ATTACHMENT #1
Project Name: Workers’ Compensation Claims Third
Party Administrator
AGREEMENT FOR PROFESSIONAL SERVICES
BETWEEN THE CITY OF THOUSAND OAKS
AND
ADMINSURE, INC.
THIS AGREEMENT is made and entered into this 1 st day of July, 2026, by and between CITY OF THOUSAND OAKS, a municipal corporation ("City"), and ADMINSURE , INC. ("Consultant").
City and Consultant agree as follows:
1. RETENTION OF CONSULTANT
City hereby retains Consultant, and Consultant hereby accepts such engagement, to perform the services described in Section 2. Consultant warrants it has the qualifications, experience, and facilities to properly and timely perform said services.
2. DESCRIPTION OF SERVICES
The services to be performed by Consultant are as follows:
Professional services in conjunction with responsive workers’ compensation claims administration services in compliance with applicable California Labor Code statutes and provisions. Services and deliverables shall generally include workers’ compensation claims administration services and are more particularly set forth in the Scope of Work, attached as Exhibit “A,” which is incorporated herein by reference.
3. COMPENSATION AND PAYMENT
(a)Maximum and Rate. The total compensation payable to Consultant by City for the services under this Agreement SHALL NOT EXCEED the sum of $250,000 (herein "not to exceed amount"), and shall be earned as the work progresses on the following basis:
Hourly, at the hourly rates and with reimbursement to Consultant for those expenses set forth in Consultant's Schedule of Fees, attached as Exhibit "B" and incorporated herein. The rates and expenses set forth in that exhibit shall be binding upon Consultant for the term of this Agreement, after which any change in the rates and expenses must be approved in writing by City's Project Manager (City is to be given 60 days’ notice of any rate increase request), provided the not to exceed amount is the total compensation due Consultant for all work described under this Agreement.
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(b)Payment. Consultant shall provide City with written verification of the actual compensation earned, in a form satisfactory to City's Project Manager. Invoices shall be made no more frequently than on a monthly basis, and describe the work performed (including, if applicable, a list of hours worked by personnel classification). All payments shall be made within 30 days after City’s approval of the invoice. (c)Extra Services. Additional work not reasonably encompassed by the Scope of Services described in Section 2 may be agreed upon only by execution of a written Amendment to this Agreement. No liability or right to compensation for extra services shall exist without such Amendment. Unless otherwise stated in the Amendment, applicable rates for extra services shall be at the rates set forth in Exhibit “B.”
4. CITY PROJECT MANAGER
The services to be performed by Consultant shall be accomplished under the general direction of, and coordinate with, City's "Project Manager", as that staff person is designated by City from time to time, and who presently is Sharon Chen.
5. TERM, PROGRESS AND COMPLETION
The term of this Agreement is from the date first written above to June 30, 2029 unless term of this Agreement is extended or the Agreement is terminated as provided for herein.
City Manager or his or her designee shall have the authority to extend the term of this Agreement in writing no more than 2 separate times, for a period of 1 year each.
Extensions of time shall be memorialized by execution of a written amendment.
Consultant shall not commence work on the services to be performed under the Agreement until (i) Consultant furnishes proof of insurance as required by paragraph 9 below, and (ii) City’s Project Manager gives written authorization to proceed with the work.
All services shall be completed within the term of this Agreement.
6. OWNERSHIP OF DOCUMENTS
All drawings, designs, data, photographs, reports and other documentation (other than Consultant's drafts, notes and internal memorandum), including duplication of same prepared by Consultant in the performance of these services, are the property of City.
City shall be entitled to immediate possession of the same upon completion of the work under this Agreement, or at any earlier or later time when requested by City. City agrees to hold Consultant harmless from all damages, claims, expenses, and losses arising out of any reuse of the plans, specifications, graphics, brochures, reports, and other documentation for purposes other than those described in this Agreement, unless written authorization of Consultant is first obtained.
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7. PERSONAL SERVICES/NO ASSIGNMENT/SUBCONTRACTS
This Agreement is for professional services, which are personal to City. Nicolas Bowers is deemed to be especially experienced and is a key member of Consultant's firm, and shall be directly involved in performing, supervising or assisting in the performance of this work. This key person shall communicate with, and periodically report to, City on the progress of the work. Should said individual be removed from assisting in this contracted work for any reason, City may terminate this Agreement.
This Agreement is not assignable by Consultant without City's prior written consent.
No part of the work described in this Agreement may be subcontracted out to other parties.
8. HOLD HARMLESS AND INDEMNITY
(a) Hold Harmless for Consultant's Damages. Consultant holds City, its elected officials, officers, agents, employees and volunteers, harmless from all of Consultant's claims, demands, lawsuits, judgments, damages, losses, injuries or liability to Consultant, to Consultant's employees, to Consultant’s contractors or subcontractors, or to the owners of Consultant's firm, which damages, losses, injuries or liability occur during the work or services required under this Agreement, or performance of any activity or work required under this Agreement.
(b) Defense and Indemnity of Third Party Claims/Liability. Consultant shall indemnify, defend with legal counsel approved by City, and hold harmless City, its officers, officials, agents, employees and volunteers from and against all liability including, but not limited to, loss, damage, expense, cost (including without limitation reasonable legal counsel fees, expert fees and all other costs and fees of litigation) of every nature arising out of or in connection with Consultant’s negligence, recklessness or willful misconduct in the performance of work hereunder or its failure to comply with any of its obligations contained in the Agreement, except such loss or damage which is caused by the sole or active negligence or willful misconduct of City. Should conflict of interest principles preclude a single legal counsel from representing both City and Consultant, or should City otherwise find Consultant’s legal counsel unacceptable, then Consultant shall reimburse City its costs of defense, including without limitation reasonable legal counsel fees, expert fees and all other costs and fees of litigation. The Consultant shall promptly pay City any final judgment rendered against City (and its officers, officials, employees and volunteers) with respect to claims determined by a trier of fact to have been the result of Consultant’s negligent, reckless or wrongful performance. It is expressly understood and agreed that the foregoing provisions are intended to be as broad and inclusive as is permitted by the law of the State of California and will survive termination of this Agreement.
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Consultant’s obligations under this section apply regardless of whether or not such claim, charge, damage, demand, action, proceeding, loss, stop notice, cost, expense, judgment, civil fine or penalty, or liability was caused in part or contributed to by an Indemnitee.
However, without affecting the rights of City under any provision of this Agreement, Consultant shall not be required to indemnify and hold harmless City for liability attributable to the active negligence of City, provided such active negligence is determined by agreement between the parties or by findings of a court of competent jurisdiction. In instances where City is shown to have been actively negligent and where City’s active negligence accounts for only a percentage of the liability involved, the obligation of the Consultant will be for that entire portion or percentage of liability not attributable to the active negligence of City.
(c) Nonwaiver. City does not waive, nor shall be deemed to have waived, any indemnity, defense or hold harmless rights under this section because of the acceptance by City, or the deposit with City, of any insurance certificates or policies described in Section 9.
9. MINIMUM SCOPE AND LIMIT OF INSURANCE
Without limiting Consultant's indemnification of City, and prior to commencement of Work, Consultant shall obtain, provide, and maintain at its own expense during the term of this Agreement, and any extension thereof, policies of insurance of the type and amounts described below and in a form that is satisfactory to City.
Coverage shall be at least as broad as:
(a).Commercial General Liability (CGL): Consultant shall, at Consultant's sole cost and expense and throughout the term of this Agreement, and any extensions thereof, carry General Liability insurance coverage at least as broad as Insurance Services form CG 00 01 in an amount not less than $2,000,000 per occurrence, $4,000,000 general aggregate for bodily injury, personal and advertising injury and property damage, including without limitation, blanket contractual liability. (b).Automobile Liability: Consultant shall, at Consultant's sole cost and expense and throughout the term of this Agreement, and any extensions thereof, carry Automobile Liability insurance coverage at least as broad as Insurance Services form CA 00 01 or the exact equivalent covering bodily injury and property damage for all activities of Consultant arising out of or in connection with the work to be performed under this Agreement, including coverage of any owned, hired, non-owned, or rented vehicles, in an amount not less than $1,000,000 combined single limit for each accident. (c).Worker’s Compensation: Consultant shall, at Consultant's sole cost and expense and throughout the term of this Agreement, and any extensions thereof, carry workers’ compensation statutory benefits as required by law with employer’s liability limits no less than $1,000,000 per accident for bodily injury or disease. Consultant shall submit to City, along with the certificate of insurance, a Waiver of Subrogation endorsement in
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favor of City, its elected officials, officers, agents, employees and volunteers for all work performed by Consultant, its employees, agents and subcontractors. (d).Professional Errors and Omissions Insurance: Consultant shall, at Consultant’s sole cost and expense throughout the term of this Agreement, and any extensions thereof, carry professional errors and omissions coverage of no less than $1,000,000 per occurrence or claim, $2,000,000 aggregate, with tail coverage for an extended reporting period of three (3) years.
If Consultant maintains higher limits than the minimum shown above, City requires and shall be entitled to coverage for the higher limits maintained by Consultant. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to City.
Other Insurance Provisions
The insurance policies are to contain, or be endorsed to contain, the following provisions:
Additional Insured Status
City, its elected officials, officers, agents, employees and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of Consultant including materials, parts, or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to Consultant’s insurance (at least as broad as ISO Form CG 20 10 11 85 or if not available, through the addition of both CG 20 10 10 01 and CG 20 37 10 01 if a later edition is used). The provision shall also apply to any excess liability policies. In addition, Consultant shall ensure that the automobile liability policy contains a provision covering City as an additional insured, and shall obtain an endorsement to that effect if it does not.
Excess Insurance
The limits of insurance required in this agreement may be satisfied by a combination of primary and umbrella or excess insurance. Umbrella or excess policies shall provide coverage at least as broad as specified for underlying coverages and covering those insured in the underlying policies. Coverage shall be “pay on behalf” with defense costs payable in addition to policy limits. There shall be no cross-liability exclusion of claims or suits by one insured against the other. Any umbrella or excess insurance shall contain or be endorsed to contain a provision that such coverage shall also apply on a primary and no-contributory basis for the benefit of City as required in written contract or agreement before City’s own insurance or self-insurance shall be called upon to protect it as a named insured.
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City’s Rights of Enforcement
In the event any policy of insurance required under this Agreement does not comply with these specifications or is cancelled and not replaced, City has the right but not the duty to obtain the insurance it deems necessary and any premium paid by City will be promptly reimbursed by Consultant, or City will withhold amounts sufficient to pay premium from Consultant’s payments. In the alternative, City may cancel this Agreement.
City’s Right to Revise Specifications
City reserves the right at any time during the term of the Agreement to change the amounts and types of insurance required by giving Consultant ninety (90) days advance written notice of such change. If such change results in substantial additional cost to Consultant, City and Consultant may renegotiate Consultant's compensation.
Primary and Non-Contributory Coverage
For any claims related to this Agreement, Consultant's insurance coverage shall be primary insurance as respects City, its elected officials, officers, agents, employees and volunteers. Any insurance or self-insurance maintained by City, its officers, officials, employees or volunteers shall be excess of Consultant's insurance and shall not contribute with it and shall be at least as broad as CG 20 01 04 13.
Notice of Cancellation
Each insurance policy required above shall provide that coverage shall not be canceled, except with notice to City.
Deductibles and Self-Insured Retentions
Any deductibles or self-insured retentions must be declared to and approved by City. City may require Consultant to provide proof of ability to pay losses and related investigations, claim administration, and defense expenses within the retention.
Acceptability of Insurers
All insurance policies shall be issued by an insurance company currently authorized by the Insurance Commissioner to transact business of insurance in the State of California, with a current A.M. Best’s rating of no less than A:VII, (unless otherwise acceptable to City).
Waiver of Subrogation
All insurance coverage maintained or procured pursuant to this Agreement shall be endorsed to waive subrogation against City, its elected officials, officers, agents, employees or volunteers or shall specifically allow Consultant or others providing insurance evidence in compliance with these specifications - to waive their right of
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recovery prior to a loss. Consultant hereby waives his own right of recovery against City, and shall require similar written express waivers and insurance clauses from each of its subcontractors. Copies of these waivers shall be submitted to City prior to commencement of work.
Claims Made Policies
If any of the required policies provided coverage on a claims-made basis:
(a). The Retroactive Date must be shown and must be before the date of the Agreement or the beginning of contract work.
(b). Insurance must be maintained and evidence of insurance must be provided for at least five (5) years after completion of the work required under this Agreement.
(c). If coverage is canceled or non-renewed, and not replaced with another claims- made policy form with a Retroactive Date prior to the Agreement effective date, Consultant must purchase “extended reporting” coverage for a minimum of five (5) years after completion of Agreement work.
Verification of Coverage
Consultant shall provide City with copies of certificates (on City certificate form or an Accord form as modified per City direction) for all policies, with the appropriate named additional insured coverage and an endorsement that they are not subject to cancellation without 30 days prior written notice to City. All certificates and endorsements are to be received and approved by City before work commences. However, failure to obtain the required documents prior to the work beginning shall not waive Consultant's obligation to provide them. City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time.
Subcontractors
Consultant shall require and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Consultant shall ensure that City is an additional insured on insurance required from subcontractors. For CGL coverage, subcontractors shall provide coverage with a form at least as broad as CG 20 38 04 13.
10. RELATION OF THE PARTIES
a.Consultant is and shall at all times remain as to the City a wholly independent contractor. The personnel performing the services under this Agreement on behalf of Contractor shall at all times be under Consultant's exclusive direction and control. Neither City nor any of its officers, employees, agents, or volunteers shall have control over the conduct of Consultant or any of Consultant's officers, employees, or
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agents except as set forth in this Agreement. Consultant shall not at any time or in any manner represent that it or any of its officers, employees or agents are in any manner officers, employees or agents of the City. Consultant shall not incur or have the power to incur any debt, obligation or liability whatever against City, or bind City in any manner. b.No employee benefits shall be available to Consultant in connection with the performance of this Agreement. Except for the fees paid to Consultant as provided in the Agreement, City shall not pay salaries, wages, or other compensation to Consultant for performing services hereunder for City. City shall not be liable for compensation or indemnification to Consultant for injury or sickness arising out of performing services hereunder.
11. CORRECTIONS
In addition to the above indemnification obligations, Consultant shall correct, at its expense, all errors in the work that may be disclosed during City's review of Consultant's report or plans. Should Consultant fail to make such correction in a reasonably timely manner, such correction shall be made by City, and the cost thereof shall be charged to Consultant or withheld from any funds due to Consultant hereunder.
12. TERMINATION BY CITY
City may terminate without cause any or all of the services agreed to be performed under this Agreement upon 60 calendar days’ written notice. If termination is for cause, no advance notice need be given. In the event of termination, Consultant shall have the right and obligation to immediately assemble work in progress for the purpose of closing out the job. All compensation for actual work performed and charges outstanding at the time of termination shall be payable by City to Consultant within 30 days following submission of a final statement by Consultant unless termination is for cause. In such event, Consultant shall be compensated only to the extent required by law.
13. ACCEPTANCE OF FINAL PAYMENT CONSTITUTES RELEASE
The acceptance by Consultant of the final payment made under this Agreement shall operate as and be a release of City from all claims and liabilities for compensation to Consultant for anything done, furnished, or relating to Consultant's work or services.
Acceptance of payment shall be any negotiation of City's check or the failure to make a written extra compensation claim within 10 calendar days of the receipt of that check.
However, approval or payment by City shall not constitute, nor be deemed, a release of the responsibility and liability of Consultant, its employees, subcontractors, agents and consultants for the accuracy and competency of the information provided and/or work performed; nor shall such approval or payment be deemed to be an assumption of such responsibility or liability by City for any defect or error in the work prepared by Consultant, its employees, subcontractors, agents and consultants.
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14. AUDIT OF RECORDS
Consultant shall maintain, in accordance with generally accepted accounting principles, complete and accurate records of all activities and operations relating to this Agreement. Records, including but not limited to, timecards, employment records, work progress reports, reimbursements, invoices, project records, proprietary data and information, as well as licensed software and any electronic records shall be kept for a period of four years beyond the termination of this Agreement. Consultant agrees that City, or its authorized representative, shall have the right to examine, audit, excerpt, copy or transcribe any of the records pertaining to this Agreement at any time during normal business hours. Consultant shall reimburse City for all reasonable costs of the audit, including travel time and auditor costs, should such audit reveal an overcharge of five (5) percent or more. Any overcharge will be considered a breach of this Agreement and could be cause for termination. The obligations of this section shall be explicitly included in any subcontracts or other agreements entered into by Consultant with respect to this Agreement.
15. WAIVER; REMEDIES CUMULATIVE
Failure by a party to insist upon the strict performance of any of the provisions of this Agreement by the other party, irrespective of the length of time for which such failure continues, shall not constitute a waiver of such party's right to demand strict compliance by such other party in the future. No waiver by a party of a default or breach of the other party shall be effective or binding upon such party unless made in writing by such party, and no such waiver shall be implied from any omissions by a party to take any action with respect to such default or breach. No express written waiver of a specified default or breach shall affect any other default or breach, or cover any other period of time, other than any default or breach and/or period of time specified. All of the remedies permitted or available to a party under this Agreement, or at law or in equity, shall be cumulative and alternative, and invocation of any such right or remedy shall not constitute a waiver or election of remedies with respect to any other permitted or available right of remedy.
16. CONFLICT OF INTEREST
Consultant is unaware of any City employee or official that has a financial interest in Consultant's business. During the term of this Agreement and/or as a result of being awarded this Agreement, Consultant shall not offer, encourage or accept any financial interest in Consultant's business by any City employee or official.
17. CONSTRUCTION OF LANGUAGE OF AGREEMENT
The provisions of this Agreement shall be construed as a whole according to its common meaning of purpose of providing a public benefit and not strictly for or against any party. It shall be construed consistent with the provisions hereof, in order to achieve the objectives and purposes of the parties. Wherever required by the context, the singular shall include the plural and vice versa, and the masculine gender shall include the
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feminine or neutral genders or vice versa.
18. MITIGATION OF DAMAGES
In all situations arising out of this Agreement, the parties shall attempt to avoid and minimize the damages resulting from the conduct of the other party.
19. GOVERNING LAW
This Agreement, and the rights and obligations of the parties, shall be governed and interpreted in accordance with the laws of the State of California. Should litigation occur, venue shall be in Superior Court of Ventura County.
20. TAXPAYER IDENTIFICATION NUMBER
Consultant shall provide City with a complete Request for Taxpayer Identification Number and Certification, Form W-9, as most recently issued by the Internal Revenue Service.
21. NON-APPROPRIATION OF FUNDS
Payments due and payable to Consultant for current services are within the current budget and within an available, unexhausted and unencumbered appropriation of City funds. In the event City has not appropriated sufficient funds for payment of Consultant’s services beyond the current fiscal year, this Agreement shall cover only those costs incurred up to the conclusion of the current fiscal year.
22. MODIFICATION/AMENDMENT OF AGREEMENT
Any amendment, modification, or variation of the terms or tasks of this Agreement shall be in writing and shall be effective only upon the mutual written approval of the City and Consultant.
23. USE OF THE TERM “CITY”
Reference to “City” in this Agreement includes the City Manager or any authorized representative acting on behalf of City.
24. PERMITS AND LICENSES
Consultant, at its sole expense, shall obtain and maintain during the term of this Agreement all appropriate permits, licenses, and certificates that may be required in connection with the performance of services under this Agreement.
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25. CAPTIONS
The captions or headings in this Agreement are for convenience only and in no other way define, limit or describe the scope or intent of any provision or section of the Agreement.
26. AUTHORIZATION
Each party has expressly authorized the execution of this Agreement on its behalf and binds said party and its respective administrators, officers, directors, shareholders, divisions, subsidiaries, agents, employees, successors, assigns, principals, partners, joint venturers, insurance carriers and any others who may claim through it to this Agreement.
27. ENTIRE AGREEMENT BETWEEN PARTIES
Except for Consultant's proposals and submitted representations for obtaining this Agreement, this Agreement supersedes any other agreements, either oral or in writing, between the parties hereto with respect to the rendering of services and contains all of the covenants and agreements between the parties with respect to said services.
28. PARTIAL INVALIDITY
If any provision in this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions will nevertheless continue in full force without being impaired or invalidated in any way.
29. NOTICES
Any notice required to be given hereunder shall be deemed to have been given by depositing said notice in the United States mail, postage prepaid, and addressed as follows:
TO CITY:Attention: Sharon Chen
Human Resources Department
City of Thousand Oaks
2100 Thousand Oaks Boulevard
Thousand Oaks, CA 91362
TO CONSULTANT: Attention: Alithia Vargas-Flores
AdminSure, Inc.
3380 Shelby St.
Ontario, CA 91764
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31. SIGNATURES
(a)Counterparts. This Agreement may be executed in two or more counterparts, each of which together shall be deemed an original, but all of which together shall constitute one and the same instrument.
(b)Scanned Signatures. In the event that any signature is delivered by facsimile transmission or submitted electronically as a scanned image (i.e. files with .pdf, .tiff or .jpeg extensions), such signature shall create a valid and binding obligation of the party executing (or on whose behalf such signature is executed) with the same force and effect as if such facsimile or scanned signature page were an original thereof. (c)Digital/Electronic Signatures. This Agreement may be executed through the use of digital or electronic signatures provided they meet the requirements of the Electronic Signatures in Global and National Commerce (ESIGN) Act and the California Uniform Electronic Transactions Act (UETA) and are produced using a City-approved method. The presence of an electronic signature on this document shall be construed as the parties’ consent to do business electronically.
In concurrence and witness whereof, this Agreement has been executed by the parties effective on the date and year first above written.
CONSULTANT
By: Alithia Vargas-Flores
Title: President
By: Ashley Sells
Title: Corporate Secretary
CITY OF THOUSAND OAKS
___________________________
Mikey Taylor, Mayor
ATTEST:
_____________________________
Laura B. Maguire, City Clerk
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APPROVED AS TO ADMINISTRATION:
Andrew P. Powers, City Manager
APPROVED BY DEPARTMENT HEAD:
Jeanette Green, HR Director
APPROVED AS TO FORM:
Office of the City Attorney
By: Noel Doran, Assistant City Attorney
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EXHIBIT A
Scope of work
Claims Administration Services
A. Assumption of Existing Claims
i. Assume responsibility for all open workers’ compensation claims at the start of the contract term.
ii. Provide appropriate notifications as required under Title 8, California Code of Regulations Section 15402(b).
iii. If needed, oversee the transition from the previous Third Party Administrator, import historic files, and ensure continuity of service.
B. Claims Processing
i. Process all claims in accordance with applicable California Labor Code regulations and City of Thousand Oaks policies and procedures. ii. Assign experienced adjusters (minimum of 3 year's experience) to each claim, ensuring adjusters have necessary experience and training in workers’ compensation claims management; specifically, experience with public entities. iii. Within 24 hours of receipt and notice of Employer’s Report of Injury, adjusters shall conduct intake meetings with injured employees, set up appropriate claim files, and coordinate with City of Thousand Oaks Risk Analyst. iv. Manage care coordination and facilitate timely return-to-work programs. v. Engage the services of medical providers including physicians, therapists, pharmacists, and investigators, defense attorneys, hearing representatives and other firms or individuals to performed specialized work in connection with claims administration.
vi. Proactive claims management: TPA will provide consistent and proactive oversight of claims, ensure timely action on required filings and payments, and promptly identify and address issues.
a. Conduct regular (biweekly) claims review meetings with City staff and provide updates on claim status, trends, and emerging issues. TPA to provide relevant reports and summaries in advance of each meeting and document action items and follow up items to ensure continuity of claims management.
b. All claim files shall be reviewed at least every thirty (30) days for active claims and at least every six (6) months for claims that have settled but are open for the employee’s future medical care.
c. Each claim file shall include a clearly documented plan of action for
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future claim handling. The plan of action shall include, but not be limited to, the employee’s current work status, medical status, reserve review, and planned future activity to move the claim towards resolution. All claims will be subject to supervisor or higher-level review for quality and consistency, and specialized service providers will be engaged as needed.
Medical Management
A. Obtain and review all medical reports for each claim.
B. Conduct ongoing verification of workers’ compensation indemnity payments with medical providers.
C. Provide medical bill review services either in-house or via an independent firm (with prior HR approval) to ensure compliance with the Medical Fee Schedule.
Utilization Review (UR)
A. Manage Utilization Review (UR) processes for all medical treatment requests, including:
i. Reviewing treatment requests for medical necessity, appropriateness, and compliance with California Labor Code.
ii. Coordinating with an independent UR provider if required. iii. Ensuring timely approvals or denials per statutory timelines. iv. Communicating UR decisions to treating providers, claimants, and City staff. v. Maintaining complete documentation of all UR activities in the claim file/portal.
Claim Payments and Reserves
A. Make timely payments to claimants and service providers on behalf of the City.
B. Estimate and maintain claim reserves based on the most probable final claim cost.
C. All reserve categories shall be reviewed on a regular basis but not less than at least every forty-five (45) calendar days for active claims and six (6) months on claims that have settled but are open to monitor future medical cases.
Settlements and Claim Resolution
A. The TPA shall prepare comprehensive settlement reports for all claims where settlement is considered. Each report shall include:
i. A detailed claim summary, including medical treatment, indemnity payments, and any other related costs.
ii. Settlement options, including recommended amounts, structured or lump-sum options, and potential impact on reserves.
iii. TPA’s professional recommendation regarding whether to settle, continue litigation, or pursue alternative resolution strategies.
B. The TPA shall obtain all necessary approvals from City staff before finalizing any settlement.
C. Maintain detailed documentation of all settlement negotiations, offers, and
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agreements for record-keeping and regulatory compliance.
Litigation Support
The TPA shall assist the City in managing claims that require litigation, including:
A. Selection of defense counsel or hearing representatives: provide recommendations and assist in evaluating potential firms or individuals.
B. Coordination with legal counsel: act as the primary liaison between the City and defense attorneys, ensuring timely exchange of claim information, documentation, and evidence.
C. Strategic guidance: Support legal counsel on developing litigation strategy, potential outcomes, and cost implications.
D. Resolution support: work with legal counsel to negotiate settlements, prepare reports for City approval, and ensure claims are resolved efficiently and in compliance with regulations.
Customer Service, Technology, and Communication
A. Respond to standard City inquiries within 24 hours, high-priority issues within 4 hours.
B. Emergency availability: The TPA shall at all times have the examiner assigned to the City, or in their absence, the supervisor or another manager, available by telephone for emergencies through a 24-hour emergency telephone number.
C. Ensure that at least one or more examiners assigned to the City is available to the City every business day throughout the term of the contract.
D. Establish escalation protocol for urgent or unresolved issues.
E. Provide a secure, web-based claims management system /portal providing authorized City staff with timely access to claim status updates, work status, relevant claim notes, documents, payment history, and reported injuries with no medical treatment.
F. Portal must support reporting, data export, and automatic intake of data files from our systems.
Cost Mitigation
A. Assist the City in identifying, reviewing, investigating and appropriately addressing suspected fraudulent claims.
B. Conduct investigations of each claim using competent and qualified personnel.
C. Pursue subrogation recovery opportunities as appropriate.
Additional Responsibilities and Reporting
A. Conduct a comprehensive annual review of all open claims, including active medical-only and indemnity claims with City staff at a mutually scheduled and agreed upon time.
B. Medical Provider Network (MPN):
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i. The TPA shall either provide an existing, fully compliant MPN that the City can use for referring injured employees, or assist the City in preparing and submitting an application to establish a City-specific MPN. ii. If assisting in establishing an MPN, the TPA shall provide ongoing guidance and updates regarding statutes, proposed changes, and regulations affecting the City’s responsibilities related to the MPN.
C. Provide information for submission of the Self-Insured Annual Report to the Department of Self-Insurance Plans prior to the October 1st deadline.
D. Excess Workers’ Compensation Insurance Reporting:
i. Prepare and submit all required reports to the City’s excess insurance carrier in accordance with policy provisions and deadlines.
ii. Coordinate with the excess carrier regarding claims that may trigger coverage, providing all necessary documentation, status updates, and supporting information.
iii. Direct status reports to the City’s excess workers’ compensation insurer as appropriate.
E. Provide monthly loss runs and activity reports within 10 days of the end of each month.
Cal-OSHA and Regulatory Compliance
A. Support compliance with Cal-OSHA recordkeeping and reporting requirements for work-related injury and illnesses, including timely preparation of required documentation (Cal-OSHA 300/300A/301 logs).
B. Ensure all claims and reporting comply with federal, state, and local occupational safety regulations.
C. Support tracking and reporting of non-medical incidents in the portal.
Confidentiality and Data Security
A. The TPA shall maintain confidentiality of all claim-related data and comply with applicable privacy laws.
B. Portal access must include secure authentication and role-based permissions.
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EXHIBIT B
Claims Administration Services Flat Monthly Fee (3% annual increase):
Year 1: $3,750
Year 2: $3,862.50
Year 3: $3,978.38
Bill Review Services Flat Fee:
$9 per bill for all Official Medical Fee Schedule (OMFS), In-Patient Hospital Fee Schedule (IHFS), and Out-Patient, etc., reviews; and when applicable, plus 7 5 cents for State of California required E-Bill/OCR Services. When applicable, up to 27% Preferred Provider Organization (PPO)/Negotiated Savings fee. If there are no applicable savings, there are no fees. No additional fees for transmitting medical billing information on behalf of the City to the Workers' Compensation Information System (WCIS) as required by State Law, i.e., Medical Bill Review EDI (Electronic Data Interchange) Reporting and Services.
3% annual increase.
Utilization Review Services (Managed Care) Flat Fee:
Physician (includes Peer and Expert) Reviews and Decisions/Non-Physician Reviews and Decisions:$300 per hour/5%flat fee of total charges ($750 cap per bill);$85 adjuster; $170 non-adjuster.
3% annual increase.
Transition Fee
No fee
Data Conversion Fee
No fee
CMS/MMSEA - Internal
Included.
City On-Line Access (All Data)
Included. At-cost fee for read/write access.
All Reports: Standard & Custom/Ad Hoc Reports
Included. At-cost fee when data is not captured.
Index Claim Search & 1099s
Included.
Training & Development of Special Account Instructions/Procedures, Banking & RMIS Customization
Included. Reference "Banking" fees, if any, please make note that any fees
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charged by the bank shall be at cost as we will not add on any fee for our internal services.
RMIS customization if any shall be at cost.
Training, Meetings, Quarterly Claim Reviews, Forms, Posters & Pamphlets Included.
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HRD: 180-50\lq\H:COMMON\Contracts\2026\AdminSure.docx
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