Pricing Sheet - City of San Clemente RFP WC TPA
Description Type
Per Claim Basis Medical Only
Indemnity
Take Over Claims
Medical Only $150 per claim open at time of takeover
Indemnity
Flat Fee Rate 1st Year $30,000
2nd Year $30,900
3rd Year $31,827
4th Year $32,782
5th Year $33,765
Other
Per Examiner / Position Rate 1st Year $245,000 per Senior Examiner based on 125 caseload 2nd Year $252,300 per Senior Examiner based on 125 caseload 3rd Year $259,921 per Senior Examiner based on 125 caseload 4th Year $267,718 per Senior Examiner based on 125 caseload 5th Year $275,750 per Senior Examiner based on 125 caseload Other
Additional Charges Bill Review 1. PPO Discounts 24% of reduction below FS (27% of reduction below
FS for Anthem Network if
used
2. Fee Schedule $9 per bill plus PPO
reduction, $300 per
inpatient/outpatient or
surgery center bill plus
PPO
3. Pass Through Bills N/A
4. Bill Check N/A
5. Other Specialized Network
access $5 per bill, bill
review charges do not
apply - DMG, Diagnostic
Testing, PT, Pharmacy
Bills not subject to Fee
Schedule - 24% of
reduction
Fees & Options
$400 month reported and $150 per month each
subsequent month claim remains open. Price will
increase by 3% annually for the life of the contract.
$400 month reported and $150 per month each
subsequent month claim remains open. Monthly fee
subject to 3% annual escalation for life of contract.
$150 per claim reported - one time charge. Per claim
fee will increase by 3% per year for the life of the
contract
ATTACHMENT 3
Pricing Sheet - City of San Clemente RFP WC TPA
Utilization Review 1. State Mandated Adjuster Review - no charge
Nurse Review - $120 flat
fee
(up to 3 medical requests
in a single review)
2. Peer Review Physician Review - $235
plus nurse charge
Pharmacy Review - $385
plus nurse charge
3. Field Case Manager $108 per hour +
incidentals (including
mileage, phone, tolls,
parking, etc.)
4. Telephonic Case
Manager
$102 per hour
5. Manager N/A
Vendor Fees 1. Legal Fees Pass through of actual
charges
2. Expert Fees Pass through of actual
charges
3. Investigation Fees Field Investigation $88 per
hour
SIU related work $98 per
hour if LWP vendor used
4. Other Fees Subrogation negotiated by
LWP staff - 15% of gross
recovery.
Lien negotiated by LWP
staff - 15% of reduction.
Administration Fees 1. Annual $2,500
2. Other
System Fees 1. System Access No charge up to 4 users -
additional uses $250 per
year
2. Data Transfer $8,500
3. Conversion Fees Included
Pricing Sheet - City of San Clemente RFP WC TPA
Medical Provider Network Provider Name /
Number of Providers
in City Area (no
greater than 25 miles
out of City)
LWP Platinum MPN /
Signature Networks Plus
LWP Platinum MPNcustombuilt and managed
by Signature Networks
Plus. 1207 providers wthin
25 miles of City (includes
specialists, acute care
hospitals, occupational
clinics, urgent care
facilities and all specialsts)
Annual Costs None
Excluded Costs List All Excluded Costs Outgoing ACH Bank Debit if utilized
Termination Terms of Cancellation Per agreement
Cancellation Fees None
File Transfer None
1. Medical Only $150 per claim reported -
one time charge
2. Indemnity $400 month reported and
$150 per month each
subsequent month claim
remains open
3. Monthly Rate
End of Contract
Claims Handling Fees