Description
California’s Department of Social Services is seeking a qualified third‑party administrator (TPA) to manage workers‑compensation claims for the state‑wide CalWORKs, IHSS/WPCS, and CalFresh Employment & Training programs. The contractor will assume full claim‑intake, adjudication, medical‑bill review, utilization review, sub‑rogation, and payment processing responsibilities, transitioning from the incumbent TPA and operating a paper‑less, web‑based system that interfaces daily with the State Controller’s Office. The contract includes a three‑year base term with an optional three‑year extension and requires strict adherence to California‑specific security, confidentiality, and insurance standards.
• Provide end‑to‑end workers‑comp claim administration (setup, eligibility, benefits, reserves, payments) for three major state programs.
• Deliver managed‑care services (bill review, nurse/field case management, utilization review) on a per‑claim or per‑hour rate schedule.
• Meet extensive performance timelines (e.g., claim file creation within 1 business day, compensability decision within 14 calendar days) and submit monthly/quarterly reports to ORIM and CDSS.
• Maintain state‑required insurance coverage, data‑security controls (AES‑256 encryption, MFA), and comply with numerous statutory reporting obligations (Medicare secondary payer, DVBE, Darfur, Iran contracting acts).