Third Party Administrator of Workers’ Compensation, General Liability, and Automobile Liability Claims (RFP)

. City of Raleigh Request for Proposal RFP # 274-FIN-20210503 Third Party Administrator of Workers Compensation, General Liability, and Automobile Liability Claims Proposal Due Date: August 13, 2021 All inquiries concerning this RFP shall be made in writing to: Ryan G. Wilson Risk and Insurance Manager Finance Department City of Raleigh Ryan.wilson@raleighnc.gov Page 2 of 52 TABLE OF CONTENTS 1 REQUEST FOR PROPOSALS ......................................................................................4 INTRODUCTION .............................................................................................. 4 CITY BACKGROUND ...................................................................................... 4 REQUEST FOR PROPOSAL ............................................................................ 5 INSTRUCTIONS TO PROPOSERS ................................................................. 5 IMPORTANT DATES

& DEADLINES ........................................................... 6 RFP QUESTIONS & CLARIFICATIONS ........................................................ 6 RIGHTS TO SUBMITTED MATERIALS ........................................................ 6 SUBMISSION OF TRADE SECRETS AND NON-PUBLIC RECORDS6 2 PROPOSALS....................................................................................................................8 FORMAT REQUIREMENTS ............................................................................ 8 CONTENT REQUIREMENTS .......................................................................... 8 SUBMITTAL REQUIREMENTS ..................................................................... 9 EVALUATION CRITERIA ............................................................................. 10 EVALUATION PROCESS .............................................................................. 10 PROPOSED COST SCHEDULE ..................................................................... 11 FINAL SELECTION ........................................................................................ 11 3 SCOPE OF SERVICES .................................................................................................13 CLAIMS ADMINISTRATION WORKERS COMPENSATION ............... 13 3.2 CLAIMS ADMINISTRATION GENERAL LIABILITY AND AUTOMOBILE LIABILITY ........................................................................... 15 CUSTOMER SERVICE ................................................................................... 16 LITIGATION MANAGEMENT ..................................................................... 17 FINANCIAL ACCOUNTING ......................................................................... 17 INFORMATION SYSTEM DATA & ACCESS ............................................. 18 REPORTING WORKERS COMPENSATION ............................................ 18 REPORTING GENERAL LIABILITY AND AUTO LIABILITY .............. 19 RECORDS RETENTION ................................................................................ 19 IMPLEMENTATION/TRANSITION ............................................................. 19 4 CONTRACT TERMS ...................................................................................................21 NON-DISCRIMINATION ............................................................................... 21 MINORITY OR WOMEN OWNED BUSINESSES ....................................... 21 ASSIGNMENT ................................................................................................ 21 APPLICABLE LAW ........................................................................................ 21 INSURANCE ................................................................................................... 21 INDEMNITY ................................................................................................... 22 INTELLECTUAL PROPERTY ....................................................................... 23 FORCE MAJEURE .......................................................................................... 23 ADVERTISING ............................................................................................... 23 CANCELLATION ........................................................................................... 23 LAWS/SAFETY STANDARDS ...................................................................... 24 APPLICABILITY OF NORTH CAROLINA PUBLIC RECORDS LAW ..... 24 MISCELLANEOUS ......................................................................................... 25 RIGHT TO AUDIT AND ACCESS TO RECORDS ....................................... 25 E-VERIFY ........................................................................................................ 25 IRAN DIVESTMENT ACT CERTIFICATION .............................................. 25 COMPANIES BOYCOTTING ISRAEL DIVESTMENT ACT CERTIFICATION.26 Page 3 of 52 APPENDIX A GENERAL QUESTIONNAIRE.. .........................................................27 APPENDIX B WORKERSS COMP QUESTIONNAIRE..........................................31 APPENDIX C AUTO AND GENERAL LIABILITY QUESTIONNAIRE ...............33 APPENDIX D TPA INFORMATION - WC .................................................................34 APPENDIX E TPA INFORMATION - AL/GL ............................................................35 APPENDIX F TPA REFERENCES...............................................................................36 APPENDIX G SUBROGATION ....................................................................................38 APPENDIX H COST PROPOSAL - WC ......................................................................39 APPENDIX I COST PROPOSAL - AL/GL ................................................................52 Page 4 of 52 1 REQUEST FOR PROPOSALS INTRODUCTION The City of Raleigh (City) is seeking proposals from qualified firms interested in serving as the Citys Third-Party Administrator (TPA) for Workers Compensation, General Liability, and Auto Liability claims. The TPA shall be responsible for providing all services required to supervise, manage, and administer the Citys self-insured workers compensation, general liability, and auto liability programs. Throughout this Request for Proposal (RFP) the terms Proposer and/or TPA refer to the qualified firms that submit proposals in response to this RFP. The City reserves the right to award a contract for some or all the services within the RFP, or any combination of the services, as determined to be in the best interest of the City. Proposers are not required to submit proposals for all the services listed in the Scope and may submit a proposal for one or both TPA services listed. The anticipated contract period for these TPA services is three (3) years commencing with the date that the award is effective July 1, 2022, with an option to extend the contract period for two additional one (1) year periods at the Citys discretion. CITY BACKGROUND The City of Raleigh, the Capital City of North Carolina, remains one of the fastest growing areas in the country. With an estimated population of more than 500,000 residents, the City currently employs approximately 4,000 full time employees and over 3,200 part-time employees. The Citys services include the following operating departments: Police, Fire, Parks & Recreation, Solid Waste, Raleigh Water Public Utilities, Transportation, and several other small departments. The City also has a Police Academy and a Fire Fighter Academy. The City has an Employee Health Center to provide the initial medical treatment for all non-emergency work related injuries. The Human Resource Department, Division of Safety, Health and Workers Compensation oversees the Third-Party Administrator in the management and administration of the Citys self-funded workers compensation program. The Citys Workers Compensation Program is self-funded at retentions levels of $1.1 million, which includes all departments except the Police and Fire with retentions levels of $1.5 million. The following information is a four-year history of reported Workers Compensation claims by fiscal year, dated July 1, 2016, to June 30, 2020. Fiscal Year Indemnity Medical Only Total Paid FY 17 67 292 359 $4.3 M FY 18 102 316 418 $3.3 M FY 19 117 236 353 $4.2 M FY 20 100 233 333 $5.9 M The Citys Risk Management Division is comprised of one Risk Management Specialist responsible for General and Auto claims submission and coordination and serving as the primary contact to the TPA along with the Risk Manager providing oversight and ensuring compliance with the Citys claim procedures and contractual agreements. The Risk Management Division also includes an Insurance Analyst focused on ensuring supplier compliance with the Citys insurance requirements. The City Attorneys Office has Page 5 of 52 designated staff attorneys to handle in-house the majority of litigated liability claims against the City and selects outside attorney assistance when needed. The Citys Liability Program is self-funded with a $1.0 million SIR and the Citys Liability Program will assert Governmental Immunity as a defense where applicable. However, the City recognizes there are claims in which it is in the public interest for the City to resolve by waiving immunity. Therefore, the City adopted Waiver of Immunity Interim Guidelines, effective January 1, 1998, to clearly define those circumstances wherein governmental immunity is waived, and consideration of tort claim payments apply. The following information is a four-year loss history of reported General Liability and Auto Liability claims dated July 1, 2016 to June 30, 2020. Fiscal Year Total GL Total AL Total RO Paid FY 17 277 157 71 $1.05M FY 18 250 139 85 $1.00M FY 19 199 135 110 $1.30M FY 20 183 136 39 $800K REQUEST FOR PROPOSAL This RFP shall be comprised of this RFP document, including all appendices and addenda released before the Contract is awarded. All appendices and addenda released for this RFP in advance of any Contract award are incorporated herein by reference. INSTRUCTIONS TO PROPOSERS The format of this RFP must not be altered and must be submitted as received. The wording and changes of this document is not allowed and may cause immediate dis-qualification when noted. The North Carolina General Statutes, City of Raleigh Charter, and City of Raleigh Ordinances, in so far as they apply to purchasing and competitive bidding, are made a part hereof. It shall be the Proposers responsibility to read this RFP in its entirety, including these Instructions, the Citys terms and conditions, all relevant attachments, and any other components made a part of this RFP. It shall be the Proposers responsibility to comply with all requirements and specifications set forth herein. It shall be the Proposers responsibility to obtain and comply with all Addenda and other changes that may be issued in connection with this RFP. The City reserves the right to reject any or all proposals. It further reserves the right to waive formalities and technicalities in so far as it is authorized to do so where it deems it advisable in protection of the best interest of the City. Oral communication with Evaluation Committee members and/or other city staff regarding this RFP is strictly prohibited and may result in the rejection of the Proposers submission. Page 6 of 52 IMPORTANT DATES & DEADLINES Date Time RFP Posted May 03, 2021 9:00 a.m. Last Date for Written Questions to City June 04, 2021 5:00 p.m. Citys Responses to Proposers Questions posted by June 25, 2021 5:00 p.m. Proposal Due Date August 13, 2021 5:00 p.m. Finalists Selected September 15, 2021 5:00 p.m. Finalist Presentations September 16-30, 2021 TBA Proposal Selected October 15, 2021 5:00 p.m. City Council Approval and announcement of TPA Nov./Dec., 2021 TBA Contract negotiations completed March 1, 2022 5:00 p.m. All times shown as Eastern Standard Time (EST). RFP QUESTIONS & CLARIFICATIONS All questions related to this RFP shall be directed to Ryan Wilson, Risk and Insurance Manager via email at the following address: Ryan.Wilson@raleighnc.gov. Responses to questions will be posted on the Citys official website and shall be considered addenda to this RFP. It is the Proposer's responsibility to assure that all addenda have been reviewed and, if need be, signed and returned. The City will not accept any questions and/or inquiries regarding this RFP, including any follow-up questions to responses previously provided by the City, after July 30, 2021. The issuance of a written response is the only official method by which interpretation, clarification, or additional information will be given by the City regarding this RFP. Only requests answered by formal written addenda will be binding on the City. RIGHTS TO SUBMITTED MATERIALS All proposals, responses, inquiries, or correspondence relating to or referencing this RFP, and all reports, charts, and other documentation submitted by Proposers (other than materials submitted as and qualifying as trade secrets under North Carolina law) shall become the property of the City when received and the entire proposal shall be subject to the public records laws of the State of North Carolina except where a proper trade secrets exception has been made by the Proposer in accordance with the procedures allowed by North Carolina law. The City reserves the right to retain all proposals submitted and to use any ideas in a proposal regardless of whether that proposal is selected. Submission of a proposal indicates acceptance by the Proposer of the conditions contained in this Request for Proposal. SUBMISSION OF TRADE SECRETS AND NON-PUBLIC RECORDS Except as modified herein, all information submitted to the City in response to this RFP shall be subject to the requirements of the North Carolina public records law (N.C.G.S. 132.1 et. seq.) and may also be subject to disclosure pursuant to subpoena or discovery requests during litigation. By submitting a response to this RFP, the Proposer understands and agrees that the City may take any and all actions necessary to comply with federal, state, and local laws and/or judicial orders, and that the City shall have no liability to Proposer for any release of information that is required by law. Page 7 of 52 Proposer agrees to indemnify and hold harmless the City and each of its officers, employees, and agents from all costs, damages, and expenses incurred in connection with the City refusing to disclose any material that the Proposer has designated as a Trade Secret. Upon conclusion of this solicitation, either through award of a contract to a proposer or withdrawal by the City of the RFP, and to the extent permitted by North Carolina law, the City may at its sole option destroy any materials designated by the Proposer as Trade Secrets or return such materials to the Proposer. However, the Proposer understands and agrees that the City may retain such materials designated by the Proposer as Trade Secrets for customary archival and audit purposes or to comply with records retention requirements pursuant to North Carolina law. Proposers are cautioned to be selective in designating submitted materials as Trade Secrets. Any proposal that is designated in its entirety as constituting Trade Secret material shall not be considered and summarily rejected. Further, the City reserves the right to reject any proposal if the designation of certain submitted materials as Trade Secrets impairs the Citys ability to adequately evaluate the proposal as a whole. Designation of Trade Secret Materials Any materials that a Proposer wishes to designate as Trade Secrets exempt from disclosure under federal or state law must be submitted to the City in a separate, sealed envelope clearly and conspicuously marked as follows: TRADE SECRET CONFIDENTIAL AND PROPRIETARY INFORMATION DO NOT DISCLOSE In addition, the above-described Trade Secret designation must be clearly and conspicuously printed or stamped on each page of the materials for which trade secret protection is claimed. No materials provided to the City prior to the proposal submission deadline set forth may be designated as Trade Secrets. Notwithstanding any Trade Secret designation, the City shall have no liability to any Proposer for disclosure of materials defined as public records pursuant to N.C.G.S. 132-1, et seq. Proposers Duty to Challenge Disclosure of Trade Secret Materials The Proposer bears sole responsibility for challenging subpoenas or other requests seeking disclosure of materials designated as Trade Secrets. The City shall have no obligation to challenge disclosure of materials designated by any Proposer as Trade Secrets in any court or tribunal. If the City receives a request to disclose materials that have been designated as Trade Secrets by a Proposer, the City shall provide the Proposer with reasonable notice of the request. Within five (5) calendar days of receipt of notice from the City, the Proposer must (1) provide the City with written instructions to withhold the requested materials; (2) provide the City with legal justification in writing for exempting the requested materials from disclosure pursuant to federal or state law; and (3) must seek, at the Proposers sole cost, appropriate judicial action to prevent the disclosure of the requested materials. If the Proposers instructions to withhold requested materials are not accompanied by legal justification or if the Proposer fails to seek appropriate judicial action within five (5) calendar days of receiving notice from the City, the Proposer shall be deemed to have given consent for the City to release the requested information. Page 8 of 52 2 PROPOSALS FORMAT REQUIREMENTS For a proposal to be considered by the City, the Proposal must follow the format described in this section. The City may reject as non-responsive at its sole discretion any proposal or any part thereof that is incomplete, inadequate in its response, or departs in any substantive way from the required format. All Proposals shall be 8 1/2" x 11" format with all text no smaller than 11-point font. All submissions should use one-sided copying and be bound with tab dividers corresponding to the content requirements specified below. CONTENT REQUIREMENTS Proposals shall include the following components and be organized as follows: A. Cover / Transmittal Letter B. Executive Summary C. Qualifications & Experience D. Questionnaire Responses E. Cost Proposal F. References Instructions relative to each part of the response to this RFP are defined in the remainder of this section. Response information should be limited to pertinent information only. Marketing and sales type information is not to be included. A. Cover/Transmittal Letter: Proposal must include a Cover/Transmittal Letter on the organizations official letterhead signed by an authorized representative of the Proposer who has authority to enter into a contract with the City on behalf of the proposer, such as a President, Vice President, or other corporate officer. The cover/transmittal letter shall provide the name, address, telephone, and facsimile numbers of the Service Provider along with the name, title, address, telephone and facsimile numbers of the authorized representative signing on behalf of the proposer. B. Executive Summary: The Proposal shall contain an executive summary, which outlines the proposal and includes, at minimum, the following: Comprehensive narrative statement that clearly illustrates an understanding of the service requirements requested by this RFP; General approach and management plan that Proposer will use to meet the services required under the Scope of Services section of this RFP; and The proposed staffing, deployment, and organization of personnel to be assigned to accomplish the work called for in this RFP. The Proposer shall include an organizational chart of personnel assigned to the project. C. Qualifications & Experience: Each proposal must provide sufficient information about Proposer so that the City can evaluate the Proposers stability and ability to support the commitments set forth in response to the RFP. The Proposer shall provide information as to the qualifications and experience of all executive, managerial, legal, claims adjusters, and professional personnel to be assigned to this project, including resumes citing experience with similar projects and the responsibilities to be assigned to each person. The City, at its option, may require a Proposer to Page 9 of 52 provide additional support or clarify requested information. See Appendix D and E at the end of the RFP and complete the Personnel Information. D. Responses to Questionnaire: Each proposal shall include complete and thorough responses to the Questions set forth in Appendix A, B, and/or C to this RFP. Failure to answer any question may result in your submission being deemed as unresponsive and rejected. E. Cost Proposal: Proposers must indicate their proposed pricing for each type of charge listed in the table set forth in Appendix H and I. Pricing should take into consideration any additional cost the TPA might incur including after-hours and holiday services. Pricing must be all-inclusive and cover every aspect of the TPA services. If there are additional costs associated with the Services not otherwise contemplated in the table in Appendix H and I, please add those additional costs to the existing table. Your Price Proposal must reflect all costs that the City will be responsible for. F. References: Provide a list all public entities you have contracted with in the past five (5) years for services similar to those requested in this RFP as set forth in Appendix F. The failure to list all similar contracts in the specified period may result in the rejection of the Proposers proposal. The evaluators may check all public sources to determine whether Proposer has listed all contracts for similar work within the designated period. If the evaluators determine that references for other public contracts for similar contracts were not listed, the evaluators may contact the public entities to make inquiry into Proposers performance of those contracts and the information obtained may be considered in evaluating Proposers proposal. SUBMITTAL REQUIREMENTS Proposals must be delivered and submitted to the City in accordance with this section. Proposals must be received (not just postmarked) by the City no later than 5:00 p.m. EST on the August 13, 2021 (the Due Date). Proposals received after the Due Date will not be considered and will be returned unopened to the return address on the submission envelope. Proposals received via facsimile or e-mail will not be considered by the City. Proposer must submit five (5) hard copies and one (1) electronic copy of the proposal to the City. The electronic version of the Proposal must be in PDF format on either a CD or USB flash drive attached to the original hard copy proposal. Proposals must be delivered to the City in a sealed envelope or package. The outside of the submittal package and USB Drive must be clearly marked with the applicable RFP number. Proposals may be delivered to the City by (a) hand-delivery, or (b) U.S. mail. A. In-Person Delivery. If delivered in person, the proposal shall be delivered to the following addresses: RFP No. __________________ c/o Ryan Wilson City of Raleigh 222 W. Hargett St., Suite 508 Raleigh, NC 27601 B. Delivery by Mail. If delivered by mail, the proposal shall be sent to the following address: RFP No. ____________________ c/o Ryan Wilson P.O. Box 590 Raleigh, NC 27602 Page 10 of 52 The City reserves the right to reject any or all proposals for any reason and to waive any informality it deems in its best interest. Any requirements in the RFP that cannot be met must be indicated in the proposal. EVALUATION CRITERIA This section provides a description of the evaluation criteria that will be used by the City to evaluate the Proposals. To be deemed responsive, it is important for the TPA to provide appropriate detail to demonstrate satisfaction of each criterion and compliance with the performance provisions outlined in this RFP. The Proposal will be the primary source of information used in the evaluation process. Proposals must contain information specifically related to the proposed services and requested herein. Failure of any Proposer to submit information requested may result in the elimination of the Proposal from further evaluation. Proposals will be evaluated based on the following criteria: Criteria (a) Weight (b) Score (0-3) (a) x (b) Weighted Score Cover Letter / Letter of Transmittal 0 Executive Summary 5 Qualifications, Experience, and References 25 Approach to Scope of Services 30 Data Management & Accessibility 30 Proposed Cost 10 Final Score Score Points 0- Missing or Does Not Meet Expectation 1- Partially Meets Expectation 2- Meets Expectation 3- Exceeds Expectation EVALUATION PROCESS The process by which proposals are evaluated by the City shall be set forth in this section. A. Evaluation Committee. The City will establish an Evaluation and Selection Committee (Committee) to evaluate the Proposals and select a proposal that represents the best value to the City. The Committee will be comprised of City personnel and any other persons as designated by the City. This Committee will determine the responsiveness and acceptability of each proposal. The Committee may request additional information from Proposers. Communication with members of the Committee is subject to 1.4 and 1.6 of this RFP. B. Proposal Review. Proposals will first be analyzed for overall responsiveness and completeness to this RFP. Each Proposal will then be evaluated based on each of the criteria as outlined in section 2.4 of this RFP. After which will be identified as either reasonably qualified or unqualified. A Proposal will be declared unqualified if it clearly fails to demonstrate, in any of the listed areas, a standard that the City believes necessary to meet the requirements set forth in this RFP. Page 11 of 52 C. Finalists Determined & Notified. Following its review of all properly submitted Proposals, the Committee may select a shortlist of the highest ranked reasonably-qualified proposals. If additional information is required by the City, the City will contact the shortlisted firms at this time. D. Proposal Presentations. Shortlisted Proposers will be invited to present their Proposal to the Committee. The purpose of the presentations will be to allow Proposers to further present their proposal and allow members of the Committee to ask questions of the proposed project team. PROPOSED COST SCHEDULE The proposers Cost Schedule shall be presented in an easily understandable manner differentiating between costs related to the initial implementation and on-going costs using the Appendix H and/or I schedule. All potential on-going costs must be separately identified and shown by their unit cost and then multiplied by the Citys expected claim count located Section 1.2. Include the following: A. All fees associated with this account for loss runs, claims reviews, any excess carrier reporting, claims adjusting, viewing of claim notes, data fees and report fees are assumed included in the individual claim fee. Comments should be made if additional fees are required for any of the above services. B. Attach a detailed schedule, which itemizes all aspects of the services outlined in this RFP. Also identify which of these costs would be a one-time charge for set-up, implementation or related to claim familiarization. In addition to the above, please outline whether there would be any other start- up / conversion or termination costs. A guaranteed fee schedule for at least the first three years of the initial three year contract is required. In addition to the above responses, please identify any other service, activity or fee not covered (i.e., postage, handling, supplies, servicing, etc.) that would be a potential cost for the City. C. Any contracts with outside vendors that will work on the account must be disclosed in your proposal. Any fee exchanges between the TPA and the vendor should be outlined in the proposal. The City will retain the right to approve any associated vendor that is in any way involved on the account. D. Address claims data transfer fees, both closed and open claims. E. Describe banking arrangements, how claims payments are made and reimbursed, and how TPA fees are paid. Please include who is the recipient of interest on the account while funds are held for claims payments. Are there any banking fees? If so, please describe. FINAL SELECTION Subsequent to the presentations to the Committee, the Committee will make a recommendation to the City Manager and / or City Council for approval to negotiate a contract with the #1 choice and if unsuccessful to then pursue negotiations with the #2 choice. All proposers will be notified of their standing immediately following Citys decision. Price quoted must be held firm for 240 days after the RFP is due. The City reserves the right to make an award without further discussion of the proposal submitted. The City shall not be bound or in any way obligated until both parties have executed a contract. The City also reserves the right to delay the award of a contract or to not award a contract. The City reserves the right to award a contract for some or all the services within the RFP, or any combination of the services, as determined to be in the best interest of the City. Firms are not required to submit proposals for all the services listed in the Scope, and may submit a proposal for one or both TPA services listed. The general conditions and specifications of the RFP and the selected proposal, as amended by agreement between the City and the proposer including e-mail or written correspondence relative to the RFP, may Page 12 of 52 become part of the contract documents. Failure of the awarded proposer to perform as represented may result in elimination of the proposer from competition or in contract cancellation or termination. Page 13 of 52 3 SCOPE OF SERVICES The TPA shall perform all services required to properly and efficiently supervise, manage, and administer the Citys self-insured workers compensation, general liability, and auto liability programs in compliance with all applicable federal, state, and local laws. The TPA shall perform, at minimum, the following services on behalf of the City: CLAIMS ADMINISTRATION WORKERS COMPENSATION Review and investigate all claims and losses reported to the TPA by the City to the extent deemed necessary in the judgment of the TPA, and adjust, settle, contest or otherwise handle all such claims within the authority granted by the City. The TPA shall obtain pre-approval from the City of any claim for benefits that the TPA recommends be disputed or contested. Maintain thorough documentation on all claims, including but not limited to notes of all claim activity, correspondence, Industrial Commission forms and filings, investigatory materials, medical records, rehabilitation and vocational reports, records, invoices, memoranda, and other documents. The TPA shall provide copies of any claim file document or materials to the Citys Human Resource Department, Division of Safety, Health and Workers Compensation upon request. Review all existing workers' compensation claim files and identify files that are closable and to continue to perform necessary services to process active claims to conclusion. Perform all administrative tasks required to properly close out the files that have been identified as closable. TPA shall assume the complete handling of all prior claims as well as new claims originating from the effective date of the contract. TPA adjuster will provide a plan of action at the initial assignment and continue to provide a plan of action every 90 days along with file reserves. TPA shall have a claims Supervisor or Manager to review all notices of injuries received from the City prior to assignment of the claim to an adjuster. Initiate contact with injured worker via telephone or email within twenty-four (24) hours of receipt of claim from City. The City shall be copied on all correspondence sent to injured worker and any attorney representing them. The TPA shall maintain contact with the injured worker, or if represented, the injured workers attorney, throughout the duration of the claim. TPA shall respond to inquiries from injured workers and/or their attorneys, and City staff within twenty-four (24) hours. The TPA shall provide the injured worker and/or their attorney, responsible customer service. Responsible customer service means to provide the injured worker prompt and accurate information about their claim. Timely file all Industrial Commission Forms and documents required by the Workers Compensation Act or Workers Compensation Rules of the North Carolina Industrial Commission. The TPA shall be responsible for the payment of all penalties and fines incurred by the TPA due to untimely filings. Comply with all State and Federal requirements including EDI reporting requirements. TPA shall also prepare, for the Citys use in filing, any self-insured reports required by the Federal Government or the State of North Carolina for lost time claims greater than seven (7) workdays. Provide a customer service representative throughout the duration of the TPAs contract with the City. The customer service representative will act as a liaison and coordinate services between the City and TPA. The 00 Page 14 of 52 customer service representative is preferred to be located in NC with the ability to meet with the City at their discretion weekly, bi-weekly, or monthly. Assist the City in coordinating all return-to work efforts of the injured employee and notify the City of any changes to the injured employees medical status including work restrictions. Promptly pay all authorized and related medical bills in compliance with the North Carolina Workers Compensation Act and the North Carolina Workers Compensation Medical Fee Schedule. Coordinate medical treatment of all accepted claims by promptly scheduling appointments and authorizing necessary physician referrals and treatments. The City reserves the right to approve or disapprove any health care provider. The TPA may employ a nurse case manager to assist in managing the medical aspect of a claim; however, such assignment is subject to City approval. The City must pre-approve all vendors/specialist assignments to claims. The TPA may assign vendors/specialists to claims only if the vendor/specialist has been pre-approved by the City and the appropriate service agreement has been executed. Vendors/specialists include but are not limited to the following: nurse case managers; vocational rehabilitation specialists; subject matter experts; transportation service providers; and investigation specialists. Provide the name and cost for each vendor on Appendix H at the back of this RFP. All claims should be reserved out of respect of the claimed injury or occupational disease. The reserve should reflect the ultimate lifetime settlement value of the claim, considering the liability and defenses available that may influence the ultimate value of the case. The final reserve should be achieved usually within 180 days of the initial creation of the claim file, taking care to avoid frequent increases. A reserve should be adequate for the life of the claim, with reserve increases only based on the development of substantial new information that would impact the value of the case. (i.e. injury worsens, surgery is required, employee does not recover from the injury timely, cannot return to work, etc.) Initial reserves are to be set by the TPAs claim supervisor on all new claims within five (5) days of receiving claim from the City. A reserve assessment must be performed on all indemnity claims at day 30 along with additional reserve assessment every 90 days thereafter. Any time there is a reserve change the TPA shall document on a reserve worksheet along with reasons. The TPAs claim supervisor must notify the City to sign off on all reserves that exceed $50,000. The TPAs shall have the following authority with regards to settlement of workers compensation claims: A. TPA shall have authority to settle and close all claims for permanent partial disability compensation benefits. B. TPA shall have authority to settle claims up to $25,000 above the amount due and payable to the injured worker with prior approval of the City. Any settlement more than $25,000 the amount due and payable shall require prior approval by the City and the City Attorneys Office as required by law. All Compromise Settlement Agreements required to effect any settlement reached shall be prepared by the City Attorneys Office. C. Any final settlement of indemnity benefits, medical benefits, or both shall be made pursuant to a Compromise Settlement Agreement (Clincher) coordinated, drafted, and approved by the City Attorneys Office. Determine, at the onset of claim, if subrogation should be pursued and to take all necessary actions to protect the Citys lien recovery rights. Third-party liability information shall be documented in the claims data system. Claim files that remain open for subrogation purposes after the closure of underlying workers compensation claim will be assigned to a Subrogation Specialist to continue recovery effort. Provide the Page 15 of 52 name and cost on Appendix G at the back of this RFP. Any waiver or reduction of the Citys lawful third- party lien recovery rights shall be subject to City approval. The TPA will close files in a timely manner and provide the Division of Safety, Health and Workers Compensation of the Citys Human Resource Department with a closing letter or the NC Industrial Commission form for each claim outlining at minimum all indemnity and medical expenses paid on claim. The City has sole authority to add or remove any and all vendors, specialists, or managed care service providers to or from any claim. The terms vendors, specialists, or managed care service providers includes but is not limited to case managers, physical therapists, medical facilities, physicians, etc. The TPA shall provide the names and costs for each of its current vendors on Appendix H of this RFP. All current medical and vocational case management claims must be reassigned to the award TPA vendors. CLAIMS ADMINISTRATION GENERAL LIABILITY AND AUTOMOBILE LIABILITY Within twenty four (24) hours of receipt of the Citys Claim Notice, the TPA will make initial contact via phone or email with the claimant, establish a claims file, and will acknowledge receipt of the new report to the Citys Risk Management Department. Conduct a thorough investigation of each reported incident, claim or loss to the extent necessary, which may include but is not limited to, photographs, diagrams, police reports, recorded statements from involved parties, and all witnesses to determine liability. All claims will be investigated for defense, to include, but not limited to immunity, contributory negligence, statute of limitations and transfer of risk. Utilize appraisers and experts appropriately on cases. Respond to emails or phone calls from claimant within (24) hours. All phone conversations, discussions and meetings will be clearly documented in each electronic file, including contact dates. Settle non-litigated claims up to $25,000 above the amount due and payable. Maintain thorough documentation of all claims, including but not limited to, correspondence, investigatory materials, medical records, invoices, memoranda, and other documents. The TPA also agrees to generate and maintain notes of all claims activity and provide a copy of all notes to the City, at their request. Respond to City staff inquiries within twenty-four (24) hours and on the same day involving important issues. Upon request, provide narrative or analytical reports regarding major cases. Maintain liaison between the excess insurance carrier and the City on matters affecting the adjustment of such claims and comply with all reporting guidelines, promptly responding to inquiries. Participate in Claim review/update meetings with Risk Management on an as-needed basis. The TPA will fully cooperate with and provide requested information to the Citys auditor and consultants when needed. CO Page 16 of 52 The TPA will close files in a timely manner and provide Risk Management with a closing letter on all denied liability files. The TPA will provide copies of all correspondence such as medical reports, denial letters, attorney correspondence, etc. upon request by Risk Management. The TPA adjuster shall set initial reserves within ten (10) days of assignment of each Claim. The TPA adjuster will provide a plan of action at the initial assignment and continue to provide a plan of action every 90 days along with file reserves. Copy Risk Management on all excess carrier correspondence and report within 30 days to excess carrier any Claims meeting their criteria. Although such claims will be under the direction of the City Attorneys Office, our excess insurer mandates the TPA provide claims notification and reporting requirements The claims notification criteria for the Citys current excess carrier, Brit Global Specialty USA*, is as follows: A. Catastrophic Injuries (including Fatalities, Paraplegia, Quadriplegia, Severe Burns, Significant Brain Injury, Amputation of Major Extremity) B. Discrimination or Violation of Civil Rights claims where the claim is reserved at 50% or more of the self-insured retention or within 90 days of a trial date, whichever is sooner. C. Third Party claims (other than auto liability) involving Law Enforcement Activities. D. Act or series of acts of Terrorism E. Sexual abuse claims F. Any claims where there is a question as to whether there will be coverage under the Policy G. All claims reserved at 50% or more of the Self-Insured Retention H. All claims where there has been a settlement demand above the self-insured retention and there is a trial, binding arbitration, or binding mediation date within ninety (90) days I. The cost of which is likely to result in payment by Underwriters under their policy. Become an approved vendor (if not already) with the Citys excess liability insurance provider. The City reserves the right to withdraw the TPA contract offer if the TPA is not currently or cannot become approved by the Citys excess insurance provider no later than 45 days prior to the contract start date. If the City changes their excess liability carrier, TPA will become an approved vendor no later than 45 days after the vendor change. CUSTOMER SERVICE Customer Service is of the utmost importance when servicing our Claims. The City is very focused on Customer Service with a philosophy to provide quality services in a manner that is courteous, responsible, accessible, and seamless. The Services will be delivered with patience, understanding, good will, and without regard to our own convenience. The selected TPA will be expected to use these guidelines in developing the Proposed Solution: A. Accessible, courteous, responsive, and seamless customer service that is both consistent and fair is our highest priority. Page 17 of 52 B. Accessible service means that citizens and employees have easy access to the organization too. C. Courteous service means that a customer or employee gets good service no matter who is responsible. D. Responsible customer service means that the information provided is accurate; that adjusters have a good understanding of how to get problems and decisions made; that adjusters are trained and evaluated for the jobs they are doing. E. Customer Service goals must be measurable and regularly evaluated. LITIGATION MANAGEMENT Advise the City when defense attorney assignment is necessary on a claim file. The City Attorneys Office shall approve and designate defense counsel. Maintain a litigation management budget for each litigated file and provide litigation status reports for each litigation file on a quarterly basis. Upon the defense attorneys assignment of a claim, the TPA shall provide the defense attorney a complete copy of the claim file, which is to include but not be limited to all adjuster notes, State/Federal court filings and pleadings, NC Industrial Commission forms and filings, correspondence, medical records, rehabilitation reports, investigatory materials and documents, subrogation information, reserve information, and an attorney referral sheet that outlines the reasons for attorney referral. The TPA shall provide investigatory assistance to the assigned defense attorney on a time and expense basis. Attend any mediation, hearing, or deposition on behalf of the City when requested by defense counsel or required by the North Carolina Industrial Commission. Notify excess insurer as required by law or contract. FINANCIAL ACCOUNTING At the end of each month, the TPA shall provide the following information to the City: A. A billing report for services. B. A billing for reimbursement of claims payment by the tenth (10th) business day of each month C. A monthly report of all open and closed claims (Loss Run Report) to include the status of each open claim assigned, including details of payment and outstanding reserves for the month and year covered by the report and such report will be provided no later than the fifth (5th) day of the following month. This report will be in the form of an electronic data transfer, which contains a download of cumulative claim information in a format specified by the City. D. A copy of the check register of all payments. Page 18 of 52 The TPA shall cooperate fully with, and provide requested information to, the Citys auditor and consultants when needed. TPA shall timely submit requests to any excess carrier(s) for all payments made in excess of the claims Self-Insured Retention to obtain the proper reimbursement for the City and provide a copy to the Division of Safety, Health and Workers Compensation or Risk Management. INFORMATION SYSTEM DATA & ACCESS Timely transfer all claims data and respective file documentation for all open and closed files into the TPAs claims information system to ensure future City loss runs will contain a complete history of all claim years. At no additional cost, the TPA shall provide designated City staff with real-time electronic, internet accessible claim file data, which includes read-only access to the following claim information: adjuster notes, all documents, payment and billing records, reserves, and any additional information requested by the City. REPORTING WORKERS COMPENSATION TPA shall comply with the reporting requirements of all City excess insurance carriers. TPA shall report immediately to the claims excess carrier any claim that involves the following: (i) fatality; (ii) spinal cord injury; (iii) brain injury; (iv) serious burn injury; (v) loss of consciousness; (vi) amputation; and (vii) accidents involving two or more City employees. TPA shall also provide prompt notice to the applicable excess carrier of any claim where: (i) the injured employees disability exceeds fifty-two (52) weeks, even if the claim is contested; or (ii) when fifty percent (50%) of Self-Insured Retention (SIR) is reached. TPA shall maintain liaison between the excess insurance carriers and the City on matters affecting the adjustment of such claims. TPA shall copy the Division of Safety, Health and Workers Compensation of the Citys Human Resource Department on all excess carrier correspondence. TPA shall be responsible for all fines, penalties, reduction in reimbursements, or any other incurred costs imposed by insurance carriers or the North Carolina Industrial Commission due to failure of the TPA to provide timely reporting to the respective carrier or agency. TPA shall provide to the City narrative or analytical reports of claims, upon request. Provide a report to the City every 30 days indicating all employees that are not working in a full duty unrestricted capacity. At the end of each fiscal year an overview report of lost workdays shall be provided to the City by the Claims Administrator. Participate in claim review meetings with the Division of Safety, Health and Workers Compensation of the Citys Human Resources Department and any other required personnel on an as-needed basis, and at a minimum, semi-annually. The file review shall include, at a minimum, information on nature of injury, medical treatment history, current status, expenditure, reserves, exposure information, subrogation, and an action plan. CO Page 19 of 52 REPORTING GENERAL LIABILITY AND AUTO LIABILITY TPA shall report immediately to the claims excess carrier any claim that involves the following injuries: (i) fatality; (ii) spinal cord injury; (iii) brain injury; (iv) serious burn injury; (v) loss of consciousness; and (vi) amputation. TPA shall report immediately to the claims excess carrier any claims that involve the following: (i) wrongful incarceration, (ii) high-level police law enforcement liability, and (iii) civil matter which the adjuster deems necessary to report. TPA shall also provide prompt notice to the applicable excess carrier of any claim where: when fifty percent (50%) of Self-Insured Retention (SIR) is reached. TPA shall also comply with any additional reporting requirements of all City excess insurance carriers. TPA shall maintain liaison between the excess insurance carriers and the City on matters affecting the adjustment of such claims. TPA shall copy the Division of Risk Management of the Citys Finance Department on all excess carrier correspondence. TPA shall be responsible for all fines, penalties, reduction in reimbursements, or any other incurred costs imposed by insurance carriers due to failure of the TPA to provide timely reporting to the respective carrier or agency. TPA shall provide to the City narrative or analytical reports of claims, upon request. Participate in claim review meetings with the Division of Risk Management of the Citys Finance Department and any other required personnel on an as-needed basis, and at a minimum, semi-annually. The file review shall include, at a minimum, information on nature of injury, medical treatment history, current status, expenditure, reserves, exposure information, subrogation, and an action plan. RECORDS RETENTION Comply with all federal, state, and local laws including public records laws. Loss and claim files shall be stored in their existing state at the time of file closure for a period of up to five (5) years from inception of the original contract. Upon expiration of this contract, at no additional cost to the City, the City shall have one of the following three options: (1) Require the TPA to return all stored files to the City; (2) require the TPA to continue storing files at the then prevailing rate; OR (3) require the TPA to transfer all stored files to another TPA. If at the end of the contract period the City has not notified the TPA in writing of its selection of one of the options as set forth above, it is agreed that the TPA will return all stored files to the City. IMPLEMENTATION/TRANSITION TPA shall meet with Division of Safety, Health and Workers Compensation of the Citys Human Resource Department, Risk Management Division of the Citys Finance Department and selected (current) TPA Vendor no later than five (5) business days after contract award to create plan for transfer of responsibility for specific contract service (if applicable) in accordance with all specifications for all existing and newly filed claims as of July 1, 2022 that includes the following elements: timing of significant tasks, responsibilities of all involved parties and staffing and location where transition work will occur. If applicable, on all existing claims the TPA shall provide the process of beginning work that ensures timely payment of ongoing benefits or ongoing service delivery with no interruption; initiate Page 20 of 52 communication with employees and with current service providers to give notice of change in TPA for respective claim service. TPA shall provide an electronic report in MS Office or Adobe format to Division of Safety, Health, and Workers Compensation of the Citys Human Resource Department and Risk Management Division of the Citys Finance Department to update the accomplished data transfer tasks by May 16, 2022. TPA shall receive all claims data from incumbent TPA by June 30, 2022. TPA shall comply with the End of Contract Transition Plan: If applicable, no less than sixty (60) days prior to the end of this contract, the current TPA shall provide newly awarded TPA with all claim information, open and closed, electronically along with hard copy files. All data will be transferred from the current electronic system to a new TPAs electronic system. The data will contain best fit data elements between the two systems for claims, payment, employee, and employer information. The City will not incur any cost for transfer of claims data from incumbent TPA to newly awarded vendor(s). Page 21 of 52 4 CONTRACT TERMS The final contract (the Contract) between the City and the selected TPA will be subject to negotiated terms acceptable to the City. Those terms shall include the terms within this section, which are mandatory for City of Raleigh contracts. No exceptions may be made to the terms set forth in this section and any attempt by Proposer to make exception to these terms shall be null and void. The City objects to and shall not be required to consider any additional terms and conditions submitted with a vendors proposal in response to this RFP. NON-DISCRIMINATION To the extent permitted by North Carolina Law, the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner on the basis of race, color, creed, national origin, sex, age, handicap, or sexual orientation with reference to the subject matter of this Contract. The parties further agree, to the extent permitted by law, to conform with the provisions and intent of City of Raleigh Ordinance 1969-889, as amended. This provision is hereby incorporated into this Contract for the benefit of the City of Raleigh and its residents, and may be enforced by action for specific performance, injunctive relief, or other remedy as provided by law. This provision shall be binding on the successors and assigns of the parties with reference to the subject matter of this Contract. MINORITY OR WOMEN OWNED BUSINESSES The City of Raleigh prohibits discrimination in any manner on the basis of race, color, creed, national origin, sex, age or handicap or sexual orientation and will pursue an affirmative policy of fostering, promoting and conducting business with women and minority owned business enterprises. The City of Raleigh encourages participation by certified minority and women-owned businesses. If there are any questions, Contact the MWBE Program Manager, PO BOX 590 Raleigh, NC 27602, mwbe@raleighnc.gov, or 919-996-4330. ASSIGNMENT This Contract may not be assigned without the express written consent of the City. APPLICABLE LAW All matters relating to this Contract shall be governed by the laws of the State of North Carolina, without regard to its choice of law provisions, and venue for any action relating to this Contract shall be Wake County Civil Superior Court or the United States District Court for the Eastern District of North Carolina, Western Division. INSURANCE Contractor agrees to maintain, on a primary basis and at is sole expense, at all times during the life of this Contract the following coverages and limits. The requirements contained herein, as well as Citys review or acceptance of insurance maintained by Contractor is not intended to and shall not in any manner limit or qualify the liabilities or obligations assumed by Contractor under this Contract. Commercial General Liability Combined single limit of no less than $1,000,000 each occurrence and $2,000,000 aggregate. Coverage shall not contain any endorsement(s) excluding nor limiting Product/Completed Operations, Contractual Liability or Cross Liability. Automobile Liability Limits of no less than $1,000,000 Combined Single Limit. Coverage shall include liability for Owned, Non-Owned and Hired automobiles. In the event Contractor does not own automobiles, Page 22 of 52 Contractor agrees to maintain coverage for Hired and Non-Owned Auto Liability, which may be satisfied by way of endorsement to the Commercial General Liability policy or separate Auto Liability policy. Automobile coverage is only necessary if vehicles are used in the provision of services under this Contract and/or are brought on a COR site. Workers Compensation & Employers Liability Contractor agrees to maintain Workers Compensation Insurance in accordance with North Carolina General Statute Chapter 97 with statutory limits and employees liability of no less than $1,000,000 each accident. Additional Insured Contractor agrees to endorse the City as an Additional insured on the Commercial General Liability, Auto Liability and Umbrella Liability if being used to meet the standard of the General Liability and Automobile Liability. The Additional Insured shall read City of Raleigh is named additional insured as their interest may appear. Certificate of Insurance Contractor agrees to provide COR a Certificate of Insurance evidencing that all coverages, limits and endorsements required herein are maintained and in full force and effect, and Certificates of Insurance shall provide a minimum thirty (30) day endeavor to notify, when available, by Contractors insurer. If Contractor receives a non-renewal or cancellation notice from an insurance carrier affording coverage required herein, or receives notice that coverage no longer complies with the insurance requirements herein, Contractor agrees to notify the City within five (5) business days with a copy of the non-renewal or cancellation notice, or written specifics as to which coverage is no longer in compliance. The Certificate Holder address should read: City of Raleigh Post Office Box 590 Raleigh, NC 27602-0590 Umbrella or Excess Liability Contractor may satisfy the minimum liability limits required above under an Umbrella or Excess Liability policy. There is no minimum Per Occurrence limit of liability under the Umbrella or Excess Liability, however, the Annual Aggregate limits shall not be less than the highest Each Occurrence limit for required policies. Contractor agrees to endorse City of Raleigh as an Additional Insured on the Umbrella or Excess Liability, unless the Certificate of Insurance states the Umbrella or Excess Liability provides coverage on a Follow-Form basis. Professional Liability Limits of no less than $1,000,000 each claim. This coverage is only necessary for professional services such as engineering, architecture, or when otherwise required by the City. All insurance companies must be authorized to do business in North Carolina and be acceptable to the City of Raleighs Risk Manager. INDEMNITY Except to the extent caused by the sole negligence or willful misconduct of the City, the Contractor shall indemnify and hold and save the City, its officers, agents and employees, harmless from liability of any kind, including all claims, costs (including defense) and losses accruing or resulting to any other person, firm, or corporation furnishing or supplying work, services, materials, or supplies in connection with the performance of this Contract, and from any and all claims, costs (including defense) and losses accruing or resulting to any person, firm, or corporation that may be injured or damaged by the Contractor in the performance of this Contract. This representation and warranty shall survive the termination or expiration of this Contract. The Contractor shall indemnify and hold and save the City, its officers, agents and employees, harmless from liability of any kind, including claims, costs (including defense) and expenses, on account of any copyrighted Page 23 of 52 material, patented or unpatented invention, articles, device or appliance manufactured or used in the performance of this Contract. INTELLECTUAL PROPERTY Any information, data, instruments, documents, studies, reports or deliverables given to, exposed to, or prepared or assembled by the Contractor under this Contract shall be kept as confidential proprietary information of the City and not divulged or made available to any individual or organization without the prior written approval of the City. Such information, data, instruments, documents, studies, reports, or deliverables will be the sole property of the City and not the Contractor. All intellectual property, including, but not limited to, patentable inventions, patentable plans, copyrightable works, mask works, trademarks, service marks and trade secrets invented, developed, created or discovered in performance of this Contract shall be the property of the City. Copyright in and to any copyrightable work, including, but not limited to, copy, art, negatives, photographs, designs, text, software, or documentation created as part of the Contractors performance of this project shall vest in the City. Works of authorship and contributions to works of authorship created by the Contractors performance of this project are hereby agreed to be works made for hire within the meaning of 17 U.S.C. 201. FORCE MAJEURE Except as otherwise provided in any environmental laws, rules, regulations or ordinances applicable to the parties and the services performed under this Contract, neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations by an act of war, hostile foreign actions, nuclear explosion, earthquake, hurricane, tornado, or other catastrophic natural event or act of God. Either party to the Contract must take reasonable measures and implement reasonable protections when a weather event otherwise defined as a force majeure event is forecast to be eligible to be excused from the performance otherwise required under this Contract by this provision. ADVERTISING The Contractor shall not use the existence of this Contract, or the name of the City of Raleigh, as part of any advertising without the prior written approval of the City. CANCELLATION The City may terminate this Contract at any time by providing thirty (30) days written notice to the Contractor. In addition, if Contractor shall fail to fulfill in timely and proper manner the obligations under this Contract for any reason, including the voluntary or involuntary declaration of bankruptcy, the City shall have the right to terminate this Contract by giving written notice to the Contractor and termination will be effective upon receipt. Contractor shall cease performance immediately upon receipt of such notice. In the event of early termination, Contractor shall be entitled to receive just and equitable compensation for costs incurred prior to receipt of notice of termination and for the satisfactory work completed as of the date of termination and delivered to the City. Notwithstanding the foregoing, in no event will the total amount due to Contractor under this section exceed the total amount due Contractor under this Contract. The Contractor shall not be relieved of liability to the City for damages sustained by the City by virtue of any breach of this Contract, and the City may withhold any payment due to the Contractor for the purpose of setoff until such time as the City can determine the exact amount of damages due the City because of the breach. Page 24 of 52 Payment of compensation specified in this Contract, its continuation, or any renewal thereof, is dependent upon and subject to the allocation or appropriation of funds to the City for the purpose set forth in this Contract. LAWS/SAFETY STANDARDS The Contractor shall comply with all laws, ordinances, codes, rules, regulations, safety standards and licensing requirements that are applicable to the conduct of its business, including those of Federal, State, and local agencies having jurisdiction and/or authority. All manufactured items and/or fabricated assemblies subject to operation under pressure, operation by connection to an electric source, or operation involving a connection to a manufactured, natural, or LP gas source shall be constructed and approved in a manner acceptable to the appropriate state inspector which customarily requires the label or re-examination listing or identification marking of the appropriate safety standard organization, such as the American Society of Mechanical Electrical Engineers for pressure vessels; the Underwriters' Laboratories and/or National Electrical Manufacturers' Association for electrically operated assemblies; or the American Gas Association for gas operated assemblies, where such approvals of listings have been established for the type(s) of devices offered and furnished. Further, all items furnished by the Contractor shall meet all requirements of the Occupational Safety and Health Act (OSHA), and state and federal requirements relating to clean air and water pollution. Contractor must comply with North Carolina Occupational Safety and Health Standards for General Industry,13 N.C.A.C. 07F (29 CFR 1910). In addition, Contractor shall comply with all applicable occupational health and safety and environmental rules and regulations. Contractor shall effectively manage their safety and health responsibilities including: A. Accident Prevention - Prevent injuries and illnesses to their employees and others on or near their job site. Contractor managers and supervisors shall ensure personnel safety by strict adherence to established safety rules and procedures. B. Environmental Protection - Protect the environment on, near, and around their work site by compliance with all applicable environmental regulations. C. Employee Education and Training - Provide education and training to all contractors employees before they are exposed to potential workplace or other hazards as required by specific OSHA Standards. APPLICABILITY OF NORTH CAROLINA PUBLIC RECORDS LAW Notwithstanding any other provisions of this Contract, this Contract and all materials submitted to the City by the Contractor are subject to the public records laws of the State of North Carolina, and it is the responsibility of the Contractor to properly designate materials that may be protected from disclosure as trade secrets under North Carolina law as such and in the form required by law prior to the submission of such materials to the City. Contractor understands and agrees that the City may take any and all actions necessary to comply with federal, state, and local laws and/or judicial orders and such actions will not constitute a breach of the terms of this Contract. To the extent that any other provisions of this Contract conflict with this paragraph, the provisions of this section shall control. Page 25 of 52 MISCELLANEOUS The Contractor shall be responsible for the proper custody and care of any property furnished or purchased by the City for use in connection with the performance of this Contract and will reimburse the City for the replacement value of its loss or damage. The Contractor shall be considered to be an Independent Contractor and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. Nothing herein is intended or will be construed to establish any agency, partnership, or joint venture. Contractor represents that it has, or will secure at its own expense, all personnel required in performing the services under this Contract. Such employees shall not be employees of or have any individual contractual relationship with the City. This Contract may be amended only by written agreement of the parties executed by their authorized representatives. RIGHT TO AUDIT AND ACCESS TO RECORDS The City may conduct an audit of any services performed and fees paid subject to this Contract. The City, or its designee, may perform such an audit throughout the contract period and for three (3) years after termination thereof or longer if otherwise required by law. The Contractor and its agents shall maintain all books, documents, papers, accounting records, contract records and such other evidence as may be appropriate to substantiate costs incurred under this Contract. The City, or its designee, shall have the right to, including but not limited to: review and copy records; interview current and former employees; conduct such other investigation to verify compliance with contract terms; and conduct such other investigation to substantiate costs incurred by this Contract. Records shall be defined as data of every kind and character, including but not limited to books, documents, papers, accounting records, contract documents, information, and materials that, in the City's sole discretion, relate to matters, rights, duties or obligations of this Contract. Records and employees shall be available during normal business hours upon advanced written notice. Electronic mail shall constitute written notice for purposes of this section. Contractor shall provide the City or its designee reasonable access to facilities and adequate and appropriate workspace for the conduct of audits. The rights established under this section shall survive the termination of the Contract, and shall not be deleted, circumvented, limited, confined, or restricted by contract or any other section, clause, addendum, attachment, or the subsequent amendment of this Contract. The Contractor shall reimburse the City for any overcharges identified by the audit within ninety (90) days of written notice of the Citys findings. Contractor shall, upon request, provide any records associated with this engagement to the North Carolina State Auditor that are necessary to comply with the provisions of N.C. G.S. 147-64.7. E-VERIFY Contractor shall comply with E-Verify, the federal E-Verify program operated by the United States Department of Homeland Security and other federal agencies, or any successor or equivalent program used to verify the work authorization of newly hired employees pursuant to federal law and as in accordance with N.C.G.S. 64-25 et seq. In addition, to the best of Contractors knowledge, any subcontractor employed by Contractor as a part of this contract shall be in compliance with the requirements of E-Verify and N.C.G.S. 64-25 et seq. IRAN DIVESTMENT ACT CERTIFICATION Contractor certifies that, as of the date listed below, it is not on the Final Divestment List as created by the State Treasurer pursuant to N.C.G.S. 147-86.55, et seq. In compliance with the requirements of the Iran Page 26 of 52 Divestment Act and N.C.G.S. 147-86.59, Contractor shall not utilize in the performance of the contract any subcontractor that is identified on the Final Divestment List. COMPANIES BOYCOTTING ISRAEL DIVESTMENT ACT CERTIFICATION Contractor certifies that it has not been designated by the North Carolina State Treasurer as a company engaged in the boycott of Israel pursuant to N.C.G.S. 147-86.81. Page 27 of 52 APPENDIX A GENERAL QUESTIONNAIRE (ALL PROPOSERS MUST COMPLETE THIS SECTION) Company Overview 1. What is the name, legal entity name or, operating name of your TPA Firm? Where is the TPA Firm headquartered? In what state is the TPA Firm incorporated? 2. Provide the names, titles, telephone numbers and email addresses of all individuals responsible for responding to this Request for Proposal. 3. Can you provide evidence of a current, valid TPA license? If, so provide a copy. 4. Is your TPA Firm private or public? If public, what is your stock ticker symbol? Is your TPA Firm national, regional, or state specific firm? 5. How long has your TPA Firm been in the business of providing Third-Party Administration services for workers compensation and/or automobile/general liability claims? 6. What experience does your TPA Firm have administering claims for other public entities? Describe your experience in handling a public entity account comparable to the City of Raleigh. 7. What differentiates your TPA Firm from other competitors and what services do you provide that are unique throughout claims process? 8. How many clients do you have? Of those, how many are public entities and how many do you service in workers compensation and automobile/general liability? 9. How many claim servicing office locations do you have in North Carolina? In what states do you have physical servicing offices with claim staff serving North Carolina? 10. Have any principals or employees ever been convicted of mishandling company funds, criminal activity, or had a lawsuit or Insurance Department complaint brought against them? If yes, what corrective actions have been taken. 11. Is your TPA firm currently or previously filed a petition in bankruptcy, taken any actions with respect to insolvency, reorganization, receivership, moratorium, or assignment for the benefit of creditors or otherwise sought relief from creditors? 12. Has your TPA firm been fined by any regulatory body in the last three (5) years? If so, explain and provide the number and the amount of those fines. 13. Has your TPA firm been a part of any bad faith actions over the last three (5) years? Explain. 14. Describe your TPA Firms confidentiality policy and standards. Claim Processing 15. What methods of claim reporting are available to your clients (internet, email, fax, 1-800 phone numbers)? Do you have a dedicated phone line for the City? 16. What is your estimated timeframe to set up claims, to assign a claim representative/adjuster to the case, and make 3-point contacts? 17. What are your criteria to take a recorded statement and investigate a claim? Who would take the recorded statement? 18. What is your TPA firms reserving philosophy? What is your process for reviewing the accuracy and timeliness of reserves? How often are reserves reviewed and by whom? Are claim estimates/reserves automated or are they based upon adjusters experience? 19. Describe your after-hours claim reporting procedures. Do you have a 24/7 Program? Page 28 of 52 20. Provide a detailed description of your subrogation recovery program. Does your TPA firm have a separate subrogation recovery department? If so, please provide the information in Appendix G. 21. Will you provide acknowledgments of new losses to the client and the excess carrier upon receipt of a new claim? If so, how are the acknowledgments provided (fax, email, regular mail)? 22. Describe banking arrangements, how claim payments are made and reimbursed and how TPA fees are paid including who is the recipient of interest on the account while funds are held for claims payments. Are there any banking fees? If so, please describe. Provide samples. Staffing 23. Will there be an Account Manager assigned to the City? Where will this individual be located? 24. What is your TPA firm current employee retention rate (including all turnover, promotions, and reassignments)? 25. Provide a profile/biography of all personnel that will serve the City along with the information on Appendix D and E. 26. How often are your supervisors engaged in reviewing claim files? Describe the supervisory involvement in claims management including nature of cases and frequency of internal audits. 27. How often are training sessions provided to claims adjusters? What type of service, education and training is available to the City? If so, is there an additional cost? 28. What are the average years of experience of your claim adjusters? 29. What is the average tenure of your claim staff? 30. Do supervisors have a desired caseload? 31. Please state the ratio of supervisors to adjusters. Information Systems and Data Management 32. Describe the hardware platform and software system you use to administer claims. Was the software developed internally, leased, or bought from another provider? If leased, provide the name of your partner/vendor. 33. Does the TPA firm store the data on its own servers or does it use a hosted solution? If the data is hosted, what company is being used & which company is responsible for the data integrity, security, access, etc. Where are the servers physical located? 34. Do you have a Claim Management Information System (CMIS) or Risk Management Information System (RMIS) system which provides clients access to adjuster file notes and the ability to run reports and generate loss runs? What is the name of your CMIS/RMIS system? How frequently is the data in your system updated? Are there any charges for the client or excess carrier to access this system? Do you provide training to use this system? 35. What types of customizable features will the City have with your CMIS/RMIS system, i.e. ability to enter notes, change date fields, etc.? Is the system read-only, or is there an option for interactive participation? 36. Will your system allow the City to use their own type and cause codes, as given by the City, or will your system only allow cause codes as assigned by the system? If so, is there an additional charge for incorporating these codes into your current system? 37. Describe your reporting capabilities and the ability to provide analytics, loss location, and date and time of the injury on a monthly and/or ad hoc basis. Describe the softwares flexibility for customization. 38. What is your strategy to ensure data integrity? What safeguards are in place to protect City data? Page 29 of 52 39. How does the City access the data, i.e., FTP site, a web portal into the TPA Firm system? 40. For data issues, the City needs US based customer support at a minimum for 8 hours per day between 8 am 5 pm EST Monday through Friday. Can this be accommodated? 41. Describe the types of standard reports that are available to the City for analyzing claims. Provide samples. Is there an additional cost? 42. Describe the frequency, content, and method of delivery of any status reports that are generated to the client and/or excess carrier throughout the life of a claim. 43. How often are loss reports sent to the excess carrier? At what dollar level or time intervals are claims reimbursement requests communicated to the excess carrier? 44. Provide a sample copy of your TPA Firms Loss Run that will be available to the City. What is the frequency of these reports? 45. Are customized reports available on request? What is the turnaround time for these reports? Is there an additional cost? 46. What auditing standards does your organization adhere to (e.g., SAS 70) 47. Are internal controls of your recordkeeping system audited by an independent account firm on an annual or more frequent basis? If so, provide a copy of the most recent result? 48. Do you have predictive modeling capabilities? If yes, what do you predict? What can you predict? Safety and Fraud 49. Explain your internal audit procedures to eliminate fraudulent activities that could be committed by your TPS staff? 50. Do you have a Special Investigative Unit in your TPA Firm? If so, describe the unit including how many personnel are in this unit? 51. Describe any services you provide associated with fraud detection such as surveillance. Specify any additional fees and an overview of the fraud investigations under Appendix H. 52. If a data breach occurred, what are your measures to address this? What notification protocols do you implement/follow? 53. Do you have a disaster recovery plan which includes cyber-attacks & theft of Personally Identifiable Information? Describe your firms Business Continuity Plans, Disaster Recovery Plans and Security Program. Account Transition 54. If applicable, describe in detail, the transition services you would provide if you were awarded the RFP contract. Transition services should include but not limited to the following: I. Have you had any previous experience taking over as new TPA? II. Description of the resources, framework and/or organization structure that your TPA Firm will use to implement a smooth transition from the Citys current workers compensation and/or automobile/general liability provider to your provision of services. III. Provide the key personnel involved in the transition and their respective responsibilities. IV. Describe how you plan to communicate between you and the existing TPA. V. Describe how your TPA Firm will establish data transfer protocols, file accounting for open and closed claims and mail delivery procedures. VI. How will you oversee data conversion, coding, excess reporting needs and compliance? Page 30 of 52 VII. What process do you use for coordination of notification letters from the prior and new TPA to vendors, defense counsel and claimants? VIII. What process do you use for coordination of mail delivery post-transition? IX. What process will you use to provide transition status reports to the City and how often? X. Does the company have experience transitioning data/files from other proprietary CMIS/RMIS systems? If so, what other systems has the company performed successful data transfers? XI. Which party will bear the costs incurred for converting existing claims data of the City into the data information system used by your organization? 55. Will there be any charges for transition activities? If yes, please describe. 56. How long will the transition take and what is the typical time frame? 57. Provide information as to what recourse the City would have if the services provide by your TPA Firm were not satisfactory. 58. Are you willing to enter a Performance Guarantee with the City? If so, provide a sample you would propose to the City to ensure service. 59. Will a transition manager be assigned to this program & is this persons job only to coordinate TPA transitions or will they have other responsibilities? Termination of Services 60. How many days notice is required to terminate your services? 61. What procedures would be followed upon termination of your services? 62. What happens with claim files and access to data should your services be terminated? Page 31 of 52 APPENDIX B WORKERS COMPENSATION QUESTIONNAIRE 1. Explain your companys procedure for establishing contact with injured workers. What is your TPA firm policy for returning phone calls and responding to written correspondence, including emails? How is compliance tracked? 2. Will you have a dedicated telephone number for employees to call in the event of an injury? 3. Where will adjusters be geographically located for Workers Compensation claims? 4. What is the average number of years experience for your organization lost time adjusters and supervisors? 5. Describe the authorization process for an employee to receive First Fill medication and thereafter. 6. Clearly state the TPA firms definitions for an Indemnity Claim, Medical Only Claim and a Report Only and any other claim terminology that you use. 7. Describe when a medical or vocation case manager should be utilized, suspended and/or terminated on a claim. 8. Do the adjusters have access to in-house nurses or physician advisors? If so, explain. 9. Do you have a Preferred Provider Organization (PPO)? Do you own, partner, or lease your PPO? 10. Provide any additional information on Bill Review that is not included under Appendix H. 11. Explain your TPA firms Medicare Set Aside procedure when its required? Describe your firms steps to be in compliance with Mandatory Insurer Reporting for Non-Group Health Plans (NGHP) Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007? Is there an extra fee when processing the mandatory yearly Medicare report? 12. Does your TPA license have a Bill Review software for State Fee schedule medical bill repricing? If so, from who? Does the software review for Usual & Customary medical bill repricing? 13. How do you maintain updates to ensure your State Fee Schedule UCR repricing schedules are current? 14. Describe your Bill Utilization and Utilization Reviews (UR) including who does the service and any associated costs. Provide a sample. 15. Describe your Hospital Bill Review including if the service is done in-house or with a vendor, the name, and any associated costs. Provide a sample. 16. What procedures does your TPA firm have in place to assist the City in return-to-work efforts of its injured workers? 17. How many full-time workers comp adjusters will be assigned to this account? How many for medical only and how many of lost time cases? Where will they be located? 18. Will there be a separate adjuster for medical only and lost time cases? 19. What is the recommended average caseload for medical only and lost time adjusters? 20. Describe your ability to track the date when a person returns to work at light duty and then released to full duty and how this information is reportable. 21. Do you have the ability to automatically track lost time and maintain absence information to generate OSHA 300 Logs? Are you able to make corrections on the OSHA 300 Log when information is missing on the FNOL/Form 19, if information did not transfer over or information needs to be updated? Page 32 of 52 22. Provide a list of all outside vendors currently used by your TPA Firm; this list should include but not be limited to the following vendors: (see Appendix H). I. Nurse and Vocation Case Managers II. Physical Therapy Specialists III. Private Investigation Firms IV. Transportation Services V. Medicaid and Medicare Solution Services 23. Provide your experience in handling claims for Fire and Police. 24. Will you be responsible for filing all State loss notices and forms at no additional charge? 25. What is your estimated timeframe to make a compensability decision and to schedule medical appointments? 26. If applicable, what process do you have planned so that processing bills and indemnity will transfer smoothly to our injured workers and vendors (physicians, medical facilities, defense counsel, etc.) Page 33 of 52 APPENDIX C AUTOMOBILE AND GENERAL LIABILITY QUESTIONNAIRE 1. Describe your Organizations experience with public entities and the use of governmental immunity in North Carolina. Please describe how an immunity analysis is conducted and how questions are resolved including the reasons why immunity would apply and would not apply. 2. Where will AL/GL claims adjusters be geographically located? 3. How many automobile and general liability adjusters will be assigned to this account? 4. Are claim estimates/reserves automated or are they based upon adjuster experience and discretion? 5. What is your organizations reserving philosophy? How often are reserves reviewed and by whom? 6. Do you have local adjusters available for on-site inspections or, do you outsource to an independent adjusting agency? If you do outsource, please include any additional fees that may be incurred and passed on to the City. 7. In-House Risk Management Claim Payments Presently, claim settlement authority resides solely with the City Attorneys Office and the TPA (subject to contract terms); however, there exists internal discussion on the potential for Risk Management to settle small non-disputed property damage claims, less than $2,000.00, which would only require recording the incident, securing a general release and, check issuance by the TPA. There exists no short-term plan to initiate this process but, it is a claim category envisioned for possible future use. (See In-House Risk Management Claims description in Exhibit A.) Do you have reduced fees for claims not requiring an investigation and only requiring recording, a general release and payment? 8. Is there a reduced fee for tendered claims requiring no investigations but, simply a form tender letter with carrier contact information? 9. What is the average caseload for liability adjusters? 10. Which office will handle the Citys liability claims? 11. Provide your experience in handling claims for Fire and Police. 12. Can you describe your organizations experience with handling litigated and non-litigated claims from beginning to end? 13. Can you explain your firms procedures for establishing contact with the claimants and the client? Page 34 of 52 APPENDIX D TPA INFORMATION - WC In addition to the information below, provide an organizational chart of your Firm and the department that will be handling the responsibilities as stated in this RFP along with the information in Appendix A, Staffing. TPA/Provider:_______________________________________________________________ Manager Name______________________________________________________________ Years of Experience__________________________ Supervisor Name_____________________________________________________________ Years of Experience__________________________ Medical Only Adjuster #1 Name_________________________________________________ Years of Experience__________________________ Medical Only Adjuster #2 Name_________________________________________________ Years of Experience__________________________ Lost Time Adjuster #1 Name_____________________________________________________ Years of Experience__________________________ Lost Time Adjuster #2 Name_____________________________________________________ Years of Experience_________________________ Additional Professional Personnel Title and Name________________________________________________________________ Years of Experience__________________________ Title and Name_______________________________________________________________ Years of Experience__________________________ Title and Name_______________________________________________________________ Years of Experience__________________________ Page 35 of 52 APPENDIX E TPA INFORMATION AL/GL In addition to the information below, provide an organizational chart of your Firm and the department that will be handling the responsibilities as stated in this RFP along with the information in Appendix A, Staffing. TPA/Provider:_______________________________________________________________ Manager Name______________________________________________________________ Years of Experience__________________________ Supervisor Name_____________________________________________________________ Years of Experience__________________________ GL/AL Liability Adjuster #1 Name_____________________________________________________ Years of Experience__________________________ GL/AL Liability Adjuster #2 Name_____________________________________________________ Years of Experience_________________________ Additional Professional Personnel Title and Name________________________________________________________________ Years of Experience__________________________ Title and Name_______________________________________________________________ Years of Experience__________________________ Title and Name_______________________________________________________________ Years of Experience__________________________ Page 36 of 52 APPENDIX F TPA REFERENCES TPA/Provider:_______________________________________________________________ TPA/Provider shall provide at least five (5) references of current or previous clients with contracts of two (2) or more years duration that the firm has performed within the past five (5) years for services of similar size and scope to that proposed herein. Reference #1: Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Service Provided:__________________________________________________________________ Service Date(s):____________________________________________________________________ Reference #2: Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Service Provided:__________________________________________________________________ Service Date(s):____________________________________________________________________ Reference #3: Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Service Provided:__________________________________________________________________ Service Date(s):____________________________________________________________________ Page 37 of 52 Reference #4: Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Service Provided:__________________________________________________________________ Service Date(s):____________________________________________________________________ Reference #5: Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Service Provided:__________________________________________________________________ Service Date(s):____________________________________________________________________ Provide a description of the reasons three former clients gave for deciding not to renew during the past two years. 1. 2. 3. Page 38 of 52 APPENDIX G SUBROGATION Claim files that remain open for subrogation purposes after the closure of underlying workers compensation claim will be assigned to a Subrogation Specialist to continue recovery effort. TPA/Provider:_______________________________________________________________ Name:____________________________________________________________________________ Address:__________________________________________________________________________ Telephone Number:_________________________________________________________________ Contact Person:____________________________________________________________________ Cost per Claim:____________________________________________________________________ Page 39 of 52 APPENDIX H COST PROPOSAL - WC Service Providers shall provide proposed pricing based on the requirements and terms set forth in the RFP. Pricing must be all-inclusive and cover every aspect of the Project. Cost must be in United States dollars rounded to the nearest quarter of a dollar. If there are additional costs associated with the Services, please add to this chart. Your Price Proposal must reflect all costs that the City will be responsible for. All fees associated with this account for loss runs, claims reviews, all state reporting, any excess carrier reporting, claims adjusting, ISO indexing, claims notes information viewing, data fees and report fees are assumed included in the individual claim fee. Comments should be made if additional fees are required for any of the above services. Claim Administration TPA/Proposer________________________________ Claim Types Cost Per Claim Additional Fees (Explain) Indemnity $ Medical Only $ Denied $ Report Only $ Tail Claims $ Other Charges Annual Administrative Fee $ One-Time Conversion Fee $ Time and Expense $ Checking and Banking Fees $ On-line Data Access $ Non-standard Customized Reports $ Bill Review $ PPO Savings $ Page 40 of 52 Miscellaneous Fees 1 $ 2 $ 3 $ Page 41 of 52 Pharmacy Benefit Management Vendor Name _______________________________ Description Rate or Unit Cost Source of Average Wholesale Price (AWP) to be Used in Drug Pricing Calculations Describe Retail Delivery - Brand Drug % of AWP Dispensing Fee $ Retail Delivery - Generic Drug % of AWP Dispensing Fee $ Mail Order Delivery - Brand Drug % of AWP Dispensing Fee $ Mail Order Delivery - Generic Drug % of AWP Dispensing Fee $ Compound Drug Describe - including pricing and dispensing fee Bill Review - Flat Rate Fee per Prescription $ Bill Review - Percentage of Savings Fee per Prescription $ Page 42 of 52 Bill Review Vendor Name _____________________________________________ Description Rate or Unit Cost Check Which Method Will Be Utilized __________ Flat Rate per Bill $ __________Per Line Charge per Bill $ Duplicate Bill Charges $ $__________ Flat Rate per Bill $__________ per Line Charge per Bill Resubmitted Bill Charges $__________ Flat Rate per Bill $__________per Line Charge per Bill Percentage of Managed Care Network/PPO Savings Fee charged for Savings per Bill __________% Page 43 of 52 Nurse Case Management Vendor #1 Name__________________________________________ (Must have at least two vendors) Description Rate or Unit Cost Medical Field Nurse Case Management $____________ per Hour Medical Task Nurse Case Management $____________ per Hour Medical Telephonic Nurse Case Management $____________ per Hour Vocation Case Management $____________ per Hour Travel Time $____________ per Hour Wait Time $____________ per Hour Mileage Fee $____________ for Minimum Miles $____________ Additional Charge per Mile Life Care Planning $____________ per Hour OR $____________ Flat Rate Page 44 of 52 Nurse Case Management Vendor #2 Name__________________________________________ (Must have at least two vendors) Description Rate or Unit Cost Medical Field Nurse Case Management $____________ per Hour Medical Task Nurse Case Management $____________ per Hour Medical Telephonic Nurse Case Management $____________ per Hour Vocation Case Management $____________ per Hour Travel Time $____________ per Hour Wait Time $____________ per Hour Mileage Fee $____________ for Minimum Miles $____________ Additional Charge per Mile Life Care Planning $____________ per Hour OR $____________ Flat Rate Page 45 of 52 Physical Therapy Vendor Name________________________________________ Description Rate or Unit Cost Initial Evaluation/Initial Treatment $____________ per Hour Physical Therapy $____________ per Hour Occupational Therapy $____________ per Hour Dry Needling $____________ Work Conditioning $____________ per Hour Functional Capacity Evaluation (FCE) $____________ Miscellaneous Services $____________ $____________ $____________ Page 46 of 52 Diagnostic Radiology Vendor Name________________________________________ Description Unit Cost CT Head with Contrast $____________ CT Head Scan without Contrast $____________ CT Cervical with Contrast $____________ CT Cervical without Contrast $____________ CT Lumbar with Contrast $____________ CT Lumbar without Contrast $____________ MRI Brain with Contrast $____________ MRI Brain without Contrast $____________ MRI Lower Extremity with Contrast $____________ MRI Lower Extremity without Contrast $____________ MRI Upper Extremity with Contrast $____________ MRI Upper Extremity without Contrast $____________ MRI Cervical with Contrast $____________ MRI Cervical without Contrast $____________ MRI Lumbar with Contrast $____________ MRI Lumbar without Contrast $____________ Page 47 of 52 Home Health and Durable Medical Equipment (DME): Vendor...