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HomeMy WebLinkAboutItem 11f - Third Party Claims Administration Services DATE: July 18, 2023 TO: Honorable Mayor and City Council FROM: Hue Quach, Administrative Services Director By: Anely Williams, Human Resources Administrator SUBJECT: AMENDMENT TO THE AGREEMENT WITH ADMINSURE INC. FOR WORKERS’ COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES EXTENDING THE TERM FOR AN ADDITIONAL TWO YEARS IN THE AMOUNT OF $209,880 CEQA: Not a Project Recommendation: Approve SUMMARY On June 16, 2020, the City Council approved a three-year Agreement with AdminSure, Inc. (“AdminSure”) for Third Party Workers’ Compensation claims administration services. At that time, the City’s risk pool, California Insurance Pool Authority (“CIPA”) went out to bid on behalf of the City of Arcadia and other participating member cities. Based on competitive bid results, CIPA negotiated a five-year contract through June 30, 2025, for all cities except City of Arcadia, who entered into a three-year contract instead. For a period of time prior to 2020, the City did not feel that it was receiving the level service it expected, and thus, wished to enter into a shorter contract term to evaluate whether the level of service would improve. Since then, the City has been extremely satisfied with the services provided and response rate received. Based on the positive experiences and the competitive bid results from 2020, it is recommended that the City Council approve, authorize, and direct the City Manager to execute an amendment to the existing agreement with AdminSure to extend the term of the agreement from June 30, 2023, to June 30, 2025. This change would align with all other CIPA member cities and would ensure continuity of service. The cost for the additional two years totals $209,880 and are as follows: • Fiscal Year 2023-2024: $103,392 • Fiscal Year 2024-2025: $106,488 Amendment to the Agreement with AdminSure for Workers’ Compensation Third Party Claims Administration Services July 18, 2023 Page 2 of 3 DISCUSSION The City of Arcadia is a member of CIPA, which operates within the guidelines of the Joint Powers Authority to self-fund the Workers’ Compensation insurance program. The program requires the services of a Third-Party Administrator (“TPA”) to handle the daily operations of the City’s claims. AdminSure has provided TPA services for the City’s Workers’ Compensation program since 1985. Although there was a short period during which the City was experiencing reduced service levels, AdminSure remained committed to providing excellent service. Through assignment of a different claims adjuster and more oversight, the City has not experienced any further concerns. AdminSure continues to provide excellent service and expertise in claims administration. The services provided by AdminSure includes all aspects of claims administration in compliance with the applicable Workers’ Compensation laws for the State of California, including but not limited to: monitoring claims, setting and updating reserves, authorizing medical treatments, processing medical bills, and meeting all reporting requirements mandated by Medicare and Medicaid. Additionally, AdminSure provides electronic access to their program database to review both open and closed claims and reserves. The proposed amendment would extend the duration of the contract from June 30, 2023, to June 30, 2025, to ensure there is continuity of service. No other contract terms will be revised, including any notification of termination. Should the City choose to terminate the contract at any time, a Request for Proposal (“RFP”) would be required, which could take several months to complete. Upon completion of the RFP, the City would need to provide 60 days’ notice to AdminSure to guarantee there is no lapse in the claims administration processes. ENVIRONMENTAL ANALYSIS The proposed action does not constitute a project under the California Environmental Quality Act (“CEQA”), based on Section 15061(b)(3) of the CEQA Guidelines, as it can be seen with certainty that it will have no impact on the environment. Thus, this matter is exempt under CEQA. FISCAL IMPACT Adequate funding has been allocated in the current FY 2023-24 budget to support these services. Next year’s costs for these services will be addressed during the annual budget adoption process: • Fiscal Year 2023-24: $103,392 • Fiscal Year 2024-25: $106,488 Amendment to the Agreement with AdminSure for Workers’ Compensation Third Party Claims Administration Services July 18, 2023 Page 3 of 3 RECOMMENDATION It is recommended that the City Council determine that this project is exempt under the California Environmental Quality Act, and approve, authorize, and direct the City Manager to execute an amendment to the agreement with AdminSure Inc. for Workers’ Compensation Third Party Claims Administration Services extending the term for an additional two years in the amount of $209,880. Attachments: Current AdminSure Agreement and First Amendment Proposed Second Amendment Extending Arcadia’s Term 1 of 23 AGREEMENT FOR CLAIMS ADMINISTRATION SERVICES Article 1. GENERAL This Agreement is entered into on July 1, 2020 by and between the CALIFORNIA INSURANCE POOL AUTHORITY (“CIPA”), a California public joint powers authority, on behalf of the CITIES OF ARCADIA, BUENA PARK, CYPRESS, IRVINE, LAGUNA BEACH, MONTCLAIR, ORANGE, TUSTIN AND YORBA LINDA (“Member Cities or Member City”) and AdminSure, Inc. (“Administrator”), having an office at 3380 Shelby Street, Ontario, California. Article 2. SCOPE OF APPOINTMENT/RELATIONSHIP OF THE PARTIES Administrator, its agents and employees are hereby appointed as CIPA and/or Member Cities’ agents and representatives to administer Member Cities’ self-insured workers' compensation programs and processes, evaluate, adjust and handle workers' compensation claims against Member Cities. Administrator agrees to provide the services set forth in Article 4 of this Agreement. The relationship of Administrator and CIPA and/or Member Cities established by this Agreement is that of independent contractors, and nothing contained in this Agreement shall be construed to establish an employer/employee relationship or to constitute the parties as partners, joint ventures, co-owners, or otherwise as participants in a joint and common undertaking. Administrator, its agents and employees are representatives of CIPA and/or Member Cities only for the purpose of administering Member Cities’ self-insured workers' compensation program as set forth in this Agreement, and they have no power or authority as agent, employee, or in any other capacity to represent, act for, bind or otherwise create or assume any obligation on behalf of CIPA and/or Member Cities for any purpose whatsoever, except as specifically required to perform Administrator's obligations under this Agreement. Article 3. DURATION This Agreement applies to all work performed by Administrator which is described in Article 4, whether performed in anticipation of or following the execution of this Agreement. The initial term shall begin on July 1, 2020 and shall expire June 30, 2025, except for City of Arcadia which shall expire on June 30, 2023. Subsequent annual terms from July 1, to June 30, may be mutually agreed upon between the parties. The Agreement shall automatically renew from year-to-year subject to termination by either party at any time during the life of the Agreement upon sixty (60) days written notice. CIPA maintains the right to terminate this Agreement if CIPA determines that it is in the best interest to do so, in CIPA’s sole discretion and with or without cause. In the event Member Cities purchase workers’ compensation insurance or its Certificate of Consent to Self-Insure is rescinded or revoked, this Agreement shall automatically terminate upon the effective date of such event. When this Agreement is terminated, the parties shall, as necessary, make an adjustment to the payment schedule in Article 6 to prorate fees through date of termination. Thereafter, Member Cities shall pay Administrator moneys due and owing after such adjustment, if any, or Administrator shall refund moneys due and owing Member Cities after such adjustment, if any. Adjustments due and owing shall be paid within 60 days after termination of the Agreement. Upon notice of termination of the Agreement, the Administrator will fully cooperate with the new Administrator, CIPA and Member Cities in providing required information and service. Failure to fully cooperate will result in a 10% reduction in fees paid to the Administrator during the period the Administrator does not fully cooperate. 2 of 23 Article 4. ADMINISTRATOR SERVICES Administrator will provide Member Cities the following services: 1.Claims Administration A. Administrator will adhere to the Minimum Performance Standards for Workers’ Compensation Claims Administration Policy, as contained in Addendum 1. Policy revisions adopted by CIPA’s Board of Directors shall be automatically incorporated into this Agreement. Any such revisions will be reviewed with Administrator prior to adoption by CIPA B. Provide all forms and reports necessary for the efficient operation of Member Cities’ programs of self-insurance with respect to workers’ compensation claims and prepare and file all forms and reports required by law in a timely manner. C. Administrator will participate and assist Member Cities in coordination of this program with other associated disability and medical programs. D. At the request of Member Cities, Administrator will attend hearings at no charge to Member Cities. E. Maintain records in accordance with legal requirements. F. Perform other general administrative services, as necessary, to effectively discharge Member Cities’ duties to its employees and under the workers' compensation State statutes. 2.Communication and Training A. Attend CIPA and Member City meetings as requested. B. Conduct on-site formal educational programs for supervisors, managers and other staff responsible for managing the workers’ compensation program as requested, and at least once a year. C. Review open claims, procedures and other issues on-site at each Member City, as requested. D. Conduct meetings with Member Cities’ preferred medical providers to maximize effectiveness of procedures and medical care as requested, and no more than quarterly for each Member City. E. To the extent allowable by law, provide copies of file correspondence and documentation as requested by CIPA and/or Member Cities. 3.State and Federal Reports A. Prepare Self-Insurer's Annual Reports for Member Cities’ and/or CIPA’s signature and submission to the State of California. B. Prepare Federal Information Return (Forms 1099) for applicable payments. 4.Information Management System A. In coordination with CIPA and/or Member Cities, develop management reports that assist CIPA and/or Member Cities and Administrator in effectively managing the workers' compensation program. Standard Reports will be provided within ten (10) days after the end of the month or quarter. B. Any hardware or cabling required by Member Cities to access the on-line system is Member Cities’ responsibility. C. The Administrator will report loss information to the excess insurance carrier(s), including CIPA, in accordance with established procedures. 3 of 23 5.Consulting Provide a comprehensive Annual Program Review which: A. Analyzes past statistics, program costs and projects future trends. B. Recommends program changes to favorably impact costs and improve procedures. C. Upon request, Administrator will provide a comprehensive program review more frequently than annually. 6.Compliance Provide all services in accordance with the applicable Workers' Compensation Laws of the State of California. 7.Allocated Loss Expense "Allocated loss expense" shall mean all reasonable costs actually incurred by Administrator including, without limitation, all Workers' Compensation Appeals Board or court fees and expenses; fees for service or process; copy service; fees to retain attorneys; the cost of the services of investigators and detectives to perform surveillance; and other professional assistance required to provide these services, if previously authorized by Member City. Allocated loss expense shall not include any costs or expenses incurred by Administrator in connection with services performed by it, which services are approved by CIPA and/or Member Cities and are normally performed in the course of administering workers' compensation claims. Allocated charges are to be paid by Member Cities. 8.Index Bureau & Edex Charges Index Bureau and Edex charges will be paid by the Administrator. Copies of the reports will be distributed to Member Cities within 10 days of receipt. 9.Storage of Closed Claims Administrator will provide storage of all closed claims, including storage of closed claims from prior administrator(s). Article 5. MEMBER CITY OBLIGATIONS In connection with this Service Agreement, Member Cities accept responsibility to: A. Provide data to Administrator on a timely basis to permit compliance with State of California reporting requirements. B. Arrange for checking account and provide appropriate funding. Article 6. COMPENSATION In consideration of the services provided by Administrator, each Member City agrees to pay Administrator the monthly fee as shown below. CIPA has no obligation to pay fees: A. Claims Administration Monthly claims administration fees by Member are shown on the following page: 4 of 23 Member Monthly Fee Monthly Fee Monthly Fee Monthly Fee Monthly Fee City (7/1/20-6/30/21) (7/1/21-6/30/22) (7/1/22-6/30/23) (7/1/23-6/30/24) (7/1/24-6/30/25) Arcadia $7,884 $8,121 $8,365 $8,616 $8,874 Buena Park $10,374 $10,685 $11,006 $11,336 $11,676 Cypress $3,182 $3,277 $3,376 $3,477 $3,582 Irvine $21,505 $23,548 $25,785 $28,235 $30,918 Laguna Beach $11,941 $12,299 $12,668 $13,048 $13,440 Montclair $4,011 $4,131 $4,255 $4,383 $4,514 Orange $19,187 $19,763 $20,356 $20,967 $21,596 Tustin $6,679 $7,835 $8,991 $9,126 $9,263 Yorba Linda $111 $115 $118 $122 $126 B.Ancillary Services Ancillary services are not tied to this Agreement and may be purchased from another vendor at the option of Member Cities. Administrator’s fee is $4.00 per bill when bill review services provided by a third-party vendor. When ancillary services are purchased from Administrator, the fee shall be as follows and no additional fees shall be charged without CIPA’s written authorization and incorporation into the Agreement: All ancillary services provided through Administrator by a third-party vendor shall be billed at actual cost with no “mark-up” by the Administrator. 1.Bill Review The flat fee per bill, including challenged and duplicate bill is $9.00, plus when applicable, $0.60 for e-bill/OCR. The PPO fee is 20% of savings above the fee schedule except for Blue Cross PPO which is at 23% of savings. PPO fees shall be billed at cost with no mark-up. If bill review services are not purchased from AdminSure, all electronic data interchange services will be provided by vendor, and not by AdminSure. 2.Utilization Review The Utilization Review fee is $85.00 flat fee per review/decision. Examiners will perform Utilization Review in accordance with the Guidelines XQOHVV RWKHUZLVH GLUHFWHG E\ &,3$ RU 0HPEHU&LW\ Utilization review by a physician is billed separately at ten (10) minute increments, at the rate of $200 per hour. 5 of 23 Article 7. REIMBURSEMENTS Member Cities agree to reimburse Administrator within thirty (30) days of presentation of an itemized statement for the costs of charges not considered allocated expenses or included in Administrator's fee, which are incurred on behalf of Member Cities, provided Member Cities have previously authorized such expense. Article 8. AUDITS Administrator agrees to cooperate with CIPA in making all claim files and records available to CIPA for audit by CIPA or Member City’s appointed representatives including auditors. During normal office hours, CIPA and/or Member City’s representatives, including auditors shall have reasonable access to the necessary portions of Administrator's facilities, files and records for review or audit purposes, so as not to interfere with Administrator's normal business. Article 9. ASSIGNMENTS Neither party may assign this Agreement, in part or in total, without the express written consent of the other party. Article 10. LEGAL RESPONSIBILITIES The Administrator shall comply with all State and Federal laws, as well as all county and municipal ordinances and regulations which in any manner affect the performance of services pursuant to this agreement, or persons employed by the Administrator. Administrator agrees that in the performance of the terms of this Agreement, no discrimination shall be made in the employment of persons because of race, color, national origin, ancestry, or religion of such persons. A violation of this provision will subject the Administrator to all penalties imposed by law. Article 11. INSURANCE The City reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. If the existing policies do not meet the insurance requirements set forth herein, Administrator agrees to amend, supplement or endorse the policies to do so. Without limiting the indemnity provisions of the contract, the Administrator shall procure and maintain in full force and effect during the term of the contract, the following policies of insurance. 1. Minimum Scope of Insurance Coverage shall be at least as broad as: A. Commercial General Liability (CGL) which affords coverage at least as broad as Insurance Services Office “occurrence” form CG 00 01, including products and completed operations, property damage, bodily injury, and personal & advertising injury with limits no less than $1,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location or the general aggregate limit shall be twice the required occurrence limit. B. Automobile Liability with coverage at least as broad as Insurance Services Office Form CA 0001 covering “Any Auto” (Symbol 1) with limit no less than $1,000,000 each accident for bodily injury and property damage. 6 of 23 C. Workers’ Compensation as required by the State of California with statutory limits, and Employer’s Liability Insurance with a limit of not less than $1,000,000 per accident for bodily injury or disease. D. Professional Liability with limit of not less than $2,000,000 each claim and $3,000,000 aggregate. Covered professional services shall specifically include all work to be performed under the contract and delete any exclusion that may potentially affect the work to be performed. E. Cyber Privacy Liability in an amount not less than $2,000,000 per claim and annual aggregate, covering (1) all acts, errors, omissions, negligence, infringement of intellectual property; (2) network security and privacy risks, including but not limited to unauthorized access, failure of security, breach of privacy perils, wrongful disclosure, collection, or negligence in the handling of confidential information, privacy perils, including coverage for related regulatory defense and penalties; (3) data breach expenses payable whether incurred by CIPA, Member Cities or Administrator, including but not limited to consumer notification, whether or not required by law, computer forensic investigations, public relations and crisis management firm fees, credit file or identity monitoring or remediation services in the performance of services for City or on behalf of City hereunder. The policy shall contain an affirmative coverage grant for bodily injury and property damage emanating from the failure of the technology services or an error or omission in the content/information provided. If a sub-limit applies to any elements of coverage, the certificate of insurance evidencing the coverage above must specify the coverage section and the amount of the sub-limit. F. Crime Bond in amount not less than $2,000,000 to include at a minimum employee theft, forgery or alteration, computer fraud and funds transfer fraud. 2. Endorsements Insurance policies shall not comply if they include any limiting provision or endorsement. The insurance policies shall contain, or be endorsed to contain, the following provisions: A. Commercial General Liability (1) Additional Insured: California Insurance Pool Authority and Member Cities, elected officials, officers, employees, volunteers, boards, agents and representatives shall be additional insureds with regard to liability and defense of suits or claims arising out of the work or operations performed by or on behalf of the Administrator including materials, parts or equipment furnished in connection with such work or operations. Additional Insured Endorsements shall not: 1. Exclude “Contractual Liability” 2. Be limited to “Ongoing Operations” 3. Restrict coverage to the “sole” liability of Administrator 4. Exclude “Third-Party-Over Actions” 5. Contain any other exclusion contrary to the contract Additional Insured Endorsements shall be at least as broad as ISO Form(s) CG 20 10 11 85; or CG 20 10 and CG 20 37. 7 of 23 (2) Primary Insurance: This insurance shall be primary and any other insurance whether primary, excess, umbrella or contingent insurance, including deductible, or self-insurance available to the insureds added by endorsement shall be in excess of and shall not contribute with this insurance. Coverage shall be at least as broad as ISO CG 20 01 04 13. B. Auto Liability (1) Additional Insured: California Insurance Pool Authority and Member Cities, elected officials, officers, employees, volunteers, boards, agents and representatives shall be additional insureds with regard to liability and defense of suits or claims arising out of the work or operations performed by or on behalf of the Administrator. (2) Primary Insurance: This insurance shall be primary and any other insurance whether primary, excess, umbrella or contingent insurance, including deductible, or self-insurance available to the insureds added by endorsement shall be in excess of and shall not contribute with this insurance. C. Workers’ Compensation (1) Waiver of Subrogation: A waiver of subrogation stating that the insurer waives all rights of subrogation against the indemnified parties. 3. Insurance Obligations of Administrator The insurance obligations under this contract shall be: (1) all the insurance coverage and/or limits carried by or available to the Administrator; or (2) the minimum insurance coverage requirements and/or limits shown in this contract; whichever is greater. Any insurance proceeds more than or broader than the minimum required coverage and/or minimum required limits, which are applicable to a given loss, shall be available to the City. No representation is made that the minimum insurance requirements of this contract are sufficient to cover the obligations of the Administrator under this contract. 4. Notice of Cancellation Required insurance policies shall not be cancelled or the coverage reduced until a thirty (30) day written notice of cancellation has been served upon the City, except ten (10) days shall be allowed for non- payment of premium. 5. Waiver of Subrogation Required insurance coverages shall not prohibit Administrator from waiving the right of subrogation prior to a loss. Administrator shall waive all rights of subrogation against the indemnified parties and policies shall contain or be endorsed to contain such a provision. This provision applies regardless of whether the City has received a waiver of subrogation endorsement from the insurer. 6. Evidence of Insurance All policies, endorsements, certificates, and/or binders shall be subject to approval by the City as to form and content. These requirements are subject to amendment or waiver only if so, approved in writing by the City. The City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. The certificates and endorsements for each insurance policy shall be signed by a person authorized by that insurer to bind coverage on its behalf. At least fifteen (15) days prior to the expiration of any such policy, evidence of insurance showing that such insurance coverage has been renewed or extended shall be filed with the City. If such coverage is cancelled or reduced, Administrator shall, within ten (10) days 8 of 23 after receipt of written notice of such cancellation or reduction of coverage, file with the City evidence of insurance showing that the required insurance has been reinstated or has been provided through another insurance company or companies. 7. Deductible or Self-Insured Retention Any deductible or self-insured retention must be approved in writing by the City and shall protect the indemnified parties in the same manner and to the same extent as they would have been protected had the policy or policies not containing a deductible or self-insured retention. The City may require the Administrator to purchase coverage with a lower retention or provide proof of ability to pay losses and related investigations, claim administration and defense expenses within the retention. The policy language shall provide, or be endorsed to provide, that the self-insured retention may be satisfied by either the Administrator or the City. 8. Contractual Liability The coverage provided shall apply to the obligations assumed by the Administrator under the indemnity provisions of this contract. 9. Failure to Maintain Coverage Administrator agrees to suspend and cease all operations hereunder during such period as the required insurance coverage is not in effect and evidence of insurance has not been furnished to the City. The City shall have the right to withhold any payment due until Administrator has fully complied with the insurance provisions of this contract. If the Administrator’s operations are suspended for failure to maintain required insurance coverage, the Administrator shall not be entitled to an extension of time for completion of the work because of production lost during suspension. 10. Acceptability of Insurers Each such policy shall be from a company or companies with a current A.M. Best’s rating of no less than A:VII and authorized to do business in the State of California, or otherwise allowed to place insurance through surplus line brokers under applicable provisions of the California Insurance Code or any federal law. Any other rating must be approved in writing by the City. 11. Claims Made Policies If coverage is written on a claims-made basis, the retroactive date on such insurance and all subsequent insurance shall coincide or precede the effective date of the initial Administrator’s contract with the City and continuous coverage shall be maintained or an extended reporting period shall be exercised for a period of at least five (5) years from termination or expiration of this contract. 12. Insurance for Subcontractors Administrator shall be responsible for causing Subcontractors to purchase the same types and limits of insurance in compliance with the terms of this contract, including adding the City as an Additional Insured, providing Primary and Non-Contributory coverage and Waiver of Subrogation to the Subcontractor’s policies. The Commercial General Liability Additional Insured Endorsement shall be on a form at least as broad as CG 20 38 04 13. Article 12. INDEMNIFICAT,ON Administrator shall defend, indemnify and hold harmless CIPA and/or Member Cities including its governing board, directors, officers, administrators, employees, and agents, from any and all claims, losses and liabilities against or incurred by CIPA and/or Member Cities arising out of the actions, omissions to act or other conduct of Administrator, its agents, employees or subcontractors, in the performance of its duties under this Agreement or otherwise in connection with its activities pursuant to this Agreement. This includes, but is not limited to, any breach by Administrator of its duties or responsibilities under the Agreement, as well as any losses occasioned by a failure of Administrator to provide the services contracted for by CIPA pursuant to this Agreement. In addition, Administrator agrees to assume the defense, at Administrator's expense, using attorneys reasonably acceptable to CIPA of any lawsuit or other proceeding which names CIPA and or Member Cities or its directors, officers, employees and agents as defendants. Article 13. BUSINESS LICENSE. Administrator shall maintain a business license for each City as required. Article 14. RIGHTS TO DATA All claim files, paper and computer, are and shall remain the property of CIPA and/or Member Cities. CIPA and/or Member Cities reserve the right to obtain original claim files, data discs, copies of reports and other documents applicable to CIPA and/or Member Cities in the event this Agreement is terminated. No documents shall be destroyed unless they have been scanned into the system. Original documents received after termination of this agreement shall be forwarded to the new administrator. Administrator shall bear the cost of relocating any claim files from the premises of Administrator to the premises of CIPA or designated party upon termination of the Agreement. Article 15. CONFIDENTIALITY It is agreed and understood that Administrator shall treat information, reports and analyses obtained or developed pursuant to this Agreement as being confidential. Prior written consent from CIPA and/or Member Cities shall be required before any information, in any format, is disclosed to any third party. It is further agreed and understood that Administrator shall produce, maintain and dispose of all such information, reports and analyses in a manner to guarantee reasonable safeguards to such confidentiality. Article 16. INTERNAL SERVICES PROVIDED BY ADMINISTRATOR No internal services shall be provided for a fee without the express written permission of Member Cities. Article 17. EXTERNAL PROVIDER/VENDOR SERVICES All services provided by external providers/vendors shall be approved by Member Cities and billed at actual cost with no “mark-up” by the Administrator. All external providers/vendors will be selected from a panel approved by each Member City. Article 18. DOCUMENTS/CORRESPONDENCE Each Member City will designate documents/correspondence they will require for their files and a timeframe for receipt of such documents/correspondence. 9 of 23 10 of 23 Article 19. MATERIAL PROBLEMS AND REGULATORY CHANGES The Administrator will advise CIPA on any material problems or need for improvements in any matter related to this Agreement, including advice relating to changes and proposed changes in statutes, regulations and rules affecting Member Cities’ workers’ compensation programs. Article 20. CONFLICT OF INTEREST Administrator agrees to disclose to CIPA any potential conflicts of interest, including but not limited to other sources of income. Article 21. NOTICES All notices required or permitted hereunder shall be sent to the other party at the following addresses, or at such other address as may be provided in writing to the other party from time to time: To Administrator: Alithia Vargas-Flores AdminSure Inc. 3380 Shelby Street Ontario, CA 91764-5566 avargas-flores@adminsure.com To CIPA: Janet D. Kiser General Manager California Insurance Pool Authority 366 San Miguel Drive Suite 312 Newport Beach, CA 92660 jk@kiserco.com Article 22. DWC AUDIT PENALTY All penalties assessed by the Workers' Compensation Division, Office of Benefit Assistance and Enforcement shall be paid, whether directly or through reimbursement, by the party responsible for the assessment of the penalty. No claim shall be settled to include payment of any penalty without the express written consent of the Member City. Settlement of any penalty incurs an additional settlement cost and the responsible party shall pay the additional cost for the penalty. If either party disputes the liability for payment of the penalty, the parties shall negotiate to resolve the dispute. If the dispute is not resolved within 30 days after notice to both parties of the penalty, then such dispute shall be submitted to arbitration for determination of the party responsible for the assessment and payment of the penalty. The provisions of this Article shall survive any termination of this Agreement. The Administrator shall provide a detailed monthly listing of penalties identifying those payable by Member Cities and those payable by the Administrator. The listing shall include fines, penalties and 10% self-imposed increases paid through settlement of a claim. The obligations of the Administrator to pay for fines, penalties, and 10% self-imposed increases shall survive the termination of this Agreement. Article 23. MMSEA REPORTING & PENALTIES The Administrator shall report all claims in compliance with Medicare, Medicaid and SCHIP Extension Act (MMSEA) Section 111 Mandatory Reporting. All Section 111 penalties shall be paid by the Administrator. CIPA and Member Cities shall be promptly notified of any Section 111 penalties assessed. The obligation of the Administrator to pay for penalties shall survive the termination of this Agreement. 11 of 23 Article 24. ASSIGNED PERSONNEL Each examiner assigned to CIPA will not have a case load that exceeds 150. Caseloads for examiners shall not exceed 150, unless approved in writing by the Member City. Caseloads that include future medical and medical only claims shall count these claims as 2:1 in the caseload limit. Dedicated examiners will not handle claims for any other account. Designated examiners, assistants and medical only clerks will be assigned. If the caseload of an examiner exceeds 150 claim files for two consecutive months, CIPA and/or Member Cities will have the discretion of allowing the overflow or will have the Administrator assign an additional non-dedicated examiner to handle the overflow claims. Administrator shall provide CIPA and Member Cities with an accounting of caseloads each June 30 and December 31. The accounting for each examiner shall include (1) the name or pseudo name of all assigned clients; and (2) the number of claims, by claim type, for each client. Each examiner shall sign acknowledgement of their claims count and provide to CIPA and Member City. The examiner assigned to the account must have a minimum of five (5) years full-time experience as a workers’ compensation examiner in California, unless requirement is waived by Member City, and the examiner shall have a California Self-Insured Workers’ Compensation Certificate. Member Cities must approve personnel assigned to their account. If, for any reason, the service provided by assigned personnel is unsatisfactory, the Administrator will agree to assign replacement personnel approved by Member Cities. Article 25. FUNDS Member Cities may provide Administrator initial funding in an amount mutually agreed to by each Member City and Administrator to be held in trust by and used by Administrator to meet the obligations of Member Cities. Administrator and Member Cites may establish written procedures for approval or ratification of expenditures from such trust accounts and methods of handling such funds; in such event Administrator shall provide a copy of the written procedures to Member Cities. Trust funds shall be used and paid out by Administrator only in the manner set forth in this Agreement. Article 26. WAIVER The failure of either party at any time to enforce any right or remedy available to it under this contract with respect to any breach or failure by the other party shall not be constructed to be a waiver of such right or remedy. Article 27. MISCELLANEOUS This Agreement shall be governed by, and construed in accordance with, the laws of the State of California. If any of the provisions of this Agreement shall be held by a court or other tribunal of competent jurisdiction to be unenforceable, the remaining portions of this Agreement shall remain in full force and effect. All terms and conditions of the Administrator’s proposals of March 26, 2020 are incorporated into this contract, except that in the event of any conflict between the Agreement and the proposal, this Agreement shall be controlling. Any modifications of this Agreement must be in writing and signed by both parties. Each member of CIPA identified herein shall be a third-party beneficiary of this Agreement with the right to enforce the provisions of this Agreement against Administrator. General Manager June 25, 2020 Janet Kiser 13 of 23 ADDENDUM 1 MINIMUM PERFORMANCE STANDARDS CLAIMS ADMINISTRATOR CIPA’s Minimum Performance Standards for Workers’ Compensation Claims Administration Policy is adopted by the Board of Directors and may be revised from time-to time. The adopted Policy is to be incorporated as a part of the Agreement between CIPA and the Administrator and is contained below. Any future revisions to the Policy will be sent to the Administrator and automatically incorporated into the Agreement between CIPA and the Administrator. The most stringent requirements shall apply if there is any conflict between these standards and the Labor Code or Code of Regulations. 1. CASELOADS A. Caseloads for examiners shall not exceed 150, unless approved in writing by the Member City. Caseloads that include future medical and medical only claims shall count these claims as 2:1 in the caseload limit. B. Administrator shall provide CIPA and Member Cities with an accounting of caseloads each June 30 and December 31. The accounting for each examiner shall include (1) the name or pseudo name of all assigned clients; and (2) the number of claims, by claim type, for each client. Each examiner shall sign acknowledgement of their claims count and provide to CIPA and Member City. C. Supervisory personnel shall not handle a caseload. Exceptions may be made for a small number of claims involving special issues. 2. INITIAL FILE SET-UP AND THREE-POINT CONTACT A. Claims will be created and entered in the computer within one (1) business day of receipt of the Form 5020. B. All Employers’ Reports of Occupational Injury or Illness, or notification of a new claim from any other source, will be reviewed for compensability and a decision made to accept, delay or deny within seven (7) calendar days of receipt, or sooner if a delay in payment or notice will result. C. Employees will be contacted by telephone or in person within one (1) business day of receipt of a claim by the Administrator unless the employee is represented by an attorney. During this initial contact, employees will be provided with an explanation of their benefits and will be asked whether they have any questions or concerns, which shall be addressed immediately. A benefits pamphlet will be sent to the employee notifying them of their rights under workers’ compensation laws of California. The examiner shall contact the employer for assistance if unable to contact the employee. All contact and attempts to contact employee and employer shall be documented in the file. D. The Member City will be contacted within two (2) business days of receipt of a claim to verify continuing disability, clarify issues and request additional required information. Contact will be made sooner if delay will result in a late payment or a penalty situation. E. The employee’s treating doctor will be contacted within two (2) business days of receipt of claim to verify duration of disability, compensability, proposed treatment, clarify issues and request additional information. Contact will be made sooner if a delay will result in a late payment or penalty situation. Thereafter, until the employee returns to work, the examiner shall maintain contact at least every thirty (30) calendar days with the attending physician, obtain medical reports, monitor medical treatment, and facilitating an early return to work. 14 of 23 3. CASE REVIEW A. Lost-time claims, except for future medical claims, shall be reviewed on diary by the assigned examiner no less than every thirty (30) calendar days or more frequently when needed. B. In cases where claims investigations are being conducted, claims will be placed on diary no less than every fourteen (14) calendar days by the assigned examiner until all outstanding issues have been resolved. C. Medical only claims will be reviewed no less than every thirty (30) calendar days for possible closure. They will be transferred to an indemnity claim when disability is due, compensability is an issue, they are over 120 calendar days old or medical payments (excluding diagnostic expenses) exceed $1,500. D. Future medical claims will be reviewed on diary at least every ninety (90) calendar days. The extent and appropriateness of medical treatment shall be evaluated and documented in the notepad entries. E. All files shall be reviewed for closure and closed within seven (7) calendar days from the date all issues have been resolved. 4. COMMUNICATION A. The injured or ill employee will be contacted at least every two (2) weeks while they are disabled from working, unless they are represented by an attorney or their claim has been finalized. B. Employer contact is required to verify continuing disability and explore the availability of modified or light duty work before processing disability payments. C. The employee will be called before sending notification of permanent disability and PQME letter, to explain the process and answer the employee’s questions. D. The Member City will be notified of any claim being delayed or denied before a Notice is sent to the employee. The Member City will also be notified before any questionable claim is accepted. E. The Member City will be notified within three (3) business days after knowledge that employee has been found permanent and stationary by the treating doctor. F. Telephone calls will be returned within one (1) business day. If the staff member called is not available within this time frame, another designated staff member will return the call. G. All written communications received shall be stamped with date of receipt. H. The examiner shall respond to all written communications within five (5) business days of receipt or sooner if an immediate response is required. 5. FILE DOCUMENTATION A. All files will have a “Plan of Action” identified, including time frames for completing activity. Progress on the plan of action will be documented, as well the reasons for any delays or modifications to the plan and include all information that relates to the direction and value of the case. An active case strategy will be documented in the file until closure. The plan of action shall be updated at each diary review. B. Delayed claims will clearly document the reasons for the delay, the information needed to determine compensability and the anticipated date of a final decision. In no case will the final decision be more than eighty-five (85) calendar days from the Member City’s date of knowledge. Cases will be diaried at least every fourteen (14) calendar days or sooner to monitor the investigation process. All delays in decision letters will be reviewed by the appropriate supervisor before mailing. 15 of 23 C. All denied claims will document the factual, medical, or legal basis for denial in accordance with State statutes. Denials will be made as soon as information is available that the claim should be denied. All denial letters will be reviewed by the appropriate supervisor before mailing. D. Notes and activities entered in the computer system must be dated and identify who completed. All action must be documented in the computer file notes. E. File notes shall not be copied from prior entries without reviewing for relevance and accuracy. F. All files will contain file contents as specified in the California Code of Regulations. 6. SUPERVISORY REVIEW A. Indemnity claims, excluding future medical claims, will be reviewed by the appropriate supervisor no less frequently than every 120 calendar days and at the following intervals: file creation, before cases are delayed and/or denied, when reserve increases exceed the examiner’s limit of authority, proposed settlements or payments exceed the examiner’s limit of authority, at AOE/COE and subrosa investigative referrals, at medical case management referrals, upon defense counsel referrals, fifteen (15) calendar days before mandatory settlement conferences and fifteen (15) calendar days before scheduled trials. Review by the supervisor, including recommended action, shall be documented. B. Future medical claims shall be reviewed by the supervisor at least every 180 calendar days. Review shall include the extent and appropriateness of medical treatment and the supervisor shall document their findings and recommendations. C. Supervisors shall review files to determine if present and prior plans of action are being implemented. D. Supervisors shall review all status reports, including adequacy of reserves, before forwarding to CIPA. Any outstanding issues should be identified by the supervisor and the status report corrected prior to forwarding to CIPA. 7. PAYMENTS & NOTICES A. Accurate and timely benefits will be paid to employees as required by State statutes. B. All medical, legal, rehabilitation, investigation and other service provider invoices will be reviewed before payment for causal relationship to injury and whether services billed are for services requested. Invoices will be paid according to State allowable rates, appropriateness, compliance with any agreements in place with the facility, or as agreed to when service was requested. Vendors providing service at an excessive rate, or billing for services that are not requested or required will be notified of the amount and reason for their reduction in payment. Member Cities shall be notified of any provider who continues to bill unreasonably for services. C. Reimbursements to injured workers shall be issued within fifteen (15) calendar days of the receipt of the claim for reimbursement. D. Advance travel expenses shall be issued to the injured worker no less than ten (10) calendar days prior to the date of travel. E. Indemnity files shall be balanced at least every 180 calendar days to reconcile periods and amounts due compared to actual payments. File notes shall contain the reconciliation. F. Penalties shall be coded to be identified as a penalty payment. G. Annual proof of life confirmation shall be obtained from claimants receiving life pensions. 16 of 23 H. Accurate and timely Benefit Notices will be sent in accordance with the California Code of Regulations. 8. INVESTIGATIONS A. Investigations shall be initiated within three (3) business days after a claim is delayed. This may include, but not be limited to, taking employee/witness statements, obtaining services of investigator, requesting medical records and beginning medical evaluation process. B. On questionable indemnity claims, investigative assignments will be made to outside vendors with prior authorization from Member City. Referrals will include specific written instructions regarding the scope of the investigation. C. Where medical causation is unclear, a qualified medical examination (QME) or agreed medical examination (AME) will be scheduled. All relevant medical records and investigative information will be provided to the physician for review before the date of examination. D. An Index Bureau and Edex Request will be submitted on all new claims. Thereafter, on claims not finalized, requests will be submitted at least annually or at appropriate intervals if the possibility of other injuries is suspected, and when requested by Member City. E. Investigators will be selected from a panel approved by Member City. The examiner shall evaluate and monitor the panel’s performance. All concerns or recommendations for panel additions/deletions will be discussed with Member City. F. Copies of voluminous medical records by subpoena or copy service will not be obtained unless necessary to the defense of the claim. The examiner will first attempt to obtain copies through plaintiffs’ attorney by seeking their cooperation in providing the desired records. 9. MEDICAL MANAGEMENT & COST CONTAINMENT A. Employees who have not pre-designated a personal physician will be directed to panel medical providers. Panel medical providers will be selected and approved by Member City. The examiner shall evaluate and monitor the panel’s performance. All concerns or recommendations for panel additions/deletions will be discussed with Member City. B. Medical treatment will be monitored to ensure that treatment is appropriate and related to the compensable injury or illness. Inappropriate medical reports will be objected to timely. C. Independent medical examinations by qualified physicians will be scheduled when needed to address necessity or reasonableness of care. A cover letter will be provided to the physician outlining the specific issues and concerns along with the examiner's questions. All medical records shall be sent to the physician prior to the examination. D. Pre-existing medical conditions and medical records will be explored/obtained on lost time claims and as requested by Member City. E. Treatment recommendations for care such as physical therapy, chiropractic manipulations, etc., will be verified with the physician as to duration, frequency, and anticipated results. F. Written authorization must be obtained from CIPA in advance and in writing from CIPA for the selection of an Agreed Medical Examiner (AME) on claims reportable to CIPA. Written authorization must be obtained before any agreement is reached with the applicant’s attorney. G. Claims referred for outside medical management services will reflect the intent and scope of services requested and must be authorized on a case-by-case basis by Member City. The Member City will approve medical management firms and all other review firms. H. On future medical claims, yearly medical reports will be obtained if the employee continues to receive medical treatment. 17 of 23 I. Medical bills submitted without a supporting medical report will not be paid until a medical report is obtained. Medical bills will be paid/denied/objected to in accordance with State statutes and paid in accordance with the fee schedule or negotiated rate. J. Medical-legal costs will be reviewed for appropriateness and necessity. Bills which do not qualify as valid medical-legal expenses will be objected to on a timely basis according to the Labor Code. 10. RETURN TO WORK A. The Member City shall be notified immediately of an injured employee’s temporary work restrictions or release to full duty and assist in returning the employee to work. Follow-up with the Member City shall take place no less than fourteen (14) calendar days after initial notice to the Member City. B. The Member City shall be notified immediately of an employee’s permanent work restrictions so that the Member City can determine the availability of alternative, modified or regular work. Follow-up with the Member City shall take place no less than fourteen (14) calendar days after initial notice to the Member City. 11. SUPPLEMENTAL JOB DISPLACEMENT/REHABILITATION MANAGEMENT A. For injuries on or after January 1, 2004, the examiner shall coordinate with Member City to offer modified or alternate work within ten (10) calendar days of the last payment of temporary disability. B. For injuries on or after January 1, 2004, employees not returning to work shall be provided a supplemental job displacement benefit in accordance with regulations, including the issuance of timely notices. 12. ALLOCATION OF CLAIM COSTS TO APPROPRIATE FILE A. For all injuries resulting in the need for permanent disability and/or future medical care where the injured worker has a prior claim to the same body part, the examiner shall obtain a medical opinion addressing allocation and payment of future benefits. The medical opinion is to determine the specific allocation for permanent disability and a separate allocation for future medical care related to the industrial injuries. The percentage allocated to indemnity and future medical care benefits will not be assumed to be the same. B. Payments and reserves will not be lumped on one claim when a claimant has multiple claims, including continuous trauma claims. Files will accurately reflect the payments and reserves related to the exposure on each separate claim. 13. LITIGATION MANAGEMENT A. The examiner shall retain primary responsibility on all claims referred to defense counsel. Defense counsel will not be used to perform routine activities that should be the responsibility of the examiner. Some examples of routine tasks include, but are not limited to, setting medical examinations, preparing medical cover letters, filing and serving medical reports, negotiating liens, and arranging for photocopying, investigators or other outside vendors. Exceptions will be approved by the Member City. B. Legal counsel will be selected from a panel approved by the Member City. The examiner shall evaluate and monitor the panel’s performance. Legal counsel will be reviewed for their ability to identify issues, aggressiveness in resolving claims, responsiveness, timeliness, and billing practices. All concerns or recommendations for panel additions/deletions will be discussed with the Member City. 18 of 23 C. Claims sent to defense counsel will be accompanied by a transmittal letter outlining the status of the case, result of investigation, primary issues, requested action, and a copy of any pertinent documentation. Ongoing documentation will be sent timely to defense counsel. D. At the close of discovery on cases going to trial, the file shall be adequately prepared to include necessary depositions, medical examinations and witness identification and contact information. E. When copies of medical reports or other records are required by defense counsel, the examiner shall make copies and provide to defense counsel. All invoices for photocopying will be closely monitored to assure compliance with this requirement. F. If defense counsel or the examiner learns of new information that could influence the outcome of the trial, they must immediately inform each other. The strategy to resolve the claim will then be assessed. G. The examiner is responsible for monitoring compliance with CIPA’s Workers’ Compensation Program Defense Counsel Policy. CIPA Members, and CIPA if applicable, shall be copied on follow-up requests to defense counsel when out of compliance. All claims examiners are responsible for being fully knowledgeable of requirements in the Workers’ Compensation Program Defense Counsel Policy. 14. CLAIM RESOLUTION & SETTLEMENT AUTHORITY A. Action shall be taken within fifteen (15) calendar days to finalize a claim upon receipt of medical information that a claim can be finalized. Continued follow-up shall occur, including with legal counsel to facilitate a settlement. The file shall document all efforts and communications regarding a settlement. B. Claim files shall fully document the value of any anticipated or proposed settlement. Settlement worksheets shall be prepared and submitted to Member City, and to CIPA if indicated, for approval on all settlements as required. Overpayments shall be identified on any settlement request. C. All settlement offers requiring any payment or potential payment from CIPA must be approved in writing in advance by CIPA. Neither the examiner or legal counsel shall make any recommendations or commitments to injured employees or their legal counsel for settlements that involve or potentially involve CIPA funds, without CIPA’s prior approval. D. Proof of settlement authorization from the Member City, and CIPA if applicable, shall be maintained in the file. E. A copy of all settlement documents on reportable claims shall be sent to CIPA within fifteen (15) calendar days of receipt by examiner. 15. SUBROGATION A. Subrogation possibilities will be identified within five (5) business days after a claim is opened, or within five (5) business days after information is available that subrogation may exist. The claim file shall document subrogation possibilities and all action related to pursuing. B. The party responsible for the injury shall be notified of the Member City’s right to subrogation within fourteen (14) calendar days after the identity of the responsible party is known by examiner. C. Contact with the responsible party and/or insurer to provide notification of the amount of estimated recovery shall be made at least every sixty (60) calendar days or sooner if costs escalate. Subrogation shall be pursued to maximize the recovery for benefits paid and credit for future benefit payments. 19 of 23 D. The Member City shall be notified within fifteen (15) calendar days after the examiner’s knowledge that injured employee filed a civil action against the responsible party. Subrogation counsel shall be assigned to file a Lien or Complaint in Intervention to the civil action, if authorized by Member City. All discussions and actions regarding subrogation shall be documented in the file. E. Member City approval is required to waive pursuit of subrogation or agree to a settlement of a third-party recovery. This approval shall be documented in the claim file. F. CIPA’s approval is required to waive pursuit of subrogation or agree to a third-party settlement if there is potential for the claim to exceed the Member City’s self-insured retention. 16. RESERVING A. Reserves established on indemnity claims, including future medical claims, will reflect the ultimate probable cost of each claim based on the information developed to date. Reserve worksheets will be used to document all reserve changes and reflect amounts allocated to temporary disability, 4850 benefits, permanent disability, life pension, vocational rehabilitation, medical care and allocated expense. The injured workers’ disability, age and occupation will be considered in estimating permanent disability. B. Reserves will be evaluated at each diary review and modified upon receipt of new information. Files shall document rationale for reserves. 17. EXCESS INSURANCE REPORTING A. The examiner shall report to the excess insurance carrier(s), including CIPA, in accordance with established procedures. B. CIPA’s Excess Claims Status Report shall be used for all initial, periodic and final reports. All portions of the report shall be completed and include the information requested. Supervisors must review for completeness and accuracy of reports. C. As defined by CIPA’s Memorandum of Coverage, as may be modified from time to time, the following claims are reportable to CIPA within five (5) business days after receipt by examiner: 1. A serious injury to two or more employees 2. Paraplegic 3. Quadriplegic 4. Brain Injury 5. Serious burns 6. Loss of vision 7. Death 8. Amputation of a major extremity D. Initial Excess Claim Status Reports are due within ten (10) business days after the total incurred is 50% or more of the Member City’s self-insured retention. E. Excess Claim Status Reports on reportable claims are due to CIPA no less frequently than as follows, and sooner if claims activity warrants: 1. Every three (3) months on claims not finalized by settlement or award 2. Semi-annually on claims finalized by settlement or award 3. Within fifteen (15) calendar days of the total incurred increasing/decreasing by 25% or more 20 of 23 4. Within thirty (30) calendar days of a reportable claim being closed 5. Within thirty (30) calendar days of no longer meeting the reporting requirements (for example, reserves less than 50% of the Member City’s SIR) 6. Within ten (10) calendar days of receipt of a New & Further filing 7. As requested by Member City or CIPA 18. MEDICARE REPORTING A. The examiner shall report all claims in compliance with Medicare, Medicaid and SCHIP Extension Act (MMSEA) Section 111 Mandatory reporting. B. Medicare eligibility shall be documented in the file no later than at the time the file is evaluated for settlement. Claims adjusters may approve the following Request(s) for Authorization (RFAs). All RFAs outside of the authorization criteria listed below must be referred to and processed by Utilization Review. Please note: Only a Physician may modify or deny RFA(s). Claim Adjusters should adhere to the MTUS Treatment Guidelines. These guidelines are located in L-Drive (UR Education for Claims > Guideline Folder). Treatment Requests - first 30 days of injury or illness Treatment Request Claims Adjuster Authorization Criteria Per Labor Code 4610 (c) First 30 days of injury or illness (Starts January 1, 2018) Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services shall be subject to prospective utilization review: x Pharmaceuticals that are non-exempt in the drug formulary x Nonemergency inpatient and outpatient surgeries, including all pre-surgical and post-surgical services x Psychological treatment services x Home health care services x Imaging and radiology services excluding x-rays x All DME that exceeds $250 x Electrodiagnostic testing Treatment Requests - after 30 days of injury or illness Treatment Request Claims Adjuster Authorization Criteria Physical Methods: x Occupational therapy x Physical therapy x Chiropractic treatment x Acupuncture May have 24 visits for the life of the claim. Initial request – up to 4-6 visits. Additional requests (sets of 4-6 visits) may be approved if provider documents functional improvement. Office Visits: x Initial evaluation x Consultation x Second opinion x Transfer of care x Office visits May be approved by the claims adjuster. Send the RFA to UR when questioning whether or not the consultation, second opinion, or transfer of care is medically necessary. Utilization Review – Claims Adjuster Authorization Criteria (;+,%,7$ Injections: x Steroid Injections are recommended based on body part accepted and injury/illness. Initial steroid injections for diagnostic and pain management can be approved by claims adjuster. Additional requests should be processed by Utilization Review. Not recommended for therapeutic use. Injections: x ESI x Facet x Hyaluronic x PRP x SI joint Injections are recommended based on body part and injury and must meet criteria outlined in the MTUS Treatment Guidelines. Surgery All surgery requests must be processed by Utilization Review. Pre-operative Testing/ Pre-operative Medical Clearance Upon approval of surgery, claims adjuster may approve the following requests: CBC, CMP, PT/PTT, EKG and Chest X- Ray. Radiology/Diagnostic: x X-rays x CT-scans x MRI x EMG/NCV May be approved by the claims adjuster. See above for directions for the time period “first 30 days.” Home Health Care The claims adjuster may approve home health care up to 7 days. All requests for home health care greater than 7 days must be processed by Utilization Review. Weight Loss/Gym Membership Weight loss and gym membership will be reviewed on a case-by-case basis to determine the necessity for utilization review. Transportation The claims adjuster may approve transportation when appropriate. Medication: x Per MTUS Formulary x Adhere to MTUS treatment guidelines for injury/illness x FDA approved x Generic drug Situation NO UR Yes UR Ongoing drugs Exempt Non-Exempt Off-label drugs Exempt Non-Exempt Brand-name drugs Brand-name drugs Physician-dispensed drugs First 7 days of injury, Exempt/Non-Exempt drugs, 4-day supply After first 7 days of injury, all medications Exempt/Non-Exempt Compound drugs Compound Special fill drugs First 7 days of injury, Exempt/Non-Exempt, 4-day supply Peri-operative fill drugs Exempt/Non-Exempt 4 days before/4 days after surgery 4-day supply Health and safety post-exposure prophylaxis (PEP) Responsibility of the employer to provide urgent PEP after an exposure to bloodborne pathogens Detox Programs All requests for detox programs will be processed by Utilization Review. Psychiatric Requests for psychiatric/neuro-psych or counseling may be approved by the claims adjuster. Cancer Treatment All specialized cancer treatment/therapy will require utilization review. Durable Medical Equipment Claims adjuster may approve all DME purchases and/or rentals. See above for directions for the time period “first 30 days.” 1 of 9 ADDENDUM I CALIFORNIA INSURANCE POOL AUTHORITY MINIMUM PERFORMANCE STANDARDS FOR WORKERS’ COMPENSATION CLAIMS ADMINISTRATION POLICY Member Agencies shall either incorporate these minimum performance standards into signed agreements with their claims administrator or obtain signed acknowledgement from their claims administrator that they will comply with the Minimum Performance Standards established by California Insurance Pool Authority (CIPA). Copies of the agreements or signed acknowledgments shall be provided to CIPA. Claims will be audited for conformance with this Policy. The most stringent requirements shall apply if there is any conflict between these standards and the Labor Code or Code of Regulations. This Policy is divided into the following sections: 1. CASELOADS 2. INITIAL FILE SET-UP AND THREE-POINT CONTACT 3. CASE REVIEW 4. COMMUNICATION 5. FILE DOCUMENTATION 6. SUPERVISORY REVIEW 7. PAYMENTS & NOTICES 8. INVESTIGATIONS 9. MEDICAL MANAGEMENT & COST CONTAINMENT 10. RETURN TO WORK 11. SUPPLEMENTAL JOB DISPLACEMENT/REHABILITATION MANAGEMENT 12. ALLOCATION OF CLAIM COSTS TO APPROPRIATE FILE 13. LITIGATION MANAGEMENT 14. CLAIM RESOLUTION & SETTLEMENT AUTHORITY 15. SUBROGATION 16. RESERVING 17. EXCESS INSURANCE REPORTING 18. MEDICARE REPORTING 2 of 9 1. CASELOADS A. Caseloads for examiners shall not exceed 150, unless approved in writing by the Member Agency. Caseloads that include future medical and medical only claims shall count these claims as 2:1 in the caseload limit. B. Administrator shall provide CIPA and Member Agency with an accounting of caseloads each June 30 and December 31. The accounting for each examiner shall include (1) the name or pseudo name of all assigned clients; and (2) the number of claims, by claim type for each client. Each examiner shall sign acknowledgement of their claims count and provide to CIPA and Member Agency. C. Supervisory personnel shall not handle a caseload. Exceptions may be made for a small number of claims involving special issues. 2. INITIAL FILE SET-UP AND THREE-POINT CONTACT A. Claims will be created and entered in the computer within one business day of receipt of the Form 5020. B. All Employers’ Reports of Occupational Injury or Illness, or notification of a new claim from any other source, will be reviewed for compensability and a decision made to accept, delay or deny within seven (7) calendar days of receipt, or sooner if a delay in payment or notice will result. C. Employees will be contacted by telephone or in person within one (1) business day of receipt of a claim by the claims administrator unless the employee is represented by an attorney. During this initial contact, employees will be provided with an explanation of their benefits and will be asked whether they have any questions or concerns, which shall be addressed immediately. A benefits pamphlet will be sent to the employee notifying them of their rights under workers’ compensation laws of California. The claims examiner shall contact the employer for assistance if unable to contact the employee. All contact and attempts to contact employee and employer shall be documented in the file. D. The Member Agency will be contacted within two (2) business days of receipt of a claim to verify continuing disability, clarify issues and request additional required information. Contact will be made sooner if delay will result in a late payment or a penalty situation. E. The employee’s treating doctor will be contacted within two (2) business days of receipt of claim to verify duration of disability, compensability, proposed treatment, clarify issues and request additional information. Contact will be made sooner if a delay will result in a late payment or penalty situation. Thereafter, until the employee returns to work, the examiner shall maintain contact at least every thirty (30) calendar days with the attending physician, obtain medical reports, monitor medical treatment, and facilitating an early return to work. 3. CASE REVIEW A. Lost-time claims, except for future medical claims, shall be reviewed on diary by the assigned examiner no less than every sixty (60) calendar days or more frequently when needed. B. In cases where claims investigations are being conducted, claims will be placed on diary no less than every fourteen (14) calendar days by the assigned examiner until all outstanding issues have been resolved. 3 of 9 C. Medical only claims will be reviewed no less than every 120 calendar days for possible closure. They will be transferred to an indemnity claim when disability is due, compensability is an issue, they are over 120 calendar days old or medical payments (excluding diagnostic expenses) exceed $1,500. D. Future medical claims will be reviewed on diary at least every ninety (90) calendar days. The extent and appropriateness of medical treatment shall be evaluated and documented in the notepad entries. E. All files shall be reviewed for closure and closed within thirty (30) calendar days from the date all issues have been resolved. 4. COMMUNICATION A. The injured or ill employee will be contacted at least every two (2) weeks while they are disabled from working unless they are represented by an attorney, or their claim has been finalized. B. Employer contact is required to verify continuing disability and explore the availability of modified or light duty work before processing disability payments. C. The employee will be called before sending notification of permanent disability and PQME letter, to explain the process and answer the employee’s questions. D. The Member Agency will be notified of any claim being delayed or denied before a Notice is sent to the employee. The Member Agency will also be notified before any questionable claim is accepted. E. The Member Agency will be notified within three (3) business days after knowledge that employee has been found permanent and stationary by the treating doctor. F. Telephone calls will be returned within one (1) business day. If the staff member called is not available within this time frame, another designated staff member will return the call. G. All written communications received shall be stamped with date of receipt. H. The examiner shall respond to all written communications within five (5) business days of receipt or sooner if an immediate response is required. 5. FILE DOCUMENTATION A. All files will have a “Plan of Action” identified, including time frames for completing activity. Progress on the plan of action will be documented, as well the reasons for any delays or modifications to the plan and include all information that relates to the direction and value of the case. An active case strategy will be documented in the file until closure. The plan of action shall be updated at each diary review. B. Delayed claims will clearly document the reasons for the delay, the information needed to determine compensability and the anticipated date of a final decision. In no case will the final decision be more than eighty-five (85) calendar days from the Member Agency’s date of knowledge. Cases will be diaried at least every fourteen (14) calendar days or sooner to monitor the investigation process. All delays in decision letters will be reviewed by the appropriate supervisor before mailing. C. All denied claims will document the factual, medical, or legal basis for denial in accordance with State statutes. Denials will be made as soon as information is available 4 of 9 that the claim should be denied. All denial letters will be reviewed by the appropriate supervisor before mailing. D. Notes and activities entered in the computer system must be dated and identify who completed. All action must be documented in the computer file notes. E. File notes shall not be copied from prior entries without reviewing for relevance and accuracy. F. All files will contain file contents as specified in the California Code of Regulations. 6. SUPERVISORY REVIEW A. Indemnity claims, excluding future medical claims, will be reviewed by the appropriate supervisor no less frequently than every 120 calendar days and at the following intervals: file creation, before cases are delayed and/or denied, when reserve increases exceed the examiner’s limit of authority, proposed settlements or payments exceed the examiner’s limit of authority, at AOE/COE and subrosa investigative referrals, at medical case management referrals, upon defense counsel referrals, fifteen (15) calendar days before mandatory settlement conferences and fifteen (15) calendar days before scheduled trials. Review by the supervisor, including recommended action, shall be documented. B. Future medical claims shall be reviewed by the supervisor at least every 180 calendar days. Review shall include the extent and appropriateness of medical treatment and the supervisor shall document their findings and recommendations. C. Supervisors shall review files to determine if present and prior plans of action are being implemented. D. Supervisors shall review all status report, including adequacy of reserves before forwarding to CIPA. Any outstanding issues should be identified by the supervisor and the status report corrected prior to forwarding to CIPA. 7. PAYMENTS & NOTICES A. Accurate and timely benefits will be paid to employees as required by State statutes. B. All medical, legal, rehabilitation, investigation and other service provider invoices will be reviewed before payment for causal relationship to injury and whether services billed are for services requested. Invoices will be paid according to State allowable rates, appropriateness, compliance with any agreements in place with the facility, or as agreed to when service was requested. Vendors providing service at an excessive rate, or billing for services that are not requested or required will be notified of the amount and reason for their reduction in payment. Member Cities shall be notified of any provider who continues to bill unreasonably for services. C. Reimbursements to injured workers shall be issued within fifteen (15) calendar days of the receipt of the claim for reimbursement. D. Advance travel expenses shall be issued to the injured worker no less than ten (10) calendar days prior to the date of travel. E. Indemnity files shall be balanced when benefits are ended to reconcile periods and amounts due compared to actual payments. File notes shall contain the reconciliation. F. Penalties shall be coded to be identified as a penalty payment. 5 of 9 G. Annual proof of life confirmation shall be obtained from claimants receiving life pensions. H. Accurate and timely Benefit Notices will be sent in accordance with the California Code of Regulations. 8. INVESTIGATIONS A. Investigations shall be initiated within seven (7) business days after a claim is delayed. This may include, but not be limited to, taking employee/witness statements, obtaining services of investigator, requesting medical records, and beginning medical evaluation process. B. On questionable indemnity claims, investigative assignments will be made to outside vendors with prior authorization from Member Agency. Referrals will include specific written instructions regarding the scope of the investigation. C. Where medical causation is unclear, a qualified medical examination (QME) or agreed medical examination (AME) will be scheduled. All relevant medical records and investigative information will be provided to the physician for review before the date of examination. D. An Index Bureau and Edex Request will be submitted on all new indemnity claims. Thereafter, on claims not finalized, requests will be submitted at appropriate intervals if the possibility of other injuries is suspected, and when requested by Member Agency. E. Investigators will be selected from a panel approved by Member Agency. The examiner shall evaluate and monitor the panel’s performance. All concerns or recommendations for panel additions/deletions will be discussed with Member Agency. F. Copies of voluminous medical records by subpoena or copy service will not be obtained unless necessary to the defense of the claim. The examiner will first attempt to obtain copies through plaintiffs’ attorney by seeking their cooperation in providing the desired records. 9. MEDICAL MANAGEMENT & COST CONTAINMENT A. Employees who have not pre-designated a personal physician will be directed to panel medical providers. Panel medical providers will be selected and approved by Member Agency. The examiner shall evaluate and monitor the panel’s performance. All concerns or recommendations for panel additions/deletions will be discussed with Member Agency. B. Medical treatment will be monitored to ensure that treatment is appropriate and related to the compensable injury or illness. Inappropriate medical reports will be objected to timely. C. Independent medical examinations by qualified physicians will be scheduled when needed to address necessity or reasonableness of care. A cover letter will be provided to the physician outlining the specific issues and concerns along with the examiner's questions. All medical records shall be sent to the physician prior to the examination. D. Pre-existing medical conditions and medical records will be explored/obtained on lost time claims and as requested by Member Agency. E. Treatment recommendations for care such as physical therapy, chiropractic manipulations, etc., will be verified with the physician as to duration, frequency, and anticipated results. 6 of 9 F. Authorization must be obtained in advance and in writing from CIPA for the selection of an Agreed Medical Examiner (AME) on claims reportable to CIPA. Written authorization must be obtained before any agreement is reached with the applicant’s attorney. G. Claims referred for outside medical management services will reflect the intent and scope of services requested and must be authorized on a case-by-case basis by Member Agency. The Member Agency will approve medical management firms and all other review firms. H. On future medical claims, yearly medical reports will be obtained if the employee continues to receive medical treatment. I. Medical bills submitted without a supporting medical report will not be paid until a medical report is obtained. Medical bills will be paid/denied/objected to in accordance with State statutes and paid in accordance with the fee schedule or negotiated rate. J. Medical-legal costs will be reviewed for appropriateness and necessity. Bills which do not qualify as valid medical-legal expenses will be objected to on a timely basis according to the Labor Code. 10. RETURN TO WORK A. The Member Agency shall be notified immediately of an injured employee’s temporary work restrictions or release to full duty and assist in returning the employee to work. Follow-up with the Member Agency shall take place no less than fourteen (14) calendar days after initial notice to the Member Agency. B. The Member Agency shall be notified immediately of an employee’s permanent work restrictions so that the Member Agency can determine the availability of alternative, modified or regular work. Follow-up with the Member Agency shall take place no less than fourteen (14) calendar days after initial notice to the Member Agency. 11. SUPPLEMENTAL JOB DISPLACEMENT/REHABILITATION MANAGEMENT A. For injuries on or after January 1, 2004, the examiner shall coordinate with Member Agency to offer modified or alternate work within ten (10) calendar days of the last payment of temporary disability. B. For injuries on or after January 1, 2004, employees not returning to work shall be provided a supplemental job displacement benefit in accordance with regulations, including the issuance of timely notices. 12. ALLOCATION OF CLAIM COSTS TO APPROPRIATE FILE A. For all injuries resulting in the need for permanent disability and/or future medical care where the injured worker has a prior claim to the same body part, the examiner shall obtain a medical opinion addressing allocation and payment of future benefits. The medical opinion is to determine the specific allocation for permanent disability and a separate allocation for future medical care related to the industrial injuries. The percentage allocated to indemnity and future medical care benefits will not be assumed to be the same. B. Payments and reserves will not be lumped on one claim when a claimant has multiple claims, including continuous trauma claims. Files will accurately reflect the payments and reserves related to the exposure on each separate claim. 7 of 9 13. LITIGATION MANAGEMENT A. The examiner shall retain primary responsibility on all claims referred to defense counsel. Defense counsel will not be used to perform routine activities that should be the responsibility of the examiner. Some examples of routine tasks include, but are not limited to, setting medical examinations, preparing medical cover letters, filing, and serving medical reports, negotiating liens, and arranging for photocopying, investigators, or other outside vendors. Exceptions will be approved by the Member Agency. B. Legal counsel will be selected from a panel approved by the Member Agency. The examiner shall evaluate and monitor the panel’s performance. Legal counsel will be reviewed for their ability to identify issues, aggressiveness in resolving claims, responsiveness, timeliness, and billing practices. All concerns or recommendations for panel additions/deletions will be discussed with the Member Agency. C. Claims sent to defense counsel will be accompanied by a transmittal letter outlining the status of the case, result of investigation, primary issues, requested action, and a copy of any pertinent documentation. Ongoing documentation will be sent timely to defense counsel. D. At the close of discovery on cases going to trial, the file shall be adequately prepared to include necessary depositions, medical examinations and witness identification and contact information. E. When copies of medical reports or other records are required by defense counsel, the examiner shall make copies and provide to defense counsel. All invoices for photocopying will be closely monitored to assure compliance with this requirement. F. If defense counsel or the examiner learns of new information that could influence the outcome of the trial, they must immediately inform each other. The strategy to resolve the claim will then be assessed. G. The examiner is responsible for monitoring compliance with CIPA’s Workers’ Compensation Program Defense Counsel Policy. CIPA Members, and CIPA if applicable, shall be copied on follow-up requests to defense counsel when out of compliance. All claims examiners are responsible for being fully knowledgeable of the requirements in the Workers’ Compensation Program Defense Counsel Policy 14. CLAIM RESOLUTION & SETTLEMENT AUTHORITY A. Action shall be taken within thirty (30) calendar days to finalize a claim upon receipt of medical information that a claim can be finalized and every forty-five (45) days thereafter until settled. Continued follow-up shall occur, including with legal counsel to facilitate a settlement. The file shall document all efforts and communications regarding a settlement. B. Claim files shall fully document the value of any anticipated or proposed settlement. Settlement worksheets shall be prepared and submitted to Member Agency, and to CIPA if indicated, for approval on all settlements as required. Overpayments shall be identified on any settlement request. C. All settlement offers requiring any payment or potential payment from CIPA must be approved in writing in advance by CIPA. Neither the examiner or legal counsel shall make any recommendations or commitments to injured employees or their legal counsel for settlements that involve or potentially involve CIPA funds, without CIPA’s prior approval. 8 of 9 D. Proof of settlement authorization from the Member Agency, and CIPA if applicable, shall be maintained in the file. E. A copy of all settlement documents on reportable claims shall be sent to CIPA within fifteen (15) calendar days of receipt by examiner. 15. SUBROGATION A. Subrogation possibilities will be identified within five (5) business days after a claim is opened, or within five (5) business days after information is available that subrogation may exist. The claim file shall document subrogation possibilities and all action related to pursuing. B. The party responsible for the injury shall be notified of the Member Agency’s right to subrogation within fourteen (14) calendar days after the identity of the responsible party is known by examiner. C. Contact with the responsible party and/or insurer to provide notification of the amount of estimated recovery shall be made at least every ninety (90) calendar days or sooner if costs escalate. Subrogation shall be pursued to maximize the recovery for benefits paid and credit for future benefit payments. D. The Member Agency shall be notified within fifteen (15) calendar days after the examiner’s knowledge that injured employee filed a civil action against the responsible party. Subrogation counsel shall be assigned to file a Lien or Complaint in Intervention to the civil action, if authorized by Member Agency. All discussions and actions regarding subrogation shall be documented in the file. E. Member Agency approval is required to waive pursuit of subrogation or agree to a settlement of a third-party recovery. This approval shall be documented in the claim file. F. CIPA’s approval is required to waive pursuit of subrogation or agree to a third-party settlement if there is potential for the claim to exceed the Member Agency’s self-insured retention. 16. RESERVING A. Reserves established on indemnity claims, including future medical claims, will reflect the ultimate probable cost of each claim based on the information developed to date. Reserve worksheets will be used to document all reserve changes and reflect amounts allocated to temporary disability, 4850 benefits, permanent disability, life pension, vocational rehabilitation, medical care, and allocated expense. The injured workers’ disability, age and occupation will be considered in estimating permanent disability. B. Reserves will be evaluated at each diary review and modified upon receipt of new information. Files shall document rationale for reserves. 17. EXCESS INSURANCE REPORTING A. The examiner shall report to the excess insurance carrier(s), including CIPA, in accordance with established procedures. B. CIPA’s Excess Claims Status Report shall be used for all initial, periodic, and final reports. All portions of the report shall be completed and include the information requested. Supervisors must review for completeness and accuracy of reports. 9 of 9 C. As defined by CIPA’s Memorandum of Coverage, as may be modified from time to time, the following claims are reportable to CIPA within five (5) business days after receipt by examiner: 1) A serious injury to two or more employees 2) Paraplegic 3) Quadriplegic 4) Brain Injury 5) Serious burns 6) Loss of vision 7) Death 8) Amputation of a major extremity D. Initial Excess Claim Status Reports are due within ten (10) business days after the total incurred is 50% or more of the Member Agency’s self-insured retention. E. Excess Claim Status Reports on reportable claims are due to CIPA no less frequently than as follows, and sooner if claims activity warrants: 1) Every three (3) months on claims not finalized by settlement or award 2) Semi-annually on claims finalized by settlement or award 3) Within fifteen (15) calendar days of the total incurred increasing/decreasing by 25% or more 4) Within thirty (30) calendar days of a reportable claim being closed 5) Within thirty (30) calendar days of no longer meeting the reporting requirements (for example, reserves less than 50% of the Member Agency’s SIR) 6) Within ten (10) calendar days of receipt of a New & Further filing 7) As requested by Member Agency or CIPA 18. MEDICARE REPORTING A. The examiner shall report all claims in compliance with Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 Mandatory reporting. B. Medicare eligibility shall be documented in the file no later than at the time the file is evaluated for settlement. Amended and Approved by the Executive Committee on September 21, 2021 Repeals June 29, 2020 Minimum Performance Standards for Workers’ Compensation Claims Administration EXHIBIT A CALIFORNIA INSURANCE POOL AUTHORITY WORKERS’ COMPENSATION ADJUSTER TREATMENT PROTOCOLS POLICY Member Agencies shall either incorporate this Workers’ Compensation Adjuster Treatment Protocols Policy and any revisions to the Policy into signed agreements with their claims administrator or obtain signed acknowledgement from their claims administrator that they will comply with this Policy established by California Insurance Pool Authority (CIPA). Copies of the agreements or signed acknowledgments shall be provided to CIPA. Claims will be audited for conformance with this Policy. Claims adjusters shall approve the following procedures: All Accepted Claims; Accepted Body Parts 1. Office Visits; 2. Specialist Referrals; 3. Non-Narcotic Medications $250 or less; 4. MRI; 5. CT Scan; 6. X-rays; 7. EMG/NCS; 8. Ultrasound; 9. Physical Therapy - up to 16 sessions; 10. Occupational Therapy - up to 16 sessions; 11. Acupuncture - up to 16 sessions; 12. Chiropractic - up to 16 sessions; 13. Aquatic Therapy - up to 16 sessions; 14. Transfer of care - on approved body parts; 15. Corticosteroid Injections; 16. Durable Medical Equipment - $2,500 or less; 17. Hearing Aid Replacements; 18. Complete Blood Count (CBC); 19. Basic Metabolic Panel (BMP); 20. Urinary Analysis (UA); 21. Electrocardiogram (ECG or EKG) - only if heart claim; and 22. Partial Thromboplastin (PTT or aPTT) Future Medical Claims 1. All 22 procedures listed above; and 2. Ongoing medications of $250 will be reviewed every six months from the date of last Utilization Review certification. Approved by the Executive Committee on September 21, 2021 SECOND AMENDMENT TO AGREEMENT FOR CLAIMS ADMINISTRATION SERVICES This Second Amendment is entered into effective July 1, 2023 as an amendment to the Agreement for Claims Administration Services dated July 1, 2020, by and between the CALIFORNIA INSURANCE POOL AUTHORITY (“CIPA”), a California public joint powers authority, on behalf of the CITIES OF ARCADIA, BUENA PARK, CYPRESS, IRVINE, LAGUNA BEACH, MONTCLAIR, ORANGE, TUSTIN AND YORBA LINDA (“Member Cities or Member City”) and AdminSure, Inc. (“Administrator”), having an office at 3380 Shelby Street, Ontario, California. The terms and conditions of the Agreement and the First Amendment shall remain in full force and effect, except as otherwise set forth in this Second Amendment. IT IS HEREBY AGREED AS FOLLOWS: The first paragraph of Article 3. Duration is deleted and replaced with the following: This Agreement applies to all work performed by Administrator which is described in Article 4, whether performed in anticipation of or following the execution of this Agreement. The initial term shall begin on July 1, 2020 and shall expire June 30, 2025, for all Member Cities. Subsequent annual terms from July 1, to June 30, may be mutually agreed upon between the parties. In witness whereof the parties hereto have signed this Agreement as of October 1, 2021. CIPA: California Insurance Pool Authority _______________________________ Authorized Signature _______________________________ Print Name _______________________________ Title _______________________________ Date ADMINISTRATOR: AdminSure, Inc. ______________________________ Authorized Signature _______________________________ Print Name _______________________________ Title _______________________________ Date