ATTACHMENT E – REQUIREMENTS TRACEABILITY MATRIX

NYS WORKERS’ COMPENSATION BOARD – TPA RFP - C140734

ID / Requirement Text (RFP Section 4.4.2) / Proposal Section/Appendix # / Proposal Page # / Proposal Paragraph #
Service Lot #1
1. / Describe Bidder’s claims administration business, including: ownership, history, client overview, organization, number of employees, business headquarters and satellite locations. Include any client service promotional material.
2. / Identify any New York state agencies that Bidder currently has a contract with, or that Bidder has had a contract with during the last three (3) years, and provide a description of the services provided.
3. / Provide the names of all entities for whom Bidder has performed services similar to those described in this RFP during the last three (3) years. The WCB reserves the right to contact any of the entities listed to confirm the veracity of the information provided.
4. / Specify how long Bidder has provided claims administration services for NYS workers’ compensation claims.
5. / Indicate how many NYS workers’ compensation claims Bidder is currently administering in NYS;
6. / Describe Bidder’s training procedures. At a minimum:
  1. Indicate whether new Claims Examiners train with a mentor prior to being assigned to work alone; if so, how long does the training period lasts;

  1. Provide copies of any handbooks or manuals outlining/describing the job duties for the provision of claims administration services; indicate whether such materials are provided to all adjusters and/or supervisory staff, or is simply an available resource; and

  1. Describe Bidder’s process for training and educating staff about updated or newly enacted laws or policies, relevant to the administration of NYS workers’ compensation claims.

7. / Indicate whether injured worker claims reporting services are available 24/7.
8. / Describe the Bidder’s processes for early intervention, claim reserving, and claim investigation, indicating the frequency of such processes; specifically including, but not limited to:
  1. Monitoring of claimant’s employment status, physical address, medical evidence, etc.;

  1. Verifying claimant’s entitlement to indemnity payments (including “alive and well” checks); and

  1. Selecting claims for, and effectuating settlements under WCL §32.

9. / Describe Bidder’s procedures for handling catastrophic/high cost claims.
10. / Describe the Bidder’s process for performing medical bill review services. Specifically:
  1. Indicate whether the medical bill review is conducted in house or outsourced and provide a brief description of the process;

  1. Indicate whether there is a preferred provider network established/utilized/available; and

  1. Provide the information requested in “a” and “b” for pharmacy benefit management services.

11. / Describe the Bidder’s practices and procedures regarding treatment authorization and utilization of the medical treatment guidelines. Specifically:
  1. Indicate whether there is a trained medical team on staff. If so, indicate the medical certifications/qualifications held by the team members;

  1. Provide a summary of the process for reviewing treatment and variance requests; and

  1. Describe Bidder’s utilization management practices.

12. / Describe the Bidder’s methods and approaches to fraud identification, investigation, and resolution;
13. / Describe Bidder’s litigation practices, including Bidder’s use of outside counsel. If outside counsel is used, indicate the services provide by such outside counsel.
14. / Describe Bidder’s methods for identifying and recovering liens, loss transfer, and other benefits.
15. / Indicate whether Bidder currently has interpretation or translation services available. If so, describe the services and how they are provided. If not, please confirm that Bidder can, and will have, interpretation and translation services available during the term of any Contract resulting from this RFP. Such services must be consistent with the requirements of NYS Executive Order 26.
16. / Describe Bidder’s “Best Practices” for the administration of workers’ compensation claims.
17. / Describe Bidder’s procedure for assigning claims to Claims Examiners and Claims Supervisors. Provide a maximum number of opened claims that will be assigned to each Claims Examiner for each of the Funds referenced in Service Lot #1, and provide a separate maximum number of opened claims that will be assigned to any such Examiner who may be handling opened claims for multiple Funds and/or claims for outside parties.
18. / Describe the minimum level of qualifications that Bidder requires for Claims Examiners, Claims Supervisors and Claims Directors, including education level and years of experience administering NYS workers’ compensation claims.
19. / Indicate which of Bidder’s claims administration staff have settlement and reserving authority, and describe how such authority is structured.
20. / Describe Bidder’s quality assurance processes (i.e. supervisory reviews, key performance indicators, internal/external procedural audits, quality controls, etc.).
21. / Describe any scenarios that could arise which would create a conflict of interest; explain how such conflicts will be identified and resolved by the Bidder.
22. / Identify any individuals and/or entities that Bidder currently subcontracts with, or anticipate subcontracting with, for the provision of any of the services, primary or ancillary, described in this RFP (e.g. Medical Set-Aside vendors, Independent Medical Examiners, Legal Counsel, Bill Review services, Accounting, etc.).
23. / Describe Bidder’s Electronic Claims Management System (“ES”), including but not limited to: software platform, functionality, notable attributes or features, report generating capabilities, remote access, data mining, predictive analytics, security features, firewalls, backup/redundancy and disaster recovery.
24. / Indicate whether the ES is proprietary or maintained/managed by a third party (if using a third-party system, provide the name and a brief description of such system).
25. / Indicate the type of technology ES is written in and its underlying database.
26. / Describe how ES will:
  1. Provide complete remote access for the WCB and NYS Office of the Comptroller;

  1. Allow simultaneous viewing of files by the WCB staff from multiple locations;

  1. Convert and store all received claims documents into ES in image format;

  1. Allow the WCB to view all imaged documents, all history of claims reporting in compliance with statutory reporting requirements, and reserving history and rationale;

  1. Allow alerts to be scheduled;

  1. Protect security of information;

  1. Allow reports to be generated;

  1. Allow segregation of claims by type (such as incident, indemnity, medical only, etc.); and

  1. Comply with mandatory use of ICD10 codes.

Service Lot #2
1. / Describe the Bidder’s medical bill review service offerings, currently available in New York State. Specifically, address:
a. Whether the Bidder currently evaluates compliance with the NYS Medical Treatment Guidelines. If so, describe how compliance is evaluated;
b. How Bidder gathers information to determine whether the treatment is medically necessary and, if so, whether the need for the treatment is causally related to the established injury sites; and
c. How many claims the Bidder is prepared to perform bill review services for.
2. / Indicate how long Bidder has been providing bill review services for NYS workers’ compensation claims.
3. / Indicate how many NYS workers’ compensation claims Bidder is currently providing such services for.
4. / Describe the Bidder’s training procedures.
5. / Describe how Bidder will evaluate SDF reimbursement requests.
6. / Identify any New York state agencies that Bidder currently has a contract with, or that Bidder has had a contract with during the last three (3) years, and provide a description of the services provided.
7. / Provide the names of all entities for whom Bidder has performed services, similar to those described in this RFP, during the last three (3) years. The WCB reserves the right to contact any of the entities listed to confirm the veracity of the information provided.
8. / Describe Bidder’s Computer System (“ES”), including but not limited to: functionality, report generating capabilities, remote access, data mining, predictive analytics, security features, firewalls, backup/redundancy and disaster recovery.
9. / Bidder may be asked to appear at the Board’s Schenectady offices to provide a demonstration of its medical bill review service offerings.

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