Specifications include, but are not limited to: The successful carrier will provide a full range of services to the West Virginia State Agencies Program. These services include but are not limited to: Professional claims adjusting. This includes all managed care, prescription drug plan, utilization review, bill review, return to work, Qualified Rehabilitation Professionals (QRPs), other allocated and unallocated claim expenses including pharmacy benefit manager fees. Claims handling and services will begin on a first dollar basis with expenses paid from the loss reimbursement fund up to the deductible limit. The carrier will discuss their reserving philosophy and strategy with the OIC. The carrier will be responsible for the setting and maintenance of the reserves on this program. The carrier must have several claim reporting options available to the State such as telephone, electronic (email), online/electronic systems (web reports), fax, and/or paper reporting capabilities. The carrier must agree to attend and to provide adequate staff to address loss reviews and services at our specified location upon our request. The carrier will issue monthly invoices (12 monthly installments) to the OIC for both premium and loss fund. The carrier must be capable of receiving and processing electronic payments. The OIC will be responsible for timely payment of the monthly invoices and for any other premium billings such as audits and true ups. A fully funded loss reimbursement fund or “loss fund” will be created to provide claim funds up to the deductible limit to pay for losses and allocated loss expenses. The OIC will pay an agreed amount of funds directly to the carrier into the loss fund on a monthly basis and the carrier will deduct monies from the account (up to the deductible limit) to pay claims costs and expenses. Each policy must have a separate fund for reconciliation purposes.
