

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
occur such as surgery or litigation, when the claim meets reserving or payment thresholds, and in the course of continuous random audits.

AIMS Supervisor has numerous duties including frequent reviews of Claim Examiner’s claims. Supervisors do not carry caseloads as they are focused on providing continuous oversight of the claims and Client programs. The following are exam ples of Supervisor duties:
 The Supervisor will review all new losses received daily to confirm contact was made timely and make an entry in the computer’s supervisor notepad.  The Claims Management Information System will set an automatic supervisor diary for 10 days following claim entry to confirm that all issues on the claim have been addressed. (i.e., subrogation, notices, benefit provision, etc.)  By the 6th business day of the following month the Supervisor will provide a report to the Branch Manager and corporate office outlining the total lost time claims received, the total timely contacts and the percentage of timely contacts.  Each Supervisor is to monitor the payment diary of their staff for timeliness and accuracy.
 The Supervisor is to monito r the review diary of their staff for timeliness and accuracy no less than once a month.
 All denials and delays shall be approved by the team supervisor. Authority to delay or deny a claim shall first be obtained from the Client.  As soon as suspect issues arise, they must be written up by the Claims Examiner and given to the immediate Supervisor with the file to be reviewed and consideration for fraud investigation will be made.
 Any file which indicates the possibility of subrogation should be forwarded to a Supervisor for review to determine if further investigation is required.  Upon receipt of a Decision or Order, the Supervisor shall make a prompt analysis regarding an appeal. If the Supervisor feels the decision should be appealed, the file should be documented as to the reasons and referred to the Branch Manager.  Upon receipt of the “Reinsurance Report” each Unit Supervisor or Branch Manager shall verify that all cases listed on the report have been reported to the Excess/Reinsurance carrier.
 All non -senior level Team member closures shall be approved by the Team Supervisor or Manager.
 In addition to the above duties, the Supervisor, as a part of his/her performance evaluation has to review a select percentage (minimum 10%) of each Claim Examiner’s files on a monthly basis. This review is conducted to ascertain that the Claim Examiner is performing up to our standard as well as the agreed upon standards of the Client. For sensitive or high exposure cases, the supervisor utilizes a personal oversight di ary, identifying those cases that warrant periodic management review. The Supervisor Review is clearly noted in the notepad.  Appropriate action is taken to ensure completions of all tasks are met. Our Supervisors provide technical oversight of the individual claims and of the employers’ workers’ compensation programs, ensuring quality, service, results as well as compliance with regulatory and Client -specific program performance

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
standards. Supervisors do not carry a caseload. All Senior Claim Examiners and above are State certified to administer self-insured workers’ compensation claims unless waived by the Client.

Monitor and Manage Case Loads: On a continual basis, we review the Claim Examiner activity dashboards that capture all new claims and closing ratios and pending open files.

The Supervisors consistently manage the Claim Examiner’s caseloads to ensure caseload levels are managed based on Client specific requirements. All files with deficiencies/recommendations are immediately conveyed to the Claim Examiner for corrective action.

AIMS is committed to fully comply with the regulations for Workers’ Compensation Examiner Certification regulations (CCR, Title 10, Sections 2592 to 2592.14) that were developed to implement Insurance Code Section 11761 effective February 22, 2006.

Education and Training: Our management staff is responsible for conducting and/or coordinating all in -service training and our Vice President of Workers’ Compensation (VP), responsibility includes monitoring for compli ance with the Insurance Code 11761, training and continuing education, on a bi -annual basis. The VP currently publishes a schedule for each branch manager indicating who in the respective office is subject to the CEU requirement annually. It becomes the responsibility of the Manager to then arrange for outside CEU opportunities or arrange to schedule in -service seminars by inviting industry professionals into our offices to conduct DWC approved courses. All professional staff is invited as well as interested Clients.

AIMS pays for our Claim Examiners and Assistants to complete their Insurance Educational Association (IEA) certificate. We also pay for the Self-Insured Administrators test if the current position requires certification. We pay for outside s eminars and conferences and provide the staff with frequent in-house educational presentations. AIMS recognizes the only way to ensure compliance with workers’ compensation laws, regulations and statutes is to maintain a high level of continuing education and training in order to keep up with legislative, legal, and regulatory changes in our industry. We conduct training on a regular basis in the areas of subrogation, fraud, medical management and other key training areas within our Best Practices Performa nce Standards. At AIMS, we require all staff to attend and complete training sessions regarding legislative, legal and regulatory changes in the workers’ compensation industry.

Partial List of Recent Mandatory Training Sessions: EDI Training, Utilization Review, Medicare Set-Aside Trusts, AMA Guides & PD Rating, Fraud Training, Medical Provider Networks, Security Awareness, 4850 & Public Safety Presumptions, Supplemental Job Displacement Benefits, Ergonomics, and Medical Roundtable.

Reserving: AIMS Claims Examiners are well versed in the tangible and intangible rationale affecting reserves and establish accurate reserves given the state of the claim facts at any point in time. Reserves are constantly reviewed at each scheduled diary.

Reserve worksheets a re prepared to support any changes made in reserving amounts and can be provided to the Client in support of a reserve increase or other change. This information is made available to the Client through online viewing of the Examiner’s electronic file notepad. If the Client desires, prior to any reserve change of a pre-agreed

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
amount or level, the Claims Examiner will confer with appropriate Client personnel to discuss the merits of the proposed change.

AIMS Examiner will review and evaluate the reserve adeq uacy and possible closure at 45 day intervals or as designated by the City.

The criteria that mandates review of reserves is based on the level of authority by position.

Provided below are the corporate guidelines applied to reserving as well as the task performance timeframes:

Examiner $0 - $250,000
Senior Examiner $0 - $500,000
Supervisor $0 - $750,000
Branch Manager $0 $1,000,000

Performance Time Frame Standards – Reserves

TASK PERFORMED TIMEFRAME
Reserves At initial file setup. Within seven (7) days for any event that triggers the need for a reserve change. Reserve reviews required at a maximum of every ninety (90) days.

Status Reports/ Plans of Action Every ninety (90) days.

Supervisory File Reviews At a maximum of every one-hundred & twenty (120) days.

Please see Exhibits 7 – Settlement Authority Request Worksheet and Exhibit 8 – AIMS4Excellence TOC

D. Ancillary Services: Identify any company -owned and affiliated ancillary services to include, but not limited to, bill review, and utilizati on review. Provide a description of each ancillary service including an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. List all outside vendors you currently work with including the services they provide. If such services were awarded to one or more vendors not owned by or affiliated with your company, describe how your firm would work with such outside providers to ensure effective and efficient service to the City.

Include any limitations you may have in working with outside vendors.

AIMS strives to provide its Clients with a thoroughly customized program. We provide assistance to our Clients in formulating customized claim report generation, customized stewardship reporting, a customized transition plan, customized Medical Provider Networks (MPN), customized Preferred Provider Organization (PPO) Networks, customized Carve-Out Programs to address cost drivers, customized utilization review (UR) and medical case management referral criteria, customized vendor panel, and in -

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
house customized training on workers’ compensation topics and trends to name a few.

For me dical cost containment services, AIMS recommends its sister company, Allied Managed Care, Inc. (AMC). AMC has been providing these services to California public agencies, self -insured’s and insurance carriers since 1995. AMC offers Medical Bill Review, Utilization Review, Nurse Case Management (including telephonic and on -site or field nurse case management) , Customized Medical Provider Networks (MPN), AlliedRx (Prescription Management), AlliedCare Complete (Early Intervention), and CallConnect (Call Center Services).

AIMS researches and will vet service providers for quality and best -value for our Client and will make our recommendations known to the City. If the City has preferences for various service providers, AIMS will use the City’s preferred vendo rs. The service provider “panel” is pre-approved by our individual Clients. Any exceptions to appropriate assignments are managed on a case-by-case basis. Through this platform, we have the ability to streamline the Claims Examiner workflow as well as t rack, manage and run reports on service provider usage.

AIMS coordinates Clients’ vendor panels and approvals in advance and all referrals to vendors in accordance with the Clients’ requirements as part of an integrated cost containment solution, which ent ails managing ancillary services and coordinating programs such as:
 Medical Bill Review
 Utilization Review
 Nurse Case Management
 Return to Work (includes on-site programs),
 Loss Control
 Workplace Safety
 Occupational Health Clinics
 Job Task Banks
 Employee Training and Medical Provider Networks (MPN) Also, AIMS continuously evaluates our strategic partner service providers to ensure performance-levels and continued value-add to our Clients.

AIMS has created an integrated referral platform called AIM S Rapid Referral Program (ARRP) to expedite this process of referral coordination between vendors and AIMS Examiners. The process integrates information directly from the Ventive System and uploads to the ARRP System. The ARRP System documents the referral and uploads the forms into the AX Document Storage System. The uploading and documentation of the referral eliminates the Examiners need to do these steps and instead completes these tasks upon creating the referral in the ARRP System. Reports are generated to track lag times and effectiveness of both the AIMS teams and the Vendors

E. Claims Management System: Describe in detail how your computer system is utilized to provide workers’ compensation services. Discuss the capabilities of the system including whether the system tracks lost time, temporary modified duty and temporary partial disability. Provide samples of standard and customized computer-

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
generated reports you prepare for your clients (Note: limit 1 - 2 pages per sample).

AIMS utilizes Ventiv System, which is an Internet-based claims management system built on Microsoft.Net technology, designed for anytime, anywhere access. The system access is web-based and runs on an SQL database platform.

Our claim management system provides a wide array of information so, the City can immediately evaluate the current condition of its customized program. Access to this information allows the City to effectively manage its workers’ compensation program and to confidently make high impact risk management decisions. Our system provides the City with extensive on-line capabilities for reporting claims, customized report generation, and immediate real time access to key information from any location.

Claim System Features of benefit to the City:
 Direct viewing of Claims System with description and details  Key data at fingertips: financial data, claims diaries, notes, lost time, temporary partial disability, and RTW
 Self-Generated ad-hoc reporting when you need it
 User defined report queries
 Web-based entry of (Employers' First Report of Industrial Injury or Illness)  1099 reporting to the Internal Revenue Service
 Self-Insurers Annual Report generation
 Occupational Safety and Health Administration (OSHA) reports – Lost Work Days
 Electronic interface with the Index Bureau and Workers’ Compensation Insurance System
 Production of all required reports and data exports (real time and viewed archived reports)
 Electronic Data Interface compliant
 Access all performance metrics (dashboard view)
AIMS claims management system accepts unlimited levels of location coding, allowing Client data to be sorted by location or cost center for loss control and financial purposes.

The department names and organizational coding is customized to fit the needs of each Client. Similarly, custom code sets allow each Client to define their own tables, such as notepads, pay types, class codes, and job descriptions.

By customizing our coding tables, we are able to extract accurate and relevant data that satisfies the needs of each Client. The primary categories for reserves have been expanded to allow us to more effectively track benefit payment, reserve, and incurred data. The system tracks lost time, t emporary modified duty, and temporary partial disability. Listed below are some of the reserve categories:
 Temporary Disability
 Permanent Disability
 Labor Code 4850
 Medical Expenses

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
 Legal Expenses
 Other Expenses (includes investigations)
 Vocational Rehabilitation Benefits
As mentioned above, the RMIS is upgraded on a continuous basis. Our claims information system utilizes state -of-the-art technology including access security, nightly back -ups with off-site storage, an uninterrupted power source to ensure continued use in the event of a power shortage, and a formal business interruption plan.

Access to our system is only gained through user specific security codes; therefore, only select personnel who have been given clearance have access to data and mo netary functions. Various security levels are granted to users, which preclude change of data and generation of payment or reserve changes unless pre -authorized. Also, the system allows password security at the location code level so user can access only their location information.

Standard & Monthly Reports: In addition to extensive reporting, the following information is a sample of what type of reports and data AIMS Clients can view within the claims system: Claims Summary, Claims Examiner Notes, Detailed Payment Information, Detail Transaction, Managed Care (UR, Fee Schedule), Billing Information, and Prior TPA Information. In addition, correspondence such as medical legal reports, depositions, denial letters, and attorney correspondence information is also captured.  AIMS electronic database is capable of producing specialized and ad hoc reports in addition to those required by the State of California. AIMS can provide various standard monthly reports and custom reports upon request. AIMS supports its Clients with a robust report library. Our system is an extremely powerful data management claims system for both standard and ad hoc report generation. Our web based system also provides convenience and access to real -time and “point in time” financials for generating customized Ad Hoc reports, multiple program reports for data downloads and monthly loss reports which can be exported into other applications such as Portable Document Format (PDF) or Microsoft Excel. Types of data available which will electronically be available to the County range from Claims Summary, Adjuster Notes/Diaries, Detailed Payment Information, Detail Transaction, Managed Care (UR, Fee Schedule), billing details to prior TPA information.

Please see Exhibit 10 – AIMS Sample Claims Reports

F. SAS 70 Audit Compliance: Indicate your firm’s compliance with SAS70 annual audit compliance reporting and indicate the date of the most recent completed audit report.

AIMS undergoes SSAE 18 audits annually to ensure our contr ols are effective because we are very earnest about our business and the security of our Client’s information. The Company has successfully undergone the audit process and is compliant with the Statement on Standards for Attestation (SSAE) No. 18, Reportin g on Controls at a Service Organization.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
The SSAE No. 18 audits effectively reports (SOC1 & SOC2 reports) on the relevant internal controls established by LJR Holdings, Inc. (LJRH) for AIMS, especially the financial controls and the information systems relevant to security, availability, processing integrity, confidentiality or privacy in performing our services for our Clients. The Company’s compliant report for Service Organization Controls (SOC1 & SOC 2) has been included in the noted exhibit.

Please see Exhibit 11 – SSAE 18/ SOC 1 & 2 Reports (CONFIDENTIAL)

G. Client References: Provide a list of five (5) clients (including full contact information) from which similar types of claims-related services are provided by your proposed service team office. Include the length of your contract with each client including the approximate number of indemnity claims annually. The City will contact these references to discuss the bidder’s performance.

The longevity of our Client relationships is based in part on the types of programs AIMS establishes, which reinforce the strategic goals of workforce excellence, organizational effectiveness, and fiscal responsibility. Provided below are references for Clients with programs similar to the City of Richmond.

REFERENCE – Claims Related Services
Agency Name
Central San Joaquin Valley Risk Management Authority (52 Member Cities JPA) Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 1995 / 1000

REFERENCE – Claims Related Services
Agency Name
City of Bakersfield
Contact Name
Jena Covey, Risk Manager
Contact Phone Number
661-326-3090
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 2007 / 500

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
REFERENCE – Claims Related Services
Agency Name
City of Huntington Beach
Contact Name
DeAnna Soria, Risk Manager
Contact Phone Number
715-536-5519
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
Client since 2010 / 500

REFERENCE – Claims Related Services
Agency Name
City of Clovis
Contact Name
Lori Shively, Personnel/Risk Manager
Contact Phone Number
559-324-2726
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims

Client since 2007 / 175

REFERENCE – Claims Related Services
Agency Name
County of Madera
Contact Name
Jason Blanks, Risk Manager
Contact Phone Number
559-675-7703
Contact Email Address
[email protected]
Length of Contract / Number of Indemnity Claims
2005 to present / 300 open claims

Bill Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing bill review services. Describe your experience doing business with self- insured public entities in California. Discuss what distinguishes your company fr om other bill review providers. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.

AIMS recommends its sister company, AMC for bill review (BR) services. AMC has one central goal – provide p rofessional medical cost containment solutions that result in improved program costs. AMC has over 100 Clients consisting of approximately 80%

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
self-insured public entities and 20% private entities throughout the continental United States and Hawaii. AMC audits approximately 230,000 bills per year.

AMC’s philosophy is, in part, that the greatest net savings and not just the lowest fee bill review company should be any employers’ decision point. Our goal is to ensure our Clients only pay what they are lega lly obligated to pay, no more or no less . Some competitors offer an extremely low fee and, to do so, they also automate nearly all of the bill review process. Fully automating BR leads to an increase of inquiry and dispute calls from the provider to the TPA/Employer, an increase in provider litigation (liens), and ultimately an increase in claims cost because of inaccurate and unjustifiable bill reviews.

Qualifications: As a full -service medical BR company, AMC adjusts medical, hospital, surgical and pharmacy bills using the Official Medical Fee Schedule (OMFS), the Official Inpatient and Outpatient Fee Schedules, and we apply discounts generated by MPN, Preferred Provider Organization (PPO) and pharmacy networks.

AMC does not simply “process” medical bills by pushing them through scanning and OCR technology for repricing, rather our certified bill reviewers manually review each and every bill in order to ensure we are recommending the most appropriate fee for the services provided. We strive to obtain the highest net savings for our Clients.

AMC Distinguishing Features: Our approach to the management of our Clients’ Medical Bill Review programs center on quality, ser vice, and results. AMC is committed to a constant focus on these key elements and provides these services in accordance with the California Labor Code and California Code of Regulations.  A paperless single source solution for BR processing
 Director of Client Services (single point of contact)  Over 20 years of expertise in California public entities including but not limited to having over 65 Clients that have safety officer employees and over 30 school districts. We have firsthand knowledge of the claim exposures, which allow us to effectively utilize all cost containment measures.  Offer a variety of PPO’s with the ability to geographically assess the best PPO  Enforcement of UR determinations/interfaced with BR
 Health Insurance Portability and Accountability Act (HIPPA) Compliant  Electronic document storage and retrieval
 Claims Examiner ToolBox (Web -based portal) – Electronic Claims Examiner Approvals/Objections
AMC maintains a partially manual process to ensure the ability of the BR analyst to verify via reading the corresponding medical reports the services billed were actually the services provided.
 Higher savings
 Improved accuracy
 Less provider disputes
 Less lien litigation
Enhanced Value for our Clients:

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
 Experience/Stability
o California focus and expertise
o Over 21 years’ experience providing bill review/utilization review services – California public and private entities
o Mandatory ongoing continuing education - effective solutions and increased cost containment savings
o Fully licensed/dedicated technical staff
o Managed care professionals collectively has over 100 years of experience o Management structure
o Proven savings results
 Consistent superior audit results
 Client specific customization of programs
o Customized Special Account Instructions based on the Client’s requirements for desired results
o Special Handling Instructions Allied Customer Expectations (ACE) o Customized protocols based on Client’s requirements
 Innovative programs for cost effective handling of medical cost containment programs
o Dedicated Client Services Director – single point of contact o Paperless Process – increased productivity, security/management o Excellent references
AMC BR Service Office and Org Chart: 10360 Old Placerville Road, Sacramento, CA, 95827.

A company-wide organizational chart has been included in the exhibit noted below.

Please see Exhibit 1 – Organizational Charts

B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify any sub-consultants you plan to utilize to supplement your proposed staff.

The AMC BR team identified below is supplemented by an ex tensive management, technical, and support staff in multiple offices located throughout the continental United States and Hawaii. Listed below are key personnel and members of the AMC Corporate Team. We do not use sub-consultants for the identified BR services.

Mark Denison, Senior Vice President of Operations : Mark oversee s the entire customized Bill Review/Utilization Review/Nurse Case Management Program. Mark’s role is to monitor all contract compliance with performance standards, audit compliance to individualized Special Account Instructions; legal and regulatory compliance; and provide ongoing communication with our Clients. Mark provides unparalleled leadership and direction to all AMC staff. He oversees all operational and administrative components of Allied Managed Care’s services, including Medical Bill Review, Utilization Review, and

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Case Management. He has over 23 years of experience in workers’ compensation cost containment, strong multi -jurisdictional managed care knowledge and practical application. His involvement ensure s that our Client’s performance standards are met and communication is ongoing. Mark is always available to meet with our Client’s staff to discuss issues and performance when requested to do so. Mark is a state board certified licensed Chiropractor, Certified Di sability Evaluator and past Division of Workers Compensation (DWC) appointed Qualified Medical Evaluator (QME). Mark joined the AMC team in 2008.

Lea Morales-Mendez, Director of Client Services : Lea has over 26 years of workers’ compensation exp erience in roles of operations and management as well as Client Services. Lea has received training in Disability Management, Health Insurance Portability and Accountability Act (HIPAA) and Utilization Review Accreditation Commission (URAC). Lea’s role is to a ssist the management team in addressing all issues related to the contract as well as serving as a resource for workers’ compensation decisions that may affect our Client. As well, as interacting with AMC’s management team to resolve all issues that may arise in UR and Bill Review; provide timely communication to the management staff of any critical developments that may affect the product delivery; meet regularly with the management team to assess AMC’s performance; discuss business decisions, and address concerns. Lea is a resource for our Clients. Lea joined AMC in 2006.

Melissa Miller, Bill Review Director: Melissa has over 20 years of experience in the industry including working for large national bill review companies. Melissa is a California Designated Bill Reviewer. She provides supervisory oversight and quality control of the entire medical bill review process for our Clients to ensure timely processing of payments.

Melissa is responsible for all administrative and operational components of the bill review unit, including staffing, training, quality, timeliness and accuracy of work performed in the unit, ensuring efficie nt and optimum workflows. She has a working knowledge of the entire bill review process, from bill entry, tracking of bills in and out of the office, review of all bill types, check-offs, invoicing, export file generation and sending, report generation according to the Special Account Instructions , the re -evaluation process and the lien process. Melissa joined AMC in 2009.

Darcy Olivares, Bill Review Supervisor: Darcy is a California Designated Bill Reviewer with over 16 years in the workers’ compensation industry. She reports to Melissa and is responsible for all administrative and operational components of the bill review unit; including staffing, training, quality, timeliness and accuracy of work performed in the unit, efficient and optimum workflows, and maintaining the positive and professional attitudes of unit members. Darcy also has a working knowledge of the entire bill review process, from bill entry, tracking of bills in and out of the office, review of all bill types, check -offs, invoicing, exporting files, report generation according to Special Account Instructions, the re-evaluation process, and the lien process. Darcy joined AMC in 2007.

Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes C. Services: Describe your bill review services, features of your system, unique capabilities, and ability to customize the delivery of your services. Provide an

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering bill review services and provide a list of three (3) you currently work with. Include your average monthly bill volume processed by your office.

AMC brings innovative medical cost containment programs for cost effective management at the onset of all claims. These programs include appropriate medical case management, formal customized utilization review programs, medical bill review, Medical Provider Networks, Preferred Provider Networks, and all necessary ancillary services to maximize all areas of medical cost containment to bring real savings back to the Client.

We bring paperless single source solutions for utilization review treatment planning and bill review processing.

Average monthly bill volume processed by your office: AMC processes approximately 21,350 (3/1/21 – 2/28/22) bills on average per month in California. As the current Bill Review services provider, AMC has reviewed 9,556 Bills between 3/1/21 – 2/28/22 for the City of Richmond.

Third Party Administrators: AMC provides BR services through the following TPA’s:

Acclamation Insurance Management Services (AIMS), TRISTAR, and several self - insured/self-administered programs.

AMC’s Bill Review Services
Client specific customization of programs: AMC develops a customized Allied Customer Expectations (ACE) for each Client and for each cost containment service. The ACE document outlines all expectations and any special requests of the Client that is required of AMC in order to comply with contract requirements.  Customized Special Account Instructions based on the Client’s requirements  Special handling instructions detailed in the ACE service document  Customized protocols based on Client’s requirements
AMC Clients benefit by having a si ngle point of contact, our Director of Client Services who is available to our Client to develop and maintain specific strategies ensuring proactive program management and compliance with all Client’s requirements. We understand medical cost containment pr ograms for public agencies. We have firsthand knowledge of the claim exposures, which allow us to effectively utilize all cost containment measures.

Innovation: These innovative programs include services to maximize all areas of cost containment and bring real savings to the City.
 Single Source Solution: AMC will provide paperless single source solutions for BR processing and UR treatment planning.
 Director of Client Services : AMC will provide a Director of Client Services (single-point-of contact) for the City to develop and maintain strategies to

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
ensure proactive program management and compliance with the City’s requirements.
 TPA Insight: We understand medical cost containment programs for public agencies. We understand the requirements, specific pro cedures and overall goals of the City. Having AIMS, a workers’ compensation claims administration firm, as our sister organization, AMC management is uniquely informed and experienced in designing programs that improve claims administration workflows and reducing costs while improving injured employee outcomes.  Best Suited PPO : AMC does not own its own PPO, therefore, AMC can provide an objective analysis as to the best suited PPO.  Interface between BR and UR : AMC has an established interface between BR and UR. We have had this in place for over 8 years, many years before it was recognized by the industry that it is a critical component to cost containment.
 Education: A key aspect of our services has been ed ucating the Claims Examiners of the importance of timely submissions, appropriate UR referrals and full documentation. Educating the Claims Examiners on SB863, ensuring they understand their responsibilities and the penalties that apply as well as the proper workflow. Training is provided to the TPA by our Medical Director, Alan Randle.
 Medical Director : AIMS/AMC’s Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all Managed Care Services provided by AMC. Dr. Randle has served as our Medical Director since 2008.

AMC’s BR services include but are not limited to:
 Fee Schedule and/or Usual & Customary Review
 Duplicate bill detection
 Offer a variety of PPO’s with the ability to geographically assess the best PPO  PPO re-pricing and administration
 Code review and re-bundling of services
 Inpatient line-item audit reviews
 Outpatient line-item audit reviews
 Complex, specialty, and rush processing
 Enforcement of UR determinations/interfaced with UR
 National Bill Review Service
 Pharmacy review/PBM services
 Explanation of Benefits with appropriate State language  Hearing Representation at no cost
 Negotiated Discount Services
 Guaranteed turnaround time
 Interface with claim systems or overnight pick up
 Health Insurance Portability and Accountability Act (HIPPA) Compliant  100% audit of reviews
 Electronic document storage and retrieval
 Examiner ToolBox (Web-based portal)

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
 Flexible account structure, customized work flows
 Provider inquiry explanation and resolution
 Extensive management/savings analysis reports (choose from a wide range of reports to gain instant access to important data)
 Data reporting to State regulatory agencies (AMC is State reporting and electronic billing compliant)
AMC’s Software Platform: AMC can provide a state of the art BR program that utilizes a highly sophisticated software platform enhanced by the expertise of the dedicated AMC Client team trained to review bills in accordance with the specific requirements of the Client. The features of our system can be customized for each of our Client’s unique needs and specific reporting requirements.

Our analysts use a web -based, automated system to generate accurate reviews and maximize savings. AMC identifies treatment that is not appropriate under America n Medical Association (AMA) guidelines, monitor and identify duplicate bills and adjust medical, hospital, surgical and pharmacy bills using the updated and accurate Official Medical Fee Schedule (OMFS), the Official Inpatient Hospital Fee Schedule, and ap ply discounts generated by the MPN and PPO providers. Our BR software is updated on a regular basis to reflect current fee schedules and PPO networks. Our qualified trained staff reviews each bill to determine appropriateness of treatment and to ensure pro vider compliance with fee schedule ground rules. AMC will provide a paperless single source solution for the processing of all medical bills through scanning technology hardware.

In addition to the distinguishing BR features previously described in this proposal provided below are capabilities unique to AMC.
 Integration of Bill Review and Utilization Review : The electronic interface between AMC’s BR and UR/Nurse Case Management is already established. When BR and UR share data, greater savings and better medical control result. Additionally, the electronic interface between AMC’s managed care services to the AIMS Claims System is already established. Because these interfaces are already established, there is no delay in taking control of the medical cost containment aspect of a Client’s program. The Client can be confident that this aspect of their program is not only in place, which often never happens on unbundled programs, but has been in place for many years with workflows streamlined and perfected over time.

AMC’s system ensures integration of real time current information and communication on all claims is available to all cost containment practices/specialists through shared screen access. All UR and case management decisions regarding treatment limits and authority are placed directly into the BR software for retrieval and review during the audit pr ocess of all incoming bills. The Claims Examiner and/or telephonic nurse case manager can easily determine if retrospective UR is potentially needed based on AMC’s advanced ability to electronically return medical bill review information sorted by prior pr ospective or concurrent UR involvement. In other words, integrated platform ensures, on an automated basis, that services approved are the services paid.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
If treatment that was never requested or authorized is billed, the BR system will flag the treatment and allow the Claims Examiner and/or telephonic nurse case manager to send the treatment through UR for a retrospective look at whether the treatment is authorized or denied.

Reports: AMC is able to track trends for Clients by providing numerous BR reports including savings reports, PPO savings, and penetration reports, provider savings, duplicate billing, claim charges, top billers, hospital reviews, and many more. The City can also request ad -hoc reporting to meet specific needs. A wide variety of report s are available to the City and can be run on any schedule required. These reports can be generated in multiple formats including: PDF, Excel, RTF, HTML, etc. The reports include information such as claim number, provider, dates of service, billed charge s, recommended allowances, etc.

Quality Assurance: AMC provides quality assurance in medical bill review on several levels as follows:

1. An override report is run at the end of each business day, to determine that all overridden bills were checked for duplicates.

2. A retrospective Quality Assurance (“QA”) is performed using reports that identify all bills reviewed by each analyst . QA is performed during the daily functions while researching bill history and processing of Add-recs. The QA is performed by the senior analysts and supervisors on a daily basis. The following is an abbreviated list of the QA points that are stringently looked at:
 Keying – ensure bill data and demographics has been correctly added into the system.
 Claim – ensure the bill has been processed against the correct claim.  Reductions – whether correctly taken or calculated.
 Reports – ensure all required reports are attached.
 Negotiated Discounts – ensure negotiated discounts have been applied.  Treatment Plans – confirm the treatment plan has been followed.  Vendor/Provider – confirm the correct vendor/provider has been selected for payment purposes.
 Billed Charges – confirm all attached billing documents and charges are for the same patient and from the same vendor/provider while ensuring no charges are missed.
 Coding – ensure correct diagnosis, service codes and DOS are entered.  EOR Message Codes – ensure the message codes applied are applicable to the services being reviewed.

3. Results are addressed with each individual analyst, noted as part of their production standards, and are logged for monthly reporting as well as performance review.

4. Results are further utilized for individual and group training sessions.

5. While conducting a QA audit, should an AMC error be discov ered, our Client will not be charged for the correction and a new EOR will be sent to our Client.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services

6. All found issues are provided to the Manager of BR who maintains spread sheets of production counts and errors. This data is used for the monthly reviews of the analysts and to determine where additional training is required.

AMC’s turnaround time averages four (4) days: AMC’s average company turnaround time is four (4) days. It is important to define and explain AMC’s turnaround time guarantee. Sometimes, a bill cannot be properly reviewed without additional information. Approximately 8 - 12% of bills received fall into this category for any number of reasons beyond AMC’s control. The AMC guarantee speaks directly to the timeframe once a bill arrives in the AMC office which has no issues relating to the accuracy of the information on the bill or the completeness of the bill.

AMC adjusts medical, hospital, surgical and pharmacy bills using the Official Medical Fee Schedule, the Official Inpatient and Outpatient Fee Schedules, and applies discounts generated by PPO and pharmacy networks. At AMC we don’t just don’t run the CPT codes as billed by the provider. In our process each bill is looked at to ensure that documentation supports the level of service being billed.

Negotiated Bills: AMC’s pro -active approach to maximizing potential savings is demonstrated in AMC’s practice that dictates we send fee schedule exempt bills as well as non-PPO bills to the negotiation unit within the AMC BR department. This unit is able to negotiate additional savings beyond PPO discounts and/or in place of when no PPO reduction is app lied by the specific PPOs. The Negotiation Unit has been building relationships with providers who are now submitting requests directly for additional savings and prompt payments. Savings are obtained by way of LOAs (letters of agreement) that apply when a 7-10 day turnaround on payments are made.

Additionally, all bills, regardless of status, that are in excess of $2,000.00 (after reductions) are reviewed for potential referral to the negotiation unit. It should be noted that our Clients pay only a perc ent of these additional savings, if we achieve savings above and beyond the fee schedule. Simply put, if no additional savings are achieved, our Client pays nothing for our review. Currently, our Negotiation Unit is averaging a 10% savings for our Clients.

AMC routinely negotiates fee reductions on bills meeting standard criteria (including in - patient hospital bills, surgical procedures, and other high dollar exposures) that fall outside our contracted PPO Network. Our negotiation approach, which include s signed negotiation letters by both AMC and the medical provider, serves two purposes:

1. Acceptance of payment as full and final payment (eliminating lien potentials).

2. Additional savings below Fee Schedule allowances (or in place of) for expanded Bill Review savings for our Clients.

Automated Recalculation of Savings and Fees of Duplicate Bills: When AMC displays data that is for additional allowance recommendations on previously reviewed bills, the billed charges are shown as zero (which is accurate) and the “savings” is shown as a negative number. In this way, we do not artificially inflate the billed charges and our total savings is actually reduced, so that at the end of each month our Client sees a true

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
“net” savings. If our Clients BR fee was ba sed on a percent of savings, then AMC recalculates the full BR fee and refunds the appropriate amount based on the updated savings on the bill. Any reconsideration with a credit to our Client is done automatically in the system. Our Client does not have to rely on the manual intervention on an individual which may be subject to error.

Unbundling is a significant cost driver that is virtually overlooked by many BR systems.

Embedded in our software platform are bundling criteria from multiple sources, including Correct Coding Initiative (CCI), AMA, and American Academy of Orthopedic Surgeons (AAOS). The system is able to identify inappropriate billing patterns through logging vendor ID numbers associated with bills that are up-coded, bundled, fall outside medical treatment guidelines, and/or exhibit excessive fees. A report is then generated to reflect these providers so action can be taken if indicated. AMC’s system reviews all CPT ranges but we pay special attention to CPT codes in the range of 97010-98778 and 98940-98943 because of the mandated limits on physical therapy and chiropractor treatments. AMC’s system generates an automatic alert indicating the 24-limit visit rule has been exceeded.

Provider Networks: AMC can provide both MPN and PPO, to be used exclusively by our individual Clients. These workers’ compensation specific networks incorporate the medical providers with extensive, specialized experience in dealing with injuries incurred at the work place or job site. AMC does not own its own PPO, therefore, AMC can provide an objective analysis as to what PPO is best suited for the Client.

Allied Managed Care Service Entity Medical Provider Network (MPN): The Division of Workers’ Compensation Medical Unit for the Allied Managed Care MPN, MPN Identification Number 2360. The approval is for a period of four (4) years. Allied Managed Care Network is filed as a “Network Service Entity” which means that we can add the City without having to refile with the state, saving many months for implementation.

On 2019 AMC received re-approval (#2360) from the Department of Industrial Relations, Division of Workers’ Compensation Medical Unit. This approval is valid for a period of four (4) years.

As a “Network Service Entity” AMC offers Clients:
 Only one filing
 Less customization
 Only one website
 Only one audit
 Better control of Network
Preferred Provider Organization (PPO): AMC has an ever-growing list of PPO’s to offer and will work with the City to determine the best PPO’s for the City’s program. Our broad menu of network relationships is designed to offer our Clients the ability to match their own experience with the PPO option that would maximize cost effectiveness. By not being tied to or owning any PPO network we avoid the potential for a conflict of interest when selecting the best PPO for our Client.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Additionally, the system allows several ways in which we can maintain and support Client specific contractual discounts. AMC can load virtually any PPO or negotiated fee arrangement by individual provider, into the BR software engine for automated application of discounts.

We work with the Client to determine the be st PPO. During the transition phase, we discuss the PPO options. We are able to use the provider zip codes from our Client’s most recent BR data to let our Client know which PPO offers the most coverage in its area. Ultimately, the Client will choose wh ich PPO provider we use. The Client may select access to one, two or three PPO’s. If more than one is selected, the PPO’s are then categorized in our BR system as primary, secondary and tertiary.

Provided below is a partial list of some of the available PPO networks:
 Blue Cross – CA
 First Health / Coventry
 Procura
 PRIME
 InterPlan
 ClarisPointe
 ASI Flex
Lesser of Language: In order for a PPO Network to be utilized by AMC for its BR services, the contract must contain the “Lesser of Language”, which all ows the reviewer to apply the lesser of fees between Fee schedule and the PPO contract.

Pharmacy Program: AMC can track narcotic prescription drug usage and recommend UR and/or Medical Case Management to work with the prescribing physician and injured worker to establish an alternative treatment course to avoid the potential for addiction and abuse.

Integration with PPO, MPN, UR, and PBM Programs:
 AMC’s BR System has a variety of PPO’s a Client can choose from and AMC can also cascade up to three PPO’s to assure maximum savings for our Clients.  AMC will load the Client’s specified MPN providers and discounts into the Bill Review System so MPN providers are assured appropriate payment.  AMC BR System can accept UR determinations from UR companies to assure only treatment approved will be paid. AMC can provide the City’s UR Company a layout of needed information in order to accept the determination in the BR System.

AMC has an Approved Ancillary Networks Panel: AMC has gone through an extensive process of researching and interviewing numerous ancillary network vendors in order to establish a complete ancillary network vendor panel which will give our Clients the best possible service. AMC does not receive any f ees for referrals to the AMC Ancillary Network Panel vendors . Any discounts received are based upon AMC’s collective buying power and passed through to our Clients. Our Clients can use the AMC networks, or AMC will work with any network preferred by the Client.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Provider Inquiries Bill Review: Provider/vendor inquiries or appeals are received via phone, mail and fax regarding underpayments and/or denial of reviewed bills. Phone calls are returned within 24 hours. Inquiries that come through the mail ar e distributed within 24 hours of receipt. If the inquiry is an appeal, that appeal will be completed within 30 days. Each appealed bill is reviewed against the claim history to determine if the bill was paid correctly on the initial review, processed und er a different document control number (DCN) or processed if the missing information/documentation is attached for further review. Upon completing an additional or follow -up review, the results are sent back to the provider via an EOR or letter.

Independent Bill Review (IBR): We work with each Client in determining the best process by which to manage the Second Requests as well as the IBR determinations. As each Client has a different workflow process, we have a questionnaire that we will complete with our Client in order to determine the best way to manage the process.

A testament of Quality Bill Review is demonstrated by AMC’s Bill Review error of less than 1% and the fact that AMC has only received a total of four (4) IBR’s from the inception of the IBR process.

AMC Implementation of Request for Second Review

1. AMC can create either pend or denial rules based on proposed time frames. Determination of which type of rule will be upon Client request.

2. AMC has created specific message codes to be utilized in conjunction with the legislation.

3. Tracking of the 14 day response timeframe to the provider can be managed by the Client in a variety of ways including the creation of specific Bill Review queues, assignments to work specific pend queues, and use of reports.

4. Any current Penalty and Interest reports will be updated to include the time frames for Request for Second Review.

Lien Resolution: AMC works together, at no additional cost , with any represen tative appointed by the Client to resolve a lien. The Bill Review Re -Evaluation Specialist advises the Claims Examiner as to the process by which the bill was reduced (OMFS or which specific PPO was applied) so this information can be passed along to the lien claimant and defense counsel if the claim is litigated. In the event of a lien trial, if paper documentation of our process does not suffice, the Bill Review Re -Evaluation Specialist is available to attend the trial to testify and will appear as need ed for expert testimony at no additional cost . We try to prevent billing disputes through a thorough re -evaluation process.

Physical location and number of employees: AMC provides all of its managed care services out of its office located at 10360 Old Pla cerville Road, Sacramento, California 95827.

As of February 2021, AMC has approximately 69 employees.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.

Please see Exhibit 1 – Organizational Charts

D. Client References: Provide three (3) client references for your firm for which you provide bill review services including full contact information.

REFERENCE #1 – Bill Review
Agency Name
County of Los Angeles
Contact Name
Alex Rossi, MBA, ARM, Workers’ Compensation Contract Administrator Contact Phone Number
(213) 738-2154
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2006

REFERENCE #2 – Bill Review
Agency Name
Central San Joaquin Valley Risk Management Authority
Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2012

REFERENCE #3 – Bill Review
Agency Name
City of Bakersfield
Contact Name
Jena Covey, Risk Manager
Contact Phone Number
661-326-3090
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services

REFERENCE #4 – Bill Review
Agency Name
Schools Insurance Group SIG
Contact Name
Gabrielle Daniels, Director of Claims and Loss Prevention Contact Phone Number
530-823-9582 X208
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care / Client since 2013

Also, all requested References have been detailed in Exhibit 5 - Client References Utilization Review
A. Firm’s Qualifications: Describe the firm and provide a brief statement of qualifications in providing utilization review services. Describe your experience doing business with self-insured public entities in California. Discuss what dist inguishes your company from other utilization review providers. Provide a company -wide organizational chart with reference to the proposed service office and proposed service team.

AIMS recommends its sister company, AMC who has been providing expert Util ization Review (UR) Services since 2005. AMC conducts over 30,000 utilization reviews per year. AMC has over 100 Clients consisting of approximately 80% self-insured public entities and 20% private entities throughout the State of California.

AMC’s Utilization Review Service Qualifications
AMC has developed a customized efficient method to handle U R referrals, meet mandated timelines for decisions, handle Peer Review and appeals, and communicate with all parties. This information is captured in a re sponsive and results oriented Policy and Procedures Manual. This manual outlines the metrics AMC uses to ensure a high standard of quality for products and services provided to our Clients.

Accompanying the Policy and Procedures Manual is a proprietary document called, Allied Customer Expectations (ACE). AMC develops a customized ACE for each Client and for each cost containment service. The ACE document outlines all expectations and any special requests of our Client that is required of AMC in order to comply with contract requirements.

Superior Audit Scores: AMC is very proud of our exceptional services being verified by the State, which is reflected in AMC’s State Audit high scores for the past five years.

Independent audits have been performed by the California Department of Workers

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Compensation; Statement on Standards for Attestation Engagement No. 1 8 (SSAE 18); and Utilization Review Accreditation Commission (URAC). AMC consistently performs well above the standard level of acceptability; as shown in our recent DWC audits. We also perform extensive in-house quality assurance audits on our employees’ work product and processes.

URAC Accreditation : Since 2010, AMC has been awarded Workers' Compensation Utilization Management Accreditation from Util ization Review Accreditation Commission (URAC). As of October 2019, AMC received a 100% score on the recertification and has been approved for an additional three (3) years. This recertification ensures AMC is consistently providing services at URAC standards.

In 2016 with the passing of SB 1160, URO’s will be required to be a ccredited in Utilization Review: “The bill would, commencing July 1, 2018, require each utilization review process to be accredited by an independent, nonprofit organization to certify that the utilization review process meets specified criteria, including, but not limited to, timeliness in issuing a utilization review decision, the scope of medical material used in issuing a utilization review decision, and requiring a policy preventing financial incentives to doctors and other providers based on the utilization review decision.” Beginning nearly ten years before this legal requirement, AMC invests time, resources and money year after year to be URAC accredited in order to protect the interests of our Clients and their employees.

URAC, an independent, nonprofit organization is a leader in promoting health care quality through accreditation and certification programs. The URAC standards keep pace with the rapid changes in the health care system, and provide a mark of distinction for health care organizations such as AMC to demonstrate their commitment to quality and accountability. This certification and URAC audits of AMC is a benefit to our Clients by providing third party assurance that we are in full compliance with data integrity, Health Insurance Portability and Accountability Act (HIPAA) requirements, proper credentialing.

Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in setting meaningful standards for the health care industry.

AMC is driven toward continual improvement of services by applying quality metrics and benchmarking to ensure we achieve top -quality performance con sistent with the URAC Workers’ Compensation Utilization Management Accreditation. Obtaining URAC accreditation demonstrates Allied Managed Care’s commitment to providing quality services for our Clients to help ensure that injured workers receive the best and most appropriate care.

Client Module – AlliedConnect: An important Part of the U R lifecycle is the Claims Examiner approval process. AMC has developed our own U R platform, AlliedConnect with the understanding that it must be user friendly for Claims Examiners. Having a TPA such as AIMS as our sister company, provides AMC with a strong unders tanding of the “pain points” a Claims Examiner can experience when processing Utilization Review requests. AMC’s AlliedConnect – Client Module is a fully integrated software, automated to help the Claims Examiner approve and distribute appropriate UR requests when

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
needed. Our proprietary system includes an easy referral process to AMC’s U R when appropriate. All Claims Examiner UR approvals and AMC Utilization Review determinations are captured, tracked, and electronically delivered to our B R platform for enforcement and payment.

Training: We hire and train the best people and streamline all systems and processes to support that goal. We provide our Client’s Claims Examiners with the training necessary to authorize treatment requests that fall within pre -approved screening criteria. We also insist that our UR managers and directors attend all Departmen t of Workers' Compensation (DWC) seminars and conferences to stay current on the constantly changing UR process.

AMC offers assistance to C laims Examiners in making first level UR decisions by providing utilization “Trigger Lists”, and on-going training. Our in-house staff of nurses is trained to review additional medical information and make decisions, within accepted guidelines, regarding treatment specific to each individual employee. For those decisions which are more advanced or when treatment may n ot be medically necessary, AMC escalates the referral to one of our many peer panels for a physician’s decision.

Licensed Nurses and P hysicians: AMC has only licensed nurses and physicians performing all Utilization Review services that go beyond the Claims Examiner. No non- professional staff authorizes treatment or requests referral to Peer Review. The AMC UR Program operates under the direction of the Medical Program Director who is a California- licensed physician. Physicians that serve to evaluate tre atment plans are licensed and board-certified with experience both as practicing physicians and in managed care/medical management. Specialty appropriate physicians are assigned to evaluate and make recommendations on plans of care.

First level reviewers (nurses) must be health professionals with a current, valid and unrestricted license, and have their credentials verified on an annual basis. Our Utilization Review Nurses must be licensed as either a Licensed Practical (Vocational) Nurse (LPN, LVN), or a Registered Nurse (RN).

Our UR team evaluates planned and provided medical care for necessity, frequency, and duration through services that include:
 Pre-Certification/Pre-Authorization reviews
 Reviews performed by our medical director and specialty peer review network  Reviews based on national evidence-based treatment guidelines Utilization Review process are compliant with 8 CCR §9792.9 (l) wherein treatment requests will not be denied on the basis of a lack of information without documentation reflecting an attempt to obtain the necessary information from the physician or from the provider of goods or services identified in the request.

Training: A key aspect of our services has been educating the Claims Examiners of the importance of timely submissions, appropriate UR referrals, and full documentation.

Educating the Claims Examiners on current legislation, ensuring they understand their responsibilities’ and the penalties that apply as well as the proper workflow. AMC’s UR workflow is outlined in a diagram and has been included as an exhibit. Training is provided

Proposal for City of Richmond
Workers’ Compensation and Managed
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to the TPA by our Medical Director, Alan Randle on a yearly basis or as needed with legislative updates.

Satisfaction Surveys: Client satisfaction surveys are conducted annually by the Director of Client Services using a survey instrument that encompasses issues of access, satisfaction with UR decision-making, turnaround time, and AMC’s Client service. The survey data is collected and analyzed by the Client Services staff and is shared with all departments. The survey results and action plan are presented to the Quality Management Committee and the Vice Chairman of the Board, who may modify or add to the plan. The results of the corrective action plan are monitored by the Quality Management Committee and Vice Chairman of the Board.

Medical Director: AIMS/AMC Medical Director, Dr. Alan Randle , who is a California - licensed physician is actively involved with not only AIMS/AMC, but also with our Clients.

Dr. Randle will work with the City to develop a mutually agreeable process for oversight of the Claims Examiner approvals and will be actively involved in the appropriate training or the claims staff in the authorization process to recognize the most appropriate claims for medical case management services.

Dr. Randle received his medical degree from the University of San Francisco in 1973. He completed his residency in Seattle, Los Angeles, and Cincinnati with a focus on general surgery and occupational medicine. Dr. Randle became certified by the American Board of Preventive Medicine in Occupational Medicine i n 1989. Dr. Randle practiced Occupational Medicine while Vice President of RediCare Industrial Medical Clinic through June of 1991. Dr. Randle is board certified in Occupational Medicine and has ultimate oversight of all UR department deci sions; education of nurses and Examiners regarding UR rules and regulations. He stays abreast of current changes in legislation and trains staff on new regulation. Dr. Randle is also the Chairperson of our Quality Management Committee and is accountable to the corporate President & CEO and Senior Vice President.

Dr. Randle has over twenty (20) years of experience with the practice of occupational medicine. This experience encompasses the clinical practice of medicine, medical evaluation, management, and academia. Dr. Ra ndle is a noted industry expert in California Utilization Review. He is a presenter and instructor to physicians, claims personnel and employers, both in private and public, on the California Utilization Review process.

Dr. Randle conducts t raining sessio ns to ensure our Claims E xaminers are aware of various modalities as well as conducting training for our Clients on topics such as best practices to use for UR. He is always available via a phone call or e -mail to immediately address any questions or concerns.

As AMC’s Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all Managed Care Services provided by AMC. Dr. Randle has served as AMC’s Medical Director since 2008. Additional information about Dr. Randle’s expertis e is further detailed in his resume, which has been included in the noted exhibit.

Physical location and number of employees: The City’s Utilization Review program is

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
conducted out of AMC’s Sacramento office located at 10360 Old Placerville Road, Sacramento, California 95827.

As of February 202, AMC has approximately 69 employees.

Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.

Please see Exhibits 1 – Organizational Charts, Exhibit 4 – Teams Resumes, Exhibit 11 – SSAE 18 Reports, Exhibit 12 URAC Reports and Exhibit 13 – AMC UR Audits

B. Service Team Qualifications: Provide a brief summary of the qualifications and experience of each proposed team member, including their length of service with your firm and their resume. Provide an organization chart representing your staff and identify and sub-consultants you plan to utilize to supplement your proposed staff.

AMC’s Dedicated, Experienced Medical Management Team: AMC’s UR team is a dedicated group of medical case management professionals with tremendous tenure and collectively over 100 years of experience.

Licensed Nurses and Physicians: AMC has only licensed nurses and physicians performing all UR services that go beyond the Claims Examiner. No non -professional staff authorizes treatment or requests referral to Peer Review.

Peer Review: Allied Managed Care utilizes the physician peer review panels of P&S, National Medical Review (NMR), Dane Str eet, and ClaimsEval; which are all URAC accredited organizations. In addition, physician peer review may be conducted by the Medical Director. The credentialing process for physician peer reviewers is delegated to the respective panels to ensure each phy sician reviewer meets URAC standards. Also, AMC is not sub-consulting any of the proposed staff.

Listed below are the key members of AMC’s UR team.

Mark Denison, Senior Vice President of Operations : Mark oversee s the entire customized Bill Review/Utilization Review/Nurse Case Management Program. Mark’s role is to monitor all contract compliance with performance standards, audit compliance to individualized Special Account Instructions; legal and regulatory compli ance; and provide ongoing communication with our Clients. Mark provides unparalleled leadership and direction to all AMC staff. He oversees all operational and administrative components of Allied Managed Care’s services, including Medical Bill Review, Utilization Review, and Case Management. He has over 23 years of experience in workers’ compensation cost containment, strong multi -jurisdictional managed care knowledge and practical application. His involvement ensure s that our Client’s performance stand ards are met and communication is ongoing. Mark will always be available to meet with our Client’s staff to discuss issues and performance when requested to do so. Mark is a state board

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
certified licensed Chiropractor, Certified Disability Evaluator and past Division of Workers Compensation (DWC) appointed Qualified Medical Evaluator (QME). Mark joined the AMC team in 2008.

Lea Morales-Mendez, Director of Client Services : Lea has over 26 years of workers’ compensation experience in roles of operations, management as well as Client Services.

Lea has received training in Disability Management, Health Insurance Portability and Accountability Act (HIPAA) and Utilization Review Accreditation Commission (URAC).

Lea’s role is to a ssist the management team in addressing all issues related to the contract as well as serving as a resource for workers’ compensation decisions that may affect our Client. Interact with AMC’s management team to resolve all issues that may arise in UR and Bill Review; provide timely c ommunication to the management staff of any critical developments that may affect the product delivery; meet regularly with the management team to assess AMC’s performance; discuss business decisions; address concerns; Lea is a resource for our Clients such as the City. Lea joined AMC in 2006.

Alan Randle, M.D., Medical Director: Dr. Randle received his medical degree from the University of San Francisco in 1973. He completed his residency in Seattle, Los Angeles and Cincinnati with a focus on general surgery and occupational medicine. Dr. Randle became certified by the American Board of Preventive Medicine in Occupational Medicine in 1989. Dr. Randle practiced Occupational Medicine while Vice President of RediCare Industrial Medical Clinic through June of 1991. Since that time Dr. Randle has served as Medical Director for several of the largest insurance companies and managed care companies in the country. As Medical Director, Dr. Randle provides oversight, leadership, and medical expertise to all M anaged Care Services provided by AMC. Dr. Randle has served as AMC’s Medical Director since 2008.

Caroline Iverson, DC, Peer Review Manager: Caroline has 20 years of UR experience with 9 years in workers’ compensation UR; eight of which were with public entities.

Caroline provides an added level of auditing of the referrals and documents sent from UR nurses to Peer Review physicians and also auditing every completed Peer Review for quality and timeliness. Caroline works closely with the UR Manager and Medical Director to ensure the quality and timeliness of all peer reviews. She coordinates our extensive Utilization Review Quality Management Program and has been a licensed Chiropractor since 1993. Caroline joined AMC in 2008.

Shannon Buelna, LVN, MHA Utilization Review Director: Shannon’s workers’ compensation UR experience includes 15 years working with public entities to ensure performance of UR services in accordance to the state protocols, guidelines, and regulations. Her initial role was as UR Supervisor and she was promoted to UR Manager in 2014 and Director of Nursing Services in 2022. She continues to be extensively involved in ongoing development of AMC’s proprietary software for UR with improved efficiencies, modifications, and adherence to regul atory requirements. She has clinical experience working in a physician’s office, skilled nursing, and as director of a 199 -bed assisted living facility. Shannon assists in the implementation of Client specific instructions and any new processes which might arise out of DWC revisions. Collaborates with Claims Examiners to ensure proper handling of each referral, understanding of claim status and medical/legal implications, and attention to Client specific instructions.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Licensed Vocational Nurse for over 9 ye ars with licenses in the State of California and the State of Texas. Shannon joined the AMC team in 2008.

Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes

C. Services: Describe your utilization review services including standards and guidelines you use to review treatment requests. Describe any unique capabilities or approaches your firm has for reviewing medical treatment requests. Discuss any methods you employ to help clients reduce utilization review costs. Provide an organizational chart, physical location, description of where the work is being conducted, management structure, and number of employees. Discuss your ability to work with TPAs in delivering utilization review services and provide a list of three (3) you currently work with.

Capabilities and Approach : As the City’s current UR vendor, AMC provides the City with UR services developed to assess the frequency, duration, intensity and appropriateness of all modalities and procedures common to workers’ compensation.

This includes concurrent management of ho spitalizations and retrospective review of medical treatment not previously reviewed. Reviews are performed by licensed nurses and physicians. The AMC UR program operates under the direction of our Medical Program Director, Dr. Randle. The UR program is co mpliant with all California -specific regulatory requirements. Reviewers use medical care guidelines such as the Medical Treatment Utilization Schedule (MTUS). Other nationally recognized and publicly available medical necessity criteria sets developed by p racticing physicians, such as Work Loss Data Institute/Official Disability Guidelines and Presley Reed/Medical Disability Advisor serve to augment MTUS guidelines. Guideline sets are evaluated annually by the Program Medical Director and updated annually. AMC has created a custom Utilization Review Program for the City of Richmond to address the specific needs called the “Rapid Referral Program”. This program expedites the approval process of services and uploads the auxiliary service request to the desi gnated service provider within 1-day a receiving the information.

AMC integrates all cost containment products electronically for maximum efficiency and centralization of data. We realize cost containment programs are a collection point of critical data to measure program costs. AMC can report virtually any data field captured in our system, and provide valuable reports to our Client. This innovative approach provides our Client’s managed care program wi th improved workflow, security/management of documents and increased productivity/turnaround time.

At AMC we have a single-minded UR goal - to help our Client employees return to work by providing the best, most appropriate treatment as quickly as possible and denying those services that are incongruous or unreasonable cost alternatives to nationally recognized treatment standards. By implementing a customized utilization review trigger list, the Claims Examiner can quickly approve a significant amount of first level treatment which allows treatment to be provided quickly as well as saving UR dollars. At AMC, we do not believe everything must be reviewed by the UR unit. We know that our Clients are

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
not all the same so AMC empowers the claims staff with the safe tools to authorize treatment which falls within the guidelines and is deemed appropriate.

Intake: The request for a UR is received by the Intake Coordinators at AMC. A confirmation email verifying receipt of the referral is sent to the Claims Examiner (and any other personnel designated by the Client) within three hours. Intake staff confirms receipt of all medicals, demographic data, and that the medicals correspond with the referral from the Claims Examiner. The referral documents are sent to the mailroom where they are indexed individually and u ploaded into a queue within AlliedConnect. The UR Manager assigns the referral to the UR nurse who will open the referral, confirm the data fields, identify if valid/invalid/incomplete/duplicate. The nurse also confirms the receipt date of the request for authorization to ensure AMC is operating under the correct due date. The nurse will indicate the claim designation (prospective, concurrent, retrospective, appeal) and process the review according to the statutory regulations and timelines.

Timeframes: All UR referrals are entered by AMC intake staff into AlliedConnect as a prospective review, at which time AlliedConnect automatically calculates the fifth business day due date. As part of the nurse’s daily triage of the new referrals, the nurses will i dentify the designation of prospective, concurrent, expedited, appeals, and retrospective. A new due date will be calculated in AlliedConnect which corresponds to the service type. If the nurses determine additional information is required, again a new due date will be calculated once the nurse submits the formal request in writing for the additional records. AlliedConnect has the ability to calculate the due dates by incorporating weekends and State holidays. The most critical component, though, is to verify the date of receipt which is verified by Intake and again by the nurses. This first critical step will ensure the calculated due dates are correct.

The Supervisor and/or Manager monitor the nurses queues daily to ensure timelines are being met consistently.

The Peer review referrals are submitted to AMC’s internal Peer unit no later than business day three, or two business days prior to calendar day fourteen if additional information has been requested. As such, the UR nurses monitor their invent ory as well throughout the day to ensure that referrals requiring physician review are sent to the Peer unit promptly and with sufficient time for the physician reviewer to make the decision.

If referred to AMC’s internal Peer unit for physician review assignment, the due dates are monitored not only by the UR nurse, but also by the Peer unit via AlliedConnect.

Peer reviews are assigned for physician review with the applicable due date clearl y marked on the referral. The Peer unit then monitors timeframes by first observing the online “pie chart” widget throughout the day in the AlliedConnect Peer module dashboard which reflects the number of reviews due each day, and second by sorting the Pe er module’s AlliedConnect in-box by due date and status to ensure that all referrals are completed by their due date. AlliedConnect reports are run by the Peer unit on a daily basis reflecting all pending physician reviews by due date to verify that the r eviews are timely. The Peer unit further manages the timeliness of physician reviews by controlling the volume of referrals assigned to each of the Peer review panels so as not to exceed the capacity of any given panel.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Expedited Reviews: Prospective or concurrent decisions related to an expedited review shall be made in a timely fashion appropriate to the injured worker’s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. The requesting physician must indicate the need for an expedited review upon submission of the request.

Peer Review Turnaround Times:
 Prospective – 2.8 business days
 Retrospective – 9.6 calendar days
 Appeals – 3.5 business days
Over-prescribing Opioid Medications: Protocols and triggers have been set up with the City’s pharmacy benefit manager to help identify trends and assist the City with flagging those providers who may be over -prescribing opioid medications. All new narcotic medication requests and any other identified class of medication can be submitted directly to the pharmacy nurse through an electronic link with the Pharmacy Benefit Management (PBM) or to the Claims Examiner who can forward the request to the AMC nurse who will review for medical appropriateness and certification. If not meeting guideline criteria, the nurse will submit this request to the Peer unit for review. If a formal utilization review has not been received when the narcotic medication is requested, and the request is not within the formulary, the nurse will contact the doctor’s office to provide the required documentation for a formal UR review.

AMC has the ability to run UR reports showing what has been requested along with the determination. AMC can identify trends through analysis of this data to identify medications being requested which have been denied or modified and by what prescribing physicians. This data can also be gathered from the PBM. By utilizing both reporting tools, AMC and the City can easily identify the ov er-prescribers of opioid medications.

A daily report is provided to the PBM that includes all information needed to ensure for the proper dispensing of prescriptions for the Client. The data exported has information that includes but is not limited to demographics for injured workers, claims c oding, Examiner information, and claim status information.

Request for Authorization: Whenever an AMC physician reviewer issues a decision to deny a request for authorization (RFA) based on the lack of medical information necessary to make a determination , the claims administrator’s file shall document the attempt by the claims administrator or reviewer to obtain the necessary medical information from the physician either by facsimile, mail, or e -mail. If AMC is in receipt of a RFA as part of a UR referral sent by the Claims Examiner after 5 business days from the documented date of receipt (or after 30 days from receipt of the information necessary to perform a retrospective review) and it is therefore determined that the referral has exceeded the timefram e for prospective or concurrent (or retrospective) decisions, the following procedure will be followed:

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services

1. The Claims Examiner will be notified that the UR referral has exceeded the 5 business day timeframe for a prospective determination and 30 days for a retrospective review within the UR Standards.

2. If the Claims Examiner can document that there has been a request for additional information issued on or before the fifth business day after the date of receipt that would appropriately allow an extension of the due date to 14 calendar days, the RFA will be managed in the normal manner as outlined above.

3. If there is no documentation of a prior written request for additional information, the Claims Examiner will have the option of either
o Authorizing the treatment request and provide appropriate written notification consistent with the UR Standards.
o Proceeding with the normal UR process for an RFA.

Written decisions approving a request for treatment authorization shall specify the specific medical treatment service approved and the date of the determination.

Written decisions modifying, delaying or denying treatment authorizations will be provided to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker’s attorney and shall only contain the following information specific to the request:

1. The date on which the DWC Form RFA was first received.

2. The date on which the decision is made (The date of the UR report is the date on which the decision was made unless otherwise specified).

3. A description of the specific course of proposed medical treatment for which authorization was requested.

4. A list of all medical records reviewed.

5. A specific description of the medical treatment service approved, if any.

6. A clear, conci se, and appropriate explanation of the reasons for the reviewing physician’s decision, including the clinical reasons regarding medical necessity and a description of the relevant medical criteria or guidelines used to reach the decision pursuant to section §9792.8. If a UR decision to modify, deny or delay a medical service is due to incomplete or insufficient information, the decision shall specify the reason for the decision and specify the information that is needed.

7. The Application for Independent Medical Review, DWC Form IMR-1, with all fields completed, except for the signature of the employee and date. The application, set forth at section 9792.10.1, shall include an addressed envelope, which may be postage-paid for mailing to the Administrative Director or his or her designee.

8. A clear statement advising the injured employee that any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code section 4610.5 and 4610.6, and that an objection to the UR decision m ust be communicated by the injured worker, the injured worker’s representative, or the injured worker's attorney on behalf of the injured worker on the enclosed Application for Independent Medical Review, DWC Form IMR-1, within 30 calendar days of receipt of the decision.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
If the request for authorization of medical treatment is not approved, or if the request for authorization for medical treatment is approved in part, any dispute shall be resolved in accordance with Labor Code sections 4610.5 and 4610.6. N either the employee nor the claims administrator shall have any liability for medical treatment furnished without the authorization of the Claims Administrator if the treatment is delayed, modified, or denied by a UR decision unless the UR decision is overturned by independent medical review or the Workers’ Compensation Appeals Board under this Article.

A request for independent medical review must be communicated by the employee, the employee’s representative, or the employee’s attorney by mail, facsimile, or electronic transmission to the Administrative Director, or the Administrative Director’s designee, within 30 days of service of the Utilization Review decision. The request must be made on the Application for Independent Medical Review, DWC Form IMR -1, and submitted with a copy of the written decision delaying, denying, or modifying the request for authorization of medical treatment.

If expedited review is requested for a decision eligible for independent medical review, the Application for Independent Medical Review, DWC Form IMR-1, shall include, unless the initial UR decision was made on an expedited basis, a certification from the employee’s treating physician indicating that the employee faces an imminent and serious threat to his or her health as described in section 9792.10.1(a)(3).

AMC’s Unique Capabilities:
 URAC (Utilization Review Accreditation Commission) Accredited since 2010  Renowned Medical Director
 Nurse and Physician Determinations – No Determinations completed by non- medical personnel
 Proprietary Software – AlliedConnect Database Access Services (AlliedConnect)
 Client Access to AlliedConnect Database of Determinations  Claims Examiner Approval Tracking
 Auto-populates claim information
 Tracking of Request for Authorizations (RFA) from submittal through determination
 Referral status/determination “Look up”
 Peer Review
 Three Medical Specialists Panels – All URAC Accredited  Quality Assurance Protocols
 Detailed Reporting
 Integrated with BR
 Independent Medical Review (IMR) Process
AMC’s Proven Medical Cost Containment Savings
 No duplicate charges
 No charge for reconsiderations within the first thirty (30) days

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
 Single charge for UR referral regardless of the number of procedures on the request
 Streamlined Claims Examiner approval process
 Direct certified services to Client specific vendors for contracted rates  Utilize the prior authorization process
Integration of Bill Review and Utilization Review: At AMC we work within our own proprietary platform called, AlliedConnect database access serv ices ( AlliedConnect).

AlliedConnect is a paperless single source solution for UR and integrates the UR and BR systems on the same proprietary platform. In this module, treatment planning or UR parameters can be entered in a highly normalized fashion into the BR system and is associated with a workers’ compensation claim. Due to the highly normalized nature of AlliedConnect treatment plans, they can be automatically applied by the BR engine during the BR process and require no BR analyst intervention to be applied. This allows UR to communicate directly with BR to ensure the appropriate payment for certified versus modified certified versus non-certified treatment. In other words, this integrated platform ensures, on an automated basis, services approved are the services paid.

AMC has developed a Client Application called, “AlliedConnect Client Module” , in which the Client can view in real time the status of past, current, and pending reviews. A copy of each determination along with fax confirmations may be printed from the Clie nt Module.

The AlliedConnect Client Module can also be provided to the Claims Examiner. From within AlliedConnect Client Module, the Claims Examiner can authorize treatment or submit referrals along with attached medicals to AMC. The Claims Examiner can review past, current or pending referrals in real time. The Claims Examiner can print a determination along with the fax confirmation. This information is also seen by the AMC UR nurses so, they will always know what treatment has been authorized by the Claims Examiner which decreases calls to the Claims Examiner for verification, prevents duplication of services, and thus additional UR fees.

Further benefits include:
 Protect documents against unexpected loss or damage
 Improve workflow by eliminating the need to manually move documents  Increase security by maintaining better control of documents and regulating document access
 Improve records management and storage
 Portability of documents and information
AMC customizes the workflow to fit the individual nee ds of the Client. As an example, some Clients have requested adding specific service vendors to the certification letters to assist them in utilizing these providers in which they have special rates or contract relationships. AMC will then send a copy of this certification letter to the specified vendor which will then trigger the referral and assignment process for that service request.

AMC Value Added Services to Reduce Costs:

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
 AMC’s policy related to bundling/unbundling the receipt of the RFA: AMC does not unbundle RFA’s. AMC keeps all RFA’s that are made by a provider within in one medical report for authorization together, we keep them “bundled”. One medical report, which contains more than one treatment request will be reviewed as a whole and the Nu rse or Peer Reviewer will make a determination on each treatment request. This is considered one referral with multiple treatment requests. AMC charges one review fee for multiple treatment requests within one referral.
 AMC offers a Claims Advice Nurse (CAN-Do) program as value added service to Clients at no additional cost. If the Claims Examiner receives a medical report and requires additional clinical expertise to assist them in understanding the medical condition and treatment requested, the Claims Advise Nurse is available to offer assistance. Many of these discussions result in the Claims Examiner being able to authorize treatment without going through the UR process which expedites the treatment and saves UR fees.
 AMC will identify, monitor and coordinate the medication safety awareness program with the Pharmacy Benefit Management (PBM) program for narcotics and opioid use.

Protocols and triggers set up with the City’s pharmacy benefit manager to help identify trends and assist the City with flagging those providers who may be over - prescribing opioid medications. All new narcotic medication requests and any other identified class of medication can be directed to the Claims Examiner by the bill review company who can forward the request to the AMC nurse who will review for medical appropriateness and certification. If the prescribing physician is not meeting guideline criteria , the nurse will submit this request to the Peer unit for review. If a formal utilization review has not been received when the narcotic medication is requested, and the request is not within the formulary, the nurse will contact the doctor’s office to pr ovide the required documentation for a formal UR review.

AMC has the ability to run reports showing what has been requested along with the determination. AMC can identify trends through analysis of this data to identify medications being requested which have been denied or modified and by what prescribing physicians. This data can also be gathered from the PBM. By utilizing both reporting tools, AMC and the City can easily identify the over -prescribers of opioid medications.

A daily report is provided to the PBM that includes all information needed to ensure for the proper dispensing of prescriptions for our Client. The data exported has information that includes but is not limited to demographics for injured workers, claims coding, Claims Examiner information, and claim status information.  AMC’s High Employee Retention Rate (Low Turnover)
Over the past three (3) years AMC has brought on board a manager to oversee case management for ten (10) nurse case managers. We have also added two (2) utilization review nurses, and additional administrative support - one (1) for Case

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
Management and two (2) for Utilization Review. These are the benefits of a solid/cohesive team for our Clients:
 Innovative long term consistent managed care program administration  Detailed knowledge and understanding of our Client’s program and needs  Satisfied, motivated employees who work hard for our Client to provide cost savings and appropriate outcomes and results
 No temporary personnel

 AMC currently has a 94% upheld rate with Maximus/IMRs.

 AMC provides documentation required to respond to requests for Independent Medical Review (IMR) at no additional cost to the City . To minimize the disruption of claims operations, AMC retains all records provided by claim staff. We use a paperless system/document storage that catalogues historical medical records so they only need to be submitted once. Claims staff submitting a second referral on a particular claim only need to submit updated medical records, thus avoiding a large v olume of medicals. When a modified or non-certification determination is made, a PDF file of all the medical records reviewed by the Peer Provider, along with the determination will be sent to the Claims Examiner. Therefore, if an IMR is requested the Cla ims Administrator can request these documents from the UR staff or AMC can ensure they are provided to the Claims Examiner at the time of the determination distribution so they have the necessary information to provide to Maximus and then only needs to inc lude any medicals within that 6 month period which are not part of the Peer packet.

Third Party Administrators: AMC provides UR services through the following TPA’s:

Acclamation Insurance Management Services (AIMS), TRISTAR, City of Sacramento and other self-insured/self-administered programs.

Physical location and number of employees: AMC provides all of its managed care services out of its office located at 10360 Old Placerville Road, Sacramento, California 95827.

As of February 2022, AMC has approximately 69 employees.

Org Chart : As requested a company -wide organizational chart with reference to the proposed service office and proposed service team has been provided in the noted exhibit.

Please see Exhibits 1 – Organizational Charts and Exhibit 4 – Team Resumes

D. Client References: Provide three (3) references for your firm for which you provide utilization review services including full contact information.

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
REFERENCE #1 – Utilization Review
Agency Name
County of Los Angeles
Contact Name
Alex Rossi, MBA, ARM, Workers’ Compensation Contract Administrator Contact Phone Number
(213) 738-2154
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2006

REFERENCE #2 – Utilization Review
Agency Name
City of Sacramento
Contact Name
Patrick Flaherty, Risk Manager
Contact Phone Number
(916) 808-8587
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care / Client since 2018

REFERENCE #3 – Utilization Review
Agency Name
Central San Joaquin Valley Risk Management Authority
Contact Name
Kevin Werner, City of Ripon, City Administrator
Contact Phone Number
(209) 599-2108
Contact Email Address
[email protected]
Brief Description of Scope of Services
All Managed Care Services / Client since 2012

REFERENCE #4 – Utilization Review
Agency Name
Schools Insurance Group (SIG)
Contact Name
Jaxine Anderson, Return to Work Coordinator

Proposal for City of Richmond
Workers’ Compensation and Managed
Care Services
REFERENCE #4 – Utilization Review
Contact Phone Number
(530) 823-9582 x205
Contact Email Address
[email protected]
Brief Description of Scope of Services
Workers’ Compensation Claims Administration and Managed Care / Client since 2013

___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:

Professional Services

Type 2 – Page 1 of 3

Revised: September 2011
In all instances where CONTRACTOR or its representatives will provide professional services (architects, engineers, construction management, counselors, medical professionals, hospitals, clinics, attorneys, consultants, accountants, etc.) to the City of Richmond (City), the City requires the following MINIMUM insurance requirements and limits.

CONTRACTOR shall procure and maintain for the duration of the contract, agreement, or other order for work, services or supplies, insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder and the results of that work by the CONTRACTOR, its agents, representatives, employees or subcontractors. Maintenance of proper insurance coverage is a material element of the contract. Failure to maintain or renew coverage or to provide evidence of renewal may be treated by the City as a material breach of contract.

CONTRACTOR agrees that in the event of loss due to any of the perils for which it has agreed to provide Commercial General Liability insurance, CONTRACTOR shall look solely to its insurance for recovery.

CONTRACTOR hereby grants to CITY, on behalf of any insurer providing Commercial General Liability insurance to either CONTRACTOR or CITY with respect to the services of CONSULTANT herein, a waiver of any right to subrogation which any such insurer of said CONTRACTOR may acquire against the CITY by virtue of the payment of any loss under such insurance.

Original, signed certificates and original, separate policy endorsements, naming the City as an additional insured for general liability coverage, as well as a waiver of subrogation for Workers’ Compensation insurance, shall be received and approved by the City before any work may begin. However, failure to do so shall not operate as a waiver of these insurance requirements.

City reserves the right to modify or require additional coverages for specific risk exposures depending on scope of CONTRACTORS work.

Minimum coverage is detailed below. The policy limits of coverage shall be made available to the full limits of the policy. The minimum limits stated herein shall not serve to reduce the policy limits of coverage of CONTRACTOR.

Minimum Scope of Insurance – the following forms shall be provided and coverage shall be at least as broad as the following:

1. Insurance Services Office Commercial General Liability coverage (ISO Occurrence Form CG 0001), and including coverage for bodily and personal injury, property damage, and products and completed operations (if applicable).

2. Insurance Services Office Automobile Liability coverage (ISO Form CA 0001, Code 1, Any Auto).

3. Original and Separate Additional Insured Endorsement for General Liability (ISO Form CG 20 10 11/85 or its equivalent) with primary and non-contributory language.

4. Workers’ Compensation Insurance as required by the State of California including Employer’s Liability coverage.

5. Original and Separate Waiver of Subrogation for Workers’ Compensation insurance.

6. Professional Liability or Errors & Omissions Liability Insurance appropriate to the CONTRACTOR’s profession (if required.)

Required Coverage Minimum Limits
Workers’ Compensation and
Employers’ Liability
Statutory limits as required by the State of California including $1 million Employers’ Liability per accident, per employee for bodily injury or disease.

If CONTRACTOR is self-insured, provide a certificate of Permission to Self- Insure, signed by the California Department of Industrial Relations and Self- Insurance. If contractor is a sole proprietor (has no employees) than contractor must sign “Contractor Release of Liability” found at:
http://www.ci.richmond.ca.us/index.aspx?nid=61.

General Liability
(primary and excess limits
combined)
$2,000,000 per occurrence for bodily injury, personal injury and property damage. If the policy includes a general aggregate, either the general aggregate shall apply separately to this project, service or location or the minimum required aggregate limit shall be twice the per occurrence limit ($4 million aggregate limit).

Policy shall be endorsed to name the City of Richmond as an additional insured per the conditions detailed below.
___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:

Professional Services

Type 2 – Page 2 of 3

Revised: September 2011
Automobile Liability $1,000,000 per occurrence for bodily injury and property damage.

PROJECT COST R EQUIRED LIMIT
$0 - $1 million $1 million p/o
$1 million - $5 million $2 million p/o
Over $5 million $5 million p/o

Professional Liability or Errors &
Omissions Liability –
Required for all professionals
including architects, engineers,
consultants, construction
management, counselors, medical
professionals, hospitals, clinics,
attorneys and accountants, & other
consultants as may be required by
the City.

Required Policy Conditions
Additional Insured Endorsement

Applicable to General Liability coverage.

The City of Richmond, its officers, officials, employees, agents and volunteers are to be named as additional insureds for all liability arising out of the operations by or on behalf of the named insured including bodily injury, deaths and property damage or destruction arising in any respect directly or indirectly in the performance of this contract.

ISO form CG 20 10 (11/85) or its equivalent is required. If the Contractor is supplying their product or providing a service then the endorsement must not
exclude products and completed operations
coverage. If it does, then CG 20 37 (10/01) is also required.

SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61
.

Primary and Noncontributory The contractor’s insurance coverage must be primary coverage as it pertains to the City, its officers, officials, employees, agents and volunteers. Any insurance or self insurance maintained by the City is wholly separate from the insurance of the contractor and in no way relieves the contractor from its responsibility to provide insurance.

Waiver of Subrogation
Endorsement Form
Contractor’s insurer will provide a Waiver of Subrogation in favor of the City for Workers’ Compensation Insurance during the life of this contract.

SAMPLE Endorsements can be found at
http://www.ci.richmond.ca.us/index.aspx?nid=61.

Deductibles and Self-Insured
Retentions
Any deductible or self-insured retention must be declared to and approved by the City. At the option of the City either the insurer shall reduce or eliminate such deductibles or self-insured retention as respects the City or the CONTRACTOR shall procure a financial guarantee in an amount equal to the deductible or self-insured retention guaranteeing payment of losses and related investigations, claims administration and defense expenses.

Contractor is responsible for satisfaction of the deductible and/or self-insured retention for each loss.

A. M. Best Rating A:VII or Better. If the A.M. Best Rating falls below the required rating, CONTRACTOR must replace coverage immediately and provide notice to City.

Umbrella/Excess Liability Policies
If an Umbrella or Excess Liability Policy is used to meet the liability limits, coverage shall be as broad as specified for underlying coverage’s and cover those insured in the underlying policies.

___ Exhibit F
___ Section 8
City of Richmond - Insurance Requirements - Type 2:

Professional Services

Type 2 – Page 3 of 3

Revised: September 2011
Claims-Made Policies
If any insurance policy is written on a claims-made form: 1) the retroactive date must be shown, and must be before the date of the contract or the beginning of contract work. 2) Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the contract of work. 3) If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with a retroactive date prior to the contract effective date, the Contractor must purchase an extended period coverage for a minimum of five (5) years after completion of contract work.

Subcontractors

CONTRACTOR
shall include all subcontractors as insured under its policies or shall furnish to the City for review and approval, separate certificates and endorsements for each subcontractor. All coverage for subcontractors shall be subject to all of the requirements stated herein.

CONTRACTOR agrees to defend and indemnify the City of Richmond for any damage resulting to it from failure of either CONTRACTOR or any subcontractor to take out or maintain the required insurance policies.

The fact that
insurance is obtained by CONTRACTOR, and/or CONTRACTOR’s subcontractors, will not be deemed to release or diminish the liability of CONTRACTOR, including, without limitation, liability under the indemnity provisions of this contract. Damages recoverable by CITY from CONTRACTOR or any third party will not be limited by the amount of the required insurance coverage.

Verification of Coverage
All original certificates and endorsements shall be received and approved by the City before work may begin .

The City of Richmond reserves the right to require complete, certified copies of all required insurance policies including endorsements affecting the coverage at any time.

Original insurance certificates and required policy endorsements shall be mailed or delivered to the Designated Project Manager for the City of Richmond.

Insurance certificates and endorsements may be faxed to the Designated Project Manger. However, CONTRACTOR must mail the original certificates and endorsements to Designated Project Manager once faxed.

Continuous Coverage
CONTRACTOR shall maintain the required insurance for the life of the contract. Should the CONTRACTOR cease to have insurance as required during this time, all work by the CONTRACTOR pursuant to this agreement shall cease until insurance acceptable to the City is provided. In the event that CONTRACTOR fails to comply with the City’s insurance requirements, the City may take such action as it deems necessary to protect the City’s interests. Such action may include but is not limited to termination of the contract, withholding of payments, or other actions as the City deems appropriate.

If services or the scope of work extend beyond the expiration dates of the required insurance policies initially approved by the City, CONTRACTOR must provide updated certificates and endorsements indicating that the required coverage, terms and conditions are still in place. Renewal certificates and updated endorsements shall be mailed to the Designated Project Manager.

Cancellation
CONTRACTOR shall ensure that coverage shall not be cancelled, reduced or otherwise materially changed except after thirty (30) days’ prior written notice has been given to the City.

Reporting Requirements

Any failure to comply with reporting or other provisions of the policies including breaches of warranties shall not affect coverage provided to the City, its officers, officials, employees or volunteers.

Consistent with Public Policy
The insuring provisions, insofar as they may be judged to be against public policy shall be void and unenforceable only to the minimum extent necessary so that the remaining terms and provisions herein may be consistent with public policy and thus enforceable.