Pricing Sheet - City of San Clemente RFP WC TPA
Description Type
Per Claim Basis Medical Only
Indemnity
Take Over Claims
Medical Only
Indemnity
Flat Fee Rate 1st Year
2nd Year
3rd Year
4th Year
5th Year
Other
Per Examiner / Position Rate 1st Year
2nd Year
3rd Year
4th Year
5th Year
Other
Additional Charges Bill Review 1. PPO Discounts
2. Fee Schedule
3. Pass Through Bills
4. Bill Check
5. Other
Utilization Review 1. State Mandated
2. Peer Review
3. Field Case Manager
4. Telephonic Case
5. Manager
Vendor Fees 1. Legal Fees
2. Expert Fees
3. Investigation Fees
4. Other Fees
Administration Fees 1. Annual
2. Other
System Fees 1. System Access
2. Data Transfer
3. Conversion Fees
Medical Provider Network Provider Name /
Number of Providers
in City Area (no
greater than 25 miles
out of City)
Annual Costs
Excluded Costs List All Excluded Costs
Termination Terms of Cancellation
Cancellation Fees
File Transfer
1. Medical Only
2. Indemnity
3. Monthly Rate
End of Contract
Claims Handling Fees
Fees & Options
$115 per open claim per month - year 1
$115 per open claim per month - year 1
Not applicable
Not applicable
Not applicable
$115 per open claim per month
$119 per open claim per month
$123 per open claim per month
$127 per open claim per month
$131 per open claim per month
3% minimum increase for all future years
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
Up to 27% of savings
$15 flat fee
$15 flat fee
$15 flat fee
.75 cents per ebill/ocr when applicable
Max. $750 per total charge
Min. $300 per hour
City's choice of vendor; at-cost
City's choice of vendor; at-cost
Not applicable
City's choice of vendor, at-cost
City's choice of vendor, at-cost
City's choice of vendor, at-cost
All vendors are city-chosen and at-cost
See above per claim basis/flat fee rate
See above per claim basis/flat fee rate
Read-only is no additional fee
Not applicable
Not applicable
The City does not currently utilize a MPN. Should the
City decide to in the future, all MPN costs/fees will be at-cost.
Not applicable
None
Per the City's Contract/Agreement
Per the City's Contract/Agreement
Per the City's Contract/Agreement
See above per claim basis/flat fee rate
See above per claim basis/flat fee rate
See above per claim basis/flat fee rate
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