Request for Proposal Workers Compensation Third Party Administration Services For the City of San Mateo

Request for Proposal Workers Compensation Third Party Administration Services For the City of San Mateo Presented by: Jennifer Crims Senior Risk Management Analyst City of San Mateo And Robin Hendrickson SVP, Workers Compensation Claims ABD Insurance & Financial Services

Table of Contents 1.0 General information 2.0 Overview of the City of San Mateo 3.0 Workers Compensation Insurance Program 4.0 Terms of Agreement and Insurance requirements 5.0 General Rules governing RFP 6.0 Proposal timetable and submission requirements 7.0 Executive Summary and TPA company overview 8.0 Account management 9.0 Claim Administration requirements and expectations 10.0 Claim staffing expectations and claim handling philosophies 11.0 Special handling instructions 12.0 Performance guarantee 13.0 Risk management information system (RMIS) 14.0 Quality management program 15.0 Pricing 16.0 Ancillary Services 17.0 Funding Workers Compensation claims 18.0 Standard Service Agreement 19.0 City of San Mateo Loss data Appendix 1: Sample TPA Contact sheet Appendix 2: Sample Reference Data sheet Appendix 3: City of San Mateo Standard Service Agreement

1.0 General Information Introduction and background The purpose of this RFP is to provide prospective Third Party Administrators (TPA) with information that will enable them to prepare and submit a proposal for third party administration services for the City of San Mateo s self-insured workers compensation program. TPAs responding to this proposal must be a recognized claims administrator of self -insured workers compensation programs, licensed to do such business in the State of California. The City of San Mateo will use the results of this RFP process to award a service agreement that will include the takeover of all existing WC claims and all new claims beginning at the program inception date of July 1, 2013. RFP submissions should include, as appropriate, responses for both life of claim and life of service agreement options. This RFP provides detailed program requirements. Each TPA must address these program requirements in their proposal submission. In addition, there is an executive summary section of the RFP that provides an opportunity for the TPA to expound and give further details on why their company is best qualified to perform the services. The City of San Mateo is looking for a TPA partnership that will deliver objective and measurable results that will reduce the cost and duration of WC claims, provide claim processing in a timely and professional manner, actively pursue subrogation, assist in returning injured employees back to work and maintaining strong communications with the injured worker and the City of San Mateo. 2.0 Overview of the City of San Mateo The City of San Mateo incorporated as a city on September 4, 1894 and employs over five hundred full time and two hundred part time employees with a city population of over 95,000. It is the second largest city in San Mateo County. It is a charter city whose charter formulates the basic rules for governing the city. The City of San Mateo is an Equal Opportunity Employer and does not discriminate on the basis of age, sex, religion, national origin, race, color, political affiliation, or disability. The City of San Mateo operates under a Council/Manager form of government. The council as the legislative body represents the entire community and is empowered by the City Charter to formulate citywide policy. The five Council Members serve at large for four-year terms.

The City of San Mateo manages its workers compensation through their human resources department directed by Jennifer Crims, Senior Risk Management Analyst, who is assisted by Kerry Mclver, human resources technician. They have been self -insured for over 30 years and have partnered with third party administrators to manage their workers compensation claims. Claims management is centralized through the human resources department. Claims are reported by designated individuals within each department who fill out the required forms sending a copy to the TPA and a copy to the City of San Mateo human resources department. Records are maintained centrally at the human resources department. The City of San Mateo supports and implements a case by case return to work program. The City of San Mateo philosophies include: We all work for one organization. Respect and value the people who work here; be supportive of each other. Look at the long term. Take actions which will maintain our ability to serve the community in the future. Seek constant improvement. Be receptive to new ideas; encourage creativity; innovation and experimentation. Lead by example. Let the community and our colleagues judge our commitment to these principles by our individual actions. These philosophies also help to govern the City of San Mateo s philosophy regarding managing workers compensation claims. 3.0 Workers Compensation Insurance Program Insurer Limits Safety National Casualty Corporation Coverage Description $25,000,000 Workers Compensation Aggregate Limit $2,000,000 Employer s Liability Per Occurrence/Aggregate $1,000,000 Self Insured Retention 4.0 Terms of agreement and Insurance requirements The Service agreement shall be effective on July 1, 2013 and shall run for three (3) years from July 1 st to June 30 th, with an option by mutual agreement of the City of San Mateo and TPA to renew for 2 additional 1- year periods. The selected TPA will be required to enter into an agreement with the City of San Mateo containing the terms and conditions set forth in the City of San Mateo s standard agreement. Copy of this standard agreement is in Appendix three (3) of this RFP. If TPA has any exceptions to the standard

terms and conditions, TPA must identify any provision they are not prepared to satisfy in their proposal submission. Any requested changes will be considered by the City of San Mateo when evaluating proposals. Failure to meet the City of San Mateo s standard agreement may result in termination of the service agreement at the discretion of the City of San Mateo. The TPA awarded the service agreement will be held accountable and liable for the acts of the TPA s employees, representatives, agents and/or sub-contractors and shall defend, indemnify and hold harmless the City of San Mateo, it s officers, employees and agents against any claim, loss or liability arising out of or resulting in any way from work performed under the service agreement due to the willful or negligent acts (active or passive) or omissions by TPA s officers, employees or agents. The acceptance of said services and duties by the City of San Mateo shall not operate as a waiver of such right of indemnification. TPA will be responsible for all penalties assessed, whether by the Administrative Director, Office of Self Insurance Plans, or the Office of Benefits and Enforcement, Workers Compensation Appeals Board, unless such penalties are for late payments which were caused by the City of San Mateo s late reporting of claim. Any and all penalties assessed as a result of the TPA, shall be the responsibility of the TPA until the entire penalty has been paid, regardless of the service agreement period and or assessment date. Insurance requirements TPA shall provide and maintain insurance in accordance with the City of San Mateo s standard service agreement, section 12. Upon execution of the service agreement, evidence of insurance will be required and annually thereafter upon expiration of the policies. TPA must be in full compliance with all statutory and applicable regulatory agencies at all times. 5.0 General rules governing RFP Any questions concerning this RFP must be submitted in writing by email on or before March 13, 2013 to: Robin Hendrickson SVP, Workers Compensation Claims ABD Insurance & Financial Services 650.488.8525 robinh@theabdteam.com If TPA discovers any significant ambiguity, error, conflict, discrepancy, or omission in this RFP, the TPA should immediately and prior to the date fixed for submission of proposals notify the above named Individual (Robin Hendrickson, ABD Insurance & Financial Services) of such error

and request modification or clarification of the RFP document. TPA will not be entitled to additional compensation or time by reason of the error or its later correction. City of San Mateo and ABD Insurance & Financial Services reserves the right to reject any and all proposals, to award the service agreement in whole or part, and to negotiate the terms of the service agreement, including the award amount, with the selected TPA prior to entering into a service agreement. TPA s with any conflict of interest or potential conflict of interest must be disclosed to the City of San Mateo and ABD Insurance & Financial Services prior to submittal of proposal and if awarded the service agreement, throughout the life of the service agreement. No TPA may contact the City of San Mateo directly regarding this RFP and are not authorized to make public disclosures relative to the RFP without the written approval of the City of San Mateo. All costs associated with responding to this RFP are the sole responsibility of the TPA. The City of San Mateo may modify this RFP, before the date scheduled for submission of proposals, by issuance of an addendum to all parties who have been furnished the RFP for the purpose of submitting a proposal. Proposals shall become the property of the City of San Mateo and ABD Insurance & Financial Services. 6.0 Proposal timetable and submission requirements Listed below are specific dates related to the RFP process. These dates must be observed during the selection process unless otherwise changed by the City of San Mateo or ABD Insurance & Financial Services. Date March 4 March 13 April 1 April 12 Week of May 6 Activity Date RFP is issued Last day to submit to ABD Insurance & Financial Services any additional questions related to the RFP Last date for proposal submissions Last date to submit responses to any additional questions posed by the RFP selection committee Selection of TPA finalists

Week of May 13 & 20 June 3 June 7 July 1 Oral presentations by finalists, and may include visits to finalists claim offices Notification of intent to award sent to TPA Submittal of final transition plan by the TPA awarded the service agreement Service agreement start date Proposals must be submitted no later than April 1, 2013 by 5:00pm. TPA must mail four (4) hard copies of their proposal responses, and clearly mark the box or package with Proposal for Workers Compensation TPA Services. Each recipient named below should receive two (2) of the four (4) hard copies, addressed and mailed to: Jennifer Crims Robin Hendrickson Sr. Risk Management Analyst SVP, WC Claims City of San Mateo ABD Insurance & Financial Services 330 W 20 th Ave 3 Waters Park Drive, Ste.100 San Mateo CA 94403 San Mateo, CA 94403 Late proposals will be rejected and returned to the TPA. TPA must select a method of delivery that ensures proposals will be delivered to the correct location by the due date and time. Proposals should be typed, organized and presented in the order and by the number assigned in the RFP, along with copies of requested documents, policies and samples of TPA reports and forms. 7.0 Executive Summary and TPA company overview 8.0 Account management 9.0 Claims Administration requirements and expectations 10.0 Claim staffing expectations and claim handling philosophies 11.0 Special handling instructions 12.0 Performance guarantee 13.0 Risk management information system (RMIS) 14.0 Quality management program 15.0 Pricing 16.0 Ancillary services 17.0 Funding Workers Compensation Claims 18.0 Standard Service Agreement Appendix 1: TPA contact sheet (Sample provided, or use your own template) Appendix 2: Reference data sheet (Sample provided, or use your own template) Further comments and/or information may be included in each section or as an addendum to the RFP.

The proposals will first be reviewed to determine if requirements in the RFP are met. Failure to meet mandatory requirements will result in the proposal being rejected. The evaluation and selection of a TPA will be based on the information submitted in the TPA s proposal, pricing, services, compatibility with the City s processes, oral presentations, references and any on- site visits. City of San Mateo and ABD Insurance & Financial Services are not obligated to disclose its specific findings ratings; evaluation or comparison to any of the TPA s who submitted a proposal. 7.0 Executive summary and TPA company overview 7.1 Provide a brief statement of your company s third party administrator experience and qualifications to meet the requirements of the City of San Mateo, including a list of current municipality clients. Include a brief description of your company, number of years in business providing TPA services, number of employees (full and part time), number of claim adjusters and claim support personnel, corporate headquarter location and location of the claim office that would be assigned to service the City of San Mateo. 7.2 Confirm your company is a recognized claims administrator of selfinsured WC programs licensed to do such business in California. 7.3 Provide a copy of your company s best claim practices. 7.4 Describe any financial and/or ownership relationship with any other company that may pose a conflict of interest and provide a conflict of interest statement and/or confidential agreement. 7.5 Describe your company s quality control program and the frequency of internal operational audits. 7.6 Provide a list of workers compensation insurance carriers you are approved as a Workers Compensation TPA. 7.7 Provide information on the circumstances and status of any disciplinary action taken or pending against your company during the last 3 years by any state regulatory bodies or professional organizations. 7.8 Describe your policy regarding penalties resulting from your company s failure to perform according to the California Labor Code.

7.9 Provide three (3) references with similar operations, including municipalities, with dates of service, client s name and contact person with telephone numbers and email addresses for which you currently provide workers compensation TPA services. In addition, provide (2) references and contact information of past clients. A sample reference data contact sheet found in Appendix 2. By providing these references, you agree that neither the City of San Mateo, ABD Insurance & Financial Services, nor the clients referenced shall have any liability regarding the provision of such references or the City s use of such references in making the selection under the RFP. 7.10 Provide your company s experience modification rate for the past 3 years. 7.11 Identify any service(s) you intend to sub-contract to others and identify the proposed sub-contractors including names, phone numbers and the qualifications of the sub-contractors company. 7.12 Provide an update on any status relative to your company regarding any recent company mergers/acquisitions within the last 5 years. 7.13 Provide a sample of your claims intake script/form. 7.14 Provide a proposed transition plan and implementation timetable. 8.0 Account Management 8.1 A claims account manager must be assigned to the City of San Mateo. This individual will play an essential role in the successful administration of this program that includes overall responsibility of the following key components of the program: Service agreement administration. Trouble shooting and providing effective solutions to resolve issues or problems with the service agreement and/or services. Identify key outcome based measurements that are tracked and deliver program improvements and cost reduction results. Monitor claim trends and audit claim handling procedures to ensure a high level of customer service and best in class claim service deliverables.

Host (quarterly) claim reviews for the City of San Mateo, with participation of the claim adjuster(s) and as needed; defense attorneys and nurse case managers. Coordination of an annual stewardship meeting to present service performance metrics, benchmarking and claim trending/loss analysis reports. 9.0 Claims Administration Requirements and Expectations 9.1 TPA must perform all services required to supervise and administer a self-insured workers compensation program for the City of San Mateo, and to act as the City of San Mateo s representative in matters relating to the City of San Mateo s obligations under the workers compensation laws of the state of California. 9.2 Provide a toll free telephone number for the City of San Mateo and claimants. 9.3 Process all claims, including but not limited to investigation, reserving and payment, filing reports, negotiating and settling of claims for amount pre-approved by the City of San Mateo. 9.4 Contact with City of San Mateo, claimant and medical provider within 24 hours of receipt of a claim for all other than medical only claims. For medical only claims, contact with City of San Mateo and medical provider within 24 hours of receipt of a claim. 9.5 Upon knowledge of a catastrophic claim, notification will be made immediately via telephone to the City of San Mateo. These catastrophic types of claims would include: Fatality Amputations Serious disfigurement Quadriplegic/Paraplegic Serious burns Brain injury 9.6 First aid claims are to be flagged with notice to the City of San Mateo and shall be identified as first aid on all loss run data reports. Bill payments for first aid claims shall be determined by the City of San Mateo. 9.7 Response to any questions or inquiries by the City of San Mateo or claimants should be responded to within one business day.

9.8 Initial investigation will be completed within 14 days from day of receipt of the claim and if needed, further investigation completed within 30 days or as soon as all the facts of the case can be reasonably gathered. 9.9 Initial plan of action must be clearly documented in the claim file within 14 days from receipt of the claim and updated every 30-60 days. 9.10 Initial estimate of reserves established within 14 days of receipt of claim. Adjusters must document the basis for each reserve calculation. 9.11 Reserve increases of $5,000 or more on any one claim must be communicated and discussed with the City of San Mateo. 9.12 Adjuster s notes should include but not limited to; comments regarding exposure, disposition plan for claim closure, financial transactions, supervisor s notes, and any other relevant claim information. 9.13 Written status reports will be provided to the City of San Mateo in cases where the incurred value of the claim increases by $10,000 or more, and/or any time upon the request of the City of San Mateo. 9.14 A comprehensive status report will be provided to the City of San Mateo at the time any claim exceeds a total incurred value of $50,000. 9.15 Prior to the denial of compensability of any claim, the adjuster must discuss the case with the City of San Mateo for mutual agreement on the denial. 9.16 TPA must keep the City of San Mateo informed and involved in all accepted cases prior to sending acceptance letters to employees. 9.17 TPA must provide copies of all correspondence to the City of San Mateo that is sent to employees on the same day the original is sent to the employee. 9.18 TPA must notify the City of San Mateo within 3 days, when any previously closed claim is reopened and provide the rationale for reopening. 9.19 Claim adjuster must notify the City of San Mateo when return to work letters are being sent to the claimant, anytime there are changes to the claimant s work restrictions and at the time of any permanent work restrictions.

9.20 Transitional/modified duty must be documented in the claim file and should include the medical diagnosis, work restrictions and estimated duration of disability. 9.21 Documented follow-up to the treating physician(s) is required no later than every 30 days prior to MMI status. Ongoing disability will be documented though ongoing medical reports. 9.22 Adjuster will notify the City of San Mateo of any legal or administrative actions that affect their claims including: appeals, pre notification of depositions, pretrial or workers compensation board hearing. 9.23 City of San Mateo should have the ability to electronically view the progression of any of their claims. Provide the City of San Mateo access to its employees claim files and related data during normal business hours. The City of San Mateo or its designated representative must be authorized to visit the TPA s processing or storage premises and have access to all data, including but not limited to paper documents, electronic documents and any other type that relates to payments or non-payments made by the TPA and charged to the City of San Mateo. Include in your response any costs associated with this access or any fees charged related to storage, copying or transferring any data to the City of San Mateo. 9.24 The City of San Mateo will have final approval for all outside case management services utilized, including but not limited to defense attorneys, nurse case managers, vocational experts and investigative firms. 9.25 The City of San Mateo must pre-approve the pursuit of any third party action/subrogation claim. 9.26 Request for surveillance must be discussed and approved by the City of San Mateo. 9.27 On all settlements, including 0% PD and future medical, a settlement authorization request must first be submitted to the City of San Mateo for their approval. 9.28 Represent the City of San Mateo at workers compensation hearings. The expense must be included in your rates. 9.29 Notify the excess carrier of potential claims as provided by the carrier s Service agreement terms. 9.30 Monitor and collect all recoveries due the City of San Mateo. 9.31 Review medical provider bills for appropriateness of fees charged utilizing the California Official Medical Fee Schedule.

9.32 A smooth integration and administration of existing Medical Provider Network program. 9.33 All claim records and claim files shall be the property of the City of San Mateo. TPA shall be responsible for providing claim data to the City of San Mateo upon request for data from the TPA s administrative data system at the administrator s expense. 9.34 Provide all printed workers compensation forms which the City of San Mateo may require, i.e. Employers First Report of Injury, medical authorization form, benefit letters, delay/denial letters, etc. 9.35 The City of San Mateo maintains a workers compensation claims trust checking account. The TPA shall be responsible for payments of benefits from this account. 9.36 TPA should calculate the City of San Mateo s experience modifier each year with an explanation of calculations, development and other rating information to the City of San Mateo. Litigation management 9.37 The City of San Mateo reserves the right to select counsel. 9.38 All defense counsel referrals need prior approval by the City of San Mateo. 9.39 Within 3 business days of referral of the case to defense counsel, a letter will be directed to the attorney outlining the case status and what is needed from a defense standpoint within a specific time frame. 9.40 Within 30 days after receipt of the case, defense should provide written opinion as to compensability, value and settlement, defense strategy and an estimate of the legal fees to handle the case. 9.41 Review each legal bill for accuracy. 9.42 What procedures do you have in place to audit the effectiveness of legal counsel on the outcome of claims? Nurse case management 9.43 Pre authorization by the City of San Mateo is required on all nurse case management assignments. 9.44 Nurse case manager s action plans and notes will be documented in the claim file, and as appropriate NCM s will participate in claim

reviews or when consultation with the NCM is requested by the City of San Mateo. 10.0 Claim Staffing expectations and Claim Handling Philosophies 10.1 A dedicated claims team must be provided. Adjusters must have at least 5 years of technical claim adjusting experience within the California jurisdiction and experience with public safety 4850 benefits. 10.2 Identify proposed staff members who would be assigned to the City of San Mateo and submit statements or resumes detailing their qualifications and experience with municipalities. 10.3 Indemnity adjusters are not to have caseloads in excess of 130 files. Describe the caseloads of your medical only and indemnity adjusters. 10.4 If workloads increase over the life of the Service agreement, propose how your company would meet the increased staffing needs. 10.5 Disclose the turnover ratio in the last 3 years of your management team, and claim adjusters. 10.6 Describe your staffing back up plan in cases when the team is not available. 10.7 Describe your adjuster s bi-lingual capabilities. 10.8 Describe how your WC adjusters coordinate other benefit plans, i.e. State disability benefits. Identify your ability to work in conjunction with the City of San Mateo to coordinate the payment amounts and timing of benefit checks to avoid duplication of benefits. 10.9 Describe your new hire orientation and ongoing training for claim adjusters, support personnel and management team regarding legislative changes and current industry trends. 10.10 Does your TPA employ board certified physicians or vocational rehabilitation specialists? If so, how do they support the claim adjusters? 10.11 What percentage of claims (separated by medical only and indemnity) do your adjusters close within one year, 2 years and beyond 2 years? 10.12 How often do your adjusters maintain contact with the claimants throughout the duration of the claim? What is your adjuster s standard method of communication to clients and claimants?

10.13 Describe how your adjusters identify and manage fraudulent claims. 10.14 Describe the source of the adjuster s absence guidelines for determining the length of disability. 10.15 Pre authorization by the City of San Mateo is required on all assignments of investigation and sub-rosa. 10.16 Describe how your adjusters provide timely payment of benefits as mandated by the California Labor Code, and the levels of authority for decision making payments and settlements. 10.17 Describe your company s reserving philosophy, including timeliness in establishing initial and subsequent reserves as well as supervisory review and approval process. 10.18 Describe how your adjusters pursue early return to work and assist with the provisions of reasonable accommodations with the treating physician, claimant and the City of San Mateo. 10.19 Describe your adjuster s philosophy on administratively closing stipulated awards with future medical. 10.20 Describe the process and timing of involvement with a medical case manager and physician. 10.21 Describe your index bureau process and what are the adjuster s requirements to follow up on index bureau s hits? 10.22 Provide a sample of an adjusters claim status report. 10.23 How have you provided claim management services for public entities along with sworn police officers and fire personnel? 10.24 Describe your process for detecting duplicate medical bills. 10.25 When overpayments are made or made to the wrong provider, describe your procedure for reconciliation. 10.26 Provide a description of your utilization review process and procedures. 11.0 Special Handling Instruction 11.1 A customized claims service instructions is required that includes claim handling best practices and any specific service requirements of the City of San Mateo.

11.2 Describe how the special handling instructions would be communicated to the claims team assigned to the City of San Mateo. 11.3 Provide a sample special handling instruction agreement. 12.0 Performance Guarantee 12.1 Indicate your willingness to agree to a performance guarantee, subject to mutual agreement between your company and the City of San Mateo. Include your suggestions regarding the performance areas to be measured, how they would be measured and what at what intervals. Include a sample of your standard performance guarantee. 13.0 Risk Management Information System (RMIS) The TPA s Risk Information System must have the following abilities: 13.1 Internet based claim system with access 24 hours a day, 7 days a week to view claim adjuster and supervisor notes, generate loss runs or other pre-scheduled or adhoc loss management/claim reports. 13.2 Ability to export claim data into various microsoft products, i.e. word, excel, power point. 13.3 Provide RMIS technical support for questions, problems or development of customized reporting. 13.4 Preferably claim data is real time, or uploaded every 24 hours. 13.5 Import all prior loss data dated before July 1, 2013 into a single database. 13.6 Provide scheduled loss reports to be sent electronically to the City of San Mateo each month, each quarter and upon request. These reports will include, but not limited to: a. Detailed listing of open claims & closed claims. b. Summaries of all open and closed claims. c. Listing of first aid only claims. d. Claims cost detail. e. Claims by department. f. Claim trending. g. Financial reconciliation ledger. h. OSHA reports. 13.7 Customized reports that may include, but not be limited to; job titles, injury types, loss causation, lost workdays, modified work

days, use of MPN or other medical clinics, and managed care reports that track cost containment activities and fees charged for these activities ( i.e. bill review, utilization review, etc.). 13.8 Quality control program to ensure data integrity and claimant confidentiality. Any RMIS problems will be resolved within 24 hours or less. 13.9 Image system to scan all documents received pertaining to the case. 13.10 Fully compliant with MMSEA Section 111 reporting requirements. Disclose any fees associated with this service, including the names of any 3 rd party TPA used for this reporting. 13.11 Secured system that may include, but not limited to; security audits, protected by intrusion prevention and intrusion detection systems, communications of any claimant s personal information or personal health information is protected (i.e. monitoring of email and internet traffic, encrypted email, access restricted by user ID and password, or other similar security methods). Additional questions relative to TPA s claim system: 13.12 When was the last release/update to your RMIS system? Describe what upgrades were made. Do you have any planned enhancements to your RMIS? If so, describe. 13.13 Describe your disaster recovery plan regarding the continuation of your claims management and risk management information system. 13.14 Provide a list of data elements you capture and indicate which data elements are available in reportable form. 13.15 What standard reports are provided within your service fee? Describe them in detail and provide a few sample reports. 13.16 What type of customized reports are available, any fees charged for customization and provide a few samples of these customized reports. 13.17 How does your system track return to work data? 13.18 Does your RMIS system have the ability to produce OSHA recordkeeping logs and forms? If so, how does your RMIS collect the necessary data for the OSHA 300 forms? 13.19 Describe your process for data transmittal at end of service agreement period including format for data to be provided to the

City of San Mateo and conversion assistance when converting data to a new TPA. Include any fees charged for this service. 13.20 Describe what system notifications that can/may be communicated and/or generated by the City of San Mateo. 13.21 Any additional charges for system upgrades, including updates that are required by changes in California state laws? 14.0 Quality Management Program 14.1 Describe your claim audit program including areas that are audited, frequency of the audit, and corrective action on areas in need of improvement. 14.2 Describe your customer satisfaction program and how concerns are addressed and resolved. 15.0 Pricing 15.1 Provide a cost proposal that includes a summary of all fees detailing services related to such fees, including full disclosure of sub-contractor fees associated with claim services to be provided through the TPA. 15.2 Provide pricing for both life of claim and life of service agreement. This should include pricing structure for both run off claims and new claims occurring as of July 1, 2013. 15.3 If more than one pricing alternative is available, describe in detail each option, including any flat fee option. 15.4 Describe the costs of your services for network access and any other charges related to the provision of provider networks. 15.5 Describe any charges related to MMSEA reporting and requirements. 15.6 Include any pricing changes over the course of the service agreement and if you offer any flat rate guarantee. 15.7 Describe and demonstrate the capabilities and cost savings comparative of your managed care/medical cost containment program including, but not limited to; case management services, utilization review and bill reviews. Indicate which services are owned by your company and which services you use subcontractors. If services are sub-contracted out, disclose any commissions and/or any other type of compensation you receive from the sub-contractors.

16.0 Ancillary Services 16.1 Does your company offer any unbundling ancillary services? If your company provides this unbundling option, please describe the services and fees charged in the areas of allocated claim expenses, including but not limited to; bill review, utilization review, prescription drug programs, managed care/preferred provider or other provider networks. 17.0 Funding Workers Compensation claims 17.1 Confirm your ability to adhere to the City of San Mateo s workers compensation trust fund program and process, as described below: The City of San Mateo has a trust fund checking account to cover payments and reimbursements applicable to the self-insured worker s compensation program. The trust fund checking account shall be established in the name of the TPA as agent of the City of San Mateo. Deposits shall be made to the account as required to ensure that funds are available for payment of claims for settlement and allocated loss expenses upon presentation of check or warrant. The TPA shall provide the bank checks stock. Checks shall be protected with state of the art security features. TPA shall not draw on the trust fund checking account for any purpose other than adjustment of claims and payment of allocated loss expenses. Once each month, TPA shall provide the City of San Mateo with a detailed accounting of all workers compensation benefits and allocated loss expenses paid from the fund. The detailed accounting shall include the date and check number of all benefit and allocated loss payments and shall also include appropriate supporting documentation for allocated loss expense payments. A monthly check register summary shall be provided. TPA is responsible for erroneous payments made from the account by their error. The amount of any such erroneous payments made from the account shall be deducted from administrative fee payments. TPA shall develop, implement and maintain security procedures to ensure safeguard of funds in the account and the bank checks. Such procedures shall be approved by the City of San Mateo. Provide a sample monthly reconciliation report. 18.0 Standard Service Agreement A copy of City of San Mateo s standard service agreement is found in Appendix 3 of this RFP. If TPA has any exceptions to the City of San Mateo s standard service agreement, TPA must identify any provision they are not prepared to satisfy. Any requested changes will be considered by the City of San Mateo when evaluating proposals.

19.0 Loss Data Claim loss data will be provided in a separate e-mail or upon request of a prospective TPA. This loss data can be used to estimate future claim frequency and types of claims. Any claim data submitted as part of the RFP process is for informational purposes only. The City of San Mateo or ABD Insurance & Financial shall not be responsible for the complete accuracy of said data.

Appendix One (Sample) Third Party Administrator Contact Sheet Complete a company contact sheet with the following information: Name of TPA: Address: City: State: Zip Code: Telephone: Contact person: Title: Address: State: Zip Code: Telephone (office): Telephone (cell): Email:

Appendix Two (Sample) Reference Data Sheet Provide company name, and contact information for 3 current clients and 2 past clients that you provide(d) workers compensation TPA services Current Clients 1. Company Name: Dates of service: Contact person: Title: Address: City: State: Zip Code: Telephone: Email: 2. Company Name: Dates of service: Contact person: Title: Address: City: State: Zip Code: Telephone:

Email: 3. Company Name: Contact person: Dates of service: Title: Address: City: State: Zip Code: Telephone: Email: Past Clients 1. Company Name: Contact person: Dates of service: Title: Address: City: State: Zip Code: Telephone: Email: 2. Company Name: Contact person:

Dates of service: Title: Address: City: State: Zip Code: Telephone: Email:

Appendix 3 City of San Mateo Standard Service Agreement AGREEMENT WITH FOR SERVICES This Agreement, made and entered into this day of,, by and between the CITY OF SAN MATEO, a municipal corporation existing under the laws of the State of California ("CITY"), and, a ("CONTRACTOR"). R E C I T A L S : A. CITY desires certain services hereinafter described. B. CITY desires to engage CONTRACTOR to provide these services by reason of its qualifications and experience for performing such services and CONTRACTOR has offered to provide the required services on the terms and in the manner set forth herein. NOW, THEREFORE, IT IS AGREED as follows: SECTION 1 - SCOPE OF SERVICES The scope of services to be performed by CONTRACTOR under this Agreement is as described in Exhibit A to this Agreement, which is attached and incorporated by reference. SECTION 2 - DUTIES OF CONTRACTOR CONTRACTOR shall be responsible for the professional quality, technical accuracy and coordination of all work furnished by CONTRACTOR under this Agreement. CONTRACTOR shall, without additional compensation, correct or revise any errors or deficiencies in its work. CONTRACTOR represents that it is qualified to furnish the services described under this Agreement. CONTRACTOR shall be responsible for employing or engaging all persons necessary to perform the services of CONTRACTOR. SECTION 3 - DUTIES OF CITY

CITY shall provide pertinent information regarding its requirements for the project. CITY shall examine documents submitted by CONTRACTOR and shall render decisions pertaining thereto promptly, to avoid unreasonable delay in the progress of CONTRACTOR'S work. SECTION 4 - TERM The services to be performed under this Agreement shall commence on and be completed on or about. SECTION 5 - PAYMENT Payment shall be made by CITY only for services rendered and upon submission of a payment request upon completion and CITY approval of the work performed. In consideration for the full performance of the services set forth in Exhibit A, CITY agrees to pay CONSULTANT a fee pursuant to rates stated in Exhibit B, attached and incorporated by reference. SECTION 6 TERMINATION Without limitation to such rights or remedies as CITY shall otherwise have by law, CITY shall have the right to terminate this Agreement or suspend work on the Project for any reason, upon ten (10) days' written notice to CONTRACTOR. CONTRACTOR agrees to cease all work under this Agreement upon receipt of said written notice. SECTION 7 - OWNERSHIP OF DOCUMENTS All documents prepared by CONTRACTOR in the performance of this Agreement are and shall be the property of CITY, whether the project for which they are made is executed or not. SECTION 8 - CONFIDENTIALITY All reports and documents prepared by CONTRACTOR in connection with the performance of this Agreement are confidential until released by CITY to the public. CONTRACTOR shall not make any such documents or information available to any individual or organization not employed by CONTRACTOR or CITY without the written consent of CITY before any such release. SECTION 9 - INTEREST OF CONTRACTOR CONTRACTOR covenants that it presently has no interest, and shall not acquire any interest, direct or indirect, financial or otherwise, which would conflict in any manner or degree with the performance of the services under this Agreement. SECTION 10 - CONTRACTOR'S STATUS

It is expressly agreed that in the performance of the services required under this Agreement, CONTRACTOR shall at all times be considered an independent contractor as defined in Labor Code Section 3353, under control of the CITY as to the result of the work but not the means by which the result is accomplished. Nothing herein shall be construed to make CONTRACTOR an agent or employee of CITY while providing services under this Agreement. SECTION 11 - INDEMNITY CONTRACTOR agrees to hold harmless and indemnify CITY, its elected and appointed officials, employees, and agents from and against any and all claims, loss, liability, damage, and expense arising out of CONTRACTOR s performance of this Agreement, except for those claims arising out of CITY s sole negligence or willful misconduct. CONTRACTOR agrees to defend City, its elected and appointed officials, employees, and agents against any such claims. SECTION 12 - INSURANCE CONTRACTOR shall provide and maintain: A. Commercial General Liability Insurance, occurrence form, with a limit of not less that $1,000,000 each occurrence. If such insurance contains a general aggregate limit, it shall apply separately to this Agreement or be no less than two (2) times the occurrence limit. Policy must include contractual liability, personal and advertising injury. B. Automobile Liability Insurance, occurrence form, with a limit of not less than $1,000,000 each occurrence. Such insurance shall include coverage for owned, hired, and non-owned automobiles. C. Workers Compensation in at least the minimum statutory limits. D. General Provisions for all insurance. All insurance shall: 1. Include the City of San Mateo, its elected and appointed officials, employees, and agents as additional insureds, except Automobile Liability, with respect to this Agreement and the performance of services in this Agreement. The coverage shall contain no special limitations on the scope of its protection to the above-designated insureds. 2. Be primary with respect to any insurance or self-insurance programs of City, its elected and appointed officials, employees, and agents. 3. Be evidenced, prior to commencement of services, by properly executed policy endorsements in addition to a certificate of insurance. 4. No changes in insurance may be made without the written approval of the City Attorney's Office. 5. Evidence of insurance must be provide upon execution of the contract and annually thereafter upon expiration of policies. 6. Any claims made policy of tail must be maintained for a minimum of 3 years after termination of the agreement/contract with the City. SECTION 13 - NONASSIGNABILITY

Both parties hereto recognize that this Agreement is for the personal services of CONTRACTOR and cannot be transferred, assigned, or subcontracted by CONTRACTOR without the prior written consent of CITY. SECTION 14 - RELIANCE UPON SKILL OF CONTRACTOR It is mutually understood and agreed by and between the parties hereto that CONTRACTOR is skilled in the performance of the work agreed to be done under this Agreement and that CITY relies upon the skill of CONTRACTOR to do and perform the work in the most skillful manner, and CONTRACTOR agrees to thus perform the work. The acceptance of CONTRACTOR's work by CITY does not operate as a release of CONTRACTOR from said obligation. SECTION 15 - WAIVERS The waiver by either party of any breach or violation of any term, covenant, or condition of this Agreement or of any provisions of any ordinance or law shall not be deemed to be a waiver of such term, covenant, condition, ordinance or law or of any subsequent breach or violation of the same or of any other term, covenant, condition, ordinance or law or of any subsequent breach or violation of the same or of any other term, condition, ordinance, or law. The subsequent acceptance by either party of any fee or other money which may become due hereunder shall not be deemed to be a waiver of any preceding breach or violation by the other party of any term, covenant, or condition of this Agreement or of any applicable law or ordinance. SECTION 16 - COSTS AND ATTORNEY FEES Attorney fees in an amount not exceeding $85 per hour per attorney, and in total amount not exceeding $5000, shall be recoverable as costs (by the filing of a cost bill) by the prevailing party in any action or actions to enforce the provisions of this Agreement. The above $5000 limit is the total of attorney fees recoverable whether in the trial court, appellate court, or otherwise, and regardless of the number of attorneys, trials, appeals, or actions. It is the intent of this provision that neither party shall have to pay the other more than $5000 for attorney fees arising out of an action, or actions to enforce the provisions of this Agreement. SECTION 17 - NON-DISCRIMINATION CONTRACTOR warrants that it is an Equal Opportunity Employer and shall comply with applicable regulations governing equal employment opportunity. Neither CONTRACTOR nor any of its subcontractors shall discriminate in the employment of any person because of race, color, national origin, ancestry, physical handicap, medical condition, marital status, sex, or age, unless based upon a bona fide occupational qualification pursuant to the California Fair Employment and Housing Act. SECTION 18 - MEDIATION Should any dispute arise out of this Agreement, any party may request that it be submitted to mediation. The parties shall meet in mediation within 30 days of a

request. The mediator shall be agreed to by the mediating parties; in the absence of an agreement, the parties shall each submit one name from mediators listed by either the American Arbitration Association, the California State Board of Mediation and Conciliation, or other agreed-upon service. The mediator shall be selected by a "blindfolded" process. The cost of mediation shall be borne equally by the parties. Neither party shall be deemed the prevailing party. No party shall be permitted to file a legal action without first meeting in mediation and making a good faith attempt to reach a mediated settlement. The mediation process, once commenced by a meeting with the mediator, shall last until agreement is reached by the parties but not more than 60 days, unless the maximum time is extended by the parties. SECTION 19 - LITIGATION CONTRACTOR shall testify at CITY'S request if litigation is brought against CITY in connection with CONTRACTOR'S services under this Agreement. Unless the action is brought by CONTRACTOR, or is based upon CONTRACTOR'S wrongdoing, CITY shall compensate CONTRACTOR for preparation for testimony, testimony, and travel at CONTRACTOR'S standard hourly rates at the time of actual testimony. SECTION 20 - NOTICES All notices hereunder shall be given in writing and mailed, postage prepaid, addressed as follows: To CITY: To CONTRACTOR: SECTION 21 - AGREEMENT CONTAINS ALL UNDERSTANDINGS; AMENDMENT This document represents the entire and integrated agreement between CITY and CONTRACTOR and supersedes all prior negotiations, representations, and agreements, either written or oral. This document may be amended only by written instrument, signed by both CITY and CONTRACTOR. SECTION 22 - GOVERNING LAW AND VENUE This Agreement shall be governed by the laws of the State of California and, in the event of litigation, venue will be in the County of San Mateo.

IN WITNESS WHEREOF, CITY and CONTRACTOR have executed this Agreement the day and year first above written. CITY OF SAN MATEO CONTRACTOR (Mayor or Dept. Head or City Manager Please Indicate ONE here include name) Its Authorized Agent ATTEST: APPROVED AS TO FORM:, City Clerk Attorney, City