R18-1751
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RESOLUTION OF OF BOYNTON
AUTHORIZINGFLORIDA, APPROVING THE RANKING AND
r SIGN A
THREE .AGREEMENT. FORM
APPROVED 1 81 1
BY THE CITY ATTORNEY FOR THIRD PARTY
ADMINISTRATION OF PROPERTY
R I' '% 1 CASUALTY
CLAIMS WITH TRISTAR RISK ENTERPRISE
MANAGEMENT, INC.; 1 PROVIDING
EFFECTIVE DATE.
WHEREAS, a on November 2, 2018 the City opened and tabulated three (3)
submittals in response to RFP #004-1710-19/IT for Third Party Administration of Workers'
Compensation, Property and Casualty Claims; and
WHEREAS, an evaluation committee was established and has analyzed the responses
and is recommending a three year Agreement for Third Party Administrator services of
Property and Casualty Claims with TRISTAR Risk Enterprise Management, Inc.; and
WHEREAS, the City Commission of the City of Boynton Beach deems it in the best
interest, health, safety and welfare of the citizens and residents of Boynton Beach to enter into
i three-year Agreement for Third Party Administration of Property and Casualty Claims with
TRISTAR Risk Enterprise Management, Inc.
Section 1. Each Whereas clause set forth above is true and correct and
herein by this reference.
Section 2, The City Commission of the City of Boynton Beach, Florida hereby
the ranking and authorizes the City Manager to sign a three-year Agreement in a
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form approved by the City Attorney for Third Party Administration of Property and Casualty
Claims with TRISTAR Risk Enterprise Management, Inc., a copy of said Agreement is
attached hereto as Exhibit "A".
Section 3. That this Resolution shall become effective immediately upon passage.
PASSED AND ADOPTED this 4th day of December, 2018.
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CITY OF B YNTON BEACH, FLORIDA
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YES NO
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Mayor --- Steven B. Grant
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Vice Mayor — Christina L. Romelus
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Commissioner — Mack McCray
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Commissioner -- Justin Katz
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Commissioner — Aimee Kelley
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VOTE
51 ATTEST.,
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55 =Judith A. Pyle, CMC
56 City Clerk
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59 i(Corporate Seal)
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All"
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PROJECT DESIGNATION. The Firm is retained by the City to perform professional third
party administration of property and casualty claims in connection with the RFP No. 004-1710-
19/IT for THIRD PARTY ADMINISTRATION FOR WORKERS' COMPENSATION FOR
PROPERTY AND CASUALTY CLAIMS
2. SCOPE OF SERVICES. Firm agrees to perform the services, identified in Section 11 — Sco
of Services and attached hereto as Exhibit A. I
3. TIME FOR PERFORMANCE. Work under this agreement shall commence upon written
notice by the City to the Firm to proceed. Firm shall perform all services and provide all work
product required pursuant to this agreement upon written notice to proceed.
4, TERM: This Agreement shall commence upon award by City Commission and shall terminate
three (3) years from that date. The City may renew this Agreement for two (2) additional one-
year renewals at the discretion of the City and based upon mutually agreeable rates.
5. PATMENT: The City will pay the Firm, the fees as set forth in Exhibit B, Fees and Payments,
which is attached hereto and made a part hereof.
These fees will be paid by the City for completed work and for services rendered under this
agreement as follows:
a. Payment for the work provided by Firm shall be made promptly on all invoices submitted
to the City properly, provided that the total amount of payment to Firm shall not exceed
the total contract price without express written modification of the Agreement signed by
the City Manager or her designee.
b. The Firm may submit invoices to the City once per quarter during the progress of the work
for partial payment for project completed to date. Such invoices will be reviewed by the
City, and upon approval thereof, payment will be made to the Firm in the amount approved.
c. Final payment of any balance due the Firm of the total contract price earned will be made
promptly upon its ascertainment and verification by the City after the completion of the
work under this Agreement and its acceptance by the City.
d. Payment as provided in this section by the City shall be full compensation for work
performed, services rendered and for all materials, supplies, equipment and incidentals
necessary to complete the work.
e. The Firm's records and accounts pertaining to this agreement are to be kept available for
inspection by representatives of the City and State for a period of three (3) years after the
termination of the Agreement. Copies shall be made available upon request.
6. OWNERSHIP AND USE OF DOCUMENTS. All documents, drawings, specifications and
other materials produced by the Firm in connection with the services rendered un•-
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eAgreement shall be the property of the City whether the project for which they are made is
executed or not. The Firm shall be permitted to retain copies, including reproducible copies,
of drawings and specifications for information, reference and use in connection with Firm's
endeavors.
7. COMPLIANCE WITH LAWS. Firm shall, in performing the services contemplated by this
Agreement, faithfully observe and comply with all federal, state and local laws, ordinances
and regulations that are applicable to the services to be rendered under this agreement.
1. INDEMNIFICATION. Firm shall indemnify, defend and hold harmless the City, its offices,
agents and employees, from and against any and all claims, losses or liability, or any portion
thereof, including fees and costs, arising from injury or death to persons, including injuries,
sickness, disease or death to Firm's own employees, or damage to property occasioned by a
negligent act, omission or failure of the Firm.
9. INSURANCE. The Firm shall secure and maintain in force throughout the duration of this
contract comprehensive general liability insurance with a minimum coverage of $1,000,000
per occurrence and $1,000,000 aggregate for personal injury; and $1,000,000 per
occurrence/aggregate for property damage, and professional liability insurance in the amount
of $1,000,000 per occurrence to $2,000,000 aggregate with defense costs in addition to limits;
workers' compensation insurance, and vehicular liability insurance.
Said general liability policy shall name the City of Boynton Beach as an "additional named
insured" and shall include a provision prohibiting cancellation of said policy except upon thirty
(30) days prior written notice to the City. Certificates of coverage as required by this section
shall be delivered to the City within fifteen (15) days of execution of this agreement.
10. INDEPENDENT CONTRACTOR. The Firm and the City agree that the Firm is an independent
contractor with respect to the services provided pursuant to this agreement. Nothing in this
agreement shall be considered to create the relationship of employer and employee between
the parties hereto. Neither Firm nor any employee of Firm shall be entitled to any benefits
accorded City employees by virtue of the services provided under this agreement. The City
shall not be responsible for withholding or otherwise deducting federal income tax or social
security or for contributing to the state industrial insurance program, otherwise assuming the
duties of an employer with respect to Firm, or any employee of Firm.
11. COVENANT AGAINST CONTINGENT FEES. The Firm warrants that he has not employed
or retained any company or person, other than a bona fide employee working solely for the
Firm, to solicit or secure this contract, and that he has not paid or agreed to pay any company
or person, other than a bona fide employee working solely for the Firm, any fee, commission,
percentage, brokerage fee, gifts, or any other consideration contingent upon or resulting from
the award or making of this contract.
For breach or violation of this warranty, the City shall have the right to annul this contrac.1
without liability or, in its discretion to deduct from the contract price or consideration, or
otherwise recover, the full amount of such fee, commission, percentage, brokerage fee, gift,
or contingent fee.
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12. DISCRIMINATION PROHIBITED. The Firm, with regard to the work performed by it under
this agreement, will not discriminate on the grounds of race, color, national origin, religion,
creed, age, sex or the presence of any physical or sensory handicap in the selection and
retention of employees or procurement of materials or supplies.
13. ASSIGNMENT. The Firm shall not sublet or assign any of the services covered by this
Agreement without the express written consent of the City.
14. NON -WAIVER. Waiver by the City of any provision of this Agreement or any time limitation
provided for in this Agreement shall not constitute a waiver of any other provision.
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a. The City reserves the right to terminate this Agreement at any time by giving t
(10) days written notice to the Firm. i
b. In the event of the death of a member, partner or officer of the Firm, or any of its
supervisory personnel assigned to the project, the surviving members of the Firm hereby
agree to complete the work under the terms of this Agreement, if requested to do so by
the City. This section shall not be a bar to renegotiations of this Agreement between
surviving members of the Firm and the City, if the City so chooses.
16. DISPUTES. Any disputes that arise between the parties with respect to the performance of
this Agreement, which cannot be resolved through negotiations, shall be submitted to a court
of competent jurisdiction in Palm Beach County, Florida. This Agreement shall be construed
under Florida Law.
Lori LaVerriere, City Manager
City of Boynton Beach
P.O. Box 310
Boynton Beach, FL 33425-031it
TRISTAR RISK ENTERPRISE MANAGEMENT, INC.
ATTN: Kevin Cothron, President
100 OCEANGATE, SUITE 700
LONG BEACH, i5 -A -790862-F
18. INTEGRATED AGREEMENT. This agreement, together with attachments or addend -
represents the entire and integrated agreement between the City and the Firm a
supersedes all prior negotiations, representations, or agreements written or oral. Th
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agreement may be amended only by written instrument signed by both City and Firm.
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The City is public agency subject to Chapter 119, Florida Statutes. The Contractor shall
comply with Florida's Public Records Law. Specifically, the Contractor shall:
A. Keep and maintain public records required by the CITY to perform the service;
B. Upon request from the CITY's custodian of public records, provide the CITY with a copy
of the requested records or allow the records to be inspected or copied within a
reasonable time at a cost that does not exceed the cost provided in chapter 119, Fla.
Stat. or as otherwise provided by law;
C. Ensure that public records- • or that are confidentialand exempt from
public record disclosure requirements are not disclosed except as authorized by law for
the duration of the contract term and, following completion of the contract, Contractor
shall destroy all copies of such confidential and exempt records remaining in its
possession once the Contractor transfers the records in its possession to the CITY; and
Upon completion of the contract, Contractor shall transfer to the CITY, at no cost to the
CITY, all public records in Contractor's possession All records stored electronically by
Contractor be provided to the CITY, upon-• •m the CITY's custodian of
public ! ! :.. in a format! i.'...... ! - with the informationil!! is
the CITY.
E. IF THE CONTRACTOR HAS QUESTIONS REGARDING
APPLICATION OF CHAPTER 119, FLORIDA STATUES, TO THE
CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS
RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN O
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PUBLIC RECORDS:
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561-742-606�
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EXHIBIT A
SGQ
The City of Boynton Beach is seeking proposals for Third Party Administration service. -
for its self-insured Workers' Compensation and for its Property & Casualty programs. Tha.
City's anticipated contract start date is January 1, 2019.
The Proposer shall perform all third party administrator services for Workers'
Compensation for Property & Casualty claims, or for both inclusive of claims handling,
information technology services, settlement coordination, management of claim records,
Medicare reporting, handling of claims in process and all other items necessary or proper
for, or incidental to, performing third party administrator services as identified herein.
The City of Boynton Beach has most recently utilized the following companies as its third
party administrators: Commercial Risk Management for workers' compensation and
Gallagher Bassett Services Inc. for property/casualty. The City will transfer the
administration for all active claims frun-off/tail clairrisl as of Janua* 1 2019to the awareltis-'
Proposer. The City is self-insured.
The City carries excess workers' compensation coverage with a SIR of $500,000 per
with Preferred Governmental Insurance Trust (PGIT).
The TPA(s) will be required to manage the claims with a comprehensive database system
which allows computer access to adjuster notes, adjuster correspondence and other
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which will allow secure web based communication between the City and the TPA and
Adjusters. This program should also allow the City to add information to the adjuster notes
section of the computer systems.
2. WORKERS COMPENSATION CLAIMS ADJUSTING AND INVESTIGATION
SERVICES
Upon receipt or notice of all workers' compensation claims, the TPA, on behalf of the
City, will perform the following services:
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2. The TPA is responsible for obtaining recorded statements from the claima-ni
and any witnesses.
The City will maintain contact with injured employees to assist the
employee in returning to work. The TPA and/or telephonic nurse case
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the injured employee.
3. The TPA will be responsible for filing all the appropriate forms with the
State (DWC1, etc.)
4. The TPA is responsible for ensuring compliance with all reporting
requirements by regulatory agencies including but not limited to Medicare
Secondary Reporting Act of 2007 and all subsequent revisions.
5. The TPA will assist the City with any written correspondence that the City
requests them to send to the injured worker or medical provider regarding
the benefits.
6. The TPA will accept or deny all reported claims for employees' injunies on
behalf of the City in accordance with the applicable Workers' Compensatic
Statutes. The decision to controvert a claim must first be discussed with
and approved by the City.
7. All lost time claimant's checks will be issued by the TPA on a weekly basis
from the City of Boynton Beach fund. The verification of any checks for
wage loss must be received by the City before 500 P.M. on the Tuesday c
a City payroll week.
8. Currently, the City requires that all medical or ancillary service providers
submit their bills to the TPA bill review unit for processing and payment. A
provider payments will be reviewed weekly by the City via the weekly TPA
check register before the provider checks can be released.
9. The TPA will be responsible for identifying any outside Firms such as
surveillance companies and field case management experts to assist in the
investigation and medical coordination of claims. Payment of the bills will
be made by the TPA from the loss fund as an allocated expense but not
without prior approval by the City.
10The TPA and/or Bill Review unit shall review all medical bills and other
services for which a claim is being made for reasonableness and conformit)
to appropriate medical and surgical fee schedules and network discounts.
11i The TPA will assist the City with light duty cases and for those City
employees who are losing time by providing a report indicating all
employees that are not working in a full duty unrestricted capacity,
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12. The designated adjusters or team from the TPA will meet with the City on a
quarterly basis to discuss summary reports on all open and active claims.
13. The Director of Human Resources and Risk Management, and/or designee
will attend all mediation conferences and may ask the TPA for reports prior
to mediation in order to facilitate any settlement.
14. The TPA shall prepare and maintain files necessary for legal defense of
claims and/or other litigation (such as actions for subrogation) or other
proceedings.
15. The TPA shall pay in a timely fashion, per Florida Medical E.D.I. guidelines,
all claims and expenses from the loss fund account established by the City,
which will be maintained by the TPA. Fees, interest and civil penalties
incurred due to late payments or adjuster mishandling are to be paid by the
TPA unless caused by late reporting from the City.
16. The TPA shall pursue all possibilities of subrogation and liens. The
Manager of Risk and Wellness must be copied on all such correspondence
relating to these issues.
17. The City will assign the attorneys that provide the defense of claims. The
TPA is to provide the defense attorney a complete copy of the file in
question at the time an assignment is made. The TPA will provide a
monthly report to the City regarding all legal assignments and the costs
associated with them.
The Director of Human Resources and Risk Management is
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responsible for approval for all settlements from the City per th I
process determined by City policy and procedures in coordinati
with applicable Florida State Statutes.
18. The TPA will timely report all claims in accordance with Florida State
Statutes to the City's excess carriers, as required by the carrier's reporti
criteria. For any late reporting penalties imposed by the carrier due to [a
reporting by the TPA, the TPA will reimburse the City for those amounts]
19. The TPA will provide all necessary status reports as required by the City's
excess carriers.
E0. The TPA will submit requests to the excess carrier for all payments above
each claim's SIR to obtain the proper reimbursement for the City. The
reimbursement checks will be forwarded to the City and the amount
recovered will be entered into the claims information system.
21 . The City will assign Field Case Managers (Qualified Rehabilitation Provider
(QRP)) to its cases as needed.
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23. The TPA must provide the City with a toll-free telephone number.
24. In all dealings, the City requires the TPA to be courteous, responsive and
sensitive to the injured employee. The TPA is required to return an injured
employee's telephone call within 24 hours, preferably the same day that
they called the TPA.
25. Identify claims subject to second injury relief fund (if reinstated during the
contract term or currently applicable), at -fault party subrogation and pursue
such recoveries on behalf of the City of Boynton Beach.
26. Provide reports to the City of Boynton Beach's Director of Human
Resources and Risk Management and Manager of Risk and Wellness as
requested or provide for system access for ad hoc reporting. Reports shall
include:
• Loss experience
• Summary of claim and loss experience, broken down by injury type,
injury cause, department, and location of injury
• Cost, frequency and severity report
• Claim activity summary (new, re-open/closed/disputed, etc.)
• Claim master file listing
• Detail list of claimants including current and prior claim activity
• Retention level analysis
• Reserve analysis detailing rationale and total cost
• OSHA 300 Log
• Lost time analysis
• PPO penetration
• Average cost by medical provider
• Number of as from DOA Date to MMI Date
1. The TPA shall use its best judgment in managing claims and in setting reserves
forfuture payment and shall perform the following functions with regardto
claims:
A. Within one (1) working day of receipt ofanewelaim, all data
shall be entered into the information system, assigned the proper
codes and initial reserves.
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C. Clearly document each file all phone conversations, discussions,
and meetings held on the case.
D. Promptly enter into the computer system all pre-approvei.
payments, reserve revisions, and file closings.
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F. The TPA is expected to be familiar with applicable la
regarding potential liability for injury or damage or other loss to
members of the public (e.g. familiarity with Florida's sovereig
immunity statutes, Federal law regarding governmental liability,
etc.). 11
G. Firefighters and Police are subject to Occupational Disease
Claims and FS 112.181. City • Boynton Beach requires that
adjusters handling these types of claims • educated
in the different statutory requirements associated with these
claims.
H. Written status reports shall be provided to the City prior to these
• claim reviews.
1. The TPA shall maintain claim review procedures in place for
supervisors • auditors within its firm.
J. The TPA shall have established standard reserving practices
to assist City in establishing reserves. Reserves shall be
reviewed at a minimum of every 90 days. File notes should
reflect reserves were reviewed.
K. The TPA shall coordinate a claims funding arrangement that is
acceptable to the City of Boynton Beach.
L. Prepare and /or assist City staff with all appropriate responses to
and inquiries • all regulatory agencies.
M. The TPA is responsible • ensuring compliance with all reporting
requirements by regulatory agencies including but not limited to
Medicare Secondary Reporting Act of 2007 and all subsequent
revisions.
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1, The TPA must prepare, maintain, and file statistical data, records, or reports as
required •\ excess insurers, City actuaries, and the State.
E. The TPA must prepare, maintain and file statistical information required by the
workers' compensation rating bureaus, including all data required for the
promulgation of the City's experience modification and state assessments.
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4. All charges related to these services identified herein are to be included in t
pricing provided for each option. Any costs associated with programming
changes that are necessary to create a report required by the City (any repo
listed in the Scope of Services) are the responsibility of the TPA.
5. Specialty reports available beyond those identified in the Scope of Services or
requested by the City are to be provided and the City will request a cost
proposal for each report based on the fee structure in the price proposal.
6. All claims data is the property of the City and any data and media will be
provided to the City upon request or upon termination of this agreement at ns
additional cost to the City.
1. The selected TPA, at their expense, will ensure all claims and payment data is
included in their loss runs. Historical data from our current TPA's database
cannot be purged. Claims data for all open and closed claims must be
transferred.
2. Loss runs are to be provided on a monthly basis sorted separately by policy
year and department/location. Loss runs should list each claim separately.
Specific summary reports also must be provided. The following reports are
required:
• Claims listing by Department
• Check register
• Cumulative report by line of coverage by year
• Annual summary reports
• Location report
• Large loss or severity report
• Safety report
• Excess insurance report
• Litigation report
• Legal payments report
• Pharmacy Penetration report
• Care Management report (Telephonic/Field)
3. All claims, expense and legal payments will be made by the TPA on checks
drawn on an account set up by the TPA and funded bi-weekly by the City. It is
understood that all funds in this account are City funds and are to be returned
to the City upon request or at termination of this contract.
4. The monthly reconciliation statement submitted by the TPA to the City will
include the following:
• Balance at inception of statement period
• Total disbursements which cleared, by date and claimant/payee
• Balance at close of statement period.
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5. The TPA will submit an invoice to the City on a monthly basis which provides
an Itemized listing of all banking fees related to the bank account set up by the
TPA on behalf of the City of Boynton Beach.
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Claim: Any report of an accident (first or third party) alleging or resulting in
injury, damage, or loss which could give rise to a demand for the payment
of money. The claim charge is applicable on a per occurrence, per claimant,
per line of coverage basis.
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tualified claim or loss: The TPA shall investigate and adjust any loss or
claim reported within the service term, provided the loss or claim type is
'dentified.
and include, but not be limited to,
• legalfees
• professional photographs
• medical record
• experts' rehabilitation costs
• accident reconstruction
• architects, contractors
• engineers
• police, fire, coroner, weather, or other such reports
• property damage appraisals
• extraordinary costs for witness statements
• official documents and transcripts sub rasa investigations
• medical examinations
• extraordinary travel made at it of Boynton Beach's request
• court reporters
• fees for service of process
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* any other similar cost, fee or expense reasonably chargeable to the
investigation, negotiation, settlement or defense of a claim or loss
is must have the explicit prior approval of the City of Boynton
Beach.
6.2. LIABILITY PROPOSER'S RESPONSIBILITIES
The TPA shall perform the following services:
1 Review each claim and loss report submitted by the City of
Boynton each during the term of this Contract.
2. Assign a qualified, experienced, Florida licensed adjuster within
24 hours of receipt of claim.
3. Contact claimant within 48 hours of assignment of claim.
4. Conduct an appropriate investigation of each qualified claim or
loss.
5. Maintain a file for each qualified claim or loss which shall t
available for review by the City of Boynton Beach.
6. Adjust, settle or resist all qualified claims or losses with th
specific approval of the City of Boynton Beach.
7. Perform necessary and customary administrative and cleric,
work in connection with each qualified claim or loss, including th
preparation of checks or vouchers, releases, agreements, and/c
other documents to manage and finalize a claim.
8. Promptly establish and update claim reserves at least every ninet
(90) days.
9. Timely notify City of Boynton Beach, City of Boynton Beach ageni
and excess insurer(s), as designated by the City of Boyntoi
Beach, of all qualified claims or losses which may exceed the Cit,
of Boynton Beach retention and, if requested, provide informatioi
on the status of those claims or losses.
10. Coordinate investigations on litigated claims with attorney.,
representing the City of Boynton Beach and with representative,,
of the excess carrier, as required. It is expressly understood tha
all legal costs and loss payment will be charged to the City o
Boynton Beach.
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11. Have internal product support staff review large and unusua'
claims at no additional cost to the City of Boynton Beach, unless
specified.
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13. Assist the City of Boynton Beach in selecting appropriate experts
or specialists as the claims may require.
14. Provide personnel needed to perform the services agreed to
herein.
15. Maintain a comprehensive database of all claims reported. This
data shall belong to the CITY OF BOYNTON BEACH and shall be
made available to the CITY OF BOYNTON BEACH at any time.
Upon termination of the Contract, the TPA shall provide the CITY
OF BOYNTON BEACH with an electronic copy of the data in
ASCII format.
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1 . The TPA is required to provide monthly and annual summaries of
claims by type of risk and shall recap each year's experience,
including prior years, to date. The reports shall be on a fiscal year
basis (October 1 st - September 30th) in a format acceptable to the
City of Boynton Beach, and shall be prepared in accordance with
the provisions below:
a. Claims Experience Reports should be provided within 15
days of the end of the period for which each report applies.
b. Adjusting Service shall provide a report of accounts
aggregate loss experience analysis.
C. City of Boynton Beach requires the ability to provide a
breakdown of experience for each department.
Supplemental claims documentation shall provide, in plain
English, sufficient information to indicate what happened, t4i
whom or what and how much has been paid or is expected
to be paid.
2Online and real time access to the administrators claim system,
including all adjuster's notes is critical to the City of Boynton Beach.
TPAs must have a software product that the City of Boynton Beach
can access to view the administrator's automated claim files,
including adjusters' notes, payments, claim notes, imaging of
invoices and messaging capabes.
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3. OSHA reporting capabilities shall include the ability to separaft.
OSHA reportable claims from Record Only claims.
4. TPA shall have staff available that can create reports wher.
requested by the City.
1 City of Boynton Beach reserves the right to direct the TPA regarding
settlement of all claims.
2. Legal Services: The City of Boynton Beach reserves the right 11
assign legal counsel to all claims.
3. City of Boynton Beach shall have the right to inspect or audit the
files, including the right to utilize an outside auditor for these
functions on City of Boynton Beach's behalf. The City of Boynton
Beach requires the TPA files to be electronically stored with access
provided to City of Boynton Beach of all stored document images,
faxes, incoming email attachments, and all documents generated by
the Claims Management System.
All claims files and other records, documents, lists, supplies, etc.,
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will be delivered to City of Boynton Beach upon contract
termination with no additional fee to the City.
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EXHIBIT B
REQUEST FOR PROPOSALS
FOR
THIRD PARTY
FOR PROPERTY
D, CLAIMS
RFP No.: 004-17104911T
AUTO LIABILITY BODILY INJURY
4
$860
AUTO LIABILITY PROPERTY DAMAGE
i
$495
AUTO PHYSAGAL DAM -AGE
0
$310
GENERAL LIABILITY BODILY INJURY
4
$835
N. LIABILITY PROPERTY DAMAGE
4
$495
PROFESSIONAL LIABILITY
0
$ 2,70D
THIS PAGE TO BE SUBMITrED FOR PROPOSAL TO BE CONSIDERED
COMPLETE AND ACCEPTABLE.
In
EXHIBIT B
FEES AND PAyMENjL(ggOjbggdj
REQUEST FOR PROPOSALS
FOR
THIRD PARTY
FOR PROPERTY AND CASUALTY CLAIMS
REP No,: 004-1710-19,11T
COST PROPOSAL FORM ICONTINUED)
PAYMEhE SCHEDULE
ELECTRONIC INCIDENTS
OR – FLA T MONTHL Y FEE
ADDITIONAL SERVICES.
MEDfGARE REPORTING (MbnMfy Fee)
PER CLAIM COST FOR RRICIR CLAIMS FILES
2018 Prujrected
No- of Claftis Claim Rate
0 $30
--�-830(lncludesly
e
handl' of open
,prior claims and up
to 15 new claims
,per year)
either to the same or separate company.",
TRISTAR Risk Enterprise Management, Inc -
COMPANY NAME
361 -857 --CM x3-3-13 —
PHONE NO.
JLynmr v.Dyer@TRISTARgroup.net
kPL ADDRESS
DATE
AUTHORIZED SIGNATURE
Anim , er
PRINTED NAME
Directorof Sales and ChentSolations
TITLE
THIS PACA TO RE SURWHED fOR PROPOSAL 70 BE CONSIDE&W
00WLETE AND ACCEFFABLE,
IN
L 1AJ311F i s
FEES AND PAYMENTS (co
Preferred Provider Spec':.ally SerAces 2018. Fires listed are fcrr Preferred Rrovider Specialty Services -
The -re fees are paid as Mocated Loss Adjustment Expenses or, where reptri�ed by state law, as loss.
-,
=Mn ,U,a , ) r„7s „ 7
Medkof Riff Reitkiv,
Prm,ider". ndl it Review
$'B.75 per bbl- or $1,54 per line ilrniiim ; 4
lines)
Hospita` Bil ems* r -i e nd ratrtpatientl
125 of savings
Implantable DeviceReview
27V. of savins
PPO/Ph r .ac fD E/ ndla f etw.e0rk
27% ;e :ails °all savings a -e prat fee
sche n±e or U&Q
5p 'rau`"ty ill' $ Netw rkeViie
32Y, of SaAvigs la'`I sevin are past fee
schedi.rear U&Q
e -billing
S 1.00 perbil
t istcsri l ft'l fte ewr Conwersinn
$7 2DOO One Tine fee at Implementation
itapiicate -Bills
Duplicate Urn! fterns
No Charge
ar thly reins Rep rtrg ;J
Pr ` ni l review
$22 perr lWi l review. Fee waived if case
proceeds to utilition re e
Pr rfi J tion in- or att ati nt)
$140 per pr cation
Concu7cent Review
$125 per haar.
fReview diring hospitalization or outpatient
treatment, as treatment progresses to ensure
d rati n and type of treatment meet
ppr pkat uide roes)
Peer
Level 1
$250 flat rate for peer review of episodes of
firicludes review of medical records and
ca identified ctrl metrical UJA review.
co-mmunication of decision in waiting to al
parties)
Level 2
$295 flat rate Men assigned by a nurse case
(Includes review W, e i :.' recon s, discussion
manager following case rrra a er file review,
Wrth treating physician and cummuniration of
orr iptf, a referral by adjurfor.r ie .
Asian in writing to all pardes)
fahoncedintake and Mrse,;
nharir d el p onlr,ftrst Notice
$20 per intake calx (waived if call moves t
o perator service by medical assistarts. Injured
th e
employ and/or supervise,- lis to report
bairns, assisuincewrit PPO direction, questions
and referrals. Optional int with ith n -se
gg
triage serve€ ..H
Telepho,,nc C rse Tn` a e
$12 per intake call
Nar°se aids injirer w or e° in se" -treatment or
sets up appointment with appropriate provider
utilizing mical triage uidelirt .4 l'rtrw upcalls)
W
I,'=—Xn- MIT B
Re
Nurse Case Management
Telephonic Case Managernerv, JFQ
$120perhou�
OR Davation Based
a First 30 days
$370 per claim
0 and 30 days
$285 per claim
0 Each 30 d
Field Case Management (FL)
$120 per hoar piss hfflle3geat prevail]ng IRS rate
Field Carve Management -Tasks
Onetime visit cD provider $475 + mileage
Two visits to pravii der $750 + mileage
Medical record retrieval $135 + mil eage
Job Analysis $475 + mileage
Catastrophic Case Management
$150 per hour + mileage
(High level of RN inteTaction with. imcnedrate
response to sigrifficant injury, e -g. severe head
injury, were burns, gure;ho'- Availabie 24/7)
Pharmary Bengrit Aftesigeiwnr (PBMP
Point of to Ldilization review
$125 per hou- bilied at 10 minutr increments
Nurse Intervention, Corex Pharmacy
$M per hour
Management., Weaning Pr cols
JAvailabie when opioids have been prescribed
for 60+ days with no evidence that physician M11
end treatment pattern.)
Physidan Interverr5on: Complex Pharmaqr
$125 per hoar nursing intervention plus pass
Management-
throu&,, of act = physician fees
(UNized in instances of numerous drug
Interactions of opioids, hypnotics and anti-
depressants, requiring a physidan-to-Ishysidan
review of treatment pattern and weaning
optiorks- Follow up calls made by nurse case
manager-)
OP
UaWlity Medical URI ReView
$25 flat feeper hJul
RN 11ablifty Medical Reviez,
5125 per hour
OtherSesidires.
Speda' investigations
OjtsoiLrced, at cost —tyjacally $85 perhour
Central Index BureaulDFAC/Child Support
$15 per report
Enfiorcement
Claim ReieorthnK: Tel
Der re a
Claim Reporting e Fax or I ntemet
$10 per report
MMSEA Reporting
$10 per claim
_Miieage
IRS alio a., rate
Re