A. Condensed Claims Administration Responsibilities 1. Accept and process injury reports 24/7, forwarding relevant details to a claims representative promptly. 2. Determine liability for claims per North Carolina Workers’ Compensation Laws. 3. Process claims per North Carolina Industrial Commission regulations. 4. Evaluate open claims and advise Wilson County Schools on proper resolution. 5. Maintain detailed claim files, including medical, factual, and financial records. 6. Compute and disburse temporary disability benefits in a timely manner. 7. Assess permanent disability and facilitate informal ratings to minimize litigation. 8. Assist employees with necessary paperwork for permanent disability ratings. 9. Process and pay all settlements, awards, and pensions. 10. Maintain reserve estimates for reported claims. 11. Conduct investigations to assess eligibility and third-party liability. 12. Report excess claims to reinsurance carriers. 13. Coordinate rehabilitation services when needed. 14. Set up and manage benefit payments per Wilson County Schools' requirements. 15. Prepare required reports for North Carolina and other regulatory agencies. 16. Participate in quarterly case management reviews for complex claims. 17. Provide Wilson County Schools staff with access to the claims system. 18. Collaborate with HR to monitor injury trends and improve workplace safety. 19. Report program performance quarterly, highlighting key metrics. 20. Review contract costs with HR, including medical, administrative, and investigative expenses. B.Medical Management 1. Provide Wilson County Schools with a predictable Workers’ Compensation budget and continue to contain Wilson County Schools’s costs. 2. Authorize, review and monitor all medical treatment required on injury or illness claims. Audit and pay all medical expenses. 3. Maintain close contact with treating physicians to ensure employees receive proper medical treatment and are returned to full employment at earliest date. 4. Consult frequently with Wilson County Schools in those cases where injury residual might involve restriction and/or retirement potential. C. Legal Administration 1. Refer litigated cases to Wilson County Schools’s attorney for purposes of defending Wilson County Schools interests before Workers’ Compensation Appeals Board and the court. 2. Work closely with counsel in preparing defense of litigated cases. 3. Obtain Wilson County Schools’s authorization on all settlements or stipulations when required. 4. Work closely with the applicant's attorney and legal counsel in informal dispositions of litigated cases. 5. Attend, when required, Workers’ Compensation Appeals Board hearings. 6. Discharge on behalf of Wilson County Schools all legal obligations to its injured employees imposed by Workers’ Compensation Appeals Board and higher courts. 7. Protect and preserve Wilson County Schools interests in all potential subrogation cases. D. Statistical 1. Report to Wilson County Schools, monthly status of claim payments and reserves on an individual claim basis and in the aggregate. 2. Report to Wilson County Schools, quarterly loss analysis of claims filed by frequency and severity. 3. Assist in the preparation of all reports required by the State of North Carolina or other Governmental agencies relating to Workers’ Compensation claims. 4. Provide the following reports on a monthly basis at minimal at Wilson County Schools discretion. o Claim Logs o Claim Activity o Claim Cost Detail o Claim Cost Summary o Claim Cost Summary by Year o Examiner Activity o Examiner Case Log o Frequency Reports o Location Summary o Management Summary o Multiple Claims Listing o Occurrence Cost o OSHA Reporting/Requirements o Payment Type Totals o Vendor Payments Detail o Vendor Payments Summary o State Annual Report E. Transition To ensure an orderly transition, Wilson County Schools may require the following: 1. As part of the response, TPA must submit an Implementation Plan which Wilson County Schools can immediately implement after vendor selection, describing all requirements for Wilson County Schools to change its panel of providers. Monthly fixed price payments to the TPA by Wilson County Schools will commence after the contract has been signed by all involved parties, and continue thereafter. 2. At the inception of the contract, the TPA will assume medical management responsibilities for all open claims and any new or reopened claims. Wilson County Schools will provide assistance in gathering required information and documentation. 3. Additional costs incurred by the TPA for the transition of existing medical care records and cases during the transition period must be quoted separately and should not be included in the annual fee quoted by the TPA. A detailed description of any such additional costs must be provided to Wilson County Schools.
