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HomeMy WebLinkAboutItem 11h - Workers' Compensation Third-Party Claims Administration Services
DATE: April 15, 2025
TO: Honorable Mayor and City Council
FROM: Anely Williams, Human Resources Director
SUBJECT: AGREEMENT WITH ADMINSURE, INC. FOR WORKERS’
COMPENSATION THIRD-PARTY CLAIMS ADMINISTRATION
SERVICES IN THE AMOUNT OF $582,312 FOR A FIVE-YEAR PERIOD,
FROM JULY 1, 2025, THROUGH JUNE 30, 2030
CEQA: Not a Project
Recommendation: Approve
SUMMARY
On July 18, 2023, the City Council approved a two-year extension to the current
Agreement with AdminSure, Inc. (“AdminSure”) for third-party Workers’ Compensation
Claims Administration Services. With the current Agreement coming to an end, the City’s
risk pool, California Insurance Pool Authority (“CIPA”), renegotiated the new Agreement
on behalf of the City of Arcadia and all other participating member cities. The proposed
Agreement includes a 3% fee escalator, effective July 1 of each year, which is the same
escalator that is included in the existing Agreement. To ensure continuity of service, and
based on competitive pricing and excellent services provided, it is recommended that the
City Council approve, authorize, and direct the City Manager to execute a five-year
Agreement with AdminSure for Workers’ Compensation Third-Party Claims
Administration Services, from July 1, 2025, through June 30, 2030, in the amount of
$582,312, as follows:
• Fiscal Year 2025-26: $109,680
• Fiscal Year 2026-27: $112,968
• Fiscal Year 2027-28: $116,364
• Fiscal Year 2028-29: $119,856
• Fiscal Year 2029-30: $123,444
BACKGROUND
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
Agreement with AdminSure for Workers’ Compensation
Third-Party Claims Administration Services
April 15, 2025
Page 2 of 3
operations of the City’s claims. AdminSure has provided TPA services for the City’s
Workers’ Compensation program since 1985.
However, to ensure the continuation of competitive pricing, CIPA issued a Request for
Proposals (“RFP”) for Workers’ Compensation and Medical Management Services in
2020. Only two companies responded to the RFP. Of the two companies, AdminSure met
all the contractual metrics required by CIPA, including indemnity requirements for all
member cities, while also offering a fee structure that was considerably less than that of
the second company.
DISCUSSION
The City’s current Agreement with AdminSure is set to expire on June 30, 2025. Over the
years, AdminSure has continued to show a strong commitment to the service provided to
the City. AdminSure continuously evaluates the needs of its clients by taking into account
the expressed areas of focus for each member agency, thus, providing a customized
approach where feasible. AdminSure has demonstrated expertise with quick response
times and an overall high level of service.
The services provided by AdminSure will continue to include 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 all reporting
requirements mandated by Medicare and Medicaid. Additionally, AdminSure provides
electronic access to their program database to review open and closed claims and
reserves.
The proposed Agreement will end on June 30, 2030, when it can be renewed,
renegotiated, or re-bid. However, if the City desires to terminate the Agreement at any
time, the City may do so by providing 60 days’ notice to AdminSure. A copy of the
proposed Agreement is attached.
In consideration of the excellent service provided by AdminSure and the favorable
Agreement, which maintains an existing 3% annual escalator, it is recommended that the
City Council approve, authorize, and direct the City Manager to execute a five-year
Agreement with AdminSure for Workers’ Compensation Third-Party Claims
Administration Services, from July 1, 2025, through June 30, 2030, in the amount of
$582,312.
Agreement with AdminSure for Workers’ Compensation
Third-Party Claims Administration Services
April 15, 2025
Page 3 of 3
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.
FISCAL IMPACT
Adequate funding has been allocated in the upcoming Fiscal Year 2025-26 budget to
support the Workers’ Compensation Third-Party Claims Administration Services. Costs
associated with these services for subsequent Fiscal Years will be addressed during the
respective year’s budget adoption process. Based on the 3% escalator, the agreement
will have the following annual costs:
• Fiscal Year 2025-26: $109,680
• Fiscal Year 2026-27: $112,968
• Fiscal Year 2027-28: $116,364
• Fiscal Year 2028-29: $119,856
• Fiscal Year 2029-30: $123,444
The total cost over five years will not exceed $582,312.
RECOMMENDATION
It is recommended that the City Council determine that this action does not constitute a
project under the California Environmental Quality Act (“CEQA”); and approve, authorize,
and direct the City Manager to execute an agreement with AdminSure, Inc. for Workers’
Compensation Third-Party Claims Administration Services in the amount of $582,312 for
a five-year period, from July 1, 2025, through June 30, 2030.
Attachment: Proposed Agreement
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AGREEMENT FOR
CLAIMS ADMINISTRATION SERVICES
Article 1. GENERAL
This Agreement is entered into on July 1, 2025 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”).
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, 2025 and shall expire June 30, 2030.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.
Article 4. ADMINISTRATOR SERVICES
Administrator will provide Member Cities the following services:
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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.
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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 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:
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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 $10.00, 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 $105.00 flat fee per review/decision with a 3% increase in each
subsequent year. Examiners will perform Utilization Review in accordance with CIPA’s Workers’
Compensation Treatment Protocols Policy unless otherwise directed by CIPA or Member City.
Utilization review by a physician is billed separately at ten (10) minute increments, at the rate of
$250 per hour with a 3% increase in each year.
Member Monthly Fee Monthly Fee Monthly Fee Monthly Fee Monthly Fee
City 7/1/25-6/30/26 7/1/26-6/30/27 7/1/27-6/30/28 7/1/28-6/30/29 7/1/29-6/30/30
Arcadia $9,140 $9,414 $9,697 $9,988 $10,287
Buena Park $12,026 $12,387 $12,759 $13,141 $13,536
Cypress $3,689 $3,800 $3,914 $4,032 $4,153
Irvine $31,846 $32,801 $33,785 $34,798 $35,842
Laguna Beach $13,843 $14,259 $14,686 $15,127 $15,581
Montclair $4,649 $4,789 $4,933 $5,081 $5,233
Orange $22,244 $22,911 $23,599 $24,307 $25,036
Tus t in $9,541 $9,827 $10,122 $10,426 $10,738
Yorba Linda $130 $134 $138 $142 $146
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Administrator shall reimburse Member Cities within thirty (30) days for any Utilization Review or
physician review that is not in compliance with the Workers’ Compensation Treatment Protocols
Policy or as directed by CIPA and/or Member City.
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 this Agreement, the Administrator shall procure and maintain in
full force and effect during the term of this Agreement, 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.
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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.
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
Agreement 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)
system failure, damage to or destruction of electronic information, data recovery, business
interruption, cyber extortion, and information theft; and (4) 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”
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5. Contain any other exclusion contrary to the Agreement
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.
(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.
D. Crime Bond
(1) Loss Payee: Losses payable under the policy shall be paid to the Member Cities as their
interests may appear.
3. Insurance Obligations of Administrator
The insurance obligations under this Agreement 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 Agreement; 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 Agreement
are sufficient to cover the obligations of the Administrator under this Agreement.
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.
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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 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. Self-Insured Retention
Self-insured retentions (SIR’s) must be approved in writing by CIPA 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 self-insured retention. CIPA 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. Self-insured retentions
shall be the sole responsibility of Administrator. Member Cities may deduct from any amounts otherwise
due Administrator to fund the SIR. Policies shall also provide that defense costs, including the allocated
loss adjustment expenses, will satisfy the SIR.
8. Contractual Liability
The coverage provided shall apply to the obligations assumed by the Administrator under the indemnity
provisions of this Agreement.
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 Agreement.
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 Agreement with the City
and continuous coverage shall be maintained or an extended reporting period shall be exercised for a
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period of at least five (5) years from termination or expiration of this Agreement.
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 Agreement, including adding the CIPA and Member Cities
as Additional Insureds, providing Primary and Non-Contributory coverage and Waiver of Subrogation to the
subcontractor’s policies.
Article 12. INDEMNIFICATION
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.
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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.
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, President
AdminSure Inc.
3380 Shelby Street
Ontario, CA 91764-5566
avargas-flores@adminsure.com
To CIPA: Janet D. Kiser, General Manager
California Insurance Pool Authority
567 San Nicolas Drive, Suite 300
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 or CIPA. 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.
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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.
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 Agreement
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.
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.
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In witness whereof the parties hereto have signed this Agreement as of the date set forth in Article 1.
CIPA: California Insurance Pool Authority
_______________________________
Authorized Signature
_______________________________
Print Name
_______________________________
Title
_______________________________
Date
ADMINISTRATOR: AdminSure, Inc.
______________________________
Authorized Signature
_______________________________
Print Name
_______________________________
Title
_______________________________
Date
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ADDENDUM 1
MINIMUM PERFORMANCE STANDARDS
CLAIMS ADMINISTRATOR
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
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
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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 facilitate 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.
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.
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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 as 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 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.
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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.
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.
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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.
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.
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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.
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 them 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
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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 s ettlements that
involve or potentially involve CIPA funds, without CIPA’s prior approval.
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.
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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 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 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 90-days on claims not finalized by settlement or award
2) Every 180-days 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 the time the file is evaluated for
settlement.