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HomeMy WebLinkAboutAllied Managed Care, Inc. (AMC) - 2015-09-21Dept ID HR 15-004 Page 1 of 2 Meeting Date 9/21/2015 A.P,0�41)e-b -7-0 CITY OF HUNTINGTON BEACH REQUEST FOR CITY COUNCIL ACTION MEETING DATE: 9/21/2015 SUBMITTED TO: Honorable Mayor and City Council Members SUBMITTED BY: Fred A Wilson, City Manager PREPARED BY: Michele Warren, Director of Human Resources SUBJECT: Approve and authorize execution of Professional Services Contracts with Acclamation Insurance Management Services (AIMS) in an amount not to exceed $983,146 over a three-year period providing Workers' Compensation, Medical and Disability Claims Administration Management Services, and, Allied Managed Care (AMC) in an amount not to exceed $825,000 over a three-year period to provide Workers' Compensation Medical and Disability Bill Review Services Statement of Issue The City currently contracts with Acclamation Insurance Management Services (AIMS) and Allied Managed Care (AMC) to provide third party administration (TPA) and medical bill review services Their current contracts are scheduled to expire as of September 30, 2015 In anticipation of the contract expiration, staff is utilizing an Inter -Agency agreement as these firms have been awarded contracts with other public agencies (City of Clovis) as recently as July 2015 Financial Impact Sufficient funding for the contracts is authorized under account numbers 55131001 69415 and 55131001 69410 as provided for in the City's annual operating budget Approximate annual costs for each service is $327,715 for AIMS and $275,000 for AMC Recommended Action A) Approve and authorize the Mayor and City Clerk to execute "Professional Services Contract Between the City of Huntington Beach and Acclamation Insurance Management Services (AIMS) to S� Provide Workers' Compensation, Medical and Disability Claims Management Services" for a three year term, and, BApprove and authorize the Mayor and City Clerk to execute "Professional Services Contract Between the City of Huntington Beach and Allied Managed Care, Inc (AMC) to Provide Workers' Compensation Medical and Disability Bill Review Services" for a three year term Alternative Action(s) Approve a contract extension for one additional year and instruct staff to start a formal Request for Proposal (RFP) process Analysis Both AIMS and AMC have performed at or above the level of service delivery expectation required to provide third party administration and medical bill review services In order to provide continuity in the City's workers' compensation program, Staff recommends the approval of additional three year xB -573- Item 13. - 1 Dept ID FIR 15-004 Page 2 of 2 Meeting Date 9/21/2015 contracts AIMS and AMC have provided efficient and regulatory compliant claims administration and continue to Improve reporting time, claims closing ratios, litigation and medical case management outcomes Both vendors have provided additional ancillary services and cost savings have been achieved with their medical bill review and utilization review processes Contracting with AIMS and AMC provides the City with streamlined processes and efficient program administration and is more cost effective than internal claims administration The claims staff at AIMS have been instrumental to the success of the administration of this program and contract continuation provides stability of service delivery to City employees, retirees, and other ancillary vendors and professionals connected to the workers' compensation claims administration program Environmental Status N/A Strategic Plan Goal Strengthen economic and financial sustainability Attachment(s) 1 AIMS Professional Service Approval Form Part 1 2 AIMS Professional Service Approval Form Part 2 3 Professional Services Contract Between the City of Huntington Beach and Acclamation S e Management Services 4 AMC Professiona ervice Approval Form Part 1 5 AMC Professional Service Approval Form Part 2 6 Professional Services Contract Between the City of Huntington Beach and Allied Managed Care, Inc (AMC) 7 AIMS and AMC Insurance Certificate 8 Interagency Agreement City of Clovis Contract Item 13. - 2 HB -574- ATTACHMENT # I' i CITY OF HUNTINGTON BEACH s Professional Service Approval Fora PART I Date: 6/4/2015 Project Manager game Patti Williams Requested by Name if different from Project Manager Department Human Resources RECEIVED JUN 15 Z015 Finance Department PARTS I OF THE PROFESSIONAL SERVICES CONTRACTS APPROVAL FORM MUST BE COMPLETED BY THE REQUESTING DEPARTMENT AND SIGNED BY THE CITY MANAGER, FOR APPROVAL, BEFORE PROCEEDING WITH THE SOLICITATION OR CONTRACT PROCESS. PART l MUST BE FILED WITH ALL APPROVED CONTRACTS. 1) Briefly provide the purpose for the agreement: Allred Managed Care To retain Medical and Disability Bill Review Services for Workers' Compensation 2) Estimated cost of the services being sought. $ 825,000.00 3) Are sufficient funds available to fund this contract? ❑ Yes ® No If no, please explain We will be asking for an increase during the budget process 4) Check below how the services will be obtained: ❑ A Bid solicitation process in accordance to the MC 3.03.060 procedures will be conducted ® MC 3.03 08(b) -Other Interagency Agreement procedure will be utilized 44n,r- 0Pr-r'cc ❑ MC 3.03.08 - Contract Limits of $30,000 or less exempt procedure will be utilized C�� f-s F C�/,'far; Ci-4-il Wr c(vvis 5) Is this contract generally described n the list of professional service contracts approved by the City Council? If the ins is qa fs "No,° the contract will require approval from the City Council } .Ye ,� No —.. Fiscal Services anager Signature (Purchasing Approval) Date 6) Amount, Business Unit (8 digits) and Object Code (5 digits) where funds are budgeted (Please note that a budget check will occur at the object code level): Account number Contractual Dollar Amount Business unit. object # Fiscal Year 15/16 Fiscal Year 16117 Fiscal Year 17/18 55131001-69410 $275000 $275000 $275000 APPROVED iMMagees Signature professional service approval form - part i - amc HB -605- REV. February 2015 W // s Date Date l-% 5- 6/ Date' Date Item 13. - 33 ATTACHMENT #5 s 1' Professional Service Approval Fore Date: 6/4/2016 Project Manager: Patti Williams Requested by Name if different from Project Manager Department: Human Resources RECEIVED JUN 15 2015 Finance Department PARTS I & It OF THE PROFESSIONAL SERVICES CONTRACTS APPROVAL FORM MUST BE COMPLETED BY THE REQUESTING DEPARTMENT AND SIGNED FOR APPROVAL. PART I & 11 MUST BE FILED WITH ALL APPROVED CONTRACTS. 1) Name of consultant Allied Managed Care (AMC) 2) Contract Number: HR (Contract numbers are obtained through Finance Administration x 5630) 3) Amount of this contract $825,000 Account number Contractual Dollar Amount Business unit object # Fiscal Year 15116 Fiscal Year 16117 Fiscal Year 17/18 55131001-69410 $275,000 $275,000 $275,000 $ $ $ Is $ $ 4) Is this contract less than $50,000? ❑ Yes (R No 5) Does this contract fall within $60,000 and $100,000? ❑ Yes ® No 6) Is this contract over $100,0007 ® Yes ❑ No (Note' Contracts requiring City Council Approval need to be signed by the Mayor and City Clerk Make sure the appropriate signature page is attached to the contract ) 7) Were formal written proposals requested from at least three available qualified consultants? D Yes ❑ No 8) Attach a list of consultants from whom proposals were requested (including a contact telephone number.) 9). Attach Exhibit A, which describes the proposed scope of work. 10) Attach Exhibi , which describes the payment terms of the contract i 6-//--/J Fiscal anagg&r (Purchasing) Date kBud CKeta=gerAppalgnature Da e 7�Y) qS� Js Director of Finance (or designee) Signature Date Item 13. - 34 ,, approval form - part a amc HB -606- 2015 ATTACHMENT #6 PROFESSIONAL SERVICES CONTRACT BETWEEN THE CITY OF HUNTINGTON BEACH AND ALLIED MANAGED CARE, INC. TO PROVIDE WORKERS' COMPENSATION MEDICAL AND DISABILITY BILL REVIEW SERVICES THIS AGREEMENT ("Agreement") is made and entered into by and between the City of Huntington Beach, a municipal corporation of the State of California, hereinafter referred to as "CITY, and ALLIED MANAGE CARE, INC., a California corporation hereinafter referred to as "CONSULTANT." WHEREAS, CITY desires to engage the services of a consultant to provide workers' compensation medical and disability management services, and Pursuant to documentation on file in the office of the City Clerk„ the provisions of the Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service contracts have been complied with; and CONSULTANT has been selected to perform these services, NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows: 1. SCOPE OF SERVICES This Agrecnrent between CONSULTANT and CITY relates to the provision of workers' compensation medical bill review services which CONSULTANT shall provide as described in Exhibit "A," which is attached hereto and incorporated into this Agreement by this reference. These services shall sometimes hereinafter be referred to as the "PROJECT " CONSULTANT hereby designates Mark Denison who shall represent it and be its sole contact and agent in all consultations with CITY during the performance of this Agreement. Page 1 of 13 15-4849/125644 2. CITY STAFF ASSISTANCE CITY shall assign a staff coordinator to work directly with CONSULTANT in the performance of this Agreement. 3. TERM • TIME OF PERFORMANCE Time is of the essence of this Agreement. The services of CONSULTANT are to commence on%j6WjM1..1J 2 r(le "Commencement Date"). This Agreement shall automatically terminate three (3) years from the Commencement Date, unless extended or sooner terminated as provided herein. All tasks specified in Exhibit "A" shall be completed within time frame required for each task until this Agreement terminates. The time for performance of the tasks identified in Exhibit "A" are generally to be shown in Exhibit "A." This schedule may be amended to benefit the PROJECT if mutually agreed to in writing by CITY and CONSULTANT. In the event the Commencement Date precedes the Effective Date, CONSULTANT shall be bound by all terms and conditions as provided herein. 4. COMPENSATION In consideration of the performance of the services described herein, CITY agrees to pay CONSULTANT a fee as specified in Exhibit "B," which is attached hereto and incorporated by reference into this Agreement. Such fee, including all costs and expenses for seivices provided pursuant to this Agreement, shall not exceed Two Hundred Seventy-five Thousand Dollars ($275,000.00) annually. In the event the cost and expenses exceed $ 2 7 5 , 0 0 0.00, the CONSULTANT shall inform CITY of the amount over and why the extra cost was incurred. This extra cost will then be negotiated between the CITY and CONSULTANT. Page 2 of 13 15-4849/125614 5. EXTRA WORK In the event CITY requires additional services not included in Exhibit "A" or changes in the scope of services described in Exhibit "A," CONSULTANT will undertake such work only after receiving written authorization from CITY. Additional compensation for such extra work shall be allowed only if the prior written approval of CITY is obtained. 6. METHOD OF PAYMENT CONSULTANT shall be paid pursuant to the terms of Exhibit "B." 7. DISPOSITION OF PLANS ESTIMATES AND OTHER DOCUMENTS CONSULTANT agrees that title to all materials prepared hereunder, including, without limitation, all original drawings, designs, reports, both field and office notices, calculations, computer code, language, data or programs, maps, memoranda, letters and other documents, shall belong to CITY, and upon expiration or termination of this Agreement or upon PROJECT completion, whichever occurs first CONSULTANT, shall turn these materials over to CITY, at no cost to CITY whatsoever, in a readable, identifiable formnat all data and programs identified herein. These materials may be used by CITY as it sees fit. 8. HOLD HARMLESS CONSULTANT hereby agrees to protect, defend, indemnify and hold harmless CITY, its officers, elected or appointed officials, employees, agents and volunteers from and against any and all claims, damages, losses, expenses, judgments, demands and defense costs (including, without limitation, costs and fees of litigation of every nature or liability of any kind or nature) arising out of or in connection with CONSULTANT's (or CONSULTANT's subcontractors, if any) negligent (or alleged negligent) performance of this Agreement or its failure to comply with any of its obligations contained in this Agreement by CONSULTANT, its Page 3 of 13 154849/125644 officers, agents or employees except such loss or damage which was caused by the sole negligence or willful misconduct of CITY. CONSULTANT will conduct all defense at its sole cost and expense and CITY shall approve selection of CONSULTANTS counsel. This indemnity shall apply to all claims and liability regardless of whether any insurance policies are applicable. The policy limits do not act as limitation upon the amount of indemnification to be provided by CONSULTANT. 9. PROFESSIONAL LIABILITY INSURANCE CONSULTANT shall obtain and furnish to CITY a professional liability insurance policy covering the work performed by it hereunder. This policy shall provide coverage for CONSULTANT's professional liability in an amount not less than One Million Dollars ($1,000,000.00) per occurrence and in the aggregate. The above -mentioned insurance shall not contain a self -insured retention without the express written consent of CITY; however an insurance policy "deductible" of Twenty -Five Thousand Dollars ($25,000.00) is permitted pursuant to a executed Insurance and Indemnification Wavier Modification Request form. A claims -made policy shall be acceptable if the policy further provides that: A. The policy retroactive date coincides with or precedes the initiation of the scope of work (including subsequent policies purchased as renewals or replacements). B. CONSULTANT shall notify CITY of circumstances or incidents that might give rise to future claims. CONSULTANT will make every effort to maintain similar insurance during the required extended period of coverage following PROJECT completion. If insurance is terminated for any reason, CONSULTANT agrees to purchase an extended reporting provision Page 4 of 13 154849/125644 of at least two (2) years to report claims arising from work performed in connection with this Agreement If CONSULTANT fails or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the CITY with required proof that insurance has been procured and is in force and paid for, the CITY shall have the right, at the CITY's election, to forthwith terminate this Agreement. Such termination shall not effect Consultant's right to be paid for its time and materials expended prior to notification of termination. CONSULTANT waives the right to receive compensation and agrees to indemnify the CITY for any work performed prior to approval of insurance by the CITY. 10. CERTIFICATE OF INSURANCE Prior to commencing performance of the work hereunder, CONSULTANT shall furnish to CITY a certificate of insurance subject to approval of the City Attorney evidencing the foregoing insurance covelage as required by this Agreement; the certificate shall: A. provide the name and policy number of each carrier and policy; B. state that the policy is currently in force; and C. shall promise that such policy shall not be suspended, voided or canceled by either party, reduced in coverage or in limits except after thirty (30) days' prior written notice; however, ten (10) days' prior written notice in the event of cancellation for nonpayment of premium. CONSULTANT shall maintain the foregoing insurance coverage in force until the work under this Agreement is fully completed and accepted by CITY. The requirement for carrying the foregoing insurance coverage shall not derogate from CONSULTANT's defense, hold harmless and indemnification obligations as set forth in Page 5 of 13 154849/125644 this Agreement. CITY or its representative shall at all times have the right to demand the original or a copy of the policy of insurance. CONSULTANT shall pay, in a prompt and timely manner, the premiums on the insurance hereinabove required. 11. INDEPENDENT CONTRACTOR CONSULTANT is, and shall be, acting at all times in the performance of this Agreement as an independent contractor herein and not as an employee of CITY CONSULTANT shall secure at its own cost and expense, and be responsible for any and all payment of all taxes, social security, state disability insurance compensation, unemployment compensation and other payroll deductions for CONSULTANT and its officers, agents and employees and all business licenses, if any, in connection with the PROJECT and/or the services to be performed hereunder. CONSULTANT shall comply with all CITY rules, regulations or instructions regarding the Scope of Work contained herein. 12. TERMINATION OF AGREEMENT 1. Termination Without Cause. Either party may terminate this Agreement without cause by giving the other parry 60 days' written notice. 2. Termination For Cause. The CITY may terminate this Agreement for cause upon written notice to the CONSULTANT. For purposes of this Agreement, cause includes, but is not limited to, any of the following. (a) breach of any term of this Agreement by the CONSULTANT, (b) violation by the CONSULTANT of any applicable laws. 3. Such notice shall specify the reason for termination and shall indicate the effective date of such termination. After written notice of breach, CONSULTANT has 30 days to cure the breach. At the end of 30 days if the CONSULTANT fails to cure the breach the CITY will provide 60 day written notice of termination. Page 6 of 13 154849/125644 4. In the event of termination, the CONSULTANT will deliver to the CITY the original of all finished and unfinished documents, exhibits, reports, and evidence and any other work performed by the CONSULTANT, as described this Agreement, and upon receipt thereof, the CONSULTANT will be paid for services performed and reimbursable expenses incurred to the date of termination. At the option of CITY, the above items shall become the property of ' CITY. 13. ASSIGNMENT AND DELEGATION This Agreement is a personal service contract and the work hereunder shall not be assigned, delegated or subcontracted by CONSULTANT to any other person or entity without the prior express written consent of CITY. If an assignment, delegation or subcontract is approved, all approved assignees, delegates and subconsultants must satisfy the insurance requirements as set forth in Sections 9 and 10 hereinabove 14. COPYRIGHTS/PATENTS CITY shall own all rights to any patent or copyright on any work, item or material produced as a result of this Agreement. 15. CITY EMPLOYEES AND OFFICIALS CONSULTANT shall employ no CITY official nor any regular CITY employee in the work performed pursuant to this Agreement. No officer or employee of CITY shall have any financial interest in this Agreement in violation of the applicable provisions of the California Government Code 16. NOTICES Any notices, certificates, or other communications hereunder shall be given either by personal delivery to CONSULTANT's agent (as designated in Section 1 hereinabove) or to Page 7 of 13 15.4849/125644 CITY as the situation shall warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the same in the United States Postal Service, to the addresses specified below. CITY and CONSULTANT may designate different addresses to which subsequent notices, certificates or other communications will be sent by notifying the other party via personal delivery, a reputable overnight carrier or U. S. certified mail -return receipt requested: TO CITY: City of Huntington Beach ATTN: Director of Duman Resources 2000 Main Street Huntington Beach, CA 92648 17. RECORDS TO CONSULTANT: Allied Managed Care, Inc. 10360 Old Placerville Road Sacramento, CA 95827 The CONSULTANT shall maintain financial records adequate to show that the CITY funds paid under this Agreement were used for purposes consistent with the terms of the contract. These records shall be maintained during the term of this Agreement and for a period of three (3) years from termination of this Agreement or until all claims, if any, have been resolved, whichever period is longer, or longer if otherwise required under other provisions of this Agreement. 18. CONSENT When CITY's consent/approval is required under this Agreement, its consentlapproval for one transaction or event shall not be deemed to be a consent/approval to any subsequent occurrence of the same or any other transaction or event. 19. MODIFICATION No waiver or modification of any language in this Agreement shall be valid unless in writing and duly executed by both parties. Page 8 of 13 154849/125644 20. SECTION HEADINGS The titles, captions, section, paragraph and subject headings, and descriptive phrases at the beginning of the various sections in this Agreement are merely descriptive and are included solely for convenience of reference only and are not representative of matters included or excluded from such provisions, and do not interpret, define, limit or describe, or construe the intent of the parties or affect the construction or interpretation of any provision of this Agreement. 21. INTERPRETATION OF THIS AGREEMENT The language of all parts of this Agreement shall in all cases be construed as a whole, according to its fair meaning, and not strictly for or against any of the parties. If any provision of this Agreement is held by an arbitrator or court of competent jurisdiction to be unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining covenants and provisions of this, Agreement. No covenant or provision shall be deemed dependent upon any other unless so expressly provided here. As used in this Agreement, the masculine or neuter gender and singular or plural number shall be deemed to include the other whenever the context so indicates or requires. Nothing contained herein shall be construed so as to require the commission of any act contrary to law, and wherever these is any conflict between any provision contained herein and any present or future statute, law, ordinance or regulation contrary to which the parties have no right to contract, then the latter shall prevail, and the provision of this Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to bring it within the requirements of the law. Page 9 of 13 15.4849/125644 22. DUPLICATE ORIGINAL The original of this Agreement and one or more copies hereto have been prepared and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of the date of its execution and delivery, be deemed an original. Each duplicate original shall be deemed an original instrument as against any partywho has signed it. 23. INMIGRATION CONSULTANT shall be responsible for full compliance with the immigration and naturalization laws of the United States and shall, in particular, comply with the provisions of the United States Code regarding employment verification. 24. LEGAL SERVICES SUBCONTRACTING PROHIBITED CONSULTANT and CITY agree that CITY is not liable for payment of any subcontractor work involving legal services, and that such legal services are expressly outside the scope of services contemplated hereunder. CONSULTANT understands that pursuant to Huntington Beach Cit}p Charter Section 309, the City Attorney is the exclusive legal counsel for CITY; and CITY shall not be liable for payment of any legal services expenses incurred by CONSULTANT. 25. ATTORNEY'S FEES In the event suit is brought by either party to construe, interpret and/or enforce the terms and/or provisions of this Agreement or to secure the performance hereof, each party shall bear its own attorney's fees, such that the prevailing party shall not be entitled to recover its attorney's fees from the nonprevailing party, Page 10 of 13 154949/125"4 26. SURVIVAL Terms and conditions of this Agreement, which by their sense and context survive the expiration or termination of this Agreement, shall so survive. 27. SUFFICIENT FUNDING This Agreement is contingent on the appropriation of sufficient funding by the CITY for the services provided by this Agreement. If funding is reduced or deleted by the CITY for purposes of this Agreement, the CITY has the option to either terminate this Agreement by giving ninety (90) days written notice to CONSULTANT or to offer an amendment to the Agreement with modified terms. CONSULTANT shall have thirty (30) days to accept or reject an amendment to the Agreement. 28. NON -COMPETITION The CITY recognizes that the employees of CONSULTANT and its sub- contractors have substantial information regarding the rates, customer policies and procedures of the CONSULTANT which are CONSULTANT's trade secrets and are very valuable to CONSULTANT and its other clients. The CITY also recognizes that, if an employee of CONSULTANT leaves CONSULTANT to work for the CITY, its subsidiaries, agents, or employees, CONSULTANT may be substantially damaged by its employees' use of those trade secrets. Furthermore, the CITY iccognizes that proof of the misuse of trade secrets is difficult even in the most egregious cases and is always expensive. Therefore, to avoid any potential of misuse of those trade secrets, the CITY agrees during the term of this agreement, and for a period of one year following its termination, that it will not employ any person employed by CONSULTANT or its sub -contractors without prior written consent of CONSULTANT. Page 11 of 13 15-48491125644 29. GOVERNING LAW This Agreement shall be governed and construed in accordance with the laws of the State of California. 30. SIGNATORIES Each undersigned represents and warrants that its signature hereinbelow has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify CITY fully for any injuries or damages to CITY in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. CONSULTANT's initials -" 31 ENTIRETY The parties acknowledge and agree that they are entering into this Agreement freely and voluntarily following extensive arm's length negotiation, and that each has had the opportunity to consult with legal counsel prior to executing this Agreement. The parties also acknowledge and agree that no representations, inducements, promises, agreements or warranties, oral or otherwise, have been made by that party or anyone acting on that party's behalf, which are not embodied in this Agreement, and that that party has not executed this Agreement in reliance on any representation, inducement, promise, agreement, warranty, fact or circumstance not expressly set forth in this Agreement. This Agreement, and the attached exhibits, contain the entire agreement between the parties respecting the subject matter of this Agreement, and supersede all prior understandings and agreements whether oral or in writing between the parties respecting the subject mattei hereof. Page 12 of 13 154849/125644 32. EFFECTIVE DATE IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized officers. This Agreement shall be effective on the date of its approval by the City Attorney This Agreement shall expire when terminated as provided herein. ALLIED MANAGED CARE, INC. a CITY OF HUNTINGTON BEACH, a California corporation municipal corporation of the State of B y:9Sc print nam ITS: (cis cle one) Chatrm e E iden ice President ITS: (circle Officer/Asst, al kk3.1,Oil -,4-1 � Page 13 of 13 I SA849/12W4 ZXHDIT A SCOPE OV SBRYICES WORKERS COMPENSATION CLAIMS The Consultant will provide the following services for workers' compensation elahns for the City as described more specifically below: A. Professional Fees Bill Review B. Bill Payment Recommendation Data C. Hospital Rill Audit D.Utiliration Review (Inpatient and Outpatient) B. Medical Case Management (Telephonic and On -site -Field) F. Peer Review Services G. Medical Director Management Services H. Computer Programming and Data Management I. Systems J. Reporting K. Negotiations 1. The CONSULTANT agrees to conduct bill review of professional service fees, including but not limited to pharmacy bills and durable medical equipment bills. 2. This bill review will consist of: a. Detection of duplicate claims and unbundling. b. Comparison to Califotnla's fee schedule, and/or to the PPO or negotiated fee arrangements and reduction to whichovor is lower. The CITY will have access to a list of PPO providers. e. Review of the pre -certification status of the services. d. Contact with providers when the validity of CPT-4 codes is in question. e. Rc-coding of old CPT-4 codes with currently valid codes included in the California Offoial Medical Fee Schedule. 3. The CONSULTANT will manually review surgical bills for unbundling and upcoding. 4. Disputed bills will be handled directly by the CONSULTANT. The CITY may override decisions made by the CONSULTANT if it is determined to be in the best interests of the CITY. S. The CONSULTANT will use its hest efforts to assist the CITY to recover overpayments and mis-payments to wrong provider. 6. The CONSULTANT will reimburse the CITY for penalties incurred by the CITY in favor of a provider that the CITY is able to prove were a result of the CONSULTANT's negligent or willful action or Inaction. 3. The CONSULTANT will be responsible for provider relations, e.g., the CONSULTANT will 10 2616.00110066 Page l of 6 I3XHIBIT A respond to all inquiries regarding payment recotrunendAtions, bill reductions, lnis-payinents, lost invoices, etc If bills inquire additional information (e.g., report not attached, missing CPT codes), the CONSULTANT will contact provider to obtain needed information for bill processing. B. BILL PAYMENT RECOMMENDATION DATA 1. Tito CONSULTANT agrees to provide bill, payment rcoornittendation data and explanation of review ("FOR.") data to the CITY daily. 2. The CONSULTANT agrees to provide explanations of review ("FORS"), which shall include each of the following items of information, to the extent that such items of information have been provided to the CONSULTANT: a. The name of the patient. b. Patient social security number. C. The dates services were rendered, d. The amount of the bill, e The amount of the reduetionladjustment, £ The amount recommended for payment. g. Tile reasons for payment reduction or denial, h. The provider's address. 1. The date received by the CITY (from the CITY date stamp on the bill). j. Description of service provided, k. Provider's name. 11 Medical service code, in, The date contractor received the bill n, The date contractor reviewed die bill C. HOSPITAL BILL AUDIT All hospital bills arc ilia through a stringent AMC coding verifleation process. Hospital bills ate roviewed by various levels of our staff, all the way up to the Medioai director and/or the Senior Vice President of AMC, depending on the eircumstances of the bill and where it falls within AMC's internal levels of authority. Hospital bills are a particular strength of AMC in that we insist on the integration of nurses' and physicians' expertise in review of not only In -patient hospital bills, but other complex medical procedures, such as surgeries, extensive diagnostic testing, and other bills commonly identified as demonstrating complex coding Issues. AMC nurses and physicians coluunonly evaluate these types of bills before released back to the client for payment, to ensure that the coding and fee allowance accurately reflects the services performed. California In -Patient Hospital Fee Schedule reimbursements are driven by DRO codes, which are derived from a multitude of pioceduic codes and diagnoses codes, AMC's process verifies each and every code on the bill in conjunction with the supporting documentation provided in the report. We ensure that the proper procedure and diagnoses codes are galled up into the proper DRQ code, which dictates the payment allowance. This process, In itself, is an "audit" process that every in -patient Page 2 of G 102416.001133066 EXHIBIT A hospital bill at AMC goes through. Once the proper DRO code is determined, the Tree Schedule is applied, any PPO discounts taken, and the Explanation of Benefits (BOB) generated to reflect the new code, the reason for the now code, and the recommended allowance. D. UTILIZATION R): YIE InpatirntUtilization Revlcw 1. The CONSULTANT agrees to provide pre -admission review, concurrent review, for all workers' compensation cases requiring inpatient stays after notification by the CITY or the network provider. 2. The CONSULTANT will provide Peer Review upon approval from the CITY. Physician Peer Review is physician to physician evaluation of cases for medical appropriateness (which often includes second surgical opinion by the physician peer reviewer) upon request of Utilization Review, Telephonic Case ManagemenWiald Case Management or claims person. 3. These utilization review programs will be administered in accordance with Title 8, California Code of Regulations, Section 9792.6, concerning utilization management. 4. The CONSULTANT will strongly encourage network providers to contact the CONSULTANT for preadmission approval. When non -network facilities are used, CITY's Claim Administrator will icier provider to the CONSULTANT for pre -admission approval. 5. Non -Certification of inpatient services by the CONSULTANT will be done in accordance with the State of California regulations on Utilization Review. 6. The CONSULTANT will provide the CITY and the appropriate facility notification of all denials and Approvals for inpatient stays and the conditions of that stay. Outpatient Utilization Reviely 1. The CONSULTANT agrees to pre -certify/ authorize treatment for chiropractic, services, physical therapy, MRIs, durable medical equipment costing in excess of $250, and outpatient surgeries performed outside of a physician's office, and agrees to maintain a concurrent review program forphysical medicine, including physical therapy or chiropractic services. 2. The CONSULTANT will provide Poor Review upon approval from the CITY. Physician Peer Review is physician to physician evaluation of cases for medical appropdateness (which often Includes second surgical opinion by the physician poor reviewer) upon request of Utilization Review, Telephonic Case ManagernenWield Case Management or claims person. 3. These utilization review programs will be administered in accordance with Title 8, California Code of Regulations, Section 9792.6, concerning utilization management. 4. The CONSULTANT will strongly encourage network providers to contact the CONSULTANT directly for preauthorization of outpatient services. 5. Non -Certification of outpatient services by the CONSULTANT will be done in accordance with the State of California regulations on Utilization Review. 10-2616001MOC,6 Page 3 of 6 EXHIBIT A u. ► � ►�_� r : _ �a siltl The CONSULTANT agrees to provide for case management at the request of the CITY: 1. Help the CITY establish criteria for iecominending case management. 2. Interact with the injured employee, the providers of medical care, and the CITY's Claims Admi►►lstrator. 3. Use criteria to establish maximum medical improvement and retuL u to work time -frames. A. Use protocols to establish acceptable patterns of treatment and to assist the, CONSULTANT in identifying excessive or inappropriate treatments. Case management will be administered in accordance with Title 8, California Code of Regulations, Section 9792.6, concerning utilization management. S. Medical case management services will include; a. On -site (Field) Nurse Case Management b. Telephonic Nurse Case Management F. PEEK REVIEW SERVICES Upon request by the City, the Consultant shall provide peer review services. The Consultant will provide peer review services ("Peer ItevioW% consistent with the regulations of the State of California and URAC, that include first level and second level review by licensed professionals (M D., D.C., Acupuncturist, eto.), within the regulatory tune francs. Physician Peor Review is physician to physician evaluation of cases for medical appropriateness (which often inoludes second surgical opinion by the physician peer reviewer) upon request of Utilization Review, Telephonic Case Management/Field Case Management or claims person. G. W.MAL DIRECI OR MAAlA.CrMMBNT SEitVTCES Upon request by the City, the Consultant shall provide Medical Director Management services. A medical director (an M.D., and licensed in California) will be provided to the City for overseeing the City's Utilization Management system at no additional cost to the Peer Review process. H. COMPUTER PROGRAMMING AND DATA MANAGEMENT 1. The CONSULTANT will perform the initial programming requir meats for the interface between the CONSULTANT and the CITY's claims management system - initial prograinming is included at no charge. 2. Prior to commencing any additional wotik requested by the CITY, the CITY and the CONSULTANT shall agree, in a written document signed by both parties, on the scope of the work to be performed And the estimated number of Hours required for completion. 1. The CONSULTANT agrees to provide integrated bill payment data, case management and utilization management systems in the foim of file -based data exchange and user-friendly 10,2616 001/53066 Page 4 of 6 EXHIBIT A screen interface directly integrated into the CITY's system, 2. The CONSULTANT agrees to allow the CITY access to the CONSULTANT's system for status and inquiry purposes. CITY access to the CONSULTANT's system will secured by password. 3. The CONSULTANTwill scan all medical bills, check claims history, and index the medical bills with the appropriato claim number prior to processing through bill review. In addition, the CONSULTANT will check the provider identification number and date of service to prevent duplicate payment. Further, the CONSULTANT will link two or more claim numbers together because they are claims of the sonic employee. The CONSULTANT will link the multiple claim numbers in the CONSULTANT's system and will cross-check For duplicates on the claim numbers as so linked. 4. The CITY will review recommended allowance by the CONSULTANT and authorize payment of medical bills in the CITY's system. S. The CONSULTANT will import a daily transmittal of basic claims data and vendor master filc data from the CITY's claims database; this database should be refreshed daily through a new transmission of the CITY's claims database. The CONSULTANT will enter bill payment information and then run a batch program that matches medical bills to claim Information and produce a listing of mJected bills that require CITY review. 5. The CONSULTANT agrees to transmit medical bill payment recommendation information Into - ihe CITY's claims management system or designee for the purposes of processing payments The CITY's claims management system or designee interfaces with the CITY's central accounting system. The CONSULTANT will supply daily a data transmittal of medical bill payment recommendation information to be transmitted into the CITY's claims management system or designee following the current Bill Review Import and Export Interface Specifications requirements. These include but not limited to the following data: a. Claim number. b. Employee's name. c. Employee's Social Security Number. d. Provider's name. e. Provider's address. f. Date received by the CITY (from CITY date stamp). g, Amountbilled. h. Date of Service. i. Descripilon of service. J. Amount recommended. k. Amount of reduction, 1. Date of payment recommendation by the CONSULTANT. in, Warrent-number. n. I)ate tho contractor received die bill o. Date the CONSULTANT reviewed the bill tasUta aatM066 Page 5 of G EXHIBIT A J. REPORTING A. Standard Reports The CONSULTANT agrees to produce and provide the CITY with standard written repotls. The CONSULTANT will provide a monthly report on referrals for all services and numbers of bills reviewed as it relates to the services. A. A.d I Ioc Reports CONSULTANT agrees to provide ad hoc written mports containing data captured in CONSULTANT's UR and Case Management SmattNotes database at no charge. Bill Review database ad hoe reporting will require a pass thru charge of$150/bour when requested by the CITY. K. NEGOTIATIONS CONSULTANT routinely negotiates fee reductions on bills meeting standard criteria. It includes but is not limited to in -patient hospital bills, surgical procedures, and other high dollar exposures, Our negotiation approach, which includes a signed negotiation letter by both CONSULTANT and tiro medical providor, serves (2) two putposest 1. Acceptance ofpaytnent as Rill and #final payment (eliminating lien potentials), and 2. Additional savings below Tee Schedule allowances, for expanded bill review savings for our clients Tho CONSULTANT Negotiation Unit is able to negotiate additional savings beyond PPO discounts and/or in place of whon no PPO reduction is applied by the specific PPOs. The Negotiation Unit has built telationships with providers who are now submitting requests directly for additional savings and prompt payments. Additionally, all bills regardless of status that are in excess of $1,200.00 (after reductions) are rcviewed'for potential referral to the negotiation unit. It should be noted that our clients pay only a percent of these additional savings, if we achieve savings above and beyond the foe schedule. Pago 6 of 6 toabtcoaus M EXHIBIT A EXHIBIT, B PRICING AND BILLING On a monthly basis the Consultant will invoice for all,services included in the Fee for Service. The invoice will include a report by claim number, employee name, and date and type of service°provided 1. Consultant shall be entitled to monthly progress payments toward Ahe fixed fee tset forth herein in accordance with the following progress .and payment schedules, a. Bill Peer Review. Per bill Pricing is $8.00per bill b. Hospital Bill- Audit: Hospital, Bill Audit is billed at 10% of savings as measured against billed charges c. Professional services bill review and,PPO network access 18-26% d Utilization Review- Utilization Review is an evaluation for appropriateness of treatment, for a3 specific procedure or block of treatment. This includes pre- eertifieationjauthorization, PT, chiropractic review, concurrent review. Nurse, level Utilization Reviews are billed at the flat rate of $80.00,per nurse level. review. e. Peer Review: Physician peer review is physician to physician evaluation of cases for medical appropriateness, (which ,often includes second surgical opinion by the physician peer review) upon request of OR, TCM of claims person, Peer review is4200_00 per review. f. Telephonic Case Management: Telephonic Case Management as a stand alone service is $80.00 per hour. This includes Hospital Pre -Certification, ,Length of Stay Review, and Discharge Planning as well as Utilization Management for all services. g. Field Case Management: Field Case Management as a stand alone service :will be charged at VQ.00 per hour. This includes Hospital Pie.Cer1ification, Length of Stay Review, and Discharge Planning as well as Utilization Management for all services. h Negotiation Service: Consultant will conduct negotiation attempts on all bills meeting or exceeding the cost outlier or are exempt from State Fee Schedules. The fee for negotiations is 15% of savings off billed charges, up to a maximum of$15,000 per negotiation. 2. Delivery of work product; A copy of every memorandum, letter, report, calculation and other documentation prepared by Consultant shall be submitted to'Chy to demonstrate progress toward completion of tasks. In the event City rejects or has Page 1 of 2 EXHIBIT B 10-2616 001/AMC DchibAD doe s a comments on any such product, City shall identify specific requirements for satisfactory completion, 3. Consultant shall submit to City an invoice for each monthly progress payment due. Such invoice shall; A) Reference this Agreement; B) Describe the services performed; C) Show the total amount of the payment due; D) Include a certification by a principal member of Consultant's firm that the work has been performed in accordance with the provisions of this Agreement; and E) For all payments include an estimate of the percentage of work completed. Upon submission of any such invoice, if City is satisfied that Consultant is making satisfactory progress toward completion of tasks in accordance with this Agreement, City shall approve the invoice, in which event payment shall be made within thirty (30) days of receipt of the invoice by City. Such approval shall not be unreasonably withheld. If City does not approve an invoice, City shall notify Consultant in writing of the reasons for non -approval and the schedule of performance set forth in Exhibit "A" may at the option of City be suspended until the parties agree that past performance by Consultant is in, or has been brought into compliance, or until this Agreement has expired or is terminated as provided herein. 4. Any billings for extra work or additional services authorized in advance and in writing by City shall be invoiced separately to City. Such invoice shall contain all of the information required above, and in addition shall list the hours expended and hourly rate charged for such time. Such invoices shall be approved by City if the work performed is in accordance with the extra work or additional services requested, and if City is satisfied that the statement of hours worked and costs incurred is accurate. Such approval shall not be unreasonably withheld. Any dispute between the parties concerning payment of such an invoice shall be treated as separate and apart from the ongoing performance of the remainder of this Agreement. 10 2616 0011AMC Exhibit B.doc Page 2 of 2 EXHIBIT B Cityof Huntington Beach UTILIZATION REIVEW TRIGGERS PHYSICAL THERAPY, CHIROPRACTIC, MASSAGE & ACUPUNCTURE initial PT/OT exceeding 18 visits and exceeding 18 visits If post surgery Initial Chiropractic visits exceeding 18 visits Acupuncture Massage Gym membership Work Harding/Work Conditioning, Functional Capacity Evaluations Slofeedback All Non -Medical exercise or treatment programs Including: Reflexology Aerobics Personal Trainers Aquatics Pllates TESTING Diagnostic testing to include: Repeat MRI's with no clear objective findings, prior to six months same body part as initial MRI CTScan Arthrogram (MRi /aye, GAD or MRA) Myelogram Video Fluoroscopy Discogram EMS/Nerve Conduction Studies ECSWT W Extracorporeal Shockwave Therapy PAIN MANAGEMENT All Epidurals Chronic pain management Morphine pumps/implanted pumps Chemonucleolysls All Spinal Cord Stimulators Prolotherapy External and Implantable Bone Growth Stimulators IDET (Int(adlecai Electrothermal Therapy) Experimental Treatment InterdlsdplInM pain programs Facet Nerve Blocks, Selective Nerve Root Blocks Detox Programs Pain Pumps Botox Synvisc, Hyalagen, orSupartz Injections Radiofrequency lesloning of any nerve (RFA) SURGERIES AND HOSPITALIZA71ONS All of the following: Inpatient surgeries in -patient hospitallzatlons/or length of stay Concurrent reviews for extended stays skilled nursing facility/rehab/step down or transitional Home health care PRESCRIPTIONS All of the following; Prescriptions for opiates, narcotics, and all medications not directly related to accepted condition or body part. Prescriptions for sleep gilds, psyche medications in excess of six month period Prescriptions for life style drugs, such as Viagra and compounded medication All IV or iM Antibiotics and SQ administered in the Home Over the counter medications exceeding $300.00 or if not medically substantiated OTHER All of the following: Weight loss programs Durable Medical Equipment, on -going rentals for DME or supplies over$5©0.00 Dental Sevlces Including dental care of dental appliances All nonmedical home services Home modifications Home exercise equipment Mattresses Vehicles orvehicle modifications All treatment that exceeds or are not recommended in MTUSJACOEMIODG City Of Huntington Beach 2000 Main Street ® Huntington Beach, CA 92648 (714) 536-5227 ® www.huntingtonbeachca.gov Office of the City Clerk Joan L. Flynn, City Clerk September 29, 2015 Allied Managed Care, Inc 10360 Old Placerville Road Sacramento, CA 95827 e To Whom it May Concern Enclosed for your records is a copy of the fully executed "Professional Services Contract Between The City of Huntington Beach and Allied Managed Care, Inc to Provide Workers' Compensation Medical and Disability Bill Review Services " Sincerely, JF pe Enclosure Sister Cities Anjo, Japan ® Wartakere, New Zealand ATTAC H M E N T { DINSURANCE AND INDEMNIFICATION WAIVER MODIFICATION REQUEST 1 Requested by Risk Management - Heather Campbell 2. Date July 21, 2015 3 Name of contractor/permittee Acclamation Insurance Management 4 Description of work to be performed Third Party Claims Administration and Managed Care Services 5 Value and length of contract: $983,146 for AIMS/ $825,000 for AMC - 3 years 6 Waiver/modification request $25,000 SIR on Professional Liability coverage 7 Reason for request and why it should be granted Sufficient funds available to cover 8 Identify the risks t946e City in approving this waiver/modification N A Department Head Signature Date APPROVALS Approvals must be obtained in the order listed on this form Two approvals are required for a request to be granted Approval f om the City Manager's Office is only required if Risk Management and e City Attorney's ffice disagree 1. 'sic Management Approved ❑ Denied la4jj;� Signature Uate 2. City Attorney's Office Approved ❑ Denied 3 Signature Date 3. City Manager's Office ` ❑ Approved ❑ Denied Signature Date If approved, the completed waiver/modiflcation request is to be submitted to the City Attorney's Office along with the contract for approval Once the contract has been approved, this form is to be filed with the Risk Management Division of Human Resources Waiver Form CiOCm 712112015 3 59 00 PM Clrantf!• R1Dr, ACCLINSU --------- - - - - ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNWr 1 7/07/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements) PRODUCER Edgewood Partners Ins Center Lic#0629730 (415) 356-3900 135 Main Street, 21th Floor San Francisco, CA 94105 COONNTACT LAURIE MARTINNA_ _ E 415 356-3934 (MAX PHONo Ext _ (A1C, NoI AE MAIL DDRESS LAURIE MARTIN@EPICBROKERS COM J -- INSURER(S) AFFORDING COVERAGE NAIC S INSURER Philadelphia Indemnity Insuranc 18058 INSURED INSURER D State Compensation Ins Fund 35076 Acclamation Insurance Management 10445 Old Placerville Road Sacramento, CA 95827 INSURERc Lloyds of London INSURER D Indian Harbor Insurance Co 36940 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER REVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVE BEEN ISSUED TOTHE INSURED NAMEDABOVE FORTHE POLICYPERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR _ ODL SUBR� POLICY EFF POLICY EXP LTR TYPEOFINSURANCE INSR WVD POLICY NUMBER MWDD (MIND LIMITS A GENERAL LIABILITY PHPK1274186 0110112015 01/011201ti $1,000,000 QpEAApC��H�qOCCC7URRENCE PRE`i�l]SES EaEaccTurrre+lce _ $1 00O 000 X COMMERCIAL GENERAL LIABILITY MEO EXP(Any one person) $5000 CLAIfs1S-1AADE OCCUR PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG $2,000,000 S POLICY 'IECt7 LOC A AUTOMOBILE LIABILITY PHPK1274186 1/01/2015 0110112016WaecodentSINGLEL11.917 1,000,000 BODILY INJURY (Per Person) S X ANY AUTO BODILYINJURY (Per aocidwt) PR-PPE«RdanDA1,1P.6E $ X ALLOWNED SCHEDULEO AUTOS _ AUTOS HIRED AUTOS X NONOIYNED AUTOS $ S A S101000,000 X UMBRELLALIAB OCCUR PHUB485028 110112015 01/0112016 EACH OCCURRENCE S10,000,000 EXCESS LIAB X CLAINIS-MADE AGGREGATE _ ICED I I RETENTION$ S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRtET0FRARTNERlEXECUTtVE YIN OFF(CERIMEMBEREXCLUDED? n (Mandatory In NH) NIA 908337915 1/01/2015 0110112016X TORYLI IT OTH- EL EACHACCIOEPIT S11,000,000 EL DISEASE - EA EMPLOYEE 51,000,000 EL DISEASE - POLICY LIP S 1,000,000 It yes, describe under DESCRIPTION OF OPERATIONS be,av C Privacy Liability 479712 7/11/2015 07/11/2016 $3,000,000 ea claim/agg D Professional Liab MPP003820603 071111201510711112016� $5,000,000 Ann Agg-E&O Errors&Omissions I I 1 $25,000 SIR E&O & C ber DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additfonal Remarks Schedule, if more apace Is required) Claims Adjusting and Claims Management Services Thirty day notice of cancellation will be provided to the certificate holder but 10 days for non-payment of premium Named Insured Includes Acclamation Insurance Management Services, Inc.; Allied Managed Care, Inc, LJR Holdings, Inc,; LJR Properties, LLC (See Attached Descriptions) City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE ACORD 25 (2010105) 1 of 2 #S382056/M381935 ©1988-2010 ACORD CORPORATION All rights reserved The ACORD name and logo are registered marks of ACORD LMA4 APPROVED AS TO FORM r� By, ( Michael Gatesr MY Atto ney DESCRIPTIONS (Continued from Page 1) 1 EMPLOYEE DISHONESTY I CRIME COVERAGE Executive Risk Indemnity, Inc #82344565 EFF: 111/15 EXP: 111116 DISHONESTY LIMIT. $2,000,000 $35,000 DEDUCTIBLE Third party claims administration services SAGITTA 25 3 (2010105) 2 of 2 #S382056IM381935 LJR 1-10mrtirUs /INCORPORATED 07/15/2015 Page 1 of 2 LJR Holdings, Inc Consolidated Balance Sheet Fiscal Year - 2016 For the Twelve Months Ending June 30, 2016 LJR CONSOLIDATED ARMS AMG RISKNET HOLDINGS 6f3912016 Assets Current Assets Cash Operating Account $500,819 02 $442,374 39 $0 00 $12,425 04 $955,618 45 Havrdii Petty Cash Account 665 18 000 000 000 665 18 EFT Accou nt 25000 000 000 000 25000 Business Piabnum Savings Account 2,000,000 00 000 Goo 000 2,000,000 00 2,501,734 20 442,374 39 0 00 12,425 04 2,956,533 63 Receivables Accounts Reveivable Reserve for Bad Debt Misc Receivables Stockholder Loan Other NR Pass thru Deferred Income Tax Asset Accruals Work in Progress Advances Salary Advances Prepalds Pre -paid Insurance Pre -paid Expenses Pre paid Rents Total Current Assets Fixed Assets Office Equipment Office Equipment - Attu Depr Furniture Fixtures Furniture Fixtures -Attu Depr Cap Lease Computers & Equip Cap Lease Comp & Equip - Accu Depr Cap Lease Furniture Cap Lease Furniture - Accu Depr Leasehold Improvements Leasehold improvements - Attu Amort Total Fixed Assets Due TolFrom Due Wfrom AIMS, AMC, & LJRH Due from LJR Properties LLC Due from Risk Net 1,820,183 70 1,398,862 67 000 000 3,219,046 37 (30,000 00) 000 000 000 (30,000 00) 48,122 37 000 000 20000 48,322 37 000 000 000 176,129 16 176,129 16 (15,000 ()0) 000 000 000 (15,00000) 000 000 000 457,437 00 457,437 00 1,823,30607 1,398,86267 000 633,76616 3,855,93490 55,393 89 59,162 90 000 000 114,556 79 000 000 000 92,624 39 92,624 39 82,490 25 000 000 11,199 37 93,689 62 86,944 31 34,685 57 000 133,392 65 255,022 53 73,567 37 000 000 000 73,567 37 243,00193 34,68557 D00 144,59202 422,27952 4,823,436 09 1,936,086 63 000 $83,407 61 7,441,929 23 2,729,847 91 87,857 32 goo 000 2,817,705 23 (2,057,56474) (85,59011) 000 000 (2,143,15485) 664,698 50 99,872 51 000 goo 764,571 01 (316,931 98) (92,765 88) 000 goo (409,697 86) 396,930 36 236,441 47 000 000 633,371 83 (362,467 27) (236,441 47) 000 000 (598,908 74) 821,703 39 337,581 34 000 000 1,159,284.73 (821,703 39) (309,618 91) 000 000 (1,131,322 30) 261,316 58 33,08258 0 00 000 294,399 16 (167,686 93) (28,066 48) 000 000 (195,753 41) 1,148,142 43 42,352 37 000 000 1,190,494 80 (4,904,689 74) 9,688,313 61 000 (4,783,623 87) 000 000 000 291,022 28 14858 000 (9,948 64) 9,80006 Total Due TolFrorn (4,904,641.16) 9,629,313 61 (0,948 64) OlherAssels Deposits 139,654 90 000 000 Capital Projects - WIP 7,02429 000 000 Capital Sofhvafe Cast 261,795 92 000 000 Capital Soft%vare Cost - Amortization (28,641 91) 000 000 Licensing 24,000 00 000 000 Licensing -Amortization (8,000 04) 000 000 Club Membership 39,000 00 000 000 Total Other Assets Total Assets 434,833 16 000 0100 0-00 291,022 28 000 (4,482,801 53) 291,022 28 10,000 00 149,654 90 000 7,02429 000 261,795 92 000 (28,641 91) 000 24,000 00 000 (8,000 04) 000 39,000 00 10,000 00 444,833 16 $1,301,870 62 $11,666,751 61 ($9,948 64) ($3,689,393 92] $9,368,279 47 (� Ljft 11OLD11\IGS P,INCORPORATED LJR Holdings, Inc Consolidated Balance Sheet Fiscal Year - 2015 For the Twelve Months Ending June 30, 2016 07/1512015 Page 2 of 2 LJR CONSOLIDATED ARAS A1dC RISKNET HOLDINGS 613012015 Liabilities Current Liablilltes Payabtes Accounts Payable $154,151 72 $456,709 15 $0 00 $43,122 86 $653,983 73 401(k) Payable 12,579 79 0 00 000 000 12,579 79 166,73151 456,70915 000 43,12286 666,56352 Accruals Accrued Payables 113,711 96 6,311 68 000 39843 120,422 07 Accrued Adjuster Wages 16 614 84 37,588 52 000 000 54,203 36 Accrued FSA 81497 000 000 000 81497 Accrued Vacation 272,975 96 171,165 15 goo 115,845 36 559,986 47 404,117 73 215,065 35 000 116,243 79 735,426 87 Taxes Excise Tax- Hav7au 6,51859 7,67162 000 coo 14,190 21 Federal, State, & Local Income Tax 000 000 O 00 (38,926 29) (38,926 29) 6,51859 7,67162 000 (38,926 29) (24,736 08) Long Term Debt, Current Portion Lease Liability - Computers 000 000 000 28,687 47 28,687 47 First ins Funding Loan Payable 31,47108 000 000 000 31,471 08 Equipment loan Payable 75,818 39 0 00 000 000 75,818 39 Loan From Officer(s) 000 0 00 000 52,142 58 52,142 58 LinesofCredit- BACC1CelUcCapitaVWFB 000 000 000 552,80524 552,80524 107,289 47 0 Ott 000 633,635 29 740,924 76 Total Current Liabilities 684,657 30 679,44612 000 754,076 65 2,118,179 07 Long Term Liabltttles Long Term Debt, Less Current Portion Lease Liability - Computers 000 0 00 000 5,54839 5,54839 Equipment Loan Payable 169,327 74 000 000 000 169,327 74 169,327 74 000 000 5,54839 174,876 13 Deferred Revenue SCIF 3,899,976 66 000 000 000 3,899,976 66 3,899,976 66 000 000 000 3.899,976 66 Other Deferred Rent 64,105 00 000 000 000 64,105 00 64,105 00 000 000 coo 64,105 00 Total Long Term Liabilities 4,133,40940 000 000 5,64839 4,138,95779 Total Ltabllittes 4,818,066 70 679,446 12 000 759,624 04 6,257,136 86 Equity Shareholders Equity Common Stock 10,000 00 1,00000 000 1,00000 12,000 00 Paid in Capital 000 0 00 000 396,186 70 396,186 70 Total shareholders Equity 10,06000 1,00000 000 397,18670 408,18670 Eamings Retained Earnings (3,577,508 11) 10,340,999 11 (9,698 64) (4,703,094 97) 2,050,697 39 Current Earnings 51,311 93 644,306 28 (250 00) (43,109 69) 652,258 52 Total Earnings (3,526J96 18) 10,986,305 39 (9,948 64) (4,746,204 66) 2,702,965 9t Total Equity 13,516,196 is) 10,986,306 39 (9,948 64) (4,349,017,96) 3,111,142 61 Total Liabilities & Equity $1,301,870 62 $11,666,761 61 ($9,948 64) ($3 580,393 92) $9,368,279 47 ATTACHMENT #8 CLAIM ADMINISTRATOR AGREEMENT THIS AGREEMENT FOR SERVICES (this "Agreement") is made and entered into as of this 1't day of July, 2015, between the City of Clovis, (the "Client'), and ACCLAMATION INSURANCE MANAGEMENT SERVICES, INC ("Claim Administrator" and/or "AIMS") for Claim Administrator to provide to Client medical and disability management services necessary to achieve the purposes of this Agreement ("Services"). The City of Clovis and Acclamation Insurance Management Services, Inc. may each be referred to herein as a "Party", or collectively as "Parties". in consideration of the mutual covenants herein contained, the Parties hereto agree as follows: I. APPOINTMENT AND AUTHORITY A. Subject to the express limitations of authority set forth herein and in accordance with the provisions of this Agreement, the Client hereby appoints AIMS to adjust and administer claims, and AiMS accepts such appointment, for such class(es) of business and in such territories as are set forth in Schedule A attached to this Agreement. AIMS and its employees, in their performance of their duties under this Agreement shall do so as independent contractors, and shall act in compliance with such rules, regulations, or Instructions as the Client may prescribe in writing. B. In executing the Services contemplated under this Agreement, the Claim Administrator agrees and is hereby authorized: 1. To Investigate, adjust, settle, resist or otherwise process all submitted claims, pursuant to the procedures and within the authority granted bythe Client as set forth in Schedule 8 attached to this Agreement. 2. To Investigate, adjust, settle, resist, or otherwise handle all submitted claims in excess of the authority granted or in variance of the procedures only with the prior approval of the Client 3. To make payment on claims approved for settlement in accordance with the procedures set forth In Schedule 8 attached. 4. To handle all submitted claims according to the requirements of any appropriate legislative and/or regulatory authority. S. To file any reports, maintain any licenses or any other authorization necessary or required by law to carry out the Claim Administrator's obligations and duties under this Agreement C. The Claim Administrator has the authority to do whatever is reasonably necessary, legal and proper to administer claims within the Claim Administrator's settlement authority limit and In accordance with the procedures established under this Agreement. The Claim Administrator Page 1 of 27 Item 13. - 64 HB -636- shall, in connection with such claims, exercise Its own judgment unless the Client specifically advises otherwise It. RECORDS AND REPORTS A Prior to the start of this Agreement, at a date to be mutually agreed to by both Parties, Claim Administrator shall retrieve, at its own expense, all open claim files from the Client or the Client's designated representative It is understood that AIMS shall not be responsible for any expenses related to the retrieval of the Client's closed claims from the Client or the Client's designated representative. All claim files, both open and closed, remain the property of the Client no matter where they are held or stored. B. The Claim Administrator shall keep accurate, complete and separate records of all claims handled pursuant to this Agreement on a timely basis and for the duration set forth herein, or as required by law and/or regulation. The claim files and records shall be established and maintained In accordance with the terms of this Agreement and any applicable law and/or regulation and shall at a minimum contain all documents, notes, and work papers that reasonably pertain to each claim in such detail that pertinent events and the dates of the events can be reconstructed and the Claim Administrator's actions pertaining to the claim can be ascertained. C. The Client, or its duly authorized representative, and any state Insurance regulatory official may at all reasonable times Inspect and copy any and all tiles, records, books, and bank account records maintained by the Claim Administrator pursuant to this Agreement. This right to inspect and copy records, books and bank account records shall survive the cancellation, suspension or termination of this Agreement and shall continue until all claims under this Agreement have been closed or returned to the Client, and all regulatory requirements have been met. D. The Claim Administrator shall furnish the Client and/or its designee(s) with standard loss run reports on a periodic and timely basis. The reports shall contain such Information, in such form, and on such schedule as Is reflected In Schedule S attached to this Agreement. E. It is understood that the Claim Administrator operates in a paperless environment, and that it is standard policy to destroy physical mail thirty (30) days after receipt. All physical mail is electronically scanned and maintained in the Claim Administrator's systems and may be accessed at any time F. The Claim Administrator shall not be responsible for any State Mandated Reporting of Medical Payments, unless the Client uses the Bill Review services offered by Allied Managed Care. Inc Ill. SERVICE FEES AND EXPENSES A. Subject to compliance by the Claim Administrator with the terms and conditions of this Agreement, the Client will pay and the Claim Administrator will accept as full compensation for the Services provided under this Agreement the service fees as set out in Schedule C attached to this Agreem ent. Page 2 of 27 HB -637- Item 13. - 65 B. AIMS shall send monthly invoices to the Client for Services contemplated in this Agreement. Client shall pay Contractor undisputed charges within thirty (30) days of receipt of the invoice. If any charges are disputed, the Client shall pay the undisputed charges, if any, within thirty (30) days of receipt of the invoice. Client and the Claim Administrator shall engage In good faith negotiations to attempt to resolve any disputed charges. C. In the event that Client has a good faith basis to dispute a portion or all of an invoice, it will notify the Claim Administrator in writing with the specific reasons for such dispute within fifteen (15) days of receiving such Invoice and pay the remaining undisputed amounts as provided herein. D The Client shall also be responsible for and shall pay all Allocated Loss Expenses, as defined herein, in addition to the Service fees as provided for in this Agreement. For the purposes of this contract, Allocated Loss Expenses include but are not limited to the following• 1. Fees for medical examinations of claimants, Including the reasonable and necessary transportation expenses of claimants. 2 Costs of reports from attending or examining physicians. 3. Attorneys fees and disbursements. 4. Costs of court report services and transcripts. 5 Costs of stenographic services and transcripts. 6. Witness attendance fees. 7. Court costs. 8. Appeal bonds. 9. Printing costs related to trials and appeals 10. Fees associated with the procuring of testimony, opinions, appraisals, reports, surveys and analyses of professionals and experts. 11. The costs of automobile and property appraisals. 12. Trial and hearing attendance fees. 13. The costs of reports from government agencies or branches. 14. The costs of credit bureau reports. 15. The costs of private investigators. 16. The costs of photographs. V. Medical or vocational rehabilitation costs. 18. Charges for medical costs containment services, i e., utilization review, pre -admission authorization, hospital bill audit, provider bill audit and medical case management. 19. Extraordinary claim investigation and/or travel expense incurred at the request of the Client. 20. The costs of any similar service related to the investigation and defense of a particular claim, or the protection of and collection of the subrogation rights of the Client, for which the Client shall have given prior approval. 21. All fees associated with field adjuster activities where personal contact, investigation and/or litigation involvement Is necessary. 22 Mediation and arbitration costs. Page 3 of 27 Item 13. - 66 xB -63 g- Such Allocated Loss Expenses are limited to reasonable, customary and necessary expenses incurred by the Claim Administrator in the course of the performance of its duties under this Agreement. IV. COMPLIANCE WITH STATE INSURANCE CODES A. The Claim Administrator agrees to operate at all times in compliance with the terms of this Agreement, Including all Schedules attached hereto, and In all material respects with applicable federal, state, and local statutes, regulations, codes and ordinances, including those applicable to unfair trade and claim practices, complaint handling, and records retention pertaining to the services contemplated under this Agreement. B. The Claim Administrator agrees to implement appropriate measures to ensure the security and confidentiality of non-public personal Information provided by the Client. The Claim Administrator further agrees, upon request by the Client, to provide confirmation that such measures have been implemented. V. TERM AND TERMINATION A. The term of this Agreement shall be for a period of three (3) years commencing on the date first written above. During the term of this Agreement the Claim Administrator is the Client's only Claims Administrator in connection with claims outlined on Schedule A attached. All new notices of such claims that the Client or its deslgnee(s) first receive during the term of this Agreement will be forwarded only to the Claim Administrator for the purposes of providing the Services as set out herein. Upon mutual agreement, confirmed in writing by both parties AIMS and the Client may extend this Agreement on a year to year basis for no more than three years. B. Either Party may cancel this Agreement by giving the other party sixty (60) days advance written - notice of its intention to do so. C. The Claim Administrator warrants that it and its adjuster employees now have all licenses necessary to conduct the business described in this Agreement. The Claim Administrator agrees it and specifically the adjusting employees who are assigned to the Client's account will maintaLn during the term of this Agreement any such necessary licenses. In the event that any such license expires or terminates, for any reason, the Claim Administrator shall notify the Client no later than fifteen (15) days after the date of the license expiration or termination, and shall matte commercially reasonable efforts to renew or acquire new and necessary licenses within forty five (45) days of such notice. If AIMS is unable to acquire such licenses, this Agreement shall automatically terminate unless the Client agrees, In writing, to modify the provisions set forth in this Paragraph. D. This Agreement covers the initial period stated above unless cancelled pursuant to the provisions of this Agreement. Any continuation or renewal shall be the subject of further negotiations between the parties. If the Agreement is not renewed, the Client shall exercise one of the following options within thirty (30) days prior to the date of termination: Page 4 of 27 HB -639- Item 13. - 67 1. Require the Claim Administrator to conclude the handling of all open claims as provided herein, subject to all the terms and conditions of this Agreement. 2. Require the Claim Administrator, at the termination of the Agreement, to deliver all files to the Client or a destination identified in writing by Client. Any time and expense incurred by the Claim Administrator in the delivery of such files will be billed to the Client, with supporting documentation for such billing, and the Client shall pay such billing to the Claim Administrator within thirty (30) days from the billing date. The Claim Administrator shall be entitled to payment for all undisputed Services rendered up to that time according to the terms of this Agreement. VI. INSURANCE AND INDEMNITY A. The Claim Administrator is required to maintain in full force and effect during the term of this Agreement a policy of errors and omissions Insurance coverage, which affords coverage In the minimum amount of $5,000,000 for each claim or occurrence, with a per claim or occurrence deductible not to exceed $25,000 Such errors and omission insurance shall be maintained by the Claim Administrator at its sole cost and expense, and shall be primary and non-contributing coverage over any other valid and collectible insurance available to the Client. The Claim Administrator shall furnish proof of such insurance to the Client prior to Initiation of this Agreement and each renewal thereof, and shall provide notification to the Client In the event of lapse of such coverage. B. The Claim Administrator is required to maintain in full force and effect during the term of this Agreement policies naming the City of Clovis, its officials, employees and volunteers as Additional Insureds and providing public liability which afford coverage in the minimum amount of $2,000,000. Automobile liability insurance which afford coverage in a minimum amount of $1,000,000. Such public liability and automobile insurance, including but not limited to Bodily Injury and Property Damage, shall be maintained by the Claim Administrator at its sole cost and expense, and shall be primary and non-contributing coverage over any other valid and collectible insurance available to the Client The Claim Administrator shall furnish proof of such insurance to the Client prior to initiation of this Agreement and each renewal thereof, and shall provide notification to the Client in the event of lapse of such coverage. C. The Claim Administrator hereby agrees to, at all times hereafter, defend, indemnify and hold the Client harmless from all claims, liability or loss which result from real or alleged, negligent or willful acts, or errors or omissions of the Claim Administrator, or the servants, agents or employees of the Claim Administrator, in the performance of duties under this Agreement. Included are all costs, expenses, attorney fees and other legal fees, penalties, fines, direct or consequential damages, assessments, verdicts (including punitive damages to the extent permissible under the law of the state where the Claim Administrator maintains its principal office) and any other expense or expenditure incurred by Client as a result of the Claim Administrator's performance or lack of performance under the terms of this Agreement. D. AIMS agrees to the Insurance requirements that are in accordance with the procedures set forth in Schedule D attached Page 5 of 27 Item 13. - 68 xB -640- VII. DISPUTE RESOLUTION A. Disputes arising out of or relating to this Agreement, other agreements between the parties, or any other relationship Involving Client and AiMS (whether occurring prior to, as part of, or after the signing of this Agreement) shall first be resolved by good faith negotiations between representatives of the parties with decislon-making authority. if either party determines that the dispute cannot be resolved through informal negotiation then the dispute shall be submitted to non -binding mediation. The site of the mediation and the selection of a mediator shall be determined by mutual agreement of the parties. Enforcement of any remedy available to either Party, shall be brought in the appropriate court in the State of California, City and County of Fresno, or in the United States District Court for the Eastern District of California, and each of the Parties submits and consents to the non-exclusive jurisdiction of either of such courts for the purpose of any such suit, action or proceeding Process in any suit, action or proceeding may be served by registered or certified mail addressed to the Party at its last known address VIII. CONFIDENTIALITY A Maintaining confidentiality of documents During the performance of this Agreement, a Party may provide to the other Party information orally, in writing or by electronic means (whether through secured access through their respective internal websltes, systems networks, and/or databases or otherwise), that is confidential and/or proprietary information ("Confidential Information") (for purposes of this Section Vlll, the Party providing Confidential information is referred to as the "Disclosing Party" and the Party receiving Confidential Information Is referred to as the "Receiving Party"), including, but not limited to: (i) business and financial data, technical data, manuals, forms, records, methods, product information, strategic plans, potential and existing strategic partner information, sales and marketing information, and other information necessary for Claim Administrator to perform its duties; (ii) trade secrets and other intellectual property, and software applications or components thereof, including the source code, whether developed In- house or otherwise owned by either of the Parties; and (iii) personally identifiable consumer information and nonpublic personal information of the Client's employees, customers, and consumers. The Receiving Party shall maintain such information as confidential and shall use reasonable efforts to ensure that such information shall be used only for the purposes contemplated in this Agreement. The Receiving Party shall implement and maintain appropriate Information security policies and procedures with the same care as used by a reasonable person In protecting his or her own confidential information, which policies and procedures shall include administrative, technical and physical safeguards designed to: (1) ensure the security and confidentiality of Confidential Information; (2) protect against any anticipated threats or hazards to the security or integrity of Confidential Information; and (3) protect against unauthorized access to or use of Confidential Information. The Receiving Party shall immediately notify the Disclosing Party of any breach of confidentiality, and shall cooperate with Disclosing Party to remedy any such breach. Any compilation, aggregations, reports, studies, or analyses generated byAIMS may be used internally by AIMS solely to assist in making assessments pursuant to this Agreement, and shall not be disseminated B. Strict limits on release of Confidential Information Claim Administrator shall not release any Confidential Information to any entity or person other than the Client's employees and Claim Administrator's representatives on an as -needed basis Page 6 of 27 HB -641- Item 13. - 69 without the express written consent of the Client or as the Claim Administrator may be required by law to disclose. C. Court -Ordered disclosure of Confidential Information If the Claim Administrator is served with a subpoena, court order, or other legal document demanding or requiring the release of Confidential Information, Claim Administrator shall immediately give notice to the Client. The Client shall decide whether to take any legal action in response to any such subpoena, court order, or other legal document and Claim Administrator shall cooperate with and assist the Client (at no cost or expense to the Claim Administrator) in seeking a protective order, moving to quash the subpoena, or otherwise obtaining relief from disclosing Confidential Information, IX. SEVERABILITY A. If any term or provision of this Agreement, or the application of any term or provision of this Agreement to a particular situation, shall be finally found to be void, invalid, illegal or unenforceable b a court, then notwithstanding that determination, the term or provision shall remain in force and effect to the extent allowed by such ruling and all other terms and provisions of the Agreement or the application of this Agreement to other situations shall remain in full force and effect B. Notwithstanding the foregoing, If any material term or provision of this agreement or the application of such material term or condition to a particular situation is finatly found to be void, invalid, Illegal or unenforceable by a court, then the Parties agree to work in good faith and fully cooperate with each other to amend this Agreement to carry out its intent. X SPECIAL PROVISIONS A Special provisions, to this Agreement are specified in Schedule E, which is attached hereto and incorporated by reference herein. XI. GENERAL PROVISIONS A. This Agreement supersedes all prior agreements of any type whatsoever by and between the Client and the Claim Administrator. B. The Claim Administrator's rights under this Agreement are not assignable, unless otherwise agreed upon in writing by an authorized officer of the Client. C The captions of the various provisions of this Agreement shall not be deemed a part of this Agreement and shall not be construed in any way to limit the content thereof but are inserted herein only for reference and for the convenience of the parties. D. This Agreement may be executed in two or more counterparts, each of which will be deemed an original, but all of which together will constitute but one and the same Agreement. E This Agreement shall in all respects be interpreted, enforced and governed under the laws of the State of California, exclusive of its choice of law rules. F. This Agreement shall be effective as of the date first written above G. All notices, requests, demands and other communications hereunder must be in writing, unless specified otherwise, and shall be deemed to have been duly given if delivery by hand or mailed Page 7 of 27 Item 13. - 70 xB -642- first class, registered mail, return receipt requested, postage and registry fees prepared, or by telex, facsimile, e-mall(if confirmed by the receiver), or cable and addressed as follows: If to the Client: City of Clovis 1033 50 Street Clovis, CA 93612 Phone: (559) 324-2725 Fax: (559) 324-2865 E-mail: loris@cityofclovis.com Attn: Personnel/Risk Manager If to the Claim Administrator: Acclamation Insurance Management Services, Inc. 10445 Old Placerville Road Sacramento, CA 95827 Phone: (916) 563-1900 Fax: (916) 563-1919 Attn: President & Chief Executive Officer Notices sent by fax will be effective upon date of fax receipt if a confirming copy is subsequently received by one of the other above methods. Addresses may be changed by notice to all Parties, in writing, signed by the addressee. Electronic mail shall be deemed recelved upon delivery if there is confirmation by the receiver Written notice provided via first class registered mail shall be deemed received three days after the date it was sent, overnight mail shall be deemed received the day after it was sent, certified mail and hand -delivered notice shall be deemed received the date it was delivered IN WITNESS WHEREOF the Parties hereto have caused this Agreement to be executed by their duly authorized representative recorded below. Dated: Dated: City of Clovis By: Name. Robert Woolley Title: City Manager ACCLAMATION INSURANCE MANAGEMENT _"SE�fICES, IN Name: - II,C� �'I�LL.I�rrafl Title. O` 6 Page 8 of 27 xB -643- Item 13. - 71 LIST OF SCHEDULES Schedule A Program Scope and Territory Schedule B Claim Administration Procedures and Authority Schedule C Claim Service Fees Schedule D Insurance Requirements Schedule E Special Provisions Page 9 of 27 Item 13. - 72 HB -644- SCHEDULE A SCOPE AND TERRITORY Program Acclamation Insurance Management Services, Inc. Administrator: Class of Business: Workers' Compensation, Cost Containment and Bill Review Cost Containment Territory: California 1. Subject to the terms and conditions set forth In the AGREEMENT, AIMS shall provide the Client professional services as contained within this AGREEMENT. AIMS shall ensure that all claims are processed in accordance with California law, codes, rules, and regulations as promulgated by the Adminstrative Director and the Manger of the Department of Self insurance Plans. 2. AIMS agrees to initiate prompt processing of all claims presented to AIMS upon notification in writing, facsimile transmission, e-mail, or by telephone from Client. 3. Penalties: A. Any penalties assessed by the Division of Workers' Compensation for delays In benefits that are the direct result of delay by AIMS shall be the responsibility of AIMS. Conversely, those penalties that are assessed as of the direct result of delay by the Client shall be the responsibility of the Client. B. Any penalties assessed by the Division of Workers' Compensation, Audit unit for which AIMS made negligent error as Identified by a State auditor shall be the responsibility of AIMS. The Client shall be responsible for paying penalties for which the Client has made a negligent error as identified by a State auditor. C AIMS shall be responsible for any and all penalties that are the result of late payments pursuant to the statutory requirements for timely payments. If the penalties are paid from the trust fund as an add -on to a bill or benefit, AIMS shall reimburse the Client on a quarterly basis. 4. Licenses, Permits, etc.- AIMS represents and warrants to the Client that It has all professional licenses, permits, qualifications, and approvals of whatsoever nature which are legally required for AIMS to practice its profession. AIMS represents and warrants to City that it shall, at its sole cost and expense, keep in effect at all times during the term of the AGREEMENT any licenses, permits, and approvals which are legally required for AIMS to practice its profession. 5. Standard of Performance- AIMS shall perform all services required pursuant to the AGREEMENT in a manner and according to the standards identified in Schedule B, and if not specified in Schedule B or elsewhere in the AGREEMENT, then the standards of performance shall be consistent with those observed by a competent practitioner of the profession In which AIMS Is engaged. All products and services of any nature that AIMS provides to Client pursuant to this AGREEMENT shall conform to the standards of quality normally observed by licensed, competent professionals practicing In AIMS profession. 6. Cooperation by Client: Client shall, to the extent reasonable and practicable, assist and cooperate with AIMS In the performance of its services hereunder. Such assistance and cooperation may include, as reasonably necessary, providing initial claim information and other material available from Client's files as may be necessary. Page 10 of 27 xs -645- Item 13. - 73 SCHEDULE B CLAIM ADMINISTRATION PROCEDURES AND AUTHORITY 1 Caseload Each examiner assigned to the account shall have a caseload not to exceed 175 open indemnity claims. Each claim assistant assigned to the account shall have a caseload not to exceed 300 open medical only claims. In situations where caseloads include future medical and medical only claims, these claims shall be counted as 2:1 In the caseload limit. For example, if a claims examiner has 200 total claims and 50 claims are medical only, future medical care or a combination thereof, the caseload would be counted as 175 claims. The supervisor shall not have a case load but may handle specific issues 2. Forms AIMS shall provide all forms necessary for the processing of benefits or claims information Including but not limited to- the Employer's Report of injury, DWC Form 1, medical service orders, return to work slips, lost time information reports, vouchers,_ checks, and other related forms. Claim File Set -Up and Diary Review Upon receipt of the Employer's Report of Injury, the AIMS will prepare an individual claim file within one (1) working day for each claim. All claim files shall be reviewed at least every thirty (30) days for active claims and at least every six (6) months for claims that have settled but are open for the employee's future medical care. The examiner shall distinguish the regular diary review from routine file documentation in the computer notepad. The supervisor shall monitor the diary reviews not less than every ninety (90) days with a note to the file reviewing the examiners plan of action, providing any necessary direction or by printing and providing the Client with a "No Activity" report each month to identify any files that have fallen off the diary system. The plan of action, shall include, but not limited to, the employee's current work status, medical status, review of reserves, and future activity to move the claims toward resolution. 4 Claim Creation -Three Point Contact AIMS shall conduct a three-point contact process for reported claims. Contact will be made with the non -represented injured worker within twenty-four (24) hours of receipt of a claim. Contact with the Client representative and treating physician shall be contacted within three (3) working days of receipt of a claim. If a nurse case manager is assigned to the claim, initial physician contact may be conducted by either the claims examiner or the nurse case manager. This initial contact should be substantive and clearly documented in the claim file In the event a party is non -responsive, there should be evidence of at least three (3) documented attempts by AIMS to reach the individual. Medical -only claims shall have this three (3) point contact requirement as well. Page 11 of 27 Item 13. - 74 xs -646- 5. Communication a. Telephone Inquiries: Return calls shall be made within one (1) working day of the original telephone inquiry. All documentation shall reflect these efforts. b. Incoming Correspondence. All correspondence received shall be clearly stamped with the date of receipt. C. Return Correspondence: All correspondence requiring a written response shall have such response completed and transmitted within five (5) working days of receipt. d. Ongoing Claimant Contact - For cases involving unrepresented injured workers who are off work, telephone contact shall be made at a minimum of once every forty-five (45) days and within three (3) working days after a scheduled surgical procedure This requirement is in addition to nurse case management involvement for claims where nurse case managers are assigned. 6. AOE/COE Investigation If a decision Is made to delay benefits for a claim, an AOE/COE investigation shall be initiated within three (3) working days of the decision to delay. This may include, but is not limited to, obtaining wltness/injured worker statements, initiating the QME/AME process, requesting medical records, etc 7. Indexine AIMS shall subscribe to a claims reporting bureau. The examiner shall request a report from the bureau on all new indemnity claims All claims shall be reported to the Index Bureau at time of initial set-up and re -Indexed -on an as needed basis thereafter. 8. Reserves Reserves shall be established based upon the ultimate probable cost of each claim. All reserve categories shall be reviewed on a regular basis but not less than at least every ninety (90) days. Such review shall be indicated in the computer notepad. The examiner shall utilize a reserve worksheet which has been approved by the City and the Local Agency Workers' Compensation Excess Joint Powers Authority pursuant to that 1PA's Resolution Establishing a Claims Management Policy Any changes to reserves shall include an explanation for the change and will be identified for the Client. The claims assistant shall have the authority to establish reserves up to $5,000. An examiner shall have authority to establish reserves up to $50,000, A senior examiner shall have authority establish reserves up to $75,000. The supervisor shall have authority to establish reserves up to $150,000. A director, vice president, or president of the AIMS shall review and approve all reserves in excess of $150,000. Page 12 of 27 xB -647- Item 13. - 75 9 Medical Administration AIMS shall select a panel of general practitioners, specialists, hospitals, and emergency treatment facilities to which injured employees should be referred, as approved by the Client, and the Claim AIMS shall regularly review and update the panel. Contact with the treating doctors shall occur every fourteen (14) days on lost time cases and will continue as needed during the continuation of temporary disability to assure that treatment is related to a compensable injury or illness. For long term disability cases, contact shall be maintained consistent with doctor recommendations. AIMS shall maintain contact with treating physicians to ensure employees receive proper medical treatment and are returned to full or modified employment at the earliest possible date. AIMS shall maintain direct contact with medical service providers to ensure their reports are received in a timely manner. AIMS shall arrange medical evaluations when needed, reasonable, and/or requested In compliance with the current Labor Code. AIMS/Allied Managed Care (AMC) shall ensure that medical bills are reduced to the Medical Fee Schedule and recommended rates established by the Administrative Director of Workers' Compensation. The Client shall pay for the use and benefits of the services provided. AIMS/AMC agrees to the requirements and fee structure that are in accordance with the procedures set forth In Schedule C. AIMS shall provide, at the Clients expense, utilization review and/or professional managed care services on an as -needed basis to injured employees and as required by Labor Code, provided the Clients approval is obtained prior to the provision of such service. 10. Medical Payments Medical bills will be matched to the file, reviewed for correctness, approved for payment, and paid within sixty (60) days of receipt if all or part of the bill is being disputed, AIMS will notify the medical provider, on the appropriate form letter, within thirty (30) days or as established under Labor Code for Utilization Review. 11. Plan of Action Each claim file shall contain the examiner's plan of action for the future handling of that claim. Such plan of action will be identified in the computer notepad within five (5) calendar days of initial claim set up. Such plan of action shall be clearly stated including the reasoning for the plan. The plan of action will be reviewed and/or updated at least every thirty (30) calendar day on active claims and at least every six (6) months on claims that have been settled but are open to monitor future medical care. Each plan of action will be clearly identified in the computer notepad. Page 13 of 27 Item 13. - 76 xB -648- 12.Comaensabdity The compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation) and the reasons for such determination will be made and documented In the file within three (3) working days of the receipt of the notification of the loss Delay of benefit letters shall be mailed in compliance with the Division of industrial Relations' guidelines 13.Provision of Benefits AIMS shall provide all compensation and medical benefits in a timely manner and in compliance with the statutory requirements of the California Labor Code and applicable case law. AIMS shall compute and pay temporary disability benefits to injured employees based upon earnings information and authorized disability periods AIMS shall review, compute, and pay all informal ratings, death benefits, findings and awards, life pensions, or compromise and release settlements. However, all such benefits shall be paid from the established trust fund. AIMS shall comply with the Client's salary continuation plan, which requires AIMS to compute temporary disability benefits and provide verification to the Client twice a month. AIMS shall also advise the Client of potential credits and penalties For all regular, full-time, non -sworn employees, the Client pays up to one (1) year salary continuation paid directly to the employee. For all regular, full-time employees, Including sworn employees, the Client requires AIMS to provide vouchers to the Client confirming employees' time -off work for temporary disability and LC 4850 benefits. For all part-time employees and employees who have exhausted salary continuation, LC 4850 benefits and coordinated paid time -off, temporary disability benefits may be paid directly to the employee through checks issued by AIMS. All disability benefit notices shall be sent to the employee as required by the Labor Code. 14 Return to Work AIMS shall provide assistance to the Client in establishing a modified work program which is appropriate for injured employees while recovering and prior to their return to regular duties. AIMS shall notify the Client immediately of any change in employee work status. AIMS shall consult frequently with the Client in those cases where the Injury residuals might involve permanent work restrictions and/or retirement potential. 15 Transportation Expense Transportation reimbursement will be mailed within five (5) days of the receipt of the claim for reimbursement. Advance travel expense payments will be mailed to the injured employee ten (10) days prior to the anticipated date of travel. 16. Litigated Cases 1 Cases Involving Outside Investigations AIMS shall promptly initiate an investigation of issues identified as material to potential litigation. The Client shall be alerted to the need for an outside investigation as soon as possible and AIMS shall appoint an investigator who is acceptable to the Client. The Client shall be kept informed on the scope and results of all Investigations. Page 14 of 27 xB -649- Item 13. - 77 When defense counsel is not necessary, AIMS shall work closely with the applicant's attorney in informal disposition of litigated cases. All assignments to outside counsel will be done with the Client authorization and consent. In conjunction with the Client, AIMS shall monitor the outside counsel's progress. AIMS shall audit all bills before payment. Settlement proposals directed to the Client shall be forwarded by AIMS or defense counsel in a concise and clear written form with a reason(s) for such recommendation. All preparation for a trial shall involve the Client so that all material evidence and witnesses are utilized to obtain a favorable result for the defense. The supervisor or the examiner will attend Workers' Compensation Appeals Board hearings, meetings with defense counsel, and meetings with members of the Client, staff, departments, and employee groups as necessary and as requested to do so. 17. Allocated Expenses All allocated expenses (Defense Attorney, Investigative Services, Nurse Case Management etc.) shall only be assigned with prior approval of Client representative. 18. Settlements AiMS shall obtain the Client's authorization on all settlements using a Settlement Evaluation Worksheet form as provided by the Client. All requests for settlement authority shall Include a written claim summary, estimate of permanent disability, and the defense counsel's comments and recommendations, if any 19.Subrogation Unless instructed otherwise by the Client, in cases where a third party is responsible for the injury to the employee AIMS will pursue subrogation and notify the Client of the subrogation plan. When subrogation is to be pursued, the third party shall be contacted within ten (10) days with notification of the Client's right to subrogation and the recovery of certain claim expenses. if the third party is a governmental entity, a claim shall be filed with the governing board within six (6) months of the injury or notice of injury. Appropriate periodic contact shall be made with the responsible party and/or insurer to provide notification of the amount of the estimated recovery to which the City will be entitled If the injured worker brings a civil action against the party responsible for the injury, the AIMS shalt consult with the Client about the value of the subrogation claim and other considerations. Upon receipt of the Client's authorization, subrogation counsel shall be assigned to file a lien or a Complaint In Intervention In the civil action. Whenever practical, AIMS should take advantage of any settlement In a civil action by attempting to settle the workers' compensation claim by means of a third party compromise and release. If such attempt does not succeed, then every effort should be made through the WCAB to offset claim expenses through a credit against the proceeds from the Injured worker's civil action. Page 15 of 27 Item 13. - 78 HB -650- 20 Job Displacement Benefit AIMS shall advise the injured worker of his/her rights to job displacement benefits. 21.Excess Insurance Cases that have potential to exceed the Client's self -insured retention shall be reported in accordance with the reporting criteria established by the Local Agency Workers' Compensation Excess Joint Powers Authority (LAWOO and any other excess insurance policies. All cases which meet the established reporting criteria are to be reported within ten (10) days of the day on which it is known the criterion is met. 22 Award Payments Payments made by AIMS for the Client on awards, computations, or compromise and release agreements will.be issued within ten (10) days following receipt of the appropriate document. 23. Penalties The Client will be advised of the assessment of any penalty for delayed payment and the reason thereof and the Claim Administrator plans for payment of such penalty within five (5) days of assessment. 24.Case Closure AIMS shall establish a goal of 100% closing ratio each month. Within thirty (30) days of being discharged by the treating physician, the employee shall be sent a closing letter. A follow-up medical appointment with the treating physician shall be set for employees who have not followed -up with recommended medical treatment. The employee shall be notified accordingly to attend this appointment. AIMS will monitor stipulated cases with future medical provisions. Reserves for future medical will be reviewed semi-annually and adjusted according to use. 25.Future Medical Claims Claims that remain open to monitor future medical care shall remain open for two (2) years from the last payment of the benefit. Reviews shall be documented in the claim notes to include settlement information, outline future medical care, last date and type of treatment, name of excess carrier, excess carrier reporting level, and excess carrier reporting history. Reserves for future medical treatment will be reviewed every six (6) months and adjusted for use over a three (3) year average and the injured Page 16 of 27 Hl3 -651- Item 13. - 79 employee's life expectancy based on the current version of the U.S. life Table. The reason(s) and calculation(s) for the adjustment(s) shall be clearly documented on the computer notepad. AIMS shall evaluate the claim at least once a year to determine a reasonable amount for settlement of future medical benefits and any remaining benefits due. The reason(s) and calculations(s) for the recommended settlement amount shall be clearly documented in the computer notepad. AIMS shall clearly document the computer notepad with the outcome of the settlement negotiations with the employee or applicant attorney. 26.loss Runs and Other Reports A loss run shall be issued by the V5 h of the month following the closing date. Any corrections that are requested to be made to the loss run shall be made within thirty (30) days. AIMS shall provide the following monthly reports to the Client: A. A report of all open and closed claims run by fiscal year and department, to include the employees name, claim number, date of injury, paid amount with 4850 benefits, paid amount without 4850 benefits, future liability, total Incurred with 4850 benefits, total incurred without 4850 benefits, frequency analysis loss cause, frequency analysis clay of the week injury, count frequency by body part and any amounts recovered for subrogation or excess Insurance; B. A Management Summary Report; C. All OSHA 300 log information. If the client communicates to AIMS the modified duty dates for each injured employee AIMS will record the information to populate the report. D. A check register, in check number order, including any voids, refunds, and recoveries received with a total page showing the payment for the month by fiscal year; E. A voucher register custom and standard run by fiscal year; F. A "No Activity" report listing the claims that have had no activity during the previous ninety (90) days. The report components should include no reserve changes, no payments, no recoveries, no refunds, and/or no note pad activity. AIMS shall provide quarterly reports, In addition to the regular monthly reports, to the Client: A. A register of temporary disability paid for the quarter; B. Claims opened and closed in the quarter; C. Claims on delayed status with current status report; D. Claims In denied status with current status report; E. Reserve increases of $10,000 or greater with current status report; F. Claims reportable to excess carrier with current status report; G. Claims reported in the quarter by department; H. Claims cost detail report of all open claims by department; Page 17 of 27 Item 13. - 80 HB -652- I Claims cost detail report of all future medical claims by department AIMS shall provide additional annual reports to the Client: A. Number of claims reported per year, B. Top 5 body parts injured for the year, C. Top 5 injury causes for the year; D Five most expensive injuries for the year; E. Claims paid by year for each department for the last five years; F. Temporary disability paid by year for each department for the last five years, G. Permanent disability paid by year for each department for the last five years, H. Medical paid by year for each department for the last five years, 1. Vocational rehabilitation paid by year for each department for the last five years; J. Legal costs paid by year for the last five years; K Investigation costs paid by year for the last five years, L. Nurse Case Management costs paid by year for the last five years, M. Utilization Review costs paid by year for the last five years, N. Bill Review costs paid by year for the last five years; AIMS will produce additional reports as reasonably needed by the Client. 27 Claims Reporting AIMS shall maintain all loss Information as required by the Workers' Compensation Insurance Rating Bureau. AIMS shall assist in the preparation of all reports which are now, or will be required by the State of California or other government agencies with respect to self-insurance programs. AIMS will also assist in the preparation of all reports or databases required by the California institute for Public Risk Analysis (CIPRA) or other statistical database organizations as requested by the Client. 28.Record Retention All claim files shall be maintained In accordance with statutory time requirements and the Client's Record Retention Policy. 29 Claim Supervision AIMS shall provide supervisory staff who will regularly review the work product of the claims examiners The supervisor shall review each claim not less than every ninety (90) days to ensure that each examiner is following the performance standards outlined in this RPP. Page 18 of 27 xB -653- Item 13. - 81 30.Availability of Personnel AIMS shall at all times have one (1) or more of the examiners assigned to the City's account, or in their absence, the supervisor or a manager of Workers' Compensation available by telephone for emergencies through a 24-hour emergency telephone number. Upon reasonable prior notice, AIMS shall ensure at least one (1) or more of the examiners or supervisors assigned to the Client's account is available to meet in person with Client staff during regular business hours throughout the term of the contract period. It is highly desirable that AIMS maintain a business office in the Clovis -Fresno metropolitan area to service the Client's account. 31. Examiner Training AIMS shall ensure each claims examiner handling the Client's claims will receive continuing education training each year. AIMS shalt annually certify this in writing on the anniversary date of the agreement between the Client and AIMS. Examiners assigned to the Client shall have a minimum of three (3) years indemnity claim handling experience and obtain their Self -insured Certificate from the State of California within one (1) year of being assigned to the Client's account 32 Member Services AIMS shall provide special on -site training services annually to personnel from the Client to ensure that the people within the Client who process workers' compensation claims are effectively carrying out the procedures required for a successful program. A copy of AIMS claims manual should be readily available for review by the appropriate Client staff or representative. AIMS shall require its examiners or other AIMS personnel, as necessary, to attend the Client's regularly scheduled meetings to report on the general state of the program and on any particular cases of interest to the Client. AIMS shall require the supervisor or other AIMS personnel, as necessary, to attend the Client quarterly claims review at City of Clovis offices. AIMS shall require one (1) of the dedicated unit supervisors/managers to meet with Client's personnel, at the Clients location, as needed to review program procedures regarding workers' compensation reporting requirements and other program matters that require the timely participation of the Client's personnel. AIMS shall require an examiner to be available and readily respond to a Client's request for assistance with problem cases, including on -site visits to the Client. AIMS shall provide the Client with information regarding statutes, proposed changes to statutes, and changes to the rules and regulations affecting the Client and its responsibility as a self -insured public employer. Page 19 of 27 Item 13. - 82 xB -654- 33.Claim Reconciliation All claim files shall be reconciled to ensure all medical, indemnity, and expense payments have been made correctly. The reconciliation Is to verify that payments were made to the correct provider, in the correct amount, and from the correct claim file. The physical file should be verified with the computer Information. All open files shall be reconciled. 34.Employee Services As required, AIMS will develop for review by the Client's materials which provide Information and guidance to employees of the Client regarding workers' compensation and the self-insurance program. As required, AIMS will meet with and assist Injured employees in resolving problems that arise from Injury or illness claims. 35. Compliance with Labor Code AIMS shall comply with all provisions of the Labor Code and Rules and Regulations in effect at the applicable date of Injury. Page 20 of 27 xB -655- Item 13. - 83 SCHEDULE C CLAIM SERVICE FEE AND OTHER FEES Workers' Compensation Third Party Claims Administration Year One 7/1/2015 — 6/30/2016 $189,860.00 _ Year Two 7/1/2016 — 6/30/2017 $195,556.00 ** Year Three 7/1/2017 — 6/30/2018 $201,423.00 ** ** Annual cost of living adjustment of 3.0% Should AIMS receive more claims than anticipated from the current claim administrator at the time of transfer and/or there is a 5% increase/decrease during the initial transfer or during any period of the contract due to significant change in the number of employees, and/or as a result of a catastrophic event, then both AIMS and the Client will negotiate, in good faith, a reasonable fee increase/decrease fee adjustment based on any revised required staffing. The total annual flat fee proposed above contemplates handling all claims activity In a 12-month period (claims already open at the beginning of the 12-month term and any new claims reported during the 12-month term). The annual fee will be invoiced in 12 equal monthly amounts in arrears. The flat annual fees Include all services detailed in the RFP proposal including, but not limited to the following services: • All Claims Management Functions (currently open & included new claims) • Data Management • Claim File Storage • Claim File Retrieval • Account Management • Claims System Reporting • Public Self -Insurers Annual Report • Prepare Federal Form 1099 notices • Custom AIMS "dashboard" • Website Access (on-line) • Detailed Stewardship Report/Presentations • Training Participation • MMSEA Reporting In the event the Client elects, upon termination of this Agreement, to require AIMS to conclude the handling of all open claims, AIMS shall invoice the Client at a monthly open rate to be negotiated in good faith between the Parties. Page 21 of 27 Item 13. - 84 HB -656- Carve -Out Aereement Prlcine- AIMS will assist the Client if the Client elects to have a Carve -Out Agreement in the negotiation of Carve -Out Agreements with their Unions. AIMS utilizes the services of an outside Applicant Attorney to assist with the discussions and presentation to the Union Members. AIMS will provide sample MOU Agreements, including physician specialty panels, mediation and nurse case management panels. AIMS will assist the Client with the preparation and tracking of all material in connection with the Agreement. Additionally, AIMS will provide tracking on all aspects of the Agreement for State Reporting purposes and to provide the Client with cost savings analysis. Negotiation/Preparation of Carve -Out Agreement: $15,000.00 per member Annual Tracking / State Reporting: $400.00 monthly fee Managed Care Services Utilizing Allied Managed Care, Inc. ("AMC') Medical Bill Review Fees Fee per bill to reduce to the Official Medical Fee Schedule (OMFS). $8.50 per bill (flat rate per bill) plus PPO access fee (see below). The following is included (at no additional charge): • Full duplicates • Appeals • Initial Setup • Technology Fees for Interface • Client Tral ni ng • Re-evaluation/provider Inquiries • Expert Testimony In Defense of Reviews • Electronic Data Interface and On-line Access • Courier Service PPO Network Fees are based on savings below Fee Schedule. Percent of savings Is dependent on which PPO network is selected Anthem Blue Cross —CA 26% First Health / Coventry 24% -- Procura 22% PRIME 22% _ InterPlan 18% ClarisPointe 18% ASI Flex 18% Negotiation of Non-OMFS and Line -Item Audit bills, including Inpatient/Outpatient Hospital bills (non-PPO charges):10% of Savings capped at a maximum of $10,000.00 * Bills that fall into this category require prior approval by the Client before an extended review is conducted. Page 22 of 27 xs -657- Item 13. - 85 Electronic billing Electronic and Standardized Billing Regulations: $1.00 per bill. Utilization Review Nurse Review Flat Rate: $85.00 per UR (nurse) Referral. This includes unlimited treatment requests and reviews per referral. Physician Review Flat Rate: $225.00 per Peer Review Referral. This includes unlimited treatment requests and reviews per referral. The following Is Included In the above fees: • Initial set-up at the time of award of contract • Customized Special Account Instructions • Documentation letters post UR and Peer Review • Technology Fees for interface • Production Reports & Metrics • Consultation with the AMC Medical Director • Client Training Telephonic Case Management, Including triage services for indemnity claims $85.00 per hour. Field c- Management $198,00 per hour* *Travel for Field Case Management (On -Site) services will be charged at the Internal Revenue Service approved rate for mileage at the time the mileage is incurred. Allied Managed Care Provider Network If the Client elects to have a Provider Network the pricing is listed below: 1st Year Pricing - $15,500 year / $1,292 per month (regardless of claim volume). • This Includes Certification from State & Enrollment Notices to all Employees. Complete monitoring of the MPN for State Compliance & reporting with toll free access/assistance for the Client and Injured Employees and all services listed under the No Charge Services. 2nd +Year(s) Pricing - $12,200 year / $1,017 per month (regardless of claim volume). First Notice of Loss 24I7 Triage Nurse Cali Center Toll free call center with nurse triage component to mirumize reportable injuries. Call center operates 24/7, directing Injured employees into appropriate treatment facilities (MPN providers & occupational clinics designated by Client). Nurse intervention at reporting level recognizes "first aid" issues and directs employees to home care Instead of seeking treatment. Call center uploads all Information into AIMS' Claims Management System eliminating the need for the employer to create a 5020. Per Reportable Claim: $150.00 Non -Reportable Claim- No Charge Secondary Calls: $60.00 Page 23 of 27 Item 13. - 86 HB -658- SCHEDULED Insurance Requirements AIMS shall procure and maintain for the duration of the contract insurance against claims for injuries to persons or damages to property which may arise from or in connection with the performance of the work hereunder by AIMS, his/her agents, representatives, employees, or subcontractors. 1. Minimum Scope of Insurance Coverage shall be at least as broad as: a. Insurance Services Office Commercial General Liability coverage ("Occurrence" Form CG 0001). b. insurance Services Office Form No. CA 0001, covering Automobile Liability, Code 1(any auto) or Code 8, 9 if no owned autos. c. Workers' Compensation Insurance as required by the Labor Code of the State of California and Employer's Liability insurance. 2. Minimum Limits of insurance AIMS shall maintain limits no less than: a. General Liability: $2,000,000 per occurrence for bodily injury, personal Injury, and property damage. If Commercial General Liability Insurance or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately or the general aggregate limit shall be twice the required occurrence limit. b. Automobile Liability. $1,000,000 per accident for bodily Injury and property damage. c. Workers' Compensation and Employer's Liability: Workers' Compensation limits as required by the Labor Code of the State of California and Employer's Liability limits of $1,000,000 per accident for bodily injury and disease. d. Errors and Omissions: $5,000,000 per occurrence and shall not be subject to a deductible and/or self -Insured retention of greater than $25,000. e. Employee Dishonesty $2,000,000 to include comprehensive employee dishonesty, disappearance, theft, and forgery or alteration coverage. 3. Deductibles and Self Insured Retentions Any deductibles or self -insured retentions must be declared to and approved by the City. At the option of the Client, either: the insurer shall reduce or eliminate such deductibles or self -insured retentions or the AIMS shall provide a financial guarantee satisfactory to the City guaranteeing payment of losses and related investigations, claim administration and defense expenses. Page 24 of 27 xs -659- Item 13. - 87 4. Other Insurance Provisions The general liability and automobile liability policies are to contain, or be endorsed to contain the following provisions. a. The City, its officers, officials, employees and volunteers are to be covered as insureds with respect to liability arising out of automobiles owned, leased, hired or borrowed by or on behalf of the TPA, and with respect to liability arising out of work or operations performed by or on behalf of the Contractor including materials, parts or equipment furnished in connection with such work or operations. b. For any claims related to the services provided pursuant to an executed agreement the AIMS insurance coverage shall be primary insurance as respects the City, its officers, officials, employees and volunteers. Any Insurance or self -Insurance maintained by the City Its officers, officials, employees or volunteers shall be excess of the AIMS insurance and shall not contribute to it. c. Each insurance policy required by this clause shall be endorsed to state that coverage shall not be canceled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. d. Coverage shall not extend to any indemnity coverage for the active negligence of the additional insured In any case where an agreement to indemnify the additional insured would be invalid under Subdivision (b) of Section 2782 of the Civil Code. S. Acceptability of Insurers Insurance Is to be placed with insurers with a current A.M. Best's rating of no less than ANIL 6. Verification of Coverage AIMS shall furnish the Client with an original certificate and amendatory endorsements affecting coverage required by this clause. All certificates and endorsements are required to be received and approved by the Client before work commences. The Client reserves the right to require complete, certified copies of all required insurance policies, including endorsements affecting coverage required by these specifications at any time. All Insurance documents are to be sent to: City of Clovis Attention: Lori Shively, Personnel/Risk Manager Personnel/Risk Management 1033 Fifth Street Clovis, CA 93612 Loris@citvofcIovis.com Page 25 of 27 Item 13. - 88 HB -660- SCHEDULE E SPECIAL PROVISIONS Additional Terms: 1. Financial Administration: The Client will establish a zero -balance trust account from which AIMS shall make all indemnity medical, and allocated loss expense payments. Payment authorization limits and payment policies will be established by Client and reviewed from time to time with AIMS. AIMS monthly service fee shall not be paid from the trust account. AIMS shall maintain complete and accurate records with respect to costs, expenses, receipts, and other such information required by the Client that relate to the performance of services under the AGREEMENT. AIMS shall maintain adequate records of services provided in sufficient detail to permit an evaluation of services. All such records shall be maintained in accordance with generally accepted accounting principles and shall be clearly Identified and readily accessible. 2. Allocated Expenses: All allocated loss expenses as defined in Schedule C, shall be the responsibility of the Client. it is agreed and understood that, whenever practicable, allocated loss expenses should be billed directly to the Client and the bills will be paid from the trust account. 3. Right to Audit: The Client or its designated representative is authorized to visit AIMS processing and/or storage premises, for purpose of performing a claims audit, and have access to all data, Including paper documents, microfilm, microfiche, and magnetically stored data which relate to payments or non - payments made by AIMS. Any assistance or service provided in response to a claims audit described above will be rendered at no additional cost of the Client. 4. Invalid Payments: No charges to the Client for payments made on behalf of persons who were not valid employees of the Client at the date of injury shall be accepted for payment by the Client. 5. Personnel: AIMS agrees to assign only competent personnel according to the reasonable and customary standards of training and experience in the relevant field to perform services pursuant to the AGREEMENT. This includes the assignment of at least one Senior level Claims Examiner. Failure to assign such competent personnel shall constitute grounds for termination of this AGREEMENT pursuant to Section V.B. of this AGREEMENT The examiners and clams assistants maybe dedicated to the exclusive handling of the Client's claims. AIMS shall be allowed to use a non -dedicated or part-time, experienced examiner when caseloads exceed the number specified In Schedule B. Each examiner shall have passed the State of California, Department of Industrial Relations, Self-insurance Administrator's Examination, or as a minimum requirement an examiner that has not passed the State examination shall be enrolled In appropriate courses leading to certification within two years. AIMS shall ensure that other personnel, such as management, clerical, accounting, and data processing, which may be required to satisfactorily provide the services required by this AGREEMENT, shall be Page 26 of 27 xB -661- Item 13. - 89 provided by AIMS within the agreed fee for services contained in this AGREEMENT. It is understood that the personnel referred to in this paragraph need not be dedicated to the exclusive use of the Client. 6. Claim Reports: AIMS shall, at its expense, provide one week prior to the quarterly claims review meeting a written summary report showing the number of claims reported during the prior quarter, separated by a category (i.e. indemnity or medical only), the number of claims closed during the prior quarter, and any medical cost savings. This report shall show a comparison of the same Information for the same quarter for the prior year. 7. Online Interface AIMS shall provide an online interface with its database, accessible from the Client's computers for the use by the Client Such data will be put in a format that will permit the Client to make print copies of the data on its printers. If the Client, under AIMS guidance, Is not able to maintain an online interface with data maintained by AIMS, AIMS shall be required to provide a copy of all data processed during the past week to the Client's office each Friday in a disk media format which is transferable and useable with the Client's computers. Page 27 of 27 Item 13. - 90 xs -662-