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HomeMy WebLinkAbout25533AGREEMENT INFORMATION AGREEMENT NUMBER 25533 NAME/TYPE OF AGREEMENT USIS, INC. DESCRIPTION AMENDMENT NO. 1 TO PROFESSIONAL SERVICES AGREEMENT/THIRD-PARTY CLAIMS ADMINISTRATION SERVICES RFP NO. 605386/FILE ID: 2044/R-17-0224/MATTER I D : 25-394 EFFECTIVE DATE June 15, 2017 ATTESTED BY TODD B. HANNON ATTESTED DATE 4/8/2025 DATE RECEIVED FROM ISSUING DEPT. 4/9/2025 NOTE DOCUSIGN AGREEMENT BY EMAIL CITY OF MIAMI DOCUMENT ROUTING FORM ORIGINATING DEPARTMENT: Department of Procurement DEPT. CONTACT PERSON: Aimee Gandarilla NAME OF OTHER CONTRACTUAL PARTY/ENTITY: USIS, INC. EXT. 1906 IS THIS AGREEMENT TO BE EXPEDITED/RUSH: TOTAL CONTRACT AMOUNT: $ TYPE OF AGREEMENT: ❑ MANAGEMENT AGREEMENT ❑ PROFESSIONAL SERVICES AGREEMENT ❑ GRANT AGREEMENT ❑ EXPERT CONSULTANT AGREEMENT ❑ LICENSE AGREEMENT OTHER: (PLEASE SPECIFY) ■ FUNDING INVOLVED? YES YES ❑ PUBLIC WORKS AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ INTER -LOCAL AGREEMENT ❑ LEASE AGREEMENT ❑ PURCHASE OR SALE AGREEMENT NO NO PURPOSE OF ITEM (DETAILED SUMMARY): Amendment No. 1 to RFP 605386 - to provide additional services to assist the City with processing and distribution of $27,904,756.23 retained by the MDC Office of the Tax Collector. This money will be used to reduce ad valorem taxes. COMMISSION APPROVAL DATE: FILE ID: ENACTMENT NO.: IF THIS DOES NOT REQUIRE COMMISSION APPROVAL, PLEASE EXPLAIN: ROUTING INFORMATION Date PLEASE PRINT AND SIGN APPROVAL BY DIRECTOR/CHIEF PROCUREMENT OFFICER April 03, 2025 108:Annie 21:Perez,30EDTPO CP �oas,9d er SIGNATURE: -4---- c?°^°1 SUBMITTED TO RISK MANAGEMENT April 03, 2025 Ann -Marie Sharpe I 09:00: 31 9°'^°r SIGNATURE:7ray:& raw,vy SUBMITTED TO CITY ATTORNEY Matter 25-394 Apri 1 4, 2025 IGg�r46:16.611 ong III �.ssde, SIGNATURE: 0 w'is, III APPROVAL BY ASSISTANT CITY MANAGER, CHIEF FINANCIAL OFFICER April 7, 2025 Larry Spring, CPA I 19: 45 : 25 EDT gnetl by .`l_i, SIGNATURE: ISpvSpr unl APPROVAL BY ASSISTANT CITY MANAGER, CHIEF OF OPERATIONS Barbara Hernandez, MPA SIGNATURE: APPROVAL BY ASSISTANT CITY MANAGER, CHIEF OF INFRASTRUCTURE Asael Marrero SIGNATURE: APPROVAL BY DEPUTY CITY MANAGER April 8, 2025 Natasha Colebrook -Williams I 11:03:49 EDT SIGNATURE: N.zN,EF c & -w;u; RECEIVED BY CITY MANAGER Arthur Noriega V SIGNATURE: SUBMITTED TO THE CITY CLERK April 9, 2025 ITT1C1117M1CRir _Dor„_s;g.ed„„ SIGNATURE: `1-'(e-f — PLEASE ATTACH THIS ROUTING FORM TO ALL DOCUMENTS THAT REQUIRE EXECUTION BY THE CITY MANAGER City of Miami Office of the City Attorney Legal Services Request To: Office of the City Attorney From: Justin Griffin Contact Person Sr. Procurement Contracting Officer Title 4/3/2025 Date: Procurement Requesting Client (305) 416-1949 Telephone Legal Service Requested: Matter 25-394: Amendment No. 1 to RFP 605386 with USIS, Inc. Complete form and forward to the Office of the City Attorney or e-mail to Legal Services. Do not assume that the Office of the City Attorney knows the background of the question and/or issue, such as opinions on the same or similar issues, the existence of relevant memos, correspondence, etc. Please attach to this form and/or e-mail all pertinent information relating to the subject. Once your request has been assigned, an e-mail will be sent to you with the Assigned Attorney's name and the issued matter identification number. All attorneys in the Office of the City Attorney shall fully comply with the Rules Regulating the Florida Bar. For Legal Services requesting an opinion from the Office of the City Attorney: nlssue opinion in writing. Publish opinion after issuance. Authorized by: Annie Perez Date response requested by: BELOW PORTION TO BE COMPLETED BY THE OFFICE OF THE CITY ATTORNEY Assigned Attorney: Date: File No. Approved by: Ultimate Client: Comments: D / R Date: Copy returned to Requesting Client Type: Matrix: Category: Copy to Ultimate Client rev. 04/14/2017 AGREEMENT/AMENDMENT OVERVIEW AGREEMENT TITLE: Amendment No. 1 to Contract No. RFP 605386 1. AWARD DELEGATED AUTHORITY: ❑ Chief Procurement Officer — Authority level of $ Q City Manager — Authority level of $ ❑ City Commission — RESOLUTION No. 2. PROCUREMENT METHOD: Q RFP/RFQ ❑ IFB ❑ ITB ❑ SOLE SOURCE ❑ PIGGY -BACK ❑ COOPERATIVE ❑ PROFESSIONAL SERVICES UNDER $25,000 3. TYPE OF AGREEMENT: El PROFESSIONAL SERVICES AGREEMENT ❑ EXPERT CONSULTANT AGREEMENT ❑ SOFTWARE AS A SERVICE AGREEMENT ❑ LEASE AGREEMENT ❑ OPERATOR AGREEMENT ❑ CONCESSION AGREEMENT ❑ OTHER (Please explain): 4. IF THIS IS AN AMENDMENT, WHAT IS THE NUMBER OF THE AMENDMENT AND WHAT DOES THIS AMENDMENT DO (INCREASE CAPACITY, CHANGE IN TERMS, ETC) BE SPECIFIC AND INCLUDE THE PAGE NUMBER(S) THAT SPECIFIES WHAT IS BEING AMENDED ON THE CONTRACT. This is Amendment No. 1 to Contract No. RFP 605386 for USIS, Inc. to provide additional services to assist the City with processing and distribution of $27,904,756.23 retained by the Miami -Dade Office of the Tax Collector. This money will be used to reduce ad valorem taxes. 5. WAS THE AMENDMENT APPROVED BY THE CITY COMMISSION? ❑ YES El NO IF YES, WHAT IS THE RESOLUTION NUMBER? 6. WHAT IS THE SCOPE OF SERVICES? Processing and distribution of the $27,904,756.23 that was retained by the Miami -Dade Office of the Tax Collector. 7. IF CITYWIDE, WHAT ARE THE MOST FREQUENT USER DEPARTMENTS? Finance, Risk Management 8. IS THE AWARDEE INCUMBENT? Yes, USIS currently provides Third -Party Claims Administration Services and has offered to assist the City with the processing and distribution of the money that was retained by the Miami -Dade Office of the Tax Collector. 9. IS THE PRICING HIGHER, LOWER OR THE SAME AS THE CURRENT CONTRACT? These are additional services for which pricing was not previously secured. The City was provided a reasonable quote by USIS, in the not -to -exceed amount of $578,039.20 ($2.65 per mailed check). 10.WHEN DOES THE CURRENT CONTRACT EXPIRE? June 1, 2025 11. WHAT WAS THE PREVIOUS SPEND ON THE CURRENT CONTRACT? N/A. These are additional services for which pricing was not previously secured. 12.WHAT IS THE METHOD OF AWARD (Group, Item by Item etc.)? On June 15, 2017, pursuant to Request for Proposals ("RFP") No. 605386 and Resolution No. 17-0224, the City entered into the Agreement with USIS, for the provision of Third -Party Claims Administration Services. Section 2.19 of the RFP titled "Additional Services," incorporated and made a part of the Agreement with USIS, allows the City to add additional services for which pricing was not previously secured, and ask USIS to provide reasonable costs for the same. Resolution No. 17-0224 allows the City Manager to negotiate and execute all other documents, including any amendments, renewals, extensions, and modifications..., in a form acceptable to the city attorney, as may be necessary for said purpose." City of Miami Contract No. RFP 605386 AMENDMENT NO. 1 TO THE PROFESSIONAL SERVICES AGREEMENT BY AND BETWEEN THE CITY OF MIAMI, FLORIDA, & USIS, INC. This Amendment No. 1 to the Professional Services Agreement date June 15, 2017 ("Agreement" or "PSA"), by and between the City of Miami, a municipal Corporation of the state of Florida ("City"), with its principal address located at 444 S.W. 2nd Avenue, Miami, FL 33130 and USIS, Inc., a Florida corporation ("USIS"), with its principal address located at 5728 Major Blvd., Suite 450, Orlando, FL 32819. RECITALS WHEREAS, on June 15, 2017, pursuant to Request for Proposals ("RFP") No. 605386 and Resolution No. 17-0224, the City entered into the Agreement with USIS, for the provision of Third -Party Claims Administration Services, and said Agreement has been extended through 120 Day Extension No. 9, dated December 12, 2024, to remain in effect until June 1, 2025; and WHEREAS, pursuant to Section 2.19 of the RFP titled "Additional Services," incorporated and made a part of the Agreement, the City is permitted "to add an additional service(s) for which pricing was not previously secured," and ask, "[USIS] to provide reasonable cost(s) for same."; and WHEREAS, Resolution No. 17-0224 further allows the City Manager "to negotiate and execute all other documents, including any amendments, renewals, extensions, and modifications... , in a form acceptable to the City Attorney, as may be necessary for said purpose."; and WHEREAS, the City is required to comply with Sections 200.065 and 200.068, Florida Statutes ("F.S."), in approving the millage rate assessment, commonly referred to as Truth in Millage ("TRIM"), as part of the normal budget approval process; and WHEREAS, on November 27, 2023, the Florida Department of Revenue ("Department") initially found the City non -compliant with the TRIM certification requirements of Section 200.065, F.S.; and WHEREAS, on December 15, 2023, the Department notified the City that upon review of the City's revised and re -advertised TRIM certification documents, the City had met the requirements of Section 200.065, F.S., and accepted the City's TRIM certification; and WHEREAS, on September 5, 2024, the Miami -Dade County ("MDC") Office of the Tax Collector notified the City that $27,904,756.23 had been retained in property tax collections from the 2023 tax roll as directed by the Florida Department of Revenue, for the period when the TRIM certification had not been accepted; and WHEREAS, on September 5, 2024, MDC also provided for the distribution of the $27,904,756.23 to the City in Fiscal Year 2024, to reduce the ad valorem taxes otherwise necessary; and WHEREAS, on January 28, 2025, USIS offered to assist the City with the processing and distribution of the $27,904,756.23, and the City was provided a reasonable quote for the cost this service in the not -to -exceed amount of $578,039.20; and 1 City of Miami Contract No. RFP 605386 NOW, THEREFORE, in consideration of the foregoing, the parties hereby amend the Agreement as follows: TERMS 1. Section 5 of the Agreement titled "Compensation" is hereby amended to add the following language: E. The amount of compensation payable to the Third -Party Administrator ("TPA") for the Special Project, Constituent Funds, shall be listed in Exhibit B, Section J. 2. Section 21 of the Agreement titled "Miscellaneous Provisions" is hereby amended to add the following language: F. Title and paragraph headings are for convenient reference and are not a part of this Agreement. G. Nothing contained in this Agreement is in any way intended to be a waiver of the limitation placed upon the Indemnitees' liability as set forth in Chapter 768, Florida Statutes. Additionally, the Indemnitees do not waive sovereign immunity, and no claim or award against the Indemnitees shall include attorneys' fees, investigative costs, pre -suit or adjusting costs, or pre -judgment interest. H. If any term or provision of this Agreement, or combination of the same, is in violation of any applicable law or regulation, or is unenforceable or void for any reason, such term, provision or combination of same shall be modified or reformed by the court to the minimum extent necessary to accomplish the intention of the entire Agreement to the maximum extent allowable, under any legal form, without violating applicable law or regulation. If such term, provision, or combination of same cannot be modified or reformed, then the same shall be deemed severable Notwithstanding, the remainder of the Agreement shall remain binding upon the parties. This Subsection shall not apply if there is a material breach of this Agreement causing cancelation or cancellation for convenience. 3. Section 32 of the Agreement, titled "Counterparts" is hereby deleted in its entirety and replaced with the following language under the title "Counterparts; Electronic Signatures": This Agreement may be executed in counterparts, each of which shall be an original as against either party whose signature appears thereon, but all of which taken together shall constitute but one and the same instrument. An executed facsimile or electronic scanned copy of this Agreement shall have the same force and effect as an original. The parties shall be entitled to sign and transmit an electronic signature on this Agreement (whether by facsimile, PDF, or other email transmission), which signature shall be binding on the party whose name is contained therein. Any party providing an electronic signature agrees to promptly execute and deliver to the other parties an original signed Agreement upon request 2 City of Miami Contract No. RFP 605386 4. Section 34, titled "E-Verify Employment Verification" is hereby added to the agreement with the following language: By entering into this Agreement, Third Party Administrator and its subcontractors are jointly and severally obligated to comply with the provisions of Section 448.095, Florida Statutes, as amended, titled "Employment Eligibility." Third Party Administrator affirms that (a) it has registered and uses the U.S. Department of Homeland Security's E-Verify system to verify the work authorization status of all new employees of Third Party Administrator; (b) it has required all subcontractors to this Agreement to register and use the E-Verify system to verify the work authorization status of all new employees of the subcontractor; (c) it can obtain an affidavit from all subcontractors to this Agreement attesting that the subcontractor does not employ, contract with, or subcontract with, unauthorized aliens; and (d) it shall maintain copies of any such affidavits for the duration of the Agreement. Registration information is available at: http://www.uscis.gov/e-verify. If the City has a good faith belief that Third Party Administrator has knowingly violated Section 448.09(1), Florida Statutes, then City shall terminate this Agreement in accordance with Section 448.095(5)(c), Florida Statutes. In the event of such termination, Third Party Administrator agrees and acknowledges that it may not be awarded a public contract for at least one (1) year from the date of such termination and that Third Party Administrator shall be liable for any additional costs incurred by the City because of such termination. In addition, if City has a good faith belief that a subcontractor has knowingly violated any provisions of Sections 448.09(1) or 448.095, Florida Statutes, but Third Party Administrator has otherwise complied with its requirements under those statutes, then Third Party Administrator agrees that it shall terminate its contract with the subcontractor upon receipt of notice from the City of such violation by subcontractor in accordance with Section 448.095(5)(c), Florida Statutes. Any challenge to termination under this provision must be filed in the Circuit or County Court by the City, Third Party Administrator, or subcontractor no later than twenty (20) calendar days after the date of said termination. 5. Section 35, titled "Antitrust Violators Vendor List" is hereby added to the agreement with the following language: Pursuant to Section 287.137, Florida Statutes, a person or an affiliate who has been placed on the Antitrust Violator Vendors List following a conviction or being held civilly liable for an antitrust violation may not submit a bid, proposal, or reply on any agreement to provide any goods or services to a public entity; may not submit a bid, proposal, or reply on any agreement with a public entity for the construction or repair of a public building or public work; may not submit a bid, proposal, or reply on leases of real property to a public entity; may not be awarded or perform work as a grantee, supplier, subcontractor, or consultant under an agreement with a public entity; and may not transact new business with a public entity. 6. Section 36, titled "Anti -Human Trafficking" is hereby added to the agreement with the following language: The Third Party Administrator confirms and certifies that it is not in violation of Section 787.06, Florida Statutes, and that it does not and shall not use "coercion" for labor or services as defined in Section 787.06, Florida Statutes. The Third Party Administrator shall execute and submit to the City an Affidavit, of even date herewith, in compliance with Section 787.06(13), Florida Statutes, 3 City of Miami Contract No. RFP 605386 attached and incorporated herein as "Anti -Human Trafficking Affidavit". If the Third Party Administrator fails to comply with the terms of this Section, the City may suspend or terminate this Agreement immediately, without prior notice, and in no event shall the City be liable to Third Party Administrator for any additional compensation or for any consequential or incidental damages. 7. Exhibit B of the Agreement, titled "Scope of Services," is hereby amended by adding the following language pursuant to Section 2.19 of RFP No. 605386 titled "Additional Services": J. Special Project: Constituent Refunds 1. Per -Check Fee: $2.65 a. This fee includes all labor and material costs associated with completing the project within the proposed 20-week timeline. b. The total amount of checks to be issued is 218,128. 2. Unclaimed Check Reporting: a. USIS will collaborate with the City to establish an appropriate protocol for handling unclaimed checks. b. Please note that the cost of any mailing related to unclaimed checks will be billed to the City, and such costs shall not be considered in the not -to -exceed fees set forth in Section J.4. 3. Returned Mail/Incorrect Addresses: a. USIS will collaborate with the City to establish an appropriate protocol for handling returned mail or incorrect addresses. b. If a new check needs to be reissued due to an address correction, it will be treated as a new check and subject to the per -check fee, and the costs associated with such reissuance shall not be considered in the not -to -exceed fees set forth in Section J.4. 4. Total not -to -exceed fees: $578,039.20 8. All terms and conditions of the Agreement shall remain in full force and effect except as expressly modified herein. 4 City of Miami Contract No. RFP 605386 IN WITNESS WHEREOF, the provider hereto has caused this instrument to be executed by their respective officials thereunto duly authorized, as of the day and year first above written. ATTEST: USIS, Inc., a Florida Corporation By::_!.,C.02.c) '� 111-10 Print Name: Lie Nit() Gar' Mare Title:E y u-htii SS i tfic�-f (Corporate Seal) pu` LESLIE ANN WHITTEMORE Notary Public - State of Florida Commission 4 HH 231127 • My Comm. Expires Jun 14, 2026 Bonded through National Notary Assn. ATTEST: z<� Signed by: BY: ./ Print Name: Viviane Ruiz Title: _President, WC Ancillary Services "City" City of Miami, a Florida municipal corporation By"P, „r, „, Todd B. Hannon, City C1er-k Arthur Noriega V, City Manager APPROVED AS TO LEGAL FORM APPROVED AS TO INSURANCE AND CORRECTNESS: Aerv, lAisot4 III George K. Wysong III Matter 25-394 REQUIREMENTS: —DOCuSi,n.E br Fran& aomv' Ann -Marie Sharpe, Director City Attorney Risk Management Department 5 City of Miami Contract No. RFP 605386 COMPANY RESOLUTION (This Resolution needs to authorize the signatory to sign) The undersigned, being all of the directors (the "Directors") of USIS, Inc., a Florida corporation ("Company") by this instrument in lieu of a special meeting, do hereby consent to the adoption of the following resolutions by written consent effective as of the date written above WHEREAS, the Company desires to enter into an Agreement with the City of Miami for the purpose of performing the work described in the contract to which this resolution is attached; and WHEREAS, the Directors have considered the matter in accordance with the bylaws of the Company and wish to authorize the Company to enter into an Agreement with the City of Miami; NOW, THEREFORE, BE IT RESOLVED BY THE BOARD that the Company is authorized to enter into the Agreement with the City, and the President and the Vice President are hereby authorized and directed to execute the Agreement in the name of this Company and to execute any other document and perform any acts in connection therewith as may be required to accomplish its purpose. RESOLVED FURTHER, that each of the Company's members, directors, officers, and authorized representatives be, and hereby is, authorized and directed to take any and all actions which they or any of them deem necessary or appropriate in order to effect the intent of the foregoing resolutions, including the execution and delivery of such other documents, instruments or certificates and the payment of such fees and expenses in connection therewith, as they or any of them deem necessary or appropriate and that all such actions so taken be, and each hereby is, authorized, approved, ratified, and confirmed. RESOLVED FURTHER, that any and all actions taken on behalf of the Company by any member, director, officer or other authorized representative of the Company in connection with 6 City of Miami Contract No. RFP 605386 the transactions contemplated by the foregoing resolutions, including, without limitation, the negotiation, execution, delivery and acceptance of any documents, instruments, certificates or other writings, prior to the date hereof be, and the same hereby are, authorized, approved, ratified and confirmed in all respects. IN WITNESS WHEREOF, being all of the directors of the Company, have duly executed this Written Consent, effective on and as of the date first set forth above. M - A _ Matthew Button Paula Kenneson Dha a atel 64i6 7 City of Miami Contract No. RFP 605386 EXHIBIT AFFIDAVIT-1 SECTION 787.06, FLORIDA STATUTES (2024) City of Miami Contract No. RFP 605386 ANTI -HUMAN TRAFFICKING AFFIDAVIT I. The undersigned affirms, certifies, attests, and stipulates as follows: a. The entity is a non-govemmental entity authorized to transact business in the State of Florida and in good standing with the Florida Department of State, Division of Corporations. b. The nongovernmental entity is either executing. renewing, or extending a contract (including, but not limited to, any amendments, as applicable) with the City of Miami ("City") or one of its agencies, authorities, boards, trusts, or other City entity which constitutes a governmental entity as defined in Section 287. 1 38(1 ), Florida Statutes (2024), c. The nongovernmental entity is not in violation of Section 787.06, Florida Statutes (2024), titled "Human Trafficking." d. The nongovernmental entity does not use "coercion" for labor or services as defined in Section 787.06, Florida Statutes (2024), attached and incorporated herein as Exhibit Affidavit- I. Under penalties of perjury, declare the following: a. I have read and understand the foregoing Anti -Human Trafficking Affidavit and that the facts, statements and representations provided in Section 1 are true and correct. b. I am an officer or a representative of the nongovernmental entity authorized to execute this Anti - Human Trafficking Affidavit_ Nongovernmental Entity: USIS, Inc Name: Viviane Ruiz Officer Title: President, WC and Ancillary Services Signature of Officer: Office Address: 2a01. itland_CenfaffArktiway 1- i ai A 11781 Email Address: yiwiant~_ruizt@.usjs-tpa r i Main Phone Number: 4(}7173,8240 FEIN No. 2/0 -4 / 5/ 8/0 /6/ 4/5 STATE OF Florida ) COUNTY OF Sarninolta i } The foregoing instrument was sworn to and subscribed before me by means (421 physical presence or ❑ online notarization, this __Y rs day of wear. Lary by rsP PULL , as the authorized officer or representative for the nongovernmental entity. I-le/she is personally known to me or has produced pargn nary ktnc,wn (NOTARY Pt !I3LIC SEAL) My Commission Expires: & r) y 12 (.P LESLIE ANN wyf1TEMORE A Notary Public • State of Florida Commission x Hit 231127 My Comm. Expires Jun 14, 2026 Bonded through National Notary Assn. Signature of Person Taking Leslie A Whit#emt2re (Printed, Typed, or Stamped Name of Notary Public) as identification. *0-64 oute"fft, City of Miami, Florida Contract No. RFP 605386 PROFESSIONAL SERVICES AGREEMENT By and Between The CITY OF MIAMI And USIS, INC. This Professional Services Agreement ("Agreement") is entered into this 154kday of JULne , 2017 ( "Effective Date") , by and between the City of Miami, a municipal corporation of the State of Florida, whose address is 444 S.W. 2"d Avenue, 10th Floor, Miami, Florida 33130 ("City"), and, USIS, INC. a corporation, qualified to do business in the State of Florida whose principal address is 5728 Major Blvd., Suite 450, Orlando, FL 32819, hereinafter referred to as the ("Third Party Administrator"). RECITALS: WHEREAS, the City of Miami issued a Request for Proposals No. 605386 on, October 5, 2016, (the "RFP" attached hereto, incorporated hereby, and made a part of as Exhibit A) for the provision of Third Party Claims Administration Services ("Services" as more fully set forth in the scope of work "Scope" attached hereto as Exhibit B) for the City's Risk Management Department and Third Party Administrator's proposal ("Proposal", attached hereto, incorporated hereby, and made part of hereof as Exhibit C), in response thereto, has been selected as the most responsive, responsible and qualified proposal for the provision of the Services; and WHEREAS, this Professional Services Agreement ("Agreement") was included in the RFP with a statement that it would require execution by the Successful Proposer selected as the Third Party Administrator; and, WHEREAS, the Evaluation/Selection Committee appointed by the City Manager determined that the Proposal submitted by the Third Party Administrator was responsive to the RFP requirements and recommended that the City Manager negotiate a contract with the Third Party Administrator; and WHEREAS, the City wishes to engage the Services of the Third Party Administrator, and the Third Party Administrator wishes to perform the Services for the City; and 1 Third Party Claims Administration Services I3 �� City of Miami, Florida Contract No. RFP 605386 WHEREAS, the City and the Third Party Administrator desire to enter into this Agreement under the terms and conditions set forth herein. NOW, THEREFORE, in consideration of the mutual covenants and promises herein contained, Third Party Administrator and the City agree as follows: TERMS: 1. RECITALS AND INCORPORATIONS; DEFINITIONS: A. The recitals are true and correct and are hereby incorporated into and made a part of this Agreement. The City's RFP is hereby incorporated into and made a part of this Agreement and attached hereto as Exhibit "A." The Services and Scope of Work are hereby incorporated into and made a part of this Agreement and attached as Exhibit "B," The Third Party Administrator's Response and Pricing Proposal dated, November 30, 2016, in response to RFP 605386, is hereby incorporated into and made a part of this Agreement as attached Exhibit "C." The Third Party Administrator's Insurance Certificate is hereby incorporated into and made a part of this Agreement as attached Exhibit "D." The order of precedence whenever there is conflicting or inconsistent language between documents is as follows in descending order of priority: (1) Professional Services Agreement ('PSA") (2) Addenda/Addendum to the RFP; (3) RFP; and (4) Third Party Administrator's Response and Price Proposal Schedule dated November 30, 2016, acknowledging scope of services and pricing component of services and, response to the Request for Proposals. 2. TERM: The Agreement shall become effective on the date on the first page of this Agreement, and shall be for an initial term of three (3) years. The City Manager shall have the option to administratively extend the Agreement as is needed in the opinion of the City Manager for a period of one hundred and twenty (120) days, and/or the option to renew the Agreement as provided in Section 3, or to terminate the Agreement for convenience, that is, for any or no cause, as provided in Section 16, City's Termination Rights. 2 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 3. OPTION TO RENEW: The City Manager shall have the option to renew for two (2) additional one (1) year periods, subject to availability and appropriation of funds. City Commission approval shall not be required for the above stated renewal terms. The total term of the Agreement inclusive of all renewals would be five (5) years. 4. SCOPE OF SERVICES: A. Third Party Administrator agrees to provide the Services as specifically described, and under the special terms and conditions set forth in Exhibits "A" and "B" hereto, which by this reference is incorporated into and made a part of this Agreement. B. Third Party Administrator represents and warrants to the City that: (i) it possesses all qualifications, licenses, certificates, degrees, authorizations, and expertise required for the performance of the Services under this Agreement, including but not limited to full qualification to do business in Florida; (ii) it is not delinquent in the payment of any sums due the City, including payment of permits, fees, occupational licenses, etc., nor in the performance of any obligations or payment of any monies to the City or presently in default of any contract it has with the City, or in presently in default of any contract with the State of Florida or any political subdivision of the State, or of any contract with a Public School Board or Special District of the State of Florida (collectively "Florida Public Agencies") nor has it been debarred or suspended under applicable laws and regulations by any of the foregoing Florida Public Agencies ; (iii) all personnel assigned to perform the Services are and shall be, at all times during the term hereof, fully qualified and trained to perform the tasks assigned to each; (iv) the Services will be performed in the manner described in Exhibit "A"; and (v) each person executing this Agreement on behalf of Third Party Administrator has been duly authorized to so execute the same and fully bind Third Party Administrator as a party to this Agreement. C. Third Party Administrator shall at all times provide fully qualified, competent and physically capable employees to perform the Services under this Agreement. Third Party Administrator shall possess and maintain any required licenses, permits, degrees, and certifications to perform the Services under this Agreement. City may require Third Party Administrator to remove any employee the City deems careless, incompetent, insubordinate, or otherwise objectionable and whose continued services under this Agreement is not in the best interest of the City. 3 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 5, COMPENSATION: A. The amount of compensation payable by the City to the Third Party Administrator shall be based on the rates quoted in Exhibit "C" hereto, which by this reference is incorporated into and made a part of this Agreement. The rates for the optional Plan Years 2020, and 2021, shall be negotiated. The Third Party Administrator shall advise the City of the recommended rates for each optional year one hundred twenty (120) days in advance of the City's open enrollment for the optional year, providing justification for any recommended rate increases above the previous year's rates. B. Payment shall be made in arrears based upon work performed to the satisfaction of the City within forty-five (45) days after receipt of Third Party Administrator's invoice for Services performed, which shall be accompanied by sufficient supporting documentation and contain sufficient detail, to allow a proper audit of expenditures, should the City require one to be performed. Invoices shall be sufficiently detailed so as to comply with the 'Florida Prompt Payment Act," §218.70. - 218.79, Florida Statutes, and other applicable laws. No advance or future payments shall be made at any time. C. Third Party Administrator agrees and understands that (i) any and all y Subcontractors providing Services related to this Agreement shall be paid through Third Party Administrator and not paid directly by the City, and / or (ii) any and all liabilities regarding payment to or use of y Subcontractors for any of the Services related to this Agreement shall be borne solely by Third Party Administrator. D. Prices shall remain firm and fixed for the first two (2) years of the Contract. The City reserves the right to negotiate the rates for Year 3 of the initial contract, and for any renewal and/or extension periods. 6. OWNERSHIP OF DOCUMENTS: Third Party Administrator understands and agrees that any information, document, report or any other material whatsoever which is given by the City to Third Party Administrator, its employees, or any Subcontractor, or which is otherwise obtained or prepared by Third Party Administrator solely and exclusively for the City pursuant to or under the terms of this Agreement, is and shall at all times remain the property of the City. Third Party Administrator agrees not to use any such information, document, report or material for any other purpose whatsoever without the written consent of the City Manager, which may be withheld or conditioned by the City Manager in his/her sole discretion. Third Party Administrator is permitted to make and to maintain duplicate copies of the files, records, documents, etc. if Third Party Administrator determines 4 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 copies of such records are necessary subsequent to the termination of this Agreement; however, in no way shall the confidentiality as permitted by applicable laws be breached. The City shall maintain and retain ownership of any and all documents which result upon the completion of the work and Services under this Agreement as per the terms of this Section 5. 7. AUDIT AND INSPECTION RIGHTS AND RECORDS RETENTION: A. Third Party Administrator agrees to provide access to the City or to any of its duly authorized representatives, to any books, documents, papers, and records of Third Party Administrator which are directly pertinent to this Agreement, for the purpose of audit, examination, excerpts, and transcripts. The City may, at reasonable times, and for a period of up to three (3) years following the date of final payment by the City to Third Party Administrator under this Agreement, audit and inspect, or cause to be audited and inspected, those books, documents, papers, and records of Third Party Administrator which are related to Third Party Administrator's performance under this Agreement. Third Party Administrator agrees to maintain any and all such books, documents, papers, and records at its principal place of business for a period of three (3) years after final payment is made under this Agreement and all other pending matters are closed. Third Party Administrator's failure to adhere to, or refusal to comply with, this condition shall result in the immediate cancellation of this Agreement by the City. B. The City may, at reasonable times during the term hereof, inspect the Third Party Administrator's facilities and perform such tests, as the City deems reasonably necessary, to determine whether the goods or services required to be provided by Third Party Administrator under this Agreement conform to the terms hereof. Third Party Administrator shall make available to the City all reasonable facilities and assistance to facilitate the performance of tests or inspections by City representatives. All audits, tests and inspections shall be subject to, and made in accordance with, the provisions of Sections 18-100, 18-101, and 18-102 of the Code of the City of Miami, Florida, which apply to this Agreement, as same may be amended or supplemented, from time to time. The foregoing City Code Sections as well as the entirety of Chapter 18, "Finance", City of Miami Code, as amended and as applicable, is deemed as being incorporated by reference herein. 8. AWARD OF AGREEMENT: Third Party Administrator represents and warrants to the City that it has not employed or retained any person or company employed by the City to solicit or secure this Agreement and that it has not offered to pay, paid, or agreed to pay any person, any fee, commission, percentage, 5 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 brokerage fee, or gift of any kind contingent upon or in connection with, the award of this Agreement. 9. PUBLIC RECORDS: A. Third Party Administrator understands that the public shall have access, at all reasonable times, to all documents and information pertaining to City Agreements, subject to the provisions of Chapter 119, Florida Statutes, and agrees to allow access by the City and the public to all documents subject to disclosure under applicable laws. Third Party Administrator's failure or refusal to comply with the provisions of this section shall result in the immediate cancellation of this Agreement by the City. B. Third Party Administrator shall additionally comply with Section 119.0701, Florida Statutes, including without limitation; (1) keep and maintain public records that ordinarily and necessarily would be required by the City to perform this service; (2) provide the public with access to public records on the same terms and conditions as the City would at the cost provided by Chapter 119, Florida Statutes, or as otherwise provided by law; (3) ensure that public records that are exempt or confidential and exempt from disclosure are not disclosed except as authorized by law; (4) meet all requirements for retaining public records and transfer, at no cost, to the City all public records in its possession upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from disclosure requirements; and, (5) provide all electronically stored public records that must be provided to the City in a format compatible with the City's information technology systems. Notwithstanding the foregoing, Third Party Administrator shall be permitted to retain any public records that make up part of its work product solely as required for archival purposes, as required by law, or to evidence compliance with the terms of the Agreement. C. Should Third Party Administrator determine to dispute any public access provision required by Florida Statutes, then Third Party Administrator shall do so at its own expense and at no cost to the City. Third Party Administrator may maintain an exemption for such personal information such as Social Security Numbers of members or medical information exempted by general law. IF THE THIRD PARTY ADMINISTRATOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE THIRD PARTY ADMINISTRATOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT (305) 416-1830, 6 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Via email at PublicRecords(iThtimiamigov.com, or regular email at City of Miami Office of the City Attorney, 444 SW 2"d Avenue, 9th FL, Miami, FL 33130. 10. PRIVACY AND CONFIDENTIALITY Third Party Administrator agrees to develop, adopt, and implement standards to safeguard the privacy and confidentiality of all personal information about eligible employees and members of the Program. For example, Third Party Administrator shall ensure that Third Party Administrator does not have completed forms containing personal information sitting in public view, left in unsecured boxes or files, or left unattended in any off -site location. Third Party Administrator's procedures shall include but not limited to safeguarding the identity of members as members of the Program and preventing unauthorized disclosure of personal information. Third Party Administrator agrees to report any unauthorized use or disclosure of the members' personal information to the City, within twenty-four (24) hours of any incident of which it becomes aware. Third Party Administrator agrees to comply with all federal and state laws concerning the privacy and confidentiality of members' information, and agrees to implement any regulations when they become effective. In the absence of exigent circumstances, Third Party Administrator shall not disclose any member's personal information to another business associate for pecuniary gain unless the City specifically prior authorizes such disclosure in writing. Third Party Administrator agrees to mitigate, to the extent practicable, any harmful effect that is known to the Third Party Administrator of a use or disclosure of members' information by the Third Party Administrator in violation of the requirements of this Agreement or federal or state laws. Third Party Administrator agrees to (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic personal information of members that Third Party Administrator creates, receives, maintains, or transmits; (ii) report to the City any security incident of which the Third Party Administrator becomes aware, and (iii) ensure that any agent of the Third Party Administrator, including any Subcontractor or sub consultant, agrees to the same restrictions and conditions that apply to the Third Party Administrator with respect to such information. Third Party Administrator agrees not to sell member information. Third Party Administrator shall not use member information unless it is aggregated blinded data, which is not identifiable on a member basis. Third Party Administrator shall not use member identified or non -aggregated information for advertising, marketing, promotion or any activity intended to influence sales or market share of any product or service. 7 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Third Party Administrator shall have full financial responsibility for any penalties, fines, or other payments imposed or required as a result of Third Party Administrator's non-compliance with, or violation of, federal or state requirements, and the Third Party Administrator shall indemnify the City with respect to any such penalties, fines, or payments. Third Party Administrator shall assure that all Third Party Administrator's staff, including Subcontractor or sub consultant, is trained in all privacy requirements, as applicable. At the request of the City, Third Party Administrator shall offer credit protection for those times in which a member's personal information is accidentally or inappropriately disclosed. This Section is not to be construed to conflict with the provisions of Chapter 119, Florida Statutes nor any exemptions from this Statute. 11. INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION AND/OR PROTECTED HEALTH INFORMATION. Any person or entity that performs or assists the City with a function or activity involving the use or disclosure of "Individually Identifiable Health Information (IIHI)" and/or Protected Health Information (PHI) shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA mandates the privacy, security, and electronic transfer standards, include but are not limited to: 1. Use of information for performing services required by the Contract or as required law; 2. Use of appropriate safeguards to prevent non -permitted disclosures; 3. Reporting to the City of any non -permitted use or disclosures; 4. Assurances that any agents and Subcontractor agree to the same restrictions and conditions that apply to the Third Party Administrator and reasonable assurances that IIHI/PHI will be held confidential; 5. Making PHI available to the customer; 6. Making PHI available to the customer for review and amendment; incorporation of any amendments requested by the customer; 7. Making PHI available to the City for an accounting of disclosures; and 8. Making internal practices, books, and records related to PHI available to the City for compliance audits. PHI shall maintain its protected status regardless of the form and method of transmission paper records, and/or electronic transfer of data). The Third Party Administrator must give its customers written notice of its privacy information practices including specifically 8 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 a description of the types of uses and disclosures that would be made with protected health information. 12. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS: Third Party Administrator understands that agreements with local governments are subject to certain laws and regulations, including laws pertaining to public records, conflict of interest, record keeping, etc. City and Third Party Administrator agree to comply with and observe all such applicable federal, state and local laws, rules, regulations, codes and ordinances, as they may be amended from time to time. Third Party Administrator further agrees to include in all of Third Party Administrator's agreements with Subcontractor for any Services related to this Agreement this provision requiring Subcontractors to comply with and observe all applicable federal, state, and local laws rules, regulations, codes and ordinances, as they may be amended from time to time. 13. INDEMNIFICATION: Third Party Administrator shall indemnify, defend (at its own cost and expense) and hold harmless the City and its officials, employees and agents for claims (collectively referred to as "Indemnitees") and each of them from and against all loss, costs, penalties, fines, damages, claims, expenses (including attorney's fees) or liabilities (collectively referred to as "Liabilities") by reason of any injury to or death of any person or damage to or destruction or loss of any property arising out of, resulting from, or in connection with (I) the negligent performance or non- performance of the Services contemplated by this Agreement (whether active or passive) of Third Party Administrator or its employees, agents or Subcontractor (collectively referred to as "Third Party Administrator") which is directly caused, in whole or in part, by any act, omission, default or negligence (whether active or passive or in strict liability) of the Indemnitees, or any of them, or (ii) the failure of the Third Party Administrator to comply materially with any of the requirements herein, or the failure of the Third Party Administrator to conform to statutes, ordinances, or other regulations or requirements of any governmental authority, local, federal or state, including without limitation, a claim for infringement of an intellectual property right, copyright, patent or trademark used by the Third Party Administrator, in connection with the performance of this Agreement even if it is alleged that the City, its officials, agents, and/or employees were negligent. Third Party Administrator expressly agrees to indemnify, defend and hold harmless the Indemnitees, or any of them, from and against all liabilities which may be asserted by an employee or former employee of Third Party Administrator, or any of its Subcontractors, as provided above, 9 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 for which the Third Party Administrator's liability to such employee or former employee would otherwise be limited to payments under state Workers' Compensation or similar laws. Third Party Administrator further agrees to indemnify, defend and hold harmless the Indemnitees from and against (i) any and all Liabilities imposed on account of the violation of any law, ordinance, order, rule, regulation, condition, or requirement, related directly to Third Party Administrator's negligent performance under this Agreement, compliance with which is left by this Agreement to Third Party Administrator, and (ii) any and all claims, and/or suits for labor and materials furnished by Third Party Administrator or utilized in the performance of this Agreement or otherwise. Third Party Administrator's obligations to indemnify, defend and hold harmless the rndemnitees shall survive the termination and/or expiration of this Agreement. The Third Party Administrator acknowledges that the granting of this Agreement is sufficient and independent consideration for the giving of this Indemnity. Third Party Administrator understands and agrees that any and all liabilities regarding the use of any Subcontractors for Services related to this Agreement shall be borne solely by Third Party Administrator throughout the duration of this Agreement and that this provision shall survive the termination or expiration of this Agreement, as applicable, 14. DEFAULT: If Third Party Administrator fails to comply with any term or condition of this Agreement, or fails to perform in any material way any of its responsibilities or obligations hereunder, and fails to cure such failure after reasonable notice from the City, which period to cure shall be complied with when stated in the written notice form the City, then Third Party Administrator shall be in default. Upon the occurrence of a default, hereunder the City, in addition to all remedies available to it by law, may immediately, upon written notice to the Third Party Administrator, terminate this Agreement whereupon all payments, advances, or other compensation paid by the City to Third Party Administrator while Third Party Administrator was in default shall be immediately returned to the City. Third Party Administrator understands and agrees that termination of this Agreement under this section shall not release Third Party Administrator from any obligation accruing prior to the effective date of termination. Should Third Party Administrator be unable or unwilling to commence to perform the Services within the time provided or contemplated herein, then, in addition to the foregoing, Third Party Administrator shall be liable to the City for all expenses incurred by the City in preparation and negotiation of this Agreement, as well as all costs and expenses incurred by the City in the re -procurement of the Services, including consequential and incidental damages. 10 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 15. RESOLUTION OF AGREEMENT DISPUTES: Third Party Administrator understands and agrees that all disputes between Third Party Administrator and the City based upon an alleged violation of the terms of this Agreement by the City shall be submitted to the City Manager for his/her resolution, prior to Third Party Administrator being entitled to seek judicial relief in connection therewith. In the event that the amount of compensation hereunder exceeds Twenty -Five Thousand Dollars and No/Cents ($25,000), the City Manager's decision shall be approved or disapproved by the City Commission. Third Party Administrator shall not be entitled to seek judicial relief unless: (i) it has first received City Manager's written decision, approved by the City Commission if the amount of compensation hereunder exceeds Twenty -Five Thousand Dollars and No/Cents ($25,000), or (ii) a period of sixty (60) days has expired, after submitting to the City Manager a detailed statement of the dispute, accompanied by all supporting documentation one hundred twenty (120) days if City Manager's decision is subject to City Commission approval; or (iii) City has expressly waived compliance with the procedure set forth in this section by written instruments, signed by the City Manager. In no event may the amount of compensation under this Section exceed the total compensation set forth in Section 5 (A) of this Agreement. 16. CITY'S TERMINATION RIGHTS; OBLIGATIONS UPON TERMINATION: A. The City, acting by and through its City Manager, shall have the right to terminate this Agreement, in its sole discretion, and without penalty, at any time, by giving written notice to Third Party Administrator at least thirty (30) calendar days prior to the effective date of such termination. In such event, the City shall pay to Third Party Administrator compensation for Services rendered and approved expenses incurred prior to the effective date of termination. In no event shall the City be liable to Third Party Administrator for any additional compensation and expenses incurred, other than that provided herein, and in no event shall the City be liable for any consequential or incidental damages. The Third Party Administrator shall have no recourse or remedy against the City for a termination under this subsection except for payment of fees due prior to the effective date of termination. B. The City, by and acting through its City Manager, shall have the right to terminate this Agreement, in its sole discretion, and without penalty, upon the occurrence of an event of an event of default hereunder, and failure to cure the same within thirty (30) days after written notice of default. In such event, the City shall not be obligated to pay any amounts to Third Party Administrator for Services rendered by Third Party Administrator after the date of termination, but 11 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 the parties shall remain responsible for any payments that have become due and owing as of the effective date of termination. In no event shall the City be liable to Third Party Administrator for any additional compensation and expenses incurred, other than that provided herein, and in no event shall the City be liable for any direct, indirect, consequential or incidental damages. 17. INSURANCE: A. Third Party Administrator shall, at al! times during the term hereof, maintain such insurance coverage(s) as may be required by the City. The insurance coverage(s) required as of the Effective Date of this Agreement are attached hereto as Exhibit "D" and incorporated herein by this reference. The City RFP number and title of the RFP must appear on each certificate of insurance. The Third Party Administrator shall add the City of Miami as an additional insured to its commercial general liability, and auto liability policies, and as a named certificate holder on all policies. Third Party Administrator shall correct any insurance certificates as requested by the City's Risk Management Administrator. All such insurance, including renewals, shall be subject to the approval of the City for adequacy of protection and evidence of such coverage(s) and shall be furnished to the City Risk Management Director on Certificates of Insurance indicating such insurance to be in force and effect and any cancelled or non -renewed policy will be replaced with no coverage gap and a current Certificate of Insurance will be provided. Completed Certificates of insurance shall be filed with the City Risk Management Director prior to the performance of Services hereunder, provided, however, that Third Party Administrator shall at any time upon request file duplicate copies of the Certificate of Insurance with the City. B. Third Party Administrator understands and agrees that any and all liabilities regarding the use of any of Third Party Administrator's employees or any of Third Party Administrator's Subcontractors for Services related to this Agreement shall be borne solely by Third Party Administrator throughout the term of this Agreement and that this provision shall survive the termination of this Agreement. Third Party Administrator further understands and agrees that insurance for each employee of Third Party Administrator and each Subcontractors providing Services related to this Agreement shall be maintained in good standing and approved by the City Risk Management Administrator throughout the duration of this Agreement. C. Third Party Administrator shall be responsible for assuring that the insurance certificates required under this Agreement remain in full force and effect for the duration of this Agreement, including any extensions hereof. If insurance certificates are scheduled to expire during the term of this Agreement and any extension hereof, Third Party Administrator shall be responsible for submitting new or renewed insurance certificates to the City's Risk Management 12 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Director as soon as coverages are bound with the insurers. In the event that expired certificates are not replaced, with new or renewed certificates which cover the term of this Agreement and any extension thereof: (i) the City shall suspend this Agreement until such time as the new or renewed certificate(s) are received in acceptable form by the City's Risk Management Director; or (ii) the City may, at its sole discretion, terminate the Agreement for cause and seek re -procurement damages from Third Party Administrator in conjunction with the violation of the terms and conditions of this Agreement. D. Compliance with the foregoing requirements shall not relieve Third Party Administrator of its liabilities and obligations under this Agreement. 18. NONDISCRIMINATION: Third Party Administrator represents to the City that Third Party Administrator does not and will not engage in discriminatory practices and that there shall be no discrimination in connection with Third Party Administrator's performance under this Agreement on account of race, color, sex, religion, age, handicap, marital status or national origin. Third Party Administrator further covenants that no otherwise qualified individual shall, solely by reason of his/her race, color, sex, religion, age, handicap, marital status or national origin, be excluded from participation in, be denied services, or be subject to discrimination under any provision of this Agreement. 19. ASSIGNMENT: The Third Party Administrator's services are considered unique in nature and highly specialized. This Agreement shall not be assigned, sold, transferred, pledged, encumbered, hypothecated, or otherwise conveyed by Third Party Administrator, in whole or in part, and Third Party Administrator shall not assign any part of its operations, without the prior written consent of the City Manager, which may be withheld, denied, or conditioned, in the City's sole discretion through the City Manager. 20. SUBCONTRACTUAL RELATIONS A. If the Third Party Administrator will cause any part of this Agreement to be performed by a Subcontractor, the provisions of this Agreement will apply to such Subcontractor and its officers, agents and employees in all respects as if it and they were employees of the Third Party Administrator; and the Third Party Administrator will not be in any manner thereby discharged from its obligations and liabilities hereunder, but will be liable hereunder for all acts 13 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 and negligence of the Subcontractor, its officers, agents, and employees, as if they were employees of the Third Party Administrator. The services performed by the Subcontractor will be subject to the provisions hereof as if performed directly by the Third Party Administrator. B. The Third Party Administrator, before making any subcontract for any portion of the services, will state in writing to the City the name of the proposed Subcontractor the portion of the Services which the Subcontractor is to do, the place of business of such Subcontractor, and such other information as the City may require. The City will have the right to require the Third Party Administrator not to award any subcontract to a person, firm or corporation disapproved by the City. C. Before entering into any subcontract hereunder, the Third Party Administrator will inform the Subcontractor fully and completely of all provisions and requirements of this Agreement relating either directly or indirectly to the Services to be performed. Such Services performed by such Subcontractor will strictly comply with the requirements of this Contract. D. In order to qualify as a Subcontractor satisfactory to the City, in addition to the other requirements herein provided, the Subcontractor must be prepared to prove to the satisfaction of the City that it has the necessary facilities, skill and experience, and ample financial resources to perform the Services in a satisfactory manner. To be considered skilled and experienced, the Subcontractor must show to the satisfaction of the City that it has satisfactorily performed services of the same general type which is required to be performed under this Agreement. E. The City shall have the right to withdraw its consent to a subcontract if it appears to the City that the Subcontractor will delay, prevent, or otherwise impair the performance of the Third Party Administrator's obligations under this Agreement. All Subcontractors are required to protect the confidentiality of the City's and City's proprietary and confidential information. Third Party Administrator shall furnish to the City copies of all subcontracts between Third Party Administrator and Subcontractor and suppliers hereunder. Within each such subcontract, there shall be a clause for the benefit of the City in the event the City finds the Third Party Administrator in breach of this Contract, permitting the City to request completion by the Subcontractor of its performance obligations under the subcontract. The clause shall include an option for the City to pay the Subcontractor directly for the performance by such Subcontractor. Notwithstanding, the foregoing shall neither convey nor imply any obligation or liability on the part of the City to any Subcontractor hereunder as more fully described herein. 14 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 20. NOTICES: All notices or other communications required under this Agreement shall be in writing and shall be given by hand -delivery or by registered or certified U.S. Mail, return receipt requested, addressed to the other party at the address indicated herein or to such other address as a party may designate by notice given as herein provided. Notice shall be deemed given on the day on which personally delivered; or, if by mail, on the fifth day after being posted or the date of actual receipt, whichever is earlier. TO THIRD PARTY ADMINISTRATOR: Ron Warble Executive Vice President 5728 Major Blvd., Suite 450 Orlando, FL 32819 Phone: 407-949-3150 Email Address: ron.warble@usis-tpa.com TO THE CITY: Daniel J. Alfonso City Manager 444 SW 2nd Avenue, 10th Floor Miami, FL 33130-1910 Annie Perez, CPPO Procurement Director 444 SW 2nd Avenue, 6th Floor Miami, FL 33130-1910 Victoria Mendez City Attorney City of Miami 444 SW 2nd Avenue, 9th Floor Miami, Florida 33130 Ann -Marie Sharpe Risk Management Director City of Miami 444 SW 2nd Avenue, 9th Floor Miami, Florida 33130 21. MISCELLANEOUS PROVISIONS: A. This Agreement shall be construed and enforced according to the laws of the State of Florida. Venue in any proceedings between the parties shall be in Miami -Dade County, Florida. Each party shall bear its own attorney's fees. Each party waives any defense, whether asserted by motion or pleading, that the aforementioned courts are an improper or inconvenient venue. Moreover, the parties consent to the personal jurisdiction of the aforementioned courts and 15 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 irrevocably waive any objections to said jurisdiction. The parties irrevocably, voluntarily and knowingly waive any rights to a jury trial. B. No waiver or breach of any provision of this Agreement shall constitute a waiver of any subsequent breach of the same or any other provision hereof, and no waiver shall be effective unless made in writing. C. Should any provision, paragraph, sentence, word or phrase contained in this Agreement be determined by a court of competent jurisdiction to be invalid, illegal or otherwise unenforceable under the laws of the State of Florida or the City of Miami, such provision, paragraph, sentence, word or phrase shall be deemed modified to the extent necessary in order to conform with such laws, or if not modifiable, then the same shall be deemed severable, and in either event, the remaining terms and provisions of this Agreement shall remain unmodified and in full force and effect or limitation of its use. D. Third Party Administrator shall comply with all applicable laws, rules and regulations in the performance of this Agreement, including but not limitedto licensure, and certifications required by law for professional service Third Party Administrators. E. This Agreement constitutes the sole and entire agreement between the parties hereto. No modification or amendment hereto shall be valid unless in writing and executed by properly authorized representatives of the parties hereto. Except as otherwise set forth in Section 2 above, the City Manager shall have the sole authority to extend, amend, or modify this Agreement on behalf of the City. 22. SUCCESSORS AND ASSIGNS: This Agreement shall be binding upon the parties hereto, their heirs, executors, legal representatives, successors, or assigns. 23. INDEPENDENT THIRD PARTY ADMINISTRATORS: Third Party Administrator has been procured and is being engaged to provide Services to the City as an independent Third Party Administrator, and not as an agent or employee of the City. Accordingly, neither Third Party Administrator, nor its employees, nor any Subcontractor hired by Third Party Administrator to provide any Services under this Agreement shall attain, nor be entitled to, any rights or benefits under the Civil Service or Pension Ordinances of the City, nor any rights generally afforded classified or unclassified employees. Third Party Administrator further understands that Florida Workers' Compensation benefits available to employees of the City are not available to Third Party Administrator, its employees, or any Subcontractor hired by 16 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 Third Party Administrator to provide any Services hereunder, and Third Party Administrator agrees to provide or to require Subcontractor (s) to provide, as applicable, workers' compensation insurance for any employee or agent of Third Party Administrator rendering Services to the City under this Agreement. Third Party Administrator further understands and agrees that Third Party Administrator's or Subcontractor's use or entry upon City properties shall not in any way change its or their status as an independent Third Party Administrator. 24. CONTINGENCY CLAUSE: Funding for this Agreement is contingent on the availability of funds and continued authorization for program activities and the Agreement is subject to amendment or termination due to lack of funds, reduction of funds, failure to allocate or appropriate funds, and/or change in applicable laws or regulations, upon thirty (30) days written notice from the City Manager. 25. FORCE MAJEURE: A "Force Majeure Event" shall mean an act of God, act of governmental body or military authority, fire, explosion, power failure, flood, storm, hurricane, sink hole, other natural disasters, epidemic, riot or civil disturbance, war or terrorism, sabotage, insurrection, blockade, or embargo. In the event that either party is delayed in the performance of any act or obligation pursuant to or required by the Agreement by reason of a Force Majeure Event, the time for required completion of such act or obligation shall be extended by the number of days equal to the total number of days, if any, that such party is actually delayed by such Force Majeure Event. The party seeking delay in performance shall give notice to the other party specifying the anticipated duration of the delay, and if such delay shall extend beyond the duration specified in such notice, additional notice shall be repeated no less than monthly so long as such delay due to a Force Majeure Event continues. Any party seeking delay in performance due to a Force Majeure Event shall use its best efforts to rectify any condition causing such delay and shall cooperate with the other party to overcome any delay that has resulted. 26. CITY NOT LIABLE FOR DELAYS: Third Party Administrator hereby understands and agrees that in no event shall the City be liable for, or responsible to Third Party Administrator or any Subcontractor, or to any other person, firm, or entity for or on account of, any stoppages or delay(s) in work herein provided for, or any damages whatsoever related thereto, because of any injunction or other legal or equitable proceedings or on account of any delay(s) for any cause over which the City has no 17 Third Party Claims Administration Services City of Miami, Florida control. Contract No. RFP 605386 27. USE OF NAME: Third Party Administrator understands and agrees that the City is not engaged in research for advertising, sales promotion, or other publicity purposes. Third Party Administrator is allowed, within the limited scope of normal and customary marketing and promotion of its work, to use the general results of this project and the name of the City. The Third Party Administrator agrees to protect any confidential information provided by the City and will not release information of a specific nature without prior written consent of the City Manager or the City Commission. 28. NO CONFLICT OF INTEREST: Pursuant to City of Miami Code Section 2-611, as amended ("City Code"), regarding conflicts of interest, Third Party Administrator hereby certifies to the City that no individual member of Third Party Administrator, no employee, and no Subcontractor under this Agreement nor any immediate family member of any of the same is also a member of any board, commission, or agency of the City. Third Party Administrator hereby represents and warrants to the City that throughout the term of this Agreement, Third Party Administrator, its employees, and its Subcontractor shall abide by this prohibition of the City Code. 29. NO THIRD -PARTY BENEFICIARY: No persons other than the Third Party Administrator and the City (and their successors and assigns) shall have any rights whatsoever under this Agreement. There are no express or implied beneficiaries to this Agreement. 30. SURVIVAL: All obligations (including but not limited to indemnity and obligations to defend and hold harmless) and rights of any party arising during or attributable to the period prior toexpirationor earlier termination of this Agreement shall survive such expiration or earlier termination. 31. TRUTH -IN -NEGOTIATION CERTIFICATION, REPRESENTATION AND WARRANTY: Third Party Administrator hereby certifies, represents and warrants to the City that on the date of Third Party Administrator's execution of this Agreement, and so long as this Agreement shall remain in full force and effect, the wage rates and other factual unit costs supporting the compensation to Third Party Administrator under this Agreement are and will continue to be 18 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 accurate, complete, and current. Third Party Administrator understands, agrees and acknowledges that the City shall adjust the amount of the compensation and any additions thereto to exclude any significant sums by which the City determines the contract price of compensation hereunder was increased due to inaccurate, incomplete, or non -current wage rates and other factual unit costs. All such contract adjustments shall be made within one (1) year of the end of this Agreement, whether naturally expiring or earlier terminated pursuant to the provisions hereof. 32. COUNTERPARTS: This Agreement may be executed in three or more counterparts, each of which shall constitute an original, but all of which, when taken together, shall constitute one and the same agreement. 33. ENTIRE AGREEMENT: This instrument and its attachments constitute the sole and only agreement of the parties relating to the subject matter hereof and correctly set forth the rights, duties, and obligations of each to the other as of its date. Any prior agreements, promises, negotiations, or representations not expressly set forth in this Agreement are of no force or effect. 19 Third Party Claims Administration Services City of Miami, Florida Contract No, RFP 605386 IN WITNESS WHEREOF, the parties hereto have caused this instrument to be executed by their respective officials thereunto duly authorized, this the day and year above written. ATTEST: Todd B. Hannon, City Clerk ATTEST: Print Name: Title: (Corporate Seal) "Third Party Administrator" VState or Florida county or Seminole On 3i2912017, before me, Ron Warble Personally appeared, Ran Wad*LXJ Personally known to me OR Li Proved to me on the basis of salrsfactory evidence to be the persons} whose name(s) ware sub cnbed to the within instrument and has hereby acknowledged to me that hersheRhey have execrated the same m hisilterttheir authorized capacrly(ies), and that by hlaberittiesr sxgnaturels) nn Ron Warble the instrument the person(s) or the R Print ame: entity upon behalf of wleoh the persons) actedexecuted the instrument Witness my hand and official seal Title: Executive Vice President f Nolary Signahve Leslie Whittemore "City" CITY OF MIAMI, a municipal corporation Daniel J. Alfonso, City USIS, INC., a Corporation (Authorized Corporate is APPROVED AS TO LEGAL FORM APPROyED AS AND CORRECTNESS: REQLIIREMEN 2 Victoria Mendez City Attorney rill_ � / cT Ann- :lie Sharp- 7 /5-33 V Risk jvlanageme t Director -57;//7 20 Third Party Claims Administration Services if CE tt Lg 8 a City of Miami, Florida Contract No. RFP 605386 EXHIBIT A RFP NO. 605386 22 Third Party Claims Administration Services ANNIE PEREZ, CPPO DANIEL J. ALFONSO Procurement DiNctor City ivL,]rtagor DATE: November 2, 2016 ADDENDUM NO. 6 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. The following are the inquiries as received and the corresponding responses: Ql. Please provide your current contract for Bill Review and Case Management Services, Al. The City's contract for Bill Review and Case Management Services is a bundle package with Gallagher Bassett Services, Inc. (Gallagher). The Contract is attached to the Header Section of the Solicitation, including the attached pricing schedule submitted by Gallagher. Ali other informati n re he same, APPROVED::, A le Perez, CPPO, Director of Procurement Date AP:Io . Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement City of Miami 000757 2/15/2016 - 2/15/2017 PRICING OPTION: BUDGETED STAFFING (Based on utilizing GBMCS) Life of Partnership Annual Cost Plus` Service ' { - ..�3>>��. e.' €3. �.:^� ti ated Year 3s xJF�`'s?rr�.">+e,°. Workers Compensation Medical Only All Fees included in salries below • ao beyond Inderrnry All Fees included in salries below Ind -Tier II -Florida, New York, Ohio and Texas All Fees included in salries below AU Fees included in salries below Lability General Bodily Injury All Fees included in salries below General Property Damage All Fees included in salries below Auto Bodily Injury All Fees included in salries below Auto Property Damage All Fees included in salries below Auto Physical Damage All Fees included in salries below Professional Liability All Fees included in salries below Total Salary Expense Actual Salaries at Commencement of lst Year of City Option - $682,516 Areal Salaries at Comm er+cem erat of 2nd Year of City Option - $641,114 Actual Salaries at Corm e cerne nt of 3rd Year of City Option - $607,5$7 Actual Salaries at Com rn e ncern ent of 4th Year of City Option - $715,274 Actual Salaries at Commencement of 5th Year of City Option - $745,298 Total Estimated Service Fee (2.30 multiplier) $1,6O3,91© $1,474,562 $1,397,451 $1,454,049 $1,512,211 Annual Fee for Licensing of SysFacs (up to six users) $O $17,500 $17,500 $17,500 $17,500 Grand Total $1,603,91 0 $1,492,062 $1,414,951 $1,471,549 $1,529,711 Quoted as fifth year of five additional year -long options for the City of Miami to renew at their sole option. Total dollar increase from year to year not to exceed 4% over expiring year. True Salaries to be Calculated at Beginning at Service Period Client and GB to Agree on Staffing Prior to Beginning of Service Period GB will perform normal salary administration pursuant to GB Procedures Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 1 City of Miami 000757 2/15/2016 - 2/15/2017 GB MANAGED CARE SERVICES Fee Schedule (Bill Review I UCR / System Savings) All Other Savings • Clinical Validation/Nurse Review (CV) • Preferred Provider Networks (PPO) • Out Of Network (OON) • Specialty Networks/ Physical Therapy (PT) 8.50 Per Bill 25 % of Savings 25 % of Savings 25 % of Savings 25 % of Savings Electronic Receipt of Medical Bills $2 additional per bill in all applicable states Telephonic Case Management $75 Medical Triage $290 per Indemnity claim (each 30 days) $130 per Medical Only claim (one time) Hospital Certification Program $120 inpatient Pre -Certification Utilization Review Program $105 Outpatient Pre -Certification Physician Review/Peer Review $270 per Review Task Based Field Case Management • Task 1: One Visit Task • Task 2: Two Visit Task • Task 3: Labor Market Survey • Task 4: Vocational Assessment • Task 5: Home Visit $530 per assignment $705 per assignment $635 per assignment $590 per assignment $660 ($730 in CA) per assignment Medical Case Management and Vocational Rehabilitation — Hourly $92 per hour plus expenses $103 per hour —AK, CA, HI, NY Priority Care 365 $90 per call Texas HCN Service Options Not Applicable Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 2 •awe' go beyond gALsse I C� City of [Miami 000757 2/15/2016 - 2/15/2017 GB MANAGED CARE SERVICES SERVICES Other State Service Options: • California MPN Service Options • Illinois PPP Service Option • New York PPO Service Option • West Virginia MHCP Service Option Not applicable Medical Cost Projection (MCP) and Clinical Recommendations $1125 per hour Pharmacy Benefit Management (PBM) — First Script Cost of prescriptions — no charge for Bill Review or PPO reductions for PBM transactions Rx Peer to Peer Review (P2P) Drug Utilization A RX Peer to Peer Review Options: • No DUA Performed - $290 per review • DUA Performed in prior 60 days-$865 per review Rx Drug Utilization Assessment (DUA) Drug Utilization Assessment - $575. Return to Work Coordinator (Injury Coordinator) Coordinator - $8,750 per month Durable Medical Equipment (DME) Program - First Script Cost of medical equipment — no charge for Bill Review or PPO reductions for Prospective DME transactions Dental Review Program Charged on a per review basis OSHA Reporting $4,500 per year Includes set-up, OSHA access & unlimited OSHA logs and summaries Taxes All applicable taxes will be added to the service fees where required Client and GB agree as follows: If another preferred managed care vendor other than Gallagher Bassett Managed Care Services is utilized, an administrative fee may apply in exchange for bona fide administrative services. The administrative services may include, but not be limited to overhead costs for the oversight and management of Managed Care vendors which includes the development and oversight of quality standards, development and maintenance of EDI interfaces and reports, and ensuring proper mandatory state compliance and reporting. Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 3 City of Miami 000757 2/15/2016 - 2/15/2017 OTHER SERVICES {y/� .,tb _.,E 3; } f 3 93f6jp j13i f Ei'• f r'. ,„„_ �Ei3 !}Rf i.., tfBf ! - C"' _ - € f3 € " "k 3 f d t 4�7 �+-. s:s�,3 P} S..i:. �i�.y¢�£ : - �.R3' { �. s_ ':h,. .., i.fr .... ax.E. PF� �..i..�v<.�fsi`i11EF....?5".....F.E.Y?i, risxfacs.com - Additional Users Sf .' '. ;..iY9�fyf9 .,. t... i }3d4d1 �. $1,000 per user GB international Claims Services Varies by Country (pricing provided upon request) Consultative Services Loss Control Consulting Services $140 per hour Appraisal Services TBD Fraud Prevention — Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations - SIU $85 per hour plus expenses Surveillance Investigations $70 per hour plus expenses Targeted Field Investigations $80 per hour plus expenses Targeted Database Investigations Rate per report Gallagher Bassett Litigation Management Program (GBLMP) Invoice and Matter Management platform for Resolution Manager/counsel 2% of net legal invoice (invoice net of disbursements and invoice review savings)_ Charged as discount off total payment remitted to counsel unless client elects to fund. 5 client licenses for Legal Analytics platform Attorney -led invoice compliance review MedInsights MSA (This pricing is for Medlnsights services only. If another vendor is selected, then other pricing applies) Workers Compensation Medicare Set -Aside Allocation (WCMSA) $2,300 per allocation Rush Fees (MSA completed within 7 days) $450 per case Revisions: $150 per hour (One free revision within six months of submission) Liability Medicare Set -Aside Allocation (LMSA) $2,300 Fee MSA Submission to CMS $850 Fee Gallagher Bassett Compliance Services (GBCS) (The following pricing is for GBCS services only. If another vendor is selected, then other pricing applies) Conditional Payment Research (CPR) $200 Flat Rate Conditional Payment Negotiations (CPN) $375 Flat Rate Secure Final Demand for Settlement (SFD) $250 Flat Rate Bundled CP Resolution Services $700 Flat Rate Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 4 City of Miami 000757 2/15/2016 - 2/15/2017 Benefit Coordination & Recovery Contractor Notification Medicare Eligibility Inquiry (MEI) SSDI Verification Release 1 Settlement Agreement Review $45 Flat Rate No Charge $175 Flat Rate Lien Resolution (Advantage Plan, Medicaid, Part D) Taxes $250 Fiat Rate $500 Flat Rate per Lien Resolution All applicable taxes will be added to the service fees where required Budgeted Staffing Cost & Terms (Revision date: 5/8/2015) Page 5 go beyond -Arse City of Miami 000757 go beyond 2/15/2016 - 2/15/2017 v:. ALLpGNf¢ry $-4SSE"" Ass �¢ PROGRAM SPECIFIC TERMS AND CONDITIONS 1. Audit Terms: Actual: • Actual — No true -ups will occur go beyond 2. Billing and Payment Terms: Fees will be billed Monthly during the calendar year. Fees are payable within 30 days upon receipt of the invoice. Gallagher Bassett reserves the right to charge 1 % per month, or the maximum legal rate, on balances unpaid after 30 days. 3. Budgeted Staffing Claim Pricing Terms: Claims will be handled for the life of the partnership with no additional per claim fees. If you should decide to non -renew or stop using GB in a specific state, the existing open files can be handled in one of three ways: ® Gallagher Bassett would continue to handle the open files at our prevailing rates fee per year per open file. ► Gallagher Bassett would continue to handle the open files on a Time and Expense basis. ® Gallagher Bassett would return the files to the client (contingent upon Carrier approval) at the client's expense "Please see Claim Charges outlined in footnote 7 under Program Specific Terms and Conditions. Note: There will be additional charges for ongoing Data Management (RISX-FACS®), risxfacs.com users, Administration, Banking fees and monthly reports for as long as GB handles claims. 4) Account Administration includes the following: a. Designated Account Manager b. Detailed Status Reports @ $50,000 c. Settlement Authority @ $10,000 (WC)/$3,000 (Liability) d. Banking Administration (SUMS) e. Two Claim Reviews a Year or One Performance Audit f. Acknowledgement Letter to claimant 4. Data Management includes the following: > New Claim Setup ➢ Historical Claims > Monthly Report by Email or the Website > Carrier Report Package by Email or Website 5. Pricing is based on using GB Managed Care (GBMCS) or Medinsights for Bill Review, PPO, out -of -network, utilization review, telephonic case management, MSA and field case management Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 6 City of Miami 000757 2/15/2016 - 2/15/2017 go beyond 6. Claim Charges: The Claim charge is applicable per claim per line of coverage. > Example: A client employee during working hours is involved in an automobile accident with another vehicle with two occupants. Both occupants were injured, both cars were damaged and our client employee was injured. The claims handling charges (example only) will be: Claimant #1 - Auto Liability Bodily injury $0 Claimant ##2 - Auto Liability Bodily Injury $p Claimant Owner - Auto Liability Property Damage S0 Client — Workers' Compensation S0 Client — Auto Physical Damage $0 $0 Administration included in the cost-plus fee. 7. The pricing of specific service offerings is the proprietary, confidential property of Gallagher Bassett Services, Inc. It has been provided to you for the sole purpose of considering a quote for claims administration services. It is not to be duplicated or shared in any form with anyone other than the individuals of such prospective client that have a business need to know the information. It must be destroyed or returned to Gallagher Bassett Services, Inc. after its intended use. S. Gallagher Bassett Services, Inc. will not pay a fee, commission, or rebate to any party for the privilege of presenting our proposal or in order to secure the awarding of any program to Gallagher Bassett Services, Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 7 o beyond gziss r( City of Miami 000757 2/15/2016 - 2/15/2017 o beyond 4as"s¢ GENERAL CONTRACT TERMS AND CONDITIONS 1. Independent resolution managers for Catastrophes - If applicable, following any significant Property loss as a result of a single event (i.e., hurricane, tornado, flood, earthquake, etc), GB reserves the right to retain outside resources (resolution managers) when appropriate and those fees will be paid as an Allocated Expense off the file. 2. Material Change - GB reserves the right to modify its fees upon sixty (60) days prior notice to CLIENT if: a. It is determined that the historical data upon which GB's fees and service charges developed were based upon erroneous, obsolete or insufficient information, or that a change in CLIENT`s business will materially change the nature and/or volume of its business or claims as contemplated at the inception of the Agreement b_ During the term of the Agreement, legislative and/or regulatory requirements materially impact or change the scope of GB's services or responsibilities 3. Taxes - All applicable taxes will be added to the service fees where required 4. Allocated Expenses: Shall be your responsibility and shall include, but not be limited to: > Legal Fees > Medical Examinations > Professional Photographs ➢ Travel made at clients request > Costs for witness statements ➢ Court reports > Medical records > Accident reconstruction > Experts' rehabilitation costs ➢ Chemist > Fees for service of process > Collection cost payable to third parties on subrogation > Architects, contractors > Engineer ➢ Any other similar cost, fee or expense reasonably chargeable to the investigation, negotiation, settlement or defense of a claim or loss which must have the explicit prior approval of the client > Police, fire, coroner, weather, or other such reports > Property damage appraisals > SIU, surveillance and sub rosa investigation > Official documents and transcripts > Pre- and post judgment interest paid ➢ Outside Investigation ➢ Index Bureau Reporting > Second Injury Fund Recovery > Data Intelligence Self -Service Reports > Managed Care - Managed Care services may include, but are not limited to: i. Preferred provider organization networks v. Medical case management and Vocational ii. Utilization review services rehabilitation network iii_ Automated state fee scheduling vi. Prospective injury management services iv. Light duty/return-to-work programs vii_ Hospital bill audit services Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 8 -JAWgo beyonc �$AL City of Miami 000757 2/15/2016 - 2/15/2017 DEFINITIONS go beyond ass' Workers Compensation - Medical Only Claims A medical only claim is a work -related Claim that meets the following criteria: (i) payments for either indemnity or vocational rehabilitation were not required, (li) the Claim has not become contested or in suit, (iii) investigation to determine compensability or subrogation requirements was not required, (iv) no loss notices, captioned reports, client meetings (other than routine meetings where the claim is listed and noted) or settlement authority approvals were required, and (v) payments on the Claim have not exceeded $2,500_ Workers Compensation - Indemnity Claims An indemnity claim is a Workers Compensation claim that is not a Medical Only Claim. Incident - Electronic and Manual An Incident is a Toss reported electronically through Claimf_ine and/or the Web, or set up manually at the branch. GB will review the Incident and make a courtesy call [if necessary] to determine if it is a claim or Incident. GB will have full discretion in the determination and handling of these incidents and/or their conversion into claim status. Liability Claims investigate, evaluate and adjudicate all third -party claims for which you may be legally obligated. Third -party claims will be managed and administered in accordance with our product guidelines. Auto Physical Damage (APD)/Property Claims Investigate, evaluate and adjudicate all first -party claims which you report involving damage or loss of real or personal property. First -party claims will be managed and administered in accordance with our product guidelines. Budgeted Staffing Cost & Terms (Revision date: 6/8/2015) Page 9 itg ANNIE PEREZ, CPPO DANIELJ. ALFONSO Procurement Director City Manager ADDENDUM NO. 5 DATE: October 28, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. A. Section 3.3.2, Liability Claims Administration, Item No, 3a, has been deleted in its entirety and corrected with the following language: a) Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the Successful Proposer. In the case of unrepresented claimants, personal contact is required the same day the claim is received. All claim files must contain adjuster's logs documenting. all contact and activity. B. The following are the inquiries as received and the corresponding responses: Q1. Please clarify what. the City is requiring in Section 2.8, B, #11 regarding Official Disability Guide ("ODG") guidelines being integrated into the rule engine? Al. The City requires the Proposer to incorporate ODG guidelines into the Proposer's decision tree/rule engine, for medical status and progression for Telephonic Case Managers and Field Case Managers, Q2. The RFP references submission of SSAE 16 SOC 1 and 2, report with the proposal. This is not a current standard requirement in the industry, As a TPA approved by all major carriers in the US, there are not any carriers or regulatory agencies requiring more than SSAE 16 (SOC 1) Type II compliance. In fact, in our SOC 1 audit, in addition to testing of information systems against best practices, controls In place to provide security, confidentiality of stored information, processing integrity of transactions, system availability and privacy testing (required in SOC 2), our SOC 1 requires testing of many other internal controls with respect to human resources, accounting, claims management, and other critical internal controls. Given that this SOC 2 may be limited, not standard requirement in the industry, and could cost hundreds of thousands of dollars to change processes and audit requirements for qualified "Big Four" firms (vs. Industry Cottage firms) to update complex audit programs, would the City would accept SSAE 16 (SOC 1) Type II report? A2, Yes, the City would accept a SSAE 16 (SOC 1) Type II report. Q3. Will the City allow a reasonable and minimum time of twelve (12) business days after the release of answers to questions for submission? A3. Refer to Addendum No. 4. The deadline for submission of proposals• has been extended until November 30, 2016, at 2:00 PM, Q4. Who are the current providers for the following managed care programs? a. Bill Review b. PPO Networks (which Networks) c. Medical Case Management A4. The current providers for the referenced managed care programs are as follows: a. Bill Review: Gallagher Bassett Services, Inc. ("Gallagher") b. PPO Networks: Gallagher — Aetna & First Health c. Medical Case Management: Gallagher 05. Provide the following annual summary information: a. # of Bills b. Amount of Billed Charges c. Amount of Fee Schedule Reductions d. Amount of PPO Reductions e. Fees for Fee Schedule Reduction f. Fees for PPO Network Access. g. Fee for Specialty Bill Review A5. The annual summary is as follows: a. # of Bills: 15,726 b. Amount of Billed Charges: $18,815,104 c. Amount of Fee Schedule Reductions: $11,118,442 d. Amount of PPO Reductions: $791,361 e. Fees for Fee Schedule Reduction: $8.50 Per Bill f. Fees for PPO Network Access: 25% of Savins g. Fee for Specialty Bill Review.: 25% of Savings 06. Approximately how many audit -in network and out -network hospitallprovider bills, are processed annually? A6. Approximately 150 audit in -network and out -network hospital/provider bills are processed annually. Q7. The City currently uses Cypress Care PBM for claims that are administered in-house, a) How many claims and what types of claims are administered in-house? b) Would the City consider the use of a different PBM for all claims administered by the TPA if it benefits the City (and in accordance to physician dispensed drug policy)? A7. The City desires to retain Cypress Care for the WC claims administered in-house from 2001 and prior. Q8, Will the City pay for specialized Loss Control services that may require the referral to a company specializing in certain loss control services? A8. Yes. The City is expecting a set number of hours to be provided within the Proposer's proposal, Any services needed in excess of the hours provided may have a predetermined rate. Q9. Are single or bi-directional interfaces required? Please explain? What is the RMIS used by the City for this interface(s)? A9. The City currently does not have a RMIS internally. The City is in the process of procuring a system. Upon acquisition of a RMIS, the City ideally would like the Successful Proposer to have bi-directional interface. Q10. Does the City desire access to the TPA claim system? If yes, for approximately how many Users? A10. Yes, the City requires access to the Successful Proposer's TPA claim system for approximately ten (10) Users. Q11. Does the City require a full time Medical Case Manager(s)? If yes, how many? Are medical case management services provided on an hourly or per case rate? Approximately how many cases are referred? a. To telephonic medical case management per year? b, For field case medical case management per year? c. For utilization review per year? Alt The City does not require full time Medical Case Managers. Medical case management is bought on an hourly rate, and cases are referred to Medical Case Managers by the City, as needed. Refer to responses to questions 10 and 11 in Addendum No. 1 for the number of cases. Q12. Section 3,3.1, Workers' Compensation Claims Administration, Page 42 of 65, Item 12: a, It appears a full claim status report has to be provided to the City every ninety days on any claim in which an employee is not working full duty, Approximately how many claims at any given time are on restricted duty? b. Approximately how many claim files require a full summary report (for the types of claims noted in Section 12 a), b), c), and d) every 90 days? Al2. a. The City currently is paying. Temporary Total Disability ("TTD"), on 55 files; b. There are currently 1,031 files that meet the criteria. The report required is a claims summary format, which should be updated every 90 days for supervisory review. Q13. Please provide the approximate number of all open claims by claim type for all claim years including: a. GL b. Auto/BI/PD c. APA d. POL & ELL e. LEL f. indemnity. Of the open indemnity approximately how many are Future medical, PD or Grover type claims that require limited / awarded payments per year? g. Medical Al3. The approximate number of all open claims, by claim type, for all claim years, are as follows: a. GL: 204 b. Auto/BI/PD:143 c. APA:140 d, POL & ELL: 86 e, LEL: 12 f. Indemnity. 1084. A report with a breakdown of the type of claims is not available at this time. g. Medical:37 Q14. is a minimum of three (3) attempts to contact appropriate parties required on simple medical claims? Please clarify. A14. Yes, ideaiiy the City requires three (3) attempts to contact parties, so that the City can gain as much information on the front side of the claim, In the event the claim changes direction unexpectedly, - - - 015. Attachment B, Cost Proposal: Section B, Managed Care/Medical Bill Review/Audit Services. Please provide: a. Clarification and volume of "Managed Care Services" (assuming this if for medical case management se.rvices). b. Number of bills processed for Fee Schedule annually. c. Number of bills processed as "Audit Services", d, Confirmation FPO Network Access fees are an allocated loss adjustment expense (ALAS). A15. Refer to response to question No. 5 above for the information requested for a, b, and c. d. Yes, the PPO access fees are included within the ALAE. Q16, Provide complete loss runs/reports for claims dada by line of coverage for each of the past five (5) years. A16. The Loss Runs Report for claims data has been attached to the Header Section of the Solicitation in Oracle. Q17. Does the current TPA utilize a subcontractor to meet any participation goals with a MBENVBE or other business enterprise? If yes, who is the subcontractor(s) and for what services? If yes, for what percentage? A17. The current TPA does have subcontractors for parts of the services they provide, however, MBE/WBE's was not a criteria. Q18. Compliance with Federal, State and Local Laws, Item Le Please confirm bidders do not have to provide Prompt Payment discounts. A18, This clause is a part of the City's general terms and conditions. For more information on Prompt Payments refer to Florida Statutes, Sections 218.79 to 218.79, Q19. What is Gallagher's current staffing model for the City of Miami claims by Position and # of FTE(s)? A19 One (1) WC Supervisor; Four (4) WC Indemnity; One (1) WC Medical Only; and Two (2) Liability Adjusters. Q20. Please provide your incoming claim counts by coverage type for the last five (5) years for the following coverage types: a. WC -indemnity b. WC -Medical only c. Auto Bl d. Auto PD e, General Liability BI f. General Liability PD g. Public Officials h. E&O i. EPLI j. Law Enforcement Liability A20. Coverage Type Incoming Claims Count 2012 2013 2014 2015 2016 a VVC-Indemnity 460 553 416 613 532 b WC -Medical only 279 247 236 215 121 c Auto BI 97 92 65 49 58 d Auto PD 397 430 398 328 275 e General Liability BI 208 202 221 235 168 f General Liability PD 231 212 198 163 149 g Public Officials 0 0 0 0 0 h E&O 0 0 5 2 1 I EPLI 0 1 2 1 0 j Law Enforcement Liability 44 30 33 21 5 Q21. Please provide your current open claim counts by coverage type. a. WC -Indemnity b. WC -Medical only c. Auto BI d. Auto PD e. General Liability BI f. General Liability PD g. Public Officials h. E&O I. EPLI j. Law Enforcement Liability A21. Refer to Addendum No. 1, responses to questions 2 and 3. Q22. Provide a break-out for the total number of legal claims for each of the coverages in question No. 21 above (provide those counts). A22. The City's current TPA is only tracking legal status within the Workers' Compensation Line of Coverage in a report format. The numbers are below: Coverage Typo WC -Indemnity 2012 110 Current Claims Count 2013 2014 2015 114 2016 108 143 67 Q23. Please provide the following for each of the last three (3) years: a. Total number of medical bills by type (DWC-9, DWC-10, DWC-11 and DWC-90) b, total billed (by bill type if that is available) c. total fee schedule paid d, total amount of PPO discounts e, all other UR savings f. total amount paid to providers (by bill type if that is available g, all fees paid for Bill Review services A23. Please see response to Question No. 5. -Q24Regarding Attachment--Section-2,jtern 3b:-Please-define °'tape-feed.-"--We-are-able to -accept file transfer via secure FTP in formats such as .xis and .txt, Is this acceptable to the City? A24. Yes, this is acceptable. Q25, Does the City require any subcontractors to mirror the coverage requirements that the TPA must follow? A25. Yes, the City requires that subcontractors shall have equal or higher coverage requirements. Q26. Please provide your current TPA's staffing model, including the number of adjusters dedicated to the City's account. A26. Refer to response for question No. 5, Addendum No 1. Q27. The RFP mentions "scene investigations, and personal claimant contact on all lost time or light duty oases". Will our WC adjusters be housed on site at the City, or do we send our WC TPA adjusters out into the field, or do you want our field adjusters to make these visits? A27. It has not been determined if the Successful Proposer's adjuster will be situated on -site or not, but scene investigations will be needed on as requested basis by the City. The City does not anticipate this to be a high volume. The City will require that a thorough investigation be completed to interview all parties and witnesses at the scene, to get all the information available about the alleged accident. Q28. Section 3.3.2., Item No. 2 of the RFP mentions outside field adjusters for liability claims. Is this fee an allocated expense charged to the claim file, or is it to be included in the annual fee? A28. This should be included within the annual fee. Q29. Section 3.3.2., Item No. 3 of the RFP indicates all under -represented claimants are to be seen in person. How many field assignments have been made by year for the last three years? A29. For clarification purposes, refer to corrected language in A above. Personal contact shall be made by phone on all unrepresented claimants and in person contact will be only needed as requested. Q30. Section 3,5, Item No. 9 of, the RFP indicates the proposer will "maintain these maximum pending caseload levels". What are the City's expected maximum pending caseloads? A30. The Proposer shall state their caseload recommendations. Q31, Section 3.6, Item No. 10 of the RFP, indicates proposers should submit resumes. Will the City accept base -line qualifications of each position in lieu of a resume since we will have to hire adjusters to handle a program of this size? Is the City interested in a new TPA attempting to retain some or all of the current team of supervisors and adjusters? A31. Yes, base -line qualifications are acceptable with the Proposer's proposal. Upon hiring of the selected individuals however, the City will require a copy of the adjuster's resume. The City also has the right to select or reject the team proposed. The current adjusting team are employees of the current TPA. Q32, Is there a requirement to -have an office in -Miami or -Dade -County? -Would the City -be -interested - in housing the adjusters on site at the City of Miami? A32, No, it is not required to have an office in the City of Miami or Miami -Dade County. The City has not decided if an on -site adjuster model would be needed at this time. The City has a right to discuss this at time of negotiation. Q33. Which MWBE-certified vendors are currently providing services for the City? Does the City wish to continue receiving services from these vendor partners? A33. Although, the current TPA does have subcontractors for parts of their services, it was not a criteria for inclusion of MBE/WE, certified vendors. Q34. Will the City consider extending the deadline for proposals? A34. Yes. Please refer to Addendum No. 4. Q35. What is the current caseload by claim type for each adjuster? A35. Refer to Addendum No 2, response to question No 10. Q36. Regarding Attachment A, section 7 on page 7: Google Chrome -compatible or Firefox-compatible claims management system platform providing real-time interactive communication and claims management between nurses, adjusters, the City, and its business units. Our claims system is currently supported on IE 10 and 11. Does the city specifically require support for Chrome and/or Firefox? A36. Internet Explorer 10 and 11 are acceptable. Ail other information remains the sarno. A p. / APPROVED: � � /V/✓'Yv9'®(_,�` �'�' ,: ;;�,,�' y /f� p�7 ���7 AP:lo An ie Perez, CPPO, Director of Procurement Dat c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ANNIE PEREZ, CPPO DANIELJ. ALFONSO Procurement Director City Manager ADDENDUM NO. 4 DATE: October 26, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO,: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. A. The deadline for receipt of proposals for RFP605386 has been extended to Wednesday, November 30, 2016, at 2:00 PM (local time), to allow additional time for Proposers to respond. B. The following language has been added to the Certification Statement, which has been revised and attached to the Header Section of the Solicitation: Please list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e., Addendum No. 1, 7/1/15). If no addenda/addendum was/were issued, please insert "N/A". Has Proposer reviewed the attached Sample Professional Services Agreement (PSA)? Does the Proposer acknowledge that the attached PSA is an example of the standard Agreement used in conjunction with the services related to this Solicitation and shall not be amended? C. Section 4, Submission Requirements, Subsection. 4.1 has been amended to revise the following information: ALL RESPONSES SHALL BE SUBMITTED IN HARD COPY FORMAT ONLY TO INCLUDE ONE (1) ORIGINAL, SIX (6) COPIES, AND AN ELECTRONIC COPY (USB OR CD). NO ON-LINE SUBMITTALS WILL BE ACCEPTED. D. The following are the inquiries as received and the corresponding responses: Q1. Provide the RFP Attachments A and B in Word Format? Al. Attachment A, Proposer Supplemental Questionnaire has been attached to the Header Section of the Solicitation in Word Format. Attachment B, Price Proposal Schedule, has been revised (refer to Addendum No. 2, A) and have been attached to the Header Section of the Solicitation in Word Format, as B1, Claims Administration Price Proposal Schedule, and B2, Managed Care Price Proposal Schedule. Q2. How many claims per year for the past five (5) years had a Telephonic or Field Nurse/Case Manager assigned to them? A2. Please refer to Addendum No. 1, response to question No. 10. Q3. Who is the current broker? A3. The current Third Party Administrator (TPA) is Gallagher Bassett Managed Care Services. Q4. Page 7 of 65, 1.4: Does the City want all addenda submitted with the proposal or just an acknowledgement of addenda, if any, satisfactory? A4. The Proposer shall acknowledge all addenda by indicating same on the Certification Statement that is attached to the Header Section of the Solicitation, See Item A above. Q5. Page 9 of 65, 1.11, Bid Bond/Bid Security: Please confirm that a Bid Bond is not required for proposal submission, and that there are no special conditions requiring this for the proposal. A5, Bid Bond/Bid Security does not apply to this Solicitation. Q6. Who are the City's excess carriers? A6. Refer to Addendum No. 3, response to Question 9. Q7. Section 4, Submission Requirements, sub -section 4,1, Page 57 of 65, requires One Original and Slx Hard Copies. Page 27 of 65 1.78: Requires submission electronically via the Oracle System, Page 57 of 65 4.1 indicates "NO ON-LINE SUBMITTALS WILL BE ACCEPTED". Please clarify. A7, See item C above. The instructions in Section 4, Submission Requirements applies to this Solicitation. The clause pertaining to electronic submission in the Oracle System does not apply. Q8, Please describe the performance guarantee currently used for Managed Care/Medical Bill Review (Part II services). A8. See response in Addendum No. 3, Question 3. All other information remains JI° a same. APPROVED: AP:lo Ar)e Perez, CPPO, Director of Pro • urement pae#0 c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ANNIE PEREZ, CPPO DANIEL J. ALFONSO Procurement Director City Manager ADDENDUM NO. 3 DATE; October 24, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation. The following are the inquiries as received and the corresponding responses: QI . Please provide the employee count for City of Miami's (City) full-time and part-time employees, Al. The City employs 3,985;full-time employees, and 152 part-time employees: Q2. What is the City's philosophy for Telephonic and Field Nurse Case Management? A2, The City must approve each assignment of Telephonic and Field Nurse Case Management. Q3. Wil1 the City provide a performance guarantee? A3. The City reserves the right to request that the Successful Proposer enter into a mutually agreed upon performance guarantee at a future date, The addendum to the Professional Services Agreement would include, but not limited to, key performance indicators, target results, and any penalty or gain share amounts, Q4. Whatwould-happen to Pharmacy Management -Services? A4. The City wishes to retain those claims currently assigned to Cypress Care. Q5. In reviewing the RFP, there is a reference to Auto losses. Should the proposing TPA be including Auto in the pricing options for Liability, or will the City look to the TPA for GL and WC claims handling? A5. The City will require the Successful Proposer to handle General Liability and Workers' Compensation claims, as well as the existing Auto Claims being handled by current Third Party Administrator (TPA). Q6. Please provide number of medical bills foreach of the past five (5) years. A6. The breakdown of medical bills for the past five (5) fiscal years (10/1 through 9/30) are as follows: 2011 to 2012: 16,464 2012 to 2013: 16,198 2013 to 2014: 13,946 2014 to 2015: 14,712 2015 to YTD: 15,726 Q7. Please provide Medical Bill Savings Report for each of the past three (3) years A7, The Medical Bills Savings Report has been attached to the Header Section of the RFP in Oracle. Q8. In attachment A, page 10, Pricing, Part 1, #1, it indicates that "All pricing should be on a life of claim basis..." a) Is the City seeking pricing on a life of contract or life of claim basis? b) Will the City accept life of contract pricing proposals? A8, The City is seeking life of contract pricing Q9, Who are the City's excess insurance carriers? A9. The City's past and current excess insurance carriers are: • State National: 10/1104 — 10/1/07 • Star Insurance Company: 10/1107 - 10/1/09 • No carrier for WC: 10/26/09 — 10/26/10 • Midland: 10/26/10 to present Q10. Provide a breakdown of all the open claims for takeover- by line of coverage and claim type. A10, See chart below: a been , it ±o'rat Auto Liability - Bodily Injury 22 Auto Liability - Property Damage 1 Employee Benefit Liability 6 Employment Practices Liability 2 Errors & Omissions 12 General Liability Bodily Injury 207 General Liability_ Property_Damage. 4 Police Professional Liability 86 WC 706 Q11. For the open workers' compensation claims, identify how many are lost time/indemnity and how many are medical only (MO) claims? All. W Q: Q1i1rC..:r: WC — indemnity 667 WC — Medical 39 Q12. Will the new TPA take over the handling of all open auto liability claims? If so, how many, or will those continued to be handled in house? Al2. Please refer to the response to Question 11. Claims identified therein will be taken over by Successful Proposer, Q13. Does the City require or prefer a fully dedicated (only working on the City's claims) unit for all claims; Workers' Compensation and Liability? Or is the City only requiring that the position of Workers' Compensation Supervisor be dedicated, as stated in Section 3,3.1, number 5? A13. Yes, the City requires a fully dedicated (only working on the City's claims) unit for all claims, Q14. How many claims annually require the services of a Field Adjuster? A14. This number should be determined by the Proposer as Field Adjusters are encouraged to go in the field as they see fit, to conduct credible claim investigation. Q15. Are there any service concerns or issues with the current TPA? Is the. City satisfied with the current level of services received, or are there areas of improvement the City is hoping to obtain? A15. There are no concerns at this time, however, continuous improvement is the City's goal. Q16. The solicitation is requesting separate price proposals for claims and managed care services, and indicated the price proposals will be evaluated and possibly awarded independent of each other. If a company is proposing both services, can it all be submitted in one proposal with sections specifically for claims and managed care services (and with separate pricing indicated), or is the City requiring two separate and distinct proposal document submissions? Please clarify. A16. No. Proposers must submit separate Proposals if proposing on both Part 1: Workers' Compensation Claims and Liability Claims Administration, and Part II - Managed Care/Medical Bill Review. Proposers must clearly indicate for which Part(s) Proposer is submitting its Proposal for, and must provide all of the information and documentation, in addition to the Supplemental Proposer Questionnaire (Attachment A), which is attached in the Header Section of this Solicitation for each part. Q17. For Medical Claims Review Services, does the City require that only a flat annual all-inclusive fee (aggregate total for three [3] years) be proposed? A17. Completion of the pricing sheet for Medical Claims Review in its entirety is required. Q18. For -Managed -Care Services, does the -City require a flat all -Inclusive -annual -fee -or- are -alternative - pricing proposals acceptable (such as medical bill review per bill fees, PPO savings fees, case management fees)? A18. Alternative pricing is acceptable, however, the pricing sheet requested for Managed Care Services must also be completed in its entirety and submitted. Q19. On Attachment B, Price Proposal Schedule, Part 1. A (Claims), if a total three (3) year fee amount is submitted, is it necessary to also complete. Section C — Breakdown of total fees? A19. Yes. Q20. The pricing page indicates that pricing should be submitted for the "life of the claim." From the RFP, it appears that the new TPA will assume handling of the existing claims and I see that the number of open claims was included in Addenda 1. a) Is the City requesting pricing for "life of claim for the life of the contract?" b) Will the City move the "tail" claims to a new TPA at the end of this contract as well? A20. a) The City is requesting Price for life of the contract. b) Yes, the City will move the "tail" claims to the new TPA. Q21. What PPO network is currently used by the City's current TPA? A21. Gallagher Bassett Managed Care Services (Please refer to Addendum No.1, Q8). Q22. Section 2.8, Minimum Qualification Requirements, Sub -Section A, Item 5 requires TPA to have five continuous years of Florida municipal claims handling experience and with 1 employer of at least 1,500 employees. Our organization has 20 plus years of continuous Florida claim handling; and has been handling public entity claims outside of the State of Florida in numerous states across the US since 1987 for employers with over 100,000 employees including large city, county and state public entities, This requirement may eliminate viable candidates for the City which may be a disadvantage to the City. Will the City please reconsider this requirement or modify it so that potential TPA's with extensive public entity experience regardless of the jurisdictional experience will be sufficient? A22. it is in the City's best interest to award to a Proposer who is experienced in handling Florida. exposures, therefore the referenced minimum requirement of five (5) continuous years of experience, handling Florida municipal claims with at least one (1) client having a minimum of 1500 employees, will remain at this time. Alt other information remains the same. APPROVED: AP;Io A'nie Perez, CPPO, Director of P/1bcurement c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney / // Date William A. Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ANNIE PEREZ, CPPO DANIELJ, ALFONSO Procurement Director City Manager ADDENDUM NO. 2 DATE: October 17, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (REP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This Addendum becomes a part of the subject solicitation, A. Attachment B, Price Proposal Schedule has been deleted in its entirety and replace with two separate Price Proposal Schedules, to accommodate Part 1, Claims Administration, and Part II, Managed Care. See attached: a. Attachment B1: Claims Administration Price Proposal Schedule; and b. Attachment B2: Managed Care Price Proposal Schedule. Updated forms have also been attached to the Header Section of this solicitation. All references in the Solicitation to Attachment B, Price Proposal Schedule will now be referred to as Attachment 131: Claims Administration Price Proposal Schedule, or B2, Managed Care Price Proposal Schedule, whichever is applicable. B. The following are the inquiries as received and the corresponding responses: QI. is this RFP for al] Liability Claims or only B] and large loss? Al. All liability claims. Q2. Can a firm submit a combined proposal? A2. No. Proposers may submit a Proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration, and/or Part II - Managed Care/Medical Bill Review. Proposers must clearly indicate for which Part(s) Proposer is submitting its Proposal for, and must provide all of the information and documentation, in addition to the Supplemental Proposer Questionnaire (Attachment A), which is attached in the Header Section of this Solicitation. 03. Should all questions be answered for both Par 1 and Part II? A3. Yes. All relevant questions must be responded to. If a question is not relevant to the category (Part 1 or II) Proposer is responding to, the Proposer should respond with "NIA". Proposers must also Include the Supplemental Proposer Questionnaire for both category. Q4, Should pricing be submitted on separate forms? A4. Refer to Item A above. 05. Will the City consider an extension if requested? AS, All inquiries and questions are considered. Q6. When does the City anticipate taking the recommendation to City Commission? A6. It is anticipated that the agenda item for award recommendation will be presented to City Commission in January/February 2017. Q7. When does the City expect for the implementation of the project to commence? A7. It is anticipated that the agenda item for award recommendation will be presented to City Commission in January/February 2017. The notice to proceed with the project will be issued shortly after that Q8. Does local preference apply to this solicitation? A8. Local preference does not apply to this solicitation. Q9. Will the City require a dedicated or designated Liability Supervisor? A9. The City requires a Liability Supervisor who will be assigned to the contract. Q10. Does the City have an established caseload requirements? Al 0. No. The Proposer shall indicate it its proposal their established caseload All other information remal:. s the same. APPROVED: jr 667; Ark' ie Perez, PPO, Director ry rocurement Date AP:Io c. Ann -Marie Sharpe, Director,. Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A, Juliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement City of Miami, Florida RFP No.606386 ATTACHMENT B1 CLAIMS ADMINISTRATION PRICE PROPOSAL SCHEDULE INSTRUCTIONS: The Proposer's price shall be submitted on this form "Price Proposal Schedule', and in the manner stated herein. Proposer is requested to fill in the applicable blanks on this form and to make no other marks. If proposing more than one category of services (Part I or Part II) Proposer must complete one separate Price Proposal Schedule for each category of service. This Price Proposal Schedule is for Part 1 Services Only: Workers' Compensation Claims and Liability Claims Administration. 1. INITIAL TERM (Years 1 through 3) A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, including one-time and recurring, and value added options, for Part I Services only. $ (Total fees and costs should be the aggregate price for the initial three years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3, Specifications/Scope of Work. The proposed fees shall be based on: a) the three year initial term Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) a flat fee broken down on an annual basis for the initial three (3) year term; e) the cost for anticipated staffing levels, based on the Proposer's proposal; and f) the implementation costs. 1. Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor $ $ 2 $ $ 3 $ 8 4 $ S 5 $ �$ a l $ qV 7 S 5 8 $ $ 9 $ $ 10 $ $ 11 $ $ 12 $ $ Proposed Total Fees and Costs $ 1 Third Patty Claims Administration Rev, 9/29/16 City of Miami, Florida RFP No,605386 2. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (°/nj Total Costs Year 1 $ $ Year 2 $ $ Year 3 $ $ Proposed Grand Total (Years 1-3) $ 3. Proposed One -Time implementation Costs Item Description Total Costs 1 $ 2 $ 3 $ 4 $ 5 $ Proposed Total Fees and Costs $ Notes: 1) The City reserves the right to correct and recalculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 1, 2, and 3 in Section 1 B above, should equal the aggregate costs in Section 1A above. 2. OPTION TO RENEW YEARS (Two, One -Year Periods - Years 4 and 5) The Proposer shall state its price below for the cost during the optional renewal years. This Price Proposal Schedule is for Part 1 Services only: Workers' Compensation Claims and Liability Claims Administration. A. Proposed Total Fees and Costs for Option to Renew Years (Years 4 and 5): The proposed total fees and costs shall include all fees, and value added options, for Part I Services only. (Total fees and costs should be the aggregate price for the two renewal years) B. Breakdown of Total Fees and Costs for Option to Renew Years (Years 4 and 51 The Proposer shall break down its price for providing the Claims Administration Services as specified in Section 3, Specifications/Scope of Work, during the option to renew years. The proposed fees shall be based on: a) the two (2) additional years of the Agreement; b) approximately 695 new indemnity claims per year; c) approximately 144 new medical only claims per year; d) a flat fee broken down on an annual basis for the two (2) additional years; e) the cost for anticipated staffing levels. 2 City of Miami, Florida RFP No.605386 4. Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor $ $ 2 $ $ 3 $ $ 4 S $ 5 $ $ 6 $ $ 7 $ $ 8 $ $ 9 $ $ Proposed Total Fees and Costs $ *Use additional paper if required 5. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 $ $ Year 2 $ $ Proposed Grand Total (Years 4 and 5) $ Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 4 and 5 in Section 2B above, should equal the aggregate costs in Section 2A above. 3. Additional Services The Scope of Work outlined herein identifies the work that the selected Proposer shall perform under the Agreement. To address future City requests for any additional services; modifications, or changes outside of the scope of work, please provide not -to -exceed hourly rates for personnel who will be assigned to this contract. 6. Additional Services Proposed Hourly Rates Personnel Not -To -Exceed Hourly Rates $ $ *Use additional paper if required 3 City of Miami, Florida RFP No,605386 Notes: 1, The proposed prices above in Sections 1A, shall be fixed and firm for the initial term of the Agreement. The proposed prices for the option to renew years, in Sections 2A, may be negotiated prior to the renewal of the contract for each option to renew period, at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current rates. 2. All out-of-pocket expenses, including employee travel, per diem and miscellaneous costs and fees, should be included in the Proposer's proposed price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3. Sections 1 and 2 will be used to determine the price points for the price criteria as indicated in Section 5.1, Evaluation Criteria of this Solicitation. 4. Notwithstanding the proposed hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 5. The positions identified in the table above shall be the same as the key positions identified in the Proposer's proposal. The City expects that the personnel in those positions will be performing the services. 4 City of Miami, Florida RFP No 605386 ATTACHMENT B2 MANAGED CARE PRICE PROPOSAL SCHEDULE INSTRUCTIONS: The Proposer's price shall be submitted on this form "Price Proposal Schedule", and in the manner stated herein. Proposer is requested to fili in the applicable blanks on this form and to make no other marks. If proposing more than one category of services (Part 1 or Part 11) Proposer must complete one Price Proposal Schedule for each category of service. This Price Schedule is for Part 11 Services only: Managed Care/Medical Bill Review/Audit Services. 1. INITIAL TERM (Years 1 through 3) A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, including one-time and recurring, and value added options, for Part II Services only. (Total fees and costs should be the aggregate price for the initial three years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 31 The Proposer shall break down its price for providing the Managed Care/Medical Bill Review/Audit Services as specified in Section 3, Specifications/Scope of Work. The proposed fees shall be based on: a) the three (3) year initial term Agreement; b) flat fee broken down on an annual basis for the three (3) year term; c) the cost for anticipated staffing levels, based on the Proposer's proposal; and d) the implementation costs. 1, Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor $ $ 2 S $ 3 $ $ 4 $ S 5 $ $ 6 $ $ 7 $ $ 8 $ $ 9 $ $ 10 $ $ 11 $ $ 12 $ $ Proposed Total Fees and Costs $ z Third Party Claims Admiiiistratiorj Rev. 9/29/ 16 City of Miami, Florida RFP No.605386 2. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 $ $ Year 2 $ $ Year 3 $ $ Proposed Grand Total (Years 1 through 3) $ 3. Proposed One -Time Implementation Costs Item Description Total Costs 1 $ 2 $ 3 $ 4 S 5 $ Proposed Total Fees and Costs $ Notes: 1) The City reserves the right to correct and re -calculate any errors found in Proposer's calculation. 2) Total Fees and Costs from Tables 1, 2, and 3, In Section 1 B above, should equal the aggregate costs in Section lA above. 2. OPTION TO RENEW YEARS (Two, One -Year Periods - Years 4 and 5) The Proposer shall state its proposed price below for the costs during the optional renewal years. This Price Proposal Schedule is for Part 1I Services Only: Managed Care/Medical Bill Review Services A. Proposed Total Fees and Costs for Initial Term (Years 1 through 3): The proposed total fees and costs shall include all fees, andvalue added options, for Part II Services Only. $ (Total fees and costs should be the aggregate price for the two renewal years) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The Proposer shall break down its price for providing the Managed Care/Medical Bill Review Services as specified in Section 3, Specificati.ons/Scope of Work, during the option to renew years. The proposed fees shall be based on: a) the two (2) additional years of the Agreement; b) flat fee broken down on an annual basis for the two years; and c) the cost for anticipated staffing levels, based on the Proposer's proposal. 2 City of Miami, Florida RFP No.605386 4. Proposed Staffing Positions FTE Annual Salary Total Costs 1 Supervisor $ $ 2 $ $ 3 $ $ 4 $ $ 5 $ $ 6 $ $ 7 $ $ 8 $ $ 9 $ $ Proposed Total Fees and Costs $ *Use additional paper if required 5. Proposed Annual Costs (inclusive of staffing costs) Base Cost ($) Projected Increase (%) Total Costs Year 1 $ $ Year 2 $ $ Proposed Grand Total (Years 4 and 5) $ Notes: 1) The City reserves the right to correct and recalculate any errors found in Proposer's calculation. 2) Total Fees and Costs from tables 4 and 5, in Section 2B above, should equal the aggregate costs in Section 2A above. 3. ADDITIONAL SERVICES (Initial Term and Option to Renew Years) The Scope of Work outlined herein identifies the work that the selected Proposer shall perform under the Agreement. To address future City requests for any additional work; modifications, or changes outside of the scope of work, please provide not -to -exceed hourly rates for personnel who will be assigned to this contract. 6. Additional Services Personnel Proposed Not -To -Exceed Hourly Rates $ $ $ $ $ 5 3 City of Miami, Florida RFP No.605386 *Use additional paper if required Notes: 1) The proposed prices above in Sections 1A, shall be fixed and firm for the initial term of the Agreement. The proposed prices for the option to renew years, in Sections 2A, may be negotiated prior to the renewal of the contract for each option to renew period, at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current rates. 2) All out-of-pocket expenses, including employee travel, per diem and miscellaneous costs and fees, should be included in the Proposer's proposed price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3) Notwithstanding the proposed hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 4) The positions identified in the table above shall be the same as the key positions identified in the Proposer's proposal. The City expects that the personnel in those positions will be performing the services. 4. BREAKDOWN OF MANAGED CARE/MEDICAL REVIEW/AUDIT SERVICES The Proposer shall state the not to exceed charges in the columns provided in Tables 7 and 8, for the itemized Managed Care Services listed on the following pages: 4 City of Miami, Florida RFP No.605386 A. MANAGED CARE/BILL REVIEW/AUDIT SERVICES - ITEMIZED Proposer shall list the not -to -exceed charge for each Service itemized below in Table 7: 7. Itemized Managed Care/Bill Review/Audit Services Services Charges Fee Schedule (Bill Review / UCR / System Savings) AI! Other Savings • Clinical Validation/Nurse Review (CV) • Preferred Provider Networks (PPO) • Out Of Network (OON) • Specialty Networks/ Physical Therapy (PT) Electronic Receipt of Medical Bills Telephonic Case Management Hospital Certification Program Utilization Review Program Physician Review/Peer Review Task Based Field Case Management • Task 1: One Visit Task • Task 2: Two Visit Task • Task 3: Labor Market Survey • Task 4: Vocational Assessment • Task 5: Home Visit Medical Case Management and Vocational Rehabilitation — Hourly Priority Care 365 Durable Medical Equipment (DME) Program - First Script Medical Cost Projection (MCP) and Clinical Recommendations Pharmacy Benefit Management (PBM) — First Script Rx Peer to Peer Review (P2P) Drug Utilization A Rx Drug Utilization Assessment (DUA) Return to Work Coordinator (Injury Coordinator) Durable Medical Equipment (DME) Program - First Script Dental Review Program OSHA Reporting Taxes (All applicable taxes will be added to the service fees where required) 5 City of Miami, Florida RFP No.605386 B. OTHER SERVICES - ITEMIZED: Proposer shall list the not -to -exceed charge for each Service itemized below in Table 7: 8. Other Services SERVICES CHARGES Online Access GB International Claims Services Consultative Services Loss Control Consulting Services Appraisal Services raud Prevention Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations - SIU Surveillance Investigations Targeted Field Investigations Targeted Database Investigations MSA Workers Compensation Medicare Set -Aside Allocation (WCMSA) Rush Fees (MSA completed within 7 days) Revisions: Liability Medicare Set -Aside Allocation (LMSA) MSA Submission to CMS Compliance Services Conditional Payment Research (CPR) Conditional Payment Negotiations (CPN) Secure Final Demand for Settlement (SFD) Bundled_CP Resolution Services Benefit Coordination & Recovery Contractor Notification Medicare Eligibility Inquiry (MEI) SSDI Verification Release / Settlement Agreement Review Lien Resolution (Advantage Plan, Medicaid, .Part D) Taxes (All applical}le taxes will be added to the service fees where required) 6 ANNIE PEREZ, CPPO DANIEL J. ALFONSO Procurement Director City Manager ADDENDUM NO. 1 DATE: October 13, 2016 TO: ALL PROSPECTIVE PROPOSERS SUBJECT: REQUEST FOR PROPOSALS (RFP) NO.: 605386 TITLE: Third Party Administration and Managed Care Services This. Addendum becomes a part of the subject solicitation. A. Attached is a copy of the Pre -Proposal Conference attendance sheet. B. Section 3.3. Part 1, Workers' Compensation and Liability Claims Administration, Sub Section 3.3.1, A., titled Hearings Conferences/Trials, Item 4, Page 45, is hereby deleted in its entirety and replaced with the following due to a scrivener's error. 4. Any recommendations made by the eceesul-P-roposer Office of the City Attorney pertaining to the file should be carried out or referred to Office of the -City -Attorney Successful Proposer. C. The 'following are the inquiries as received and the corresponding responses: QI. Is this RFP for all Liability Claims or only BI and large loss? Al. All liability claims. Q2. Please provide the number of open liability claims to be transferred to the new Third Party Administrator (TPA), broken out by type of claim. A2, Table of open liability claims to be transferred to the new TPA: =. n I I Gau Auto Liability - Bodily Injury . 22 Auto Liability - Property Damage 1 Employee Benefit Liability 6 Employment Practices Liability 2 Errors & Omissions 12 General Liability Bodily Injury 207 General Liability Property Damage 4 Police Professional Liability 86 Q3. Please provide the number of open Workers' Compensation claims, broken out by Indemnity, and Medical Only. A3. See table below: a•.w�R l..',o tx�.�., WC— indemnity667 WC — Medical 39 Q4. Please provide the number of new claims for each of the past three (3) years, broken out by type of claim. A4. Se table below. h'Iease note that.the claims count includes report/incident m:..a 2013 2014 2015 2016 Auto Liability - Bodily injury . 3 0 0 0 Auto Liability- Property Damage 1 0 0 0 Employee Benefit Liability 0 2 0 0 Employment Practices Liability 1 2 1 3 Errors & Omissions 0 4 2 1 General Liability Bodily Injury 52 53 106 16.3 General Liability Property Damage 2 2 2 5 Police Professional Liability 22 24 18 5 Workers' Compensation 794 652 828 631 'rot s f r' 13 �016 `Y®^`^^ 87' ._«ur _r+ya:�S£� _xw..�. 3 .. e. .s^-«_.,,em, 9'57 .............._...... 808 tee.......,.. — only claims. Q5. Please provide a breakdown of the current TPA's staffing levels for the services to be provided: a) Workers' Compensation (WC) Supervisors; b) WC Indemnity Adjusters; c) WC Medical Only Adjusters; d) Liability adjusters; and e) Telephonic Nurse Case Managers. A5. a)1;b)4;c)1;d)2;and e)0. 06. Please provide the number of medical bills for each of the past three (3) years. A6. Following are the number of medical bills by year: 2013: 14,552 2014: 13,648 2015: 15,022 2016 YTD: 12,170 Q7. Please provide a Medical Bill Savings Report for each of the past three (3) years. A7. Following is the Medical Savings Report by year: 2013: $11,291,126.39 2014: $10,516,730.55 2015: $11,203,698.45 2016 YTD: 511,658,641.71 Q8. Please provide the name of the current PPO network provider. A8. Gallagher Bassett Managed Care Services Q9. Does the City currently have all Workers' Compensation claims medically triaged by Telephonic Nurse Case Managers? If not, how many claims were medically triaged for each of the past three (3) years? A9, No. Q10. How many claims on average are assigned to Telephonic Nurse Case Management? A10. Twenty-seven (27) claims are assigned on average per year. Q11. How many claims on average are assigned to Field Nurse Case Management? Alt Sixty-seven (67) claims, on average, are assigned per year All other information remains the same. APPROVED: r LeAlLa /IU An le Perez, CPPO, Director o Procurement Date / AP:lo c. Ann -Marie Sharpe, Director, Risk Management Rafael Suarez -Rivas, Senior Assistant City Attorney William A. ,tuliachs, Senior Assistant City Attorney Lydia Osborne, CPPO, Assistant Director of Procurement Yadissa Calderon, CPPB, Senior Procurement Manager, Procurement ATTENDANCE SHEET RFP/RFQ NUMBER: RFP 605386 - Third Party Claims Administration and Managed Care Services LOCATION: 6th FL Large Conference Room PURPOSE: Pre -Proposal Conference DATE: Wednesday, October 12, 2016 at 2:00 PM Completing this attendance sheet is optional. § Os—teTt...(TL -5✓ o k �R �V E C'c—: -`'.�. P•v �f�d� -r Ea C` 4 ) 5 & €-22- 1�F� r^` C �i _ c h��'i ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ; ( ) ( ) ( ) ev- Page cif City of Miami Procurement Department Miami Riverside Center 444 SW 2nd Avenue, 6 h Floor Miami, Florida 33130 Web Site Address: www,miamigov.com/procurement Number: Title: Issue Date/Time: Closing Date/Time: Pre-Bid/Pre-Proposal Conference: Pre-Bid/Pre-Proposal Date/Time: Pre-Bid/Pre-Proposal Location: Deadline for Request for Clarification: Contracting Officer: Hard Copy Submittal Location: Contracting Officer E-Mail Address: Contracting Officer Facsimile: 605386 Request for Proposals for Third Party Claims Adm. & Managed Care Services 05-OCT-2016 10-NOV-2016 @ 14:00:00 Voluntary Wednesday, October 12, 2016, at 2:00 PM 444 SW 2nd Avenue, 6th Floor South Conference Room, Miami, Florida Tuesday, November 1, 2016 at 5:00 PM Calderon, Yadissa City of Miami - City Clerk 3500 Pan American Drive Miami FL 33133 US ycalderon@miamigov.com 305-400-5369 Page 1 of 65 Certification Statement Please quote on this form, if applicable, net prices for the item(s) listed. Return signed original and retain a copy for your files. Prices should include all costs, including transportation to destination. The City reserves the right to accept or reject all or any part of this submission. Prices should be firm for a minimum of 180 days following the time set for closing of the submissions. In the event of errors in extension of totals, the unit prices shall govern in determining the quoted prices, We (I) certify that we have read your solicitation, completed the necessary documents, and propose to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein. The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations, or debarred or suspended as set in section 18-107 or Ordinance No. 12271. All exceptions to this submission have been documented in the section below (refer to paragraph and section). EXCEPTIONS: We (I) certify that any and all .information contained in this submission is true; and we (I) further certify that this submission is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a submission for the same materials, supplies, equipment, or service, and is in all respects fair and without collusion or fraud, We (I) agree to abide by all terms and conditions of this solicitation and certify that I am authorized to sign this submission for the submitter. Please print the following and sign your name: PROPOSER NAME. ADDRESS: PHONE: FAX EMAIL. CELL(Optional) SIGNED BY. TITLE: DATE: FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM SHALL DISOUALIFY THIS RESPONSE. Page 2 of 65 Certifications Legal Name of Firm: FEIN No: Entity Type: Partnership, Sole Proprietorship, Corporation, etc. Year Established: Business Address: City, State, and Zip Code: Telephone Number: Fax Number: E-mail Address: Office Location: City of Miami, Miami -Dade County, or Other Business Tax Receipt/Occupational License Number: Business Tax Receipt/Occupational License Issuing Agency: Business Tax Receipt/Occupational License Expiration Date: Will Subcontractor or Sub consultant (s) be used? Sub consultant shall mean the same thing as a Page 3 of 65 Subcontractor in these documents. (Yes or No) (if yes for what and what percentage of such work) Will furnish and provide professional services to the City, at minimum, in compliance with all contract documents and in compliance with all applicable laws, rules and regulations. Certifies that neither the Proposer nor any of its principal owners or personnel or any subsidiary of the Proposer, have been convicted of any of the violation(s) or crimes or actions and conduct involving moral turpitude as defined by applicable laws, or debarred or suspended as set forth in Section 18-107, City Code, or as provided by 287.133, Florida Statutes. The Proposer further certifies that the Proposer has not been debarred or suspended by the United States Government, the State of Florida, any political subdivision of the State of Florida or any Special District or Public School Board in the State of Florida. Proposer understands that exceptions not timely or correctly taken are waived. Page 4 of 65 Line: 1 Description: Disregard this line item. Please refer to Attachment A, attached to the Header Section of this solicitation. Proposer shall clearly indicate in proposal if providing a response for Part I and/or Part II Services. Category: 95327-00 Unit of Measure: Year Unit Price: $ Number of Units: 3 Total: $ Page 5 of 65 605386 Table of Contents Terms and Conditions . 7 1. General Conditions 7 1.1. GENERAL TERMS AND CONDITIONS 7 2. SPECIAL CONDITIONS 29 2.1. PURPOSE 29 2.2. DEADLINE FOR RECEIPT OF REQUEST FOR ADDITIONAL INFORMATION/ 29 2.3, VOLUNTARY PRE -PROPOSAL CONFERENCE 29 2,4. DEFINITIONS 29 3. Specifications 39 3,1, SPECIFICATIONS/SCOPE OF WORK 39 4. Submission Requirements 57 4.1. CMIA Submission Requirements 57 5. Evaluation Criteria 64 5.1. CMIA Evaluation Criteria 64 Page 6 of 65 605386 Terms and Conditions 1. General Conditions 1.1. GENERAL TERMS AND CONDITIONS References to goods only apply insofar as they are applicable to "Goods" as defined in Section 18-73 of the City Code. References to "Professional and Personal Services" are as defined in Section 18-73 of the City Code, Intent: The General Terms and Conditions described herein apply to the acquisition of goods/equipment/services with an estimated aggregate cost of $25,000.00 or more. Definition: A formal solicitation is defined as issuance of an Invitation for Bids, Request for Proposals, Request for Qualifications, or Request for Letters of Interest pursuant to the City of Miami Procurement Code and/or Florida Law, as amended. Formal Solicitation and Solicitation shall be defined in the same manner herein. 1.1, ACCEPTANCE OF GOODS OR EQUIPMENT- Any good(s) or services delivered under this format solicitation, if applicable, shall remain the property of the seller until a physical inspection and actual usage of the good is made, and thereafter is accepted as satisfactory to the City, It must comply with the terms herein and be fully in accordance with specifications and of the highest quality. In the event the goods/equipment supplied to the City are found to be defective or does not conform to specifications, the City reserves the right to cancel [he order upon written notice to the Successful Proposer and return the product to the Successful Proposer at the Successful Proposers expense. 1.2. ACCEPTANCE OF OFFER- The signed or electronic submission of your proposal shall be considered an offer on the part of the Successful Proposer: such offer shall be deemed accepted upon issuance by the City of a purchase order. 1.3. ACCEPTANCE/REJECTION , The City reserves the right to accept or reject any or all responses or parts of after opening/closing date and request re -issuance on the goods/services described in the format solicitation, In the event of such rejection, the Director of Procurement shall notify all affected bidders/proposers and make available a written explanation for the rejection, The City also reserves the right, to reject the response of any Successful Proposer who has previously failed to properly perform under the terms and conditions of a contract, to deliver on time contracts of a similar nature, and who is not in a position to perform the requirements defined in this format solicitation. The City further reserves the right to waive any irregularities or minor informalities or technicalities in any or all responses and may, al its discretion, re -issue this formal solicitation. 1.4. ADDENDA - It is the bidder's/proposer's responsibility to ensure receipt of all Addenda. Addenda are available at the City's website at: http://www.ci.miami.fLus/procurement 1.5. ALTERNATE RESPONSES WILL NOT BE CONSIDERED. 1.6. ASSIGNMENT - Successful Proposer agrees not to subcontract, assign, transfer, convey, sublet, transfer, pledge, encumber, or otherwise dispose of the resulting Contract, in whole or in part or any or all of its right, title or interest herein, without City of Miami's prior written consent. These particular services are considered unique in nature and specialized in training and experience and the City will select a Proposer in reliance on such training and experience. 1.7. ATTORNEY'S FEES- In connection with any litigation, in trial and appellate levels, mediation and arbitration Page 7 of 65 605386 arising out of this Contract, each party shall bear their own attorney's fees through and including appellate litigation and any post judgment proceedings. 1.8. AUDIT RIGHTS AND RECORDS RETENTION- The Successful Proposer agrees to provide access at all reasonable times to the City, or to any or its duly authorized representatives, to any books, documents, papers, and records of Successful Proposer which are directly pertinent to this formal solicitation, for the purpose of audit, examination, excerpts, and transcriptions. The Successful Proposer shall maintain and retain any and all of the books, documents, papers and records pertinent to the Contract for three (3) years after the City makes final payment and all other pending matters are closed. SuccessfulProposer's failure to or refusal to comply with this condition shall result in the immediate cancellation of this contract by the City. The Audit Rights set forth in Section 18-102 of the City Cade apply as supplemental terms and are deemed as being incorporated by reference herein. 1.9. AVAILABILITY OF CONTRACT STATE-WIDE- Any Governmental, not -for -profit or quasi - governmental entity in the State of Florida, may avail itself of this contract and purchase any and all goods/services, specified herein from the Successful Proposer at the contract price(s) established herein, when permissible by federal, state, and local laws, rules, and regulations. Each Governmental, not -for -profit or quasi -governmental entity which uses this formal solicitation and resulting bid contract or agreement will establish its own contract/agreement; place its own orders, issue its own purchase orders, be invoiced there from and make its own payments, determine shipping terms and issue its own exemption certificates as required by the Successful Proposer. 1.10. AWARD OF CONTRACT: A. The Formal Solicitation, Proposer's response, any addenda issued, the Professional Services Agreement ("PSA") attached hereto as an Exhibit, and the purchase order shall constitute the entire contract, unless modified in accordance with any ensuing contract/agreement, amendment or addenda. B. The award of a contract where there are Tie Bids will be decided by the Director of Procurement or designee in the instance that Tie Bids can't be determined by applying Florida Statute Section 287,087, Preference to Businesses with Drug -Free Workplace Programs. C. The award of this contract may be preconditioned on the subsequent submission of other documents as specified in the Special Conditions or Technical Specifications. Proposer shall be in default of its contractual obligation if such documents are not submitted in a timely manner and in the form required by the City. Where Proposer is in default of these contractual requirements, the City, through action taken by the Procurement Department, will void its acceptance of the Proposer's Response and may accept the Response from the next lowest responsive, responsible Proposal most advantageous to the City or re -solicit the City's requirements. The City, at its sole discretion, may seek monetary restitution from Successful Proposer and its proposal bond or guaranty, if applicable, as a result of damages or increased costs sustained as a result of the Proposer's default, D. The term of the contract shall be specified in one of three documents which shall be issued to the Successful Proposer. These documents may either be a purchase order, notice of award and/or contract award sheet. E. The City reserves the right to automatically extend this contract for up to one hundred twenty (120) calendar days beyond the stated contract term in order to provide City departments with continual service and supplies while a new contract is being solicited, evaluated, and/or awarded. If the right is exercised, the City shall notify the Successful Proposer, in writing, of its intent to extend the contract at the same price, terms and conditions for a specific number of days. Additional extensions over the first one hundred twenty (120) day extension may occur, if, the City and the Successful Proposer are in mutual agreement of such extensions. F. Where the contract involves a single shipment of goods to the City, the contract term shall conclude upon Page 8 of 65 605386 completion of the expressed or implied warranty periods. G. The City reserves the right to award the contract on a split -order, lump sum or individual -item basis, or such combination as shall best serve the interests of the City unless otherwise specified. H. A Contract/Agreement may be awarded to the Successful Proposer by the City Commission based upon the minimum qualification requirements reflected herein. As a result of a RFP, RFQ, or RFLI, the City reserves the right to execute, a Professional Services Agreement ("PSA" or "Agreement") in substantially the form attached to the Solicitation, with the Proposer, whichever is determined to be in the City's best interests. Such agreement will be furnished by the City, will contain certain terns as are in the City's best interests, and will be subject to approval as to legal form by the City Attorney. Certain terms, including, without limitation, the cancellation for convenience and the hold harmless/ duty to defend and indemnify are long standing City requirements and may not be modified. 1.11. BID BOND/ BID SECURITY -A cashier's or certified check issued by a bank authorized to transact banking business in Florida, or a Bid Bond signed by a recognized surety company that is licensed to do business in the State of Florida, payable to the City of Miami, for the amount bid is required from all Proposers, if so indicated under the Special Conditions. This check or bond guarantees that a Successful Proposer will accept the order or Agreement, as proposed, if it is awarded to Successful Proposer. Successful Proposer shall forfeit bid deposit to the City should City award Agreement to Successful Proposer and Successful Proposer fails to accept the award. The City reserves the right to reject arty and all surety tendered to the City. Bid deposits are returned to unsuccessful Proposers within ten (1,0) clays after the award and Successful Proposer's acceptance of award. If one hundred eighty (180) days have passed after the date of the formal solicitation closing date, and no contract has been awarded, all bid deposits will be returned on demand. 1.12. RESPONSE FORM (HARDCOPY FORMAT)- Alt farms should be completed, signed and submitted accordingly. 1.13. BID SECURITY FORFEITED LIQUIDATED DAMAGES- Failure to execute an Agreement and/or file an acceptable Bid / Payment/ Performance Bond, when required, as provided herein, shall be just cause for the rescission of the award and the forfeiture of the Bid Security to the City, which forfeiture shall be considered, not as a penalty, but in mitigation of damages sustained. Award may then be made to the next lowest responsive, responsible Proposer most advantageous to the City or all responses may be rejected. 1.14. BRAND NAMES- If and wherever in the specifications brand names, inakes, models, names of any manufacturers, trade names, or Successful Proposer catalog numbers are specified, it is for the purpose of establishing the type, function, minimum standard of design, efficiency, grade or quality of goods only. When the City does not wish to rule out other competitors' brands or makes, the phrase "OR EQUAL" is added. When proposing an approved equal, Proposers will submit, with their response, complete sets of necessary data (factory information sheets, specifications, brochures, etc.) in order for the City to evaluate and determine the equality of the item(s) proposed. The City shall be the sole judge of equality and its decision shall be final, Unless otherwise specified, evidence in the form of samples may he requested if the proposed brand is other than specified by the City. Such samples are to be furnished after formal solicitation opening/closing only upon request of the City. If samples should be requested, such samples must be received by the City no later than seven (7) calendar days after a formal request is made. 1.15. CANCELLATION- The City reserves the right to cancel all formal solicitations before it's opening/closing. In the event of bid/proposal cancellation, the Director of Procurement shall notify all prospective bidders/proposers and make available a written explanation for the cancellation. 1.16. CAPITAL EXPENDITURES Successful Proposer understands that any capital expenditures that the firm makes, or prepares to make, in order to deliver/perform the goods/services required by the City, is a business risk Page 9 of 65 605386 which the Proposer must assume. The City will not be obligated to reimburse amortized or unamortized capital expenditures, or to maintain the approved status of any Proposer. If Proposer has been unable to recoup its capital expenditures during the time it is rendering such goods/services, it shall not have any claim upon the City. 1.17. CITY NOT LIABLE FOR DELAYS- It is further expressly agreed that in no event shall the City be liable for, or responsible to, the Successful Proposer, any sub- contractor /sub -consultant, or to any other person for, or on account of, any stoppages or delay in the work herein provided for by injunction or other legal or equitable proceedings or on account of any delay for any cause over which the City has no control. 1,18. COLLUSION - Proposer, by submitting a response, certifies that its response is made without previous understanding, agreement or connection either with any person, firm or corporation submitting a response for the same items/services or with the City of Miami's Procurement Department or initiating department. The Proposer certifies that its response is fair, without control, collusion, fraud or other illegal action. Proposer certifies that it is in compliance with the Conflict of Interest and Code of Ethics Laws. The City will investigate all potential situations where collusion may have occurred and the City reserves the right to reject any and all responses where collusion may have occurred. 1.19. COMPLIANCE WITH FEDERAL, STATE AND LOCAL LAWS - Successful Proposer understands that contracts between private entities and local governments are subject to certain laws and regulations, including laws pertaining to public records, conflict of interest, records keeping, etc. City and Successful Proposer agree to comply with and observe all applicable laws, codes and ordinances as that may in any way affect the goods or equipment offered, including but not limited to: A.Executive Order 11246, which prohibits discrimination against any employee, applicant, or client because of race, creed, color, national origin, sex, or age with regard to, but not Iimited to, the following: employnent practices, rate of pay or other compensation methods, and training selection. B.Occupational, Safety and Health Act (OSHA), as applicable to this Formal Solicitation. C.The State of Florida Statutes, Section 287.1330 on Public Entity Crimes. D.Environment Protection Agency (EPA), as applicable to this Formal Solicitation, E.Cniform Commercial Code (Florida Statutes, Chapters 672-679), F,Americans with Disabilities Act of 1990, as amended. G.National Institute of Occupational Safety Hazards (NIOSH), as applicable to this Formal Solicitation. H,National Forest Products Association (NFPA), as applicable to this Forma! Solicitation. I.City Procurement Ordinance City Code Section 18, Article III, J.Conflict of Interest, City Code Section 2-611; 61, K.Cone of Silence, City Code Section 18-74. L.The Florida Statutes Sections 218,70 to 218.79 on Prompt Payments. Lack of knowledge by the Successful Proposer will in no way be a cause for relief from responsibility, Non-compliance with all applicable local, state, and federal directives, orders, codes, rules, regulations, and Iaws may be considered grounds for termination of contract(s) at the option of the City Manager. Copies of the City Ordinances may be obtained from the City Clerk's Office. 1.20. CONE OF SILENCE - Pursuant to Section 18-74 of the City of Nliami Code, a "Cone of Silence" is imposed Page 10 of 65 605386 upon each RFP, RFQ, RFLI, or IFB after advertisement and terminates at the time the City Manager issues a written recommendation to the Miami City Commission, The Cone of Silence shalt be applicable only to Contracts for the provision of goods and services and public works or improvements for amounts greater than $200,000. The Cone of Silence prohibits any communication regarding RFPs, RFQs, RFLI or IFBs (bids) between, among others: Potential vendors, service providers, bidders, lobbyists or consultants and the City's professional staff including, but not limited to, the City Manager and the City Manager's staff; the Mayor, City Commissioners, or their respective staffs and any member of the respective selection/evaluation committee, The provision does not apply to, among other communications: oral communications with the City Procurement staff, provided the communication is limited strictly to matters of process or procedure already contained in the formal solicitation document; the provisions of the Cone of Silence do not apply to oral communications at duly noticed site visits/inspections, pre -proposal or pre -bid conferences, oral presentations before selection/evaluation committees, contract negotiations during any duly noticed public meeting, or public presentations made to the Miami City Commission during a duly noticed public meeting; or communications in writing or by email at any time with any City employee, official or member of the City Commission unless specifically prohibited by the applicable RFP, RFQ, RFLI or IFB (bid) documents (See Section 2.2. of the Special Conditions); or communications in connection with the collection of industry comments or the performance of market research regarding a particular RFP, RFQ, RFLI OR IFB by City Procurement staff, Proposers ar bidders must file a copy of any written communications with the Office of the City Clerk, which shall he made available. to any person upon request. The City shall respond in writing and file a copy with the Office of the City Clerk, which shall be made available to any person upon request Written communications may be in the form of e-mail, with a copy to the Office of the City Clerk. In addition to any other penalties provided by law, violation of the Cone of Silence by any Proposer shall render any award voidable. A violation by a particular Proposer, Offeror, Respondent, lobbyist or consultant shall subject same to potential penalties pursuant to the City Code. Any person having personal knowledge of a violation of these provisions shall report such violation to the State Attorney and/or may file a complaint with the Ethics Commission. Proposers should reference Section 18-74 of the City of Miami Code for further clarification. This language is only a summary of the key provisions of the Cone of Silence. Please review City of Miami Code Section 18-74 for a complete and thorough description of the Cone of Silence. You may contact the City Clerk at 305-250-5360, to obtain a copy of same. 1.21. CONFIDENTIALITY- As a political subdivision, the City of Miami is subject to the Florida Sunshine Law and Public Records Law. If this Contract/Agreement contains a confidentiality provision, it shall have no application when disclosure is required by Florida law or upon court order, 1.22. CONFLICT OF INTEREST - Proposers, by responding to this Formal Solicitation, certify that to the best of their knowledge or belief, no elected/appointed official or employee of the City of Miami is financially interested, directly or indirectly, in the purchase of goods/services specified in this Formal Solicitation. Any such interests on the part of the Successful Proposer or its employees must be disclosed in writing to the City, Further, you must disclose the name of any City employee who owns, directly or indirectly, an interest of five percent (5%) or more of the total assets of capital stock in your firm, Page 11 of 65 605386 A. Successful Proposer further agrees not to use or attempt to use any knowledge, properly or resource which may be within his/her/its trust, or perform his/her/its duties, to secure a special privilege, benefit, or exemption for himself/herself/itself, or others. Successful Proposer may not disclose or use information not available to members of the general public and gained by reason of his/her/its position, except for information relating exclusively to governmental practices, far his/her/its personal gain or benefit or for the personal gain or benefit of any other person or business entity. B. Successful Proposer hereby acknowledges that he/she/it has not contracted or transacted any business with the City or any person or agency acting for the City, and has not appeared in representation of any third party before any board, commission or agency of the City within the past two years. Successful Proposer further warrants that he/sire/it is not related, specifically the spouse, son, daughter, parent, brother or sister, to: (i) any member of the commission; (li) the Mayor: (bi) any City employee: or (iv) any member of any board or agency of the City, C. A violation of this section may subject the Successful Proposer to immediate termination of any professional services agreement with the City, imposition of the maximum fine and/or any penalties allowed by law. Additionally, violations may be considered by and subject to action by the 1Vlianri-Dade County Commission on Ethics. 1.23. COPYRIGHT OR PATENT RIGHTS - Proposers warrant that there has been no violation of copyright or patent rights in manufacturing, producing, or selling the goods shipped or ordered and/or services provided as a result of this formal solicitation, and Proposers agree to hold the City harmless from any and all liability, loss, or expense occasioned by any such violation. 1.24. COST INCURRED BY SUCCESSFUL PROPOSER- All expenses involved with the preparation and submission of Responses to the City, or any work performed in connection therewith shall be borne by the Proposer(s) , 1.25. DEBARMENT AND SUSPENSIONS (Sec 18-107, City Code) (a) Authority and requirement to debar and suspend. After reasonable notice to an actual or prospective Contractual Party, and after reasonable opportunity for such party to be heard, the City Manager, after consultation with the Chief Procurement Officer and the City Attorney, shall have the authority to debar a Contractual Party, for the causes Iisted below, from consideration for award of City Contracts. The debarment shall be for a period of not fewer than three years. The City Manager shall also have the authority to suspend a Contractual Party from consideration for award of City Contracts if there is probable cause for debarment, pending the debarment determination. The authority to debar and suspend Proposer s shall be exercised in accordance with regulations which shall be issued by the Chief Procurement Officer after approval by the City Manager, the City attorney, and the City Commission. (b) Causes for debarment or suspension. Causes for debarment or suspension include the following: (1) Conviction for commission of a criminal offense incident to obtaining or attempting to obtain a public or private Contract or subcontract, or incident to the performance of such Contract or subcontract. (2) Conviction under state or federal statutes of embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property, or any other offense indicating a lack of business integrity or business honesty. (3) Conviction under state or federal antitrust statutes arising out of the submission of Bids or Proposals. (4) Violation of Contract provisions, which is regarded by the Chief Procurement Officer to be indicative of non - Page 12 of 65 605386 responsibility, Such violation may include failure without good cause to perform in accordance with the terms and conditions of a Contract or to perform within the lime limits provided in a Contract, provided that failure to perform caused by acts beyond the control of a party shall not be considered a basis for debarment or suspension. (5) Debarment or suspension of the Contractual Party by any federal. state or other governmental entity. (6) False certification pursuant to paragraph (c) below, (7) Found in violation of a zoning ordinance or any other City ordinance or regulation and for which the violation remains noncompliant. (8) Found in violation of a zoning ordinance or any other City ordinance or regulation and for which a civil penalty or fine is clue and owing to the City. (9) Any other cause judged by the City Manager to be so serious and compelling as to affect the responsibility of the Contractual Party performing City Contracts. (c) Certification. All Contracts for goods and services, sales, and leases by the City shall contain a certification that neither the Contractual Party nor any of its principal owners or personnel have been convicted of any of the violations set forth above or debarred or suspended as set forth in paragraph (h) (5). (d) Debarment and suspension decisions. Subject to the provisions of paragraph (a), the City Manager shall render a written decision stating the reasons for the debarment or suspension. A copy of the decision shall be provided promptly to the Contractual Party, along with a notice of said party's right to seek judicial relief, 1.26. DEBARRED/SUSPENDED VENDORS - An entity or affiliate who has been placed on the State of Florida debarred or suspended vendor list may not submit a response on a contract to provide goods or services to a public entity, may not submit a response on a contract with a public entity for the construction or repair of a public building or public work, may not submit response on leases of real property to a public entity, may not award or perform work as a Proposer , supplier, subcontractor, or consultant under contract with any public entity, and may not transact business with any public entity. 1.27, DEFAULT/FAILURE TO PERFORM -The City shall be the sole judge of nonperformance, which shall include any failure on the part of the Successful Proposer to accept the award, to furnish required documents, and/or to fulfill any portion of this contract within the time stipulated. Upon default by the Successful Proposer to meet any terms of this agreement, the City will notify the Successful Proposer of the default and will provide the Successful Proposer three (3) days (weekends and holidays excluded) to remedy the default. Failure on the Successful Proposer's part to correct the default within the required three (3) days shall result in the Contract being terminated and upon the City notifying in writing the Successful Proposer of its intentions and the effective date of the termination. The following shall constitute default: A. Failure to perform the work or deliver the goods/services required under the Contract and/or within the time required or failing to use the sub Proposer s, entities and personnel as identified and set forth, and to the degree specified in the Contract, B. Failure to begin the work under this Contract within the time specified. C. Failure to perform the work with sufficient workers and equipment or with sufficient materials to ensure timely completion. D. Neglecting or refusing to remove materials or perform new work where prior work has been rejected as nonconforming with the terms of the Contract. Page 13 of 65 605386 E. Becoming insolvent, being declared bankrupt, or committing any act of bankruptcy or insolvency, or making an assignment for the benefit of creditors, if the insolvency, bankruptcy, or assignment renders the Successful Proposer 'incapable of performing the work in accordance with and as required by the Contract. F. Failure to comply with any of the terms of the Contract in any material respect. A1I costs and charges incurred by the City as a result of a default or a default incurred beyond the time limits stated, together with the cost of completing the work, shall be deducted from any monies due or which may become due on this Contract. 1.28. DETERMINATION OF RESPONSIVENESS -Each Response will be reviewed to determine if it is responsive to the submission requirements outlined in the Formal Solicitation, A "responsive" response is one which follows the requirements of the formal solicitation, includes all documentation, is submitted in the format outlined in the formal solicitation, is of timely submission, and has appropriate signatures as required on each document. Failure to comply with these requirements may deem a Response non -responsive. A Responsible Proposer shall mean a Proposer who has submitted a Proposal and who has the capability, as determined under the City Procurement Ordinance, in all respects to fully perform the contract requirements, and the integrity and reliability of which give reasonable assurance of good faith and performance. 1.29. DISCOUNTS OFFERED DURING TERM OF CONTRACT -Discount Prices offered in the response shall be fixed after the award by the Commission, unless otherwise specified in the Special Terms and Conditions. Price discounts off the original prices quoted in the response will be accepted from Successful Proposer(s) during the term of the contract. Such discounts shall remain in effect for a minimum of 120 days from approval by the City Commission Any discounts offered by a manufacturer to Successful Proposer will be passed on to the City. 1.30. DISCREPANCIES, ERRORS, AND OMISSIONS -Any discrepancies, errors, or ambiguities in the Formal Solicitation or addenda (if any) should be reported in writing to the City's Procurement Department. Should IL be found necessary, a written addendum will be incorporated in the Formal Solicitation and will become part of the purchase agreement (contract documents). The City will not be responsible for any oral instructions, clarifications, 'or other communications, A. Order of Precedence , Any inconsistency in this formal solicitation shall be resolved by giving precedence to the following documents, the first of such list being the governing documents, 1) Addenda (as applicable) 2) Specifications 3) Special Conditions 4) General Terms and Conditions 1.31. EMERGENCY / DISASTER PERFORMANCE - In the event of a hurricane or other emergency or disaster situation, the successful vendor shall provide the City with the commodities/services defined within the scope of this formal solicitation at the price contained within vendor's response. Further, successful vendor shall deliver/perform for the City on a priority basis during such times of emergency, 1.32. ENTIRE BID CONTRACT OR AGREEMENT -The Agreement consists of this City of Miami Formal Solicitation and specifically this General Conditions Section, Proposer 's Response and any written agreement Page 14 01' 65 605356 entered into by the City of Miami and Proposer in cases involving RFPs, RFQs, and RFLIs, and represents the entire understanding and agreement between the parties with respect to the subject matter hereof and supersedes all other negotiations, understanding and representations, if any, made by and between the parties. To the extent that the agreement conflicts with, modifies, alters or changes any of the terms and conditions contained in the Formal Solicitation and/or Response, the Formal Solicitation and then the Response shall control. This Contract may he modified only by a written agreement signed by the City of Miami and Proposer. 1.33. ESTIMATED QUANTITIES LEstimated quantities or estimated dollars are provided for your guidance only. No guarantee is expressed ar implied as to quantities that will be purchased during the contract period. The City is not obligated to place an order for any given amount subsequent to the award of this contract. Said estimates may be used by the City for purposes of determining the most advantageous proposer meeting specifications. The City reserves the right to acquire additional quantities at the prices proposed or at lower prices in this Formal Solicitation. 1.34. EVALUATION OF RESPONSES A. Rejection of Responses The City may reject a Response for any of the following reasons: 1)Successful Proposer fails to acknowledge receipt of addenda; 2)Successful Proposer misstates or conceals any material fact in the Response; 3)Response does not conform to the requirements of the Formal Solicitation; 4)Response requires a conditional award that conflicts with the method of award; 5)Response does not include required samples, certificates, licenses as required; and, 6)Resporise was not executed by the Proposer(s) authorized agent. The foregoing is not an all-inclusive list of reasons for which a Response may be rejected. The City may reject and re -advertise for all ar any part of the Formal Solicitation whenever it is deemed in the best interest of the City. B. Elimination from Consideration 1) A contract shall not be awarded to any person or firm which is in arrears to the City upon any debt or contract, or which is a defaulter as surety or otherwise upon any obligation to the City, 2) A contract may not be awarded to any person or firm who has failed to perform under the terms and conditions of any previous contract with the City Cr deliver on time contracts of a similar nature. 3) A contract may not be awarded to any person or firm who has been debarred by the City in accordance with the City's Debarment and Suspension Ordinance. C. Determination of Responsibility 1) Responses will only be considered from entities who are regularly engaged in the business of providing the goods/equipment/services required by the Formal Solicitation. Successful Proposer must be able to demonstrate a satisfactory record of performance and integrity; and, have sufficient financial, material, equipment, facility, personnel resources, and expertise to meet all contractual requirements. The terms "equipment and organization" as used herein shall be construed to mean a fully equipped and well established entity in line with the best industry practices in the industry as determined by the City. 2) The City may consider any evidence available regarding the financial, technical and other qualifications and Page 15 of 65 605386 abilities of a Successful Proposer, including past performance (experience) with the City or any other governmental entity in making the award. 3) The City may require the Proposer(s) to show proof that they have been designated as an authorized representative of a manufacturer or Proposer which is the actual source of supply, if required by the Formal Solicitation. 1.35. EXCEPTIONS TO GENERAL AND/OR SPECIAL CONDITIONS OR SPECIFICATIONS Exceptions to the specifications shall be listed on the Response and shall reference the section. Any exceptions to the General or Special Conditions shall be cause for the Proposal to be considered non -responsive. It also may be cause for a RFP, RFQ, or RFLI to be considered non -responsive: and, if exceptions are taken to the terms and conditions of the resulting agreement it may lead to terminating negotiations. 1.36. F.O.B. DESTINATION -Unless otherwise specified in the Formal Solicitation, all prices quoted/proposed by the Successful Proposer must be F.O.B. DESTINATION, inside delivery, with all delivery costs and charges included in the bid/proposal price, unless otherwise specified in this Formal Solicitation. Failure to do so may be cause for rejection of proposal. 1.37, FIRM PRICES - The Successful Proposer warrants that prices, terrns, and conditions quoted in its response will be firm throughout the duration of the contract unless otherwise specified in the Formal Solicitation. Such prices will remain firm for the period of performance or resulting purchase orders or contracts, which are to be performed or supplied over a period of time. 1.33, FLORIDA MINIMU1\I WAGE -The Constitution of the State of Florida, Article X, Section 24, states that employers shall pay employee wages no less than the minimum wage for all hours worked in Florida, Accordingly, it is the Proposer's and its' subcontractor(s) responsibility to understand and comply with this Florida constitutional minimum wage requirement and pay its employees the current established hourly minimum wage rate, which is subject to change or adjusted by the rate of inflation using the consumer price index for urban wage earners and clerical workers, CPI-W, or a successor index as calculated by the United States Department of Labor, Each adjusted minimum wage rate calculated shall be determined and published by the Agency Workforce Innovation on September 30th of each year and take effect on the following January 1st. At the time of responding, it is the Proposer and his/her subcontractor(s), if applicable, full responsibility to determine whether any of its employees may be impacted by this Florida Law at any given point in time during the term of the contract. If impacted, Proposer must furnish employee name(s), job title(s), job description(s), and current pay rate(s). Failure to submit this information at the time of submitting a response constitute Proposer's acknowledgement and understanding that the Florida Minimum Wage Law will not impact its prices throughout the term of contract and waiver of any contractual price increase request(s). The City reserves the right to request, and Successful Proposer must provide for any and all information to make a wage and contractual price increase(s) determination. In the event a City of Miami "Living Wage" Ordinance is enacted prior to the award of an Agreement its provisions may be applicable to the employees of the Proposer. 1.39, GOVERNING LAW AND VENUE -The validity and effect of this Contract shall be governed by the laws of the Stale of Florida. The parties agree that any action, proceeding, mediation or arbitration arising out of this Contract shall take place in Miami -Dade County, Florida. In any action or proceeding each party shall bear their own respective attorney's fees. Page 16 of 65 605386 1.40. HEADINGS AND TERMS -The headings to the various paragraphs of this Contract have been inserted for convenient reference only and shah not in any manner be construed as modifying, amending or affecting in any way the expressed terms and provisions hereof. 1.41. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)- Any person or entity that performs or assists the City of Nliami with a function or activity involving the use or disclosure of " individually identifiable health information (IIHI) and/or Protected Health Information (PHI) shall comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the City of Miami Privacy Standards. HIPAA mandates for privacy, security and electronic transfer standards, which include but are not limited to: A. Use of information only for performing services required by the contract or as required by law; B. Use of appropriate safeguards to prevent non -permitted disclosures; C. Reporting to the City of Miami of any non -permitted use or disclosure; D. Assurances that any agents and sub Proposer s agree to the same restrictions and conditions that apply to the Successful Proposer and reasonable assurances that IIHI/PHI will be held confidential; E. Making Protected Health Information (PHI) available to the customer; F. Making PHI available to the customer for review and amendment; and incorporating any amendments requested by the customer; G. Making PHI available to the City of Miami for an accounting of disclosures; and H. Making internal practices, books and records related to PHI available to the City of Miami for compliance audits. PHI shall maintain its protected status regardless of the form and method of transmission (paper records, andlor electronic transfer of data), The Proposer must give its customers written notice of its privacy information practices including specifically, a description of the types of uses and disclosures that would be made with protected health information. 1.42 INDEMNIFICATION - Successful Proposer shall indemnify, hold/save harmless and defend at its own costs and expense the City, its officials, officers, agents, directors, and employees, frorn liabilities, damages, losses, and costs, including, but not limited to reasonable attorney's fees, to the extent caused by the negligence, recklessness or intentional wrongful misconduct of Successful Proposer and persons employed or utilized by Successful Proposer in the performance of this Contract and will indemnify, hold harmless and defend the City, its officials, officers, agents, directors and employees against, any civil actions, statutory or similar claims, injuries or damages arising or resulting from the permitted work, even if it is alleged that the City, its officials and/or employees were negligent. These indemnifications shall survive the term of this Contract. In the event that any action or proceeding is brought against the City by reason of any such claim or demand, Successful Proposer shall, upon written notice from the City, resist and defend such action or proceeding by counsel satisfactory to the City, The Successful Proposer expressly understands and agrees that any insurance protection required by this Contract or otherwise provided by Proposer shall in no way limit the responsibility to indemnify, keep and save harmless and defend the City or its officers, employees, agents and instrumentalities as herein provided. The indemnification provided above shall obligate Successful Proposer to defend at its own expense to and through appellate, supplemental or bankruptcy proceeding, or to provide for such defense, at the City's option, any and all claims of liability and all suits and actions of every name and description which may be brought against the City whether performed by Successful Proposer, or persons employed or utilized by Proposer. This indemnity, hold harmless and duty to defend will survive the cancellation or expiration of the Contract, This indemnity will be interpreted under the laws of the State of Florida, including without limitation and which conforms to the limitations of §725.06 and/or §725.08, Fla. Statutes, as amended from time to time as applicable. Page 17 of 65 605386 Successful Proposer shall require all Subcontractor agreements to include a provision that they will indemnify the City. The Successful Proposer agrees and recognizes that the City shall not be held liable or responsible for any claims which may result from any actions or omissions of the Successful Proposer in which the City participated either through review or concurrence of the Successful Proposer's actions, In reviewing, approving or rejecting any submissions by the Successful Proposer or other acts of the Successful Proposer, the City in no way assumes or shares any responsibility or liability of the Successful Proposer or Subcontractor, under this Agreement. 1,43. FORMATION AND DESCRIPTIVE LITERATURE - Proposer must furnish all information requested in the spaces provided in the Formal Solicitation, Further, as may be specified elsewhere, each Proposer must submit for evaluation, cuts, sketches, descriptive literature, technical specifications, and Material Safety Data Sheets (MSDS) as required, covering the products offered, Reference to literature submitted with a previous response or on file with the Buyer will not satisfy this provision. 1.44. INSPECTIONS -The City may, at reasonable times during the term hereof, inspect Successful Proposer's facilities and perform such tests, as the City deems reasonably necessary, to determine whether the goods and/or services required to be provided by the Successful Proposer under this Contract conform to the terms and conditions of the Formal Solicitation, Successful Proposer shall make available to the City all reasonable facilities and assistance to facilitate the performance of tests or inspections by City representatives. All tests and inspections shall be subject to, and made in accordance with, the provisions of the City of Miami Procurement Ordinance Section 18-79, City Code ), as same may be amended or supplemented from time to time. 1.45. INSPECTION OF RESPONSE -Responses received by the City pursuant to a Formal. Solicitation will not be made available until such time as the City provides notice of a decision or intended decision or within 30 days after bid closing, whichever is earlier. Proposal results will be tabulated and may be furnished upon request via fax or e-mail to the Sr. Procurement Specialist issuing the Solicitation, Tabulations also are available on the City's Web Site following recommendation for award. 1.46. INSURANCE -Within ten (10) clays after receipt of Notice of Award, the Successful Proposer, shall furnish Evidence of Insurance to the Procurement Department, if applicable. Submitted evidence of coverage shall demonstrate strict compliance to all requirements listed on the Special Conditions entitled "Insurance Requirements". The City shall be listed as an "Additional Insured." Issuance of a Purchase Order is contingent upon the receipt of proper insurance documents. If the insurance certificate is received within the specified time frame but not in the manner prescribed in this Solicitation the Successful Proposer shall be verbally notified of such deficiency and shall have an additional five (5) calendar days to submit a corrected certificate to the City. If the Successful Proposer fails to submit the required insurance documents in the manner prescribed in this Solicitation within Fifteen (15) calendar days after receipt Notice of Award, the Successful Proposer shall be in default of the contractual terms and conditions and shall not be awarded the contract. Under such circumstances, the Successful Proposer may be prohibited from submitting future responses to the City. Information regarding any insurance requirements shall be directed to the Risk Management Director r, Department of Risk Management, at 444 SW 2nd Avenue, 9th Floor, Miami, Florida 33130, 305-416-1604. The Successful Proposer shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in effect for the duration of the contractual period; including any and all option terms that may Page 18 of 65 605386 be granted to the Successful Proposer. 1.47. INVOICES -Invoices shall contain purchase order number and details of goods and/or services delivered (i.e. quantity, unit price, extended price, etc.): and in compliance with Chapter 218 of the Florida Statutes (The Local Government Prompt Payment Act). 1.48. LOCAL PREFERENCE A. City Code Section 18-86, states, "the RFP, RFLI or RFQ, as applicable, may, in the exercise of the reasonable professional discretion of the City Manager, director of the using agency, and the Chief Procurement Officer, include a five (5%) percent evaluation criterion in favor of Proposers who maintain a local office, as defined in Section 18-73. In such cases, this five (5%) percent evaluation criterion in favor of Proposers who maintain a local office will be specifically defined in the RFP, RFLI or RFQ, as applicable; otherwise, it will not apply. 1.49. MANUFACTURER'S CERTIFICATION -The City reserves the right to request from Proposers a separate Manufacturer's Certification of all statements made in the proposal. Failure to provide such certification may result in the rejection of proposal or termination of Agreement, for which the Successful Proposer must bear full liability. 1.50. MODIFICATIONS OR CHANGES IN PURCHASE ORDERS AND CONTRACTS -No contract or understanding to modify this Formal Solicitation and resultant purchase orders or contracts, if applicable, shall be binding upon the City unless made in writing by the Director of Procurement of the City of Miami, Florida through the issuance of a change order, addendum, amendment, or supplement to the contract, purchase order or award sheet as appropriate. 1,51. NO PARTNERSHIP OR JOINT VENTURE -Nothing contained in the Agreement will be deemed or construed to create a partnership or joint venture between the City of Miami and Successful Proposer, or to create any other similar relationship between the parties. 1,52. NONCONFORMANCE TO CONTRACT CONDITIONS -Items may be tested for compliance with specifications under the direction of the Florida Department of Agriculture and Consumer Services or by other appropriate testing Laboratories as determined by the City. The data derived from any test for compliance with specifications is public record a.nd open to examination thereto in accordance with Chapter 119, Florida Statutes. Items delivered not conforming to specifications may be rejected and returned at Proposer's expense. These non -conforming items not delivered as per delivery date in the response and/or Purchase Order may result in Successful Proposer being found in default in which event any and all re -procurement costs may be charged against the defaulted Proposer , Any violation of these stipulations may also result in the supplier's name being removed Frorn the City of Miami's Supplier's list, 1.53. NONDISCRIMINATION - Successful Proposer agrees that it shall not discriminate as to race, sex, color, age, religion, national origin, marital status, or disability in connection with its performance under this formal solicitation, Furthermore, Successful Proposer agrees that no otherwise qualified individual shall solely by reason of his/her race, sex, color, age, religion, national origin, marital status or disability be excluded from the participation in, be denied benefits of, or be subjected to, discrimination under any program or activity. In connection with the conduct of its business, including performance of services and employment of personnel, Successful Proposer shall not discriminate against any person on the basis of race, color, religion, disability, age, sex, marital status or national origin. All persons having appropriate qualifications shall be afforded equal opportunity for employment. 1.54. NON-EXCLUSIVE CONTRACT/ PIGGYBACK PROVISION -At such times as may serve its best interest, the City of Miami reserves the right to advertise for, receive, and award additional contracts for these herein Page 19 of 65 605386 goods and/or services, and to make use of other competitively bid (governmental) contracts, agreements, or other similar sources for the purchase of these goods and/or services as may be available in accordance with the applicable provisions of the City of Miami Procurement Ordinance. It is hereby agreed and understood that this formal solicitation does not constitute the exclusive rights of the Successful Proposer(s) to receive all orders that may be generated by the City in conjunction with this Formal Solicitation, In addition, any and all commodities, equipment, and services required by the City in conjunction with construction projects are solicited under a distinctly different solicitation process and shall not be purchased under the terms, conditions and awards rendered under this solicitation, unless such purchases are determined to be in the best interest of the City. 1.55. OCCUPATIONAL LICENSE -Any person, firm, corporation or joint venture, with a business location in the City of Miami and is submitting a Response under this Formal Solicitation shall meet the City's Occupational License Tax requirements in accordance with Chapter 31.1, Article I of the City of Miami Charter. Others with a location outside the City of Miami shall meet their local Occupational License Tax requirements. A copy of the license must be submitted with the response; however, the City may at its sole option and in its best interest allow the Successful Proposer to supply the license to the City during the evaluation period, but prior to award, 1.5G. ONE PROPOSAL -Only one (1) Response from an individual, firm, partnership, corporation or joint venture will be considered in response to this Formal Solicitation. 1.57. OWNERSHIP OF DOCUMENTS -It is understood by and between the parties that any documents, records, files, or any other matter whatsoever which is given by the City to the Successful Proposer pursuant to this Formal solicitation shall at all times remain the property of the City and shall not be used by the Successful Proposer for any other purposes whatsoever without the written consent of the City, 1.58. PARTIAL INVALIDITY -If any provision of this Contract or the application thereof to any person or circumstance shall to any extent be held invalid, then the remainder of this Contract or the application of such provision to persons or circumstances other than those as to which it is held invalid shall not be affected thereby, and each provision of this Contract shall be valid and enforced to the fullest extent permitted by law, 1.59. PERFORMANCE/PAYMENT BOND LA Successful Proposer may be required to furnish a Performance/Payment Bond as part of the requirements of this Contract, in an amount equal to one hundred percent (100%) of the contract price. Any bond furnished will comply with Florida Law and be in a form acceptable to the City of Miami Risk Management Director. 1.60, PREPARATION OF RESPONSES (HARDCOPY FORMAT) - Proposers are expected to examine the specifications, required delivery, drawings, and all special and general conditions. All proposed amounts, if required, shall be either typewritten or entered into the space provided with ink. Failure to do so will he at the Proposers risk. A. Each Proposer shall furnish the information required in the Formal Solicitation. The Proposer shall sign the Response and print in ink or type the name of the Proposer, address, and telephone number on the face page and on each continuation sheet thereof on which he/she makes an entry, as required. B. If so required, the unit price for each unit offered shah be shown, and such price shall include packaging, handling and shipping, and F.O.B. Miami. delivery inside City premises unless otherwise specified. Proposer shall include in the response all taxes, insurance, social security, workmen's compensation, and any other benefits Page 20 of 65 605386 normally paid by the Proposer to its employees. If applicable, a unit price shall be entered in the "Unit Price" column for each item. Based upon estimated quantity, an extended price shall be entered in the "Extended Price" column for each item offered. In case of a discrepancy between the unit price and extended price, the unit price will be presumed correct. C. Proposer must state a definite time, if required, in calendar days for delivery of goods and/or services. D. Proposer should retain a copy of all response documents for future reference. E. All responses, as described, must be fully completed and typed or printed in ink and must be signed in ink with the firm's name and by an officer or employee having authority to bind the company or firm by his/her signature. Proposals having any erasures or corrections must be initialed in ink by person signing the response or the response may be rejected. F. Responses are to remain valid for at least 180 days. Upon award of a contract, the content of the Proposer's response may be included as part of the contract, at the City's discretion. G. The City's Response Forms, shall be used when Proposer is submitting its response in hardcopy format. Use of any other forms will result in the rejection of the response, IF SUBMITTING l-IARDCOPY FORMAT, THE ORIGINAL AND SIX (6) COPIES OF THESE SETS OF FORMS, UNLESS OTHERWISE SPECIFIED, AND ANY REQUIRED ATTACHMENTS MUST BE RETURNED TO THE CITY OR YOUR RESPONSE MAY BE DEEMED NON -RESPONSIVE. 1.61. PRICE ADJUSTMENTS - Any price decrease effectuated during the contract period either by reason of market change or on the part of the Successful Proposer to other customers shall be passed on to the City of Miami. 1.62. PRODUCT SUBSTITUTES -In the event a particular awarded and approved manufacturer's product becomes unavailable during the term of the Contract, the Successful Proposer awarded that item may arrange with the City's authorized representative(s) to supply a substitute product at the awarded price or lower, provided that a sample is approved in advance of delivery and that the new product meets or exceeds all quality requirements, 1.63. CONFLICT OF INTEREST, AND UNETHICAL BUSINESS PRACTICE PROHIBITIONS Successful Proposer represents and warrants to the City that it has not employed or retained any person or company employed by the City to solicit or secure this Contract and that it has not offered to pay, paid, or agreed to pay any person any fee, commission, percentage, brokerage fee, or gift of any kind contingent upon or in connection with, the award of this Contract, 1.64. PROMPT PAYMENT - Proposers may offer a cash discount for prompt payment; however, discounts shall not be considered in determining the lowest net cost for response evaluation purposes. Proposers are required to provide their prompt payment terms in the space provided on the Formal Solicitation. If no prompt payment discount is being offered, the Proposer must enter zero (0) for the percentage discount to indicate no discount. If the Proposer fails to enter a percentage, it is understood and agreed that the terms shall be 2% 20 days, effective after receipt of invoice or final acceptance by the City, whichever is later. When the City is entitled to a cash discount, the period of computation will commence on the date of delivery, or receipt of a correctly completed invoice, whichever is later. If an adjustment in payment is necessary due to damage, the cash discount period shall commence on the date final approval for payment is authorized. If a discount is part of the contract, but the invoice does not reflect the existence of a cash discount, the City is entitled to a cash discount with the period commencing on the date it is determined by the City that a cash discount applies. Price discounts off the original prices quoted on the Price Sheet will be accepted from Successful Proposers daring Page 21 of 65 605386 the term of the contract. 1.65. PROPERTY -Property owned by the City of Miami is the responsibility of the City of Miami. Such property furnished to a Successful Proposer for repair, modification, study, etc., shall remain the property of the City of Miami. Damages to such property occurring while in the possession of the Successful Proposer shall be the responsibility of the Successful Proposer. Damages occurring to such property while in route to the City of Miami shall be the responsibility of the Successful Proposer. In the event that such property is destroyed or declared a total loss, the Successful Proposer shall be responsible for replacement value of the property at the current market value, less depreciation of the property, if any. 1.66. PROVISIONS BINDING -Except as otherwise expressly provided in the resulting Contract, all covenants, conditions and provisions of the resulting Contract shall be binding upon and shall inure to the benefit of the parties hereto and their respective heirs, legal representatives, successors and assigns. 1.67. PUBLIC ENTITY CRIMES -A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a response on a contract to provide any goods or services to a public entity, may not submit a response on a contract with a public entity for the construction or repair of a public building or public work, may not submit responses on leases of real property to a public entity, may not be awarded or perform work as a Proposer, supplier, subcontractor, or subconsultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287,017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 1.68. PUBLIC RECORDS - Successful Proposer understands that the public shall have access, at all reasonable times, to all documents and information pertaining to City contracts, subject to the provisions of' Chapter 119, Florida Statutes, and City of Miami Code, Section 18, -Article III, and agrees to allow access by the City and the public to all documents subject to disclosure under applicable law. Successful Proposer shall additionally comply with the provisions of Section 119.0701, Florida. Statutes, entitled "Contracts; public records". 119,071 Florida Statutes is deemed as being incorporated by reference herein. In summation it provides: Successful Proposer shall additionally comply with Section 119.0701, Florida Statutes, including without limitation: (1) keep and maintain public records that ordinarily and necessarily would be required by the City to perform this service: (2) provide the public with access to public records on the same terms and conditions as the City would at the cost provided by Chapter 119, Florida Statutes, or as otherwise provided by law; (3) ensure that public records that are exempt or confidential and exempt from disclosure are not disclosed except as authorized by law; (4) meet all requirements for retaining public records and transfer , at no cost, to the City all public records in its possession upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from disclosure requirements: (5) All electronically stored public records must be provided to the City in a format compatible with the City's information technology systems Successful Proposer's failure or refusal to comply with the provision of this section shalt result in the immediate cancellation of this Contract by the City. 1.69. QUALITY OF GOODS, MATERIALS, SUPPLIES, PRODUCTS, AND EQUIPMENT- Ail materials used in the manufacturing or construction of supplies, materials, or equipment covered by this solicitation shall he new. The items proposed must be of the latest make or model, of the best quality, and of the highest grade of workmanship, unless as otherwise specified in this Solicitation. Page 22 of 65 605386 1,70. QUALITY OF WORK/SERVICES- The work/services performed must be of the highest quality and workmanship. Materials furnished to complete the service shall be new and of the highest quality except as otherwise specified in this Solicitation. 1.71. REMEDIES PRIOR TO AWARD (Sec. 18-106)- If prior to Contract award it is determined that a formal solicitation or proposed award is in violation of law, then the solicitation or proposed award shall be cancelled by the City Commission, the City. Manager or the Chief Procurement Officer, as may be applicable, or revised to comply with the law. 1.72. RESOLUTION OF CONTRACT DISPUTES (Sec. 18-105) (a) Authority to resolve Contract disputes. The City Manager, after obtaining the approval of the City attorney, shalt have the authority to resolve controversies between the Contractual Party and the City which arise under, or by virtue of, a Contract between them; provided that, in cases involving an amount greater than $25,000, the City Commission must approve the City Manager's decision, Such authority extends, without limitation, to controversies based upon breach of Contract, mistake, misrepresentation or lack of complete performance, and shall be invoked by a Contractual Party by submission of a protest to the City Manager. (b) Contract dispute decisions. If a dispute is not resolved by mutual consent, the City Manager shall promptly render a written report stating the reasons for the action taken by the City Commission or the City Manager which shall be final and conclusive. A copy of the decision shall be immediately provided to the protesting party, along with a notice of such party's right to seek judicial relief, provided that the protesting party shall not be entitled to such judicial relief without first having followed the procedure set forth in this section, 1.73. RESOLUTION OF PROTESTED SOLICITATIONS AND AWARDS (Sec. 18-104, City Code) (a) Right to protest. The following procedures shall be used for resolution of protested solicitations and awards except for purchases of goads, supplies, equipment, and services, the estimated cost of which does not exceed $25,000. Protests thereon shall be governed by the Administrative Policies and Procedures of Procurement. 1. Protest of Solicitation. I. Any prospective Proposer who perceives itself aggrieved in connection with the solicitation of a Contract may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within three days after the Request for Proposals, Request for Qualifications or Request for Letters of Interest is published in a newspaper of general circulation. A notice of intent to file a protest is -considered filed when received by the Chief Procurement Officer; or ii. Any prospective Proposer who intends to contest the Solicitation Specifications or a solicitation may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within three days after the solicitation is published in a newspaper of general circulation. A notice of intent to file a protest is considered filed when received by the Chief Procurement Officer, 2. Protest of Award, i. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within two days after receipt by the Proposer of the notice of the City Manager's recommendation for award of Contract, which will be posted on the City of Miami Procurement Department website, in the Supplier Corner, Current Solicitations and Page 23 of 65 505386 Notice of Recommendation of Award Section. The notice of the City Manager's recommendation can be Found by selecting the details of the solicitation and is listed as Recommendation of Award Posting Date and Recommendation of Award To fields. If "various" is indicated in the Recommendation of Award To field, the Successful Proposer must contact the buyer for that solicitation to obtain the suppliers name, It shall be the responsibility of the Successful Proposer to check this section of the website daily after responses are submitted to receive the notice; or ii. Any actual Responsive and Responsible Bidder whose Bid is lower than that of the recommended bidder may protest to the Chief Procurement Officer. A written notice of intent to file a protest shall be filed with the Chief Procurement Officer within two days after receipt by the bidder of the notice of the City's determination of non - responsiveness or non -responsibility, The receipt by bidder of such notice shall be confirmed by the City by facsimile or electronic mail or U.S. mail, return receipt requested. A notice of intent to file a protest is considered filed when received by the Chief Procurement Officer. A written protest based on any of the foregoing must be submitted to the Chief Procurement Officer within five (5) days after the date the notice of protest was filed. A written protest is considered filed when received by the Chief Procurement Officer. The written protest may not challenge the relative weight of the evaluation criteria or the formula for assigning points in snaking an award determination. The written protest shalt state with particularity the specific facts and law upon which the protest of the solicitation or the award is based, and shall include all pertinent documents and evidence and shall be accompanied by the required Filing Fee as provided in subsection (f). This shall form the basis for review of the written protest and no facts, grounds, documentation or evidence not contained in the protester's submission to the Chief Procurement Officer at the time of filing the protest shall be permitted in the consideration of the written protest. No time will be added to the above limits for service by mail, In computing any period of time prescribed or allowed by this section, the day of the act, event or default from which the designated period of time begins to run shall not be included. The last day of the period so computed shall be included unless it is a Saturday, Sunday or legal holiday in which event the period shall run until the end of the next day which is neither a Saturday, Sunday or legal holiday. Intermediate Saturdays, Sundays and legal holidays shall be excluded in the computation of the time for filing. (b) Authority to resolve protests; hearing officer (s). Hearing officers appointed by the City shall have authority to resolve protests filed under this Chapter of the City Code. The City Manager shall appoint a hearing officer, from a separate list of potential hearing officers pre -approved by the City Commission, to resolve protests filed in accordance with this Section, no later than five (5) working days following the filing of a bid protest. The hearing officer shall have the authority, to settle and resolve any written protest. The hearing officer shall submit said decision to the protesting party and to the other persons specified within ten (10) days after he/she holds a hearing under the protest. (1) Hearing officer. The hearing officer may be a Special Master as defined in Chapter 2, Article X, Sec. 2-811 of the City Code, or a lawyer in good standing with the Florida Bar for a minimum of ten (10) years with a preference given to a lawyer who has served as an appellate or trial judge, The hearing officer may be appointed from alternative sources (e.g. expert consulting agreements, piggyback contracts, etc.) where the City Commission adopts a recommendation of the City Attorney that such action is necessary to achieve fairness in the proceedings. The engagement of hearing officers is excluded from the Procurement Ordinance as legal services. The hearing officers appointed in the pre -qualified group should be scheduled to hear protests on a rotational basis. (2) Right of Protest. Any actual bidder or proposer who has standing under Florida law dissatisfied and aggrieved Page 24 of 65 605386 with the decision of the City regarding the protest of a solicitation or the protest of an award as set forth above in this Section may request a protest hearing. Such a written request for a protest must be initiated with a notice of intent to protest followed by an actual protest as provider/ in Section 18-104(a), The notice of intent to protest and the actual protest must each be timely received by the Chief Procurement Officer and must comply with all requirements set forth in Section 18-104 (a). Failure to submit the required notice of intent to protesl and the actual protest within the specified timeframes will result in an administrative dismissal of the protest, (3) Hearing Date. Within thirty (30) days of receipt of the notice of protest the Chief Procurement Officer shall schedule a hearing before a hearing officer, at which time the person protesting shall be given the opportunity to demonstrate why the decision of the City relative to the solicitation or the award, which may include a recommendation for award by the City Manager to the City Commission, as applicable, should be overturned. The party recommended for award, if it is a protest of award, shall have a right to intervene and be heard, (4) Hearing Procedure. The procedure for any such hearing conducted under this Article shall be as follows: (i) The City shall cause to be served by certified mail a notice of hearing stating the time, date, and place of the hearing. The notice of hearing shall be sent by certified mail, return receipt requested, to the mailing address of the protester. (it) The party, any intervenor and the City shall each have the right to be represented by counsel, to call and examine witnesses, to introduce evidence, to examine opposing or rebuttal witnesses on any relevant matter related to the protest even though the matter was not covered in the direct examination, and to impeach any witness regardless of which party first called him/her to testify, The hearing officer may extend the deadline for completion of the protest hearing for good cause shown, but such an extension shall not exceed an additional Five (5) business days. The hearing officer shall consider the written protest and supporting documents and evidence appended thereto, supporting documents or evidence from any intervenor, and the decision or recommendation as to the solicitation or award being protested, as applicable, The protesting party, and any intervenor, must file all pertinent documents supporting his/her protest or motion to intervene at least five (5) business days before the hearing, as applicable. The hearing officer shall allow a maximum of two (2) hours for the protest presentation and a maximum of two (2) hours for the City response. When there is an intervenor, a maximum of two (2) hours will be added for the intervenor-. In the event of multiple protests for the same project, the hearing officer shall allocate Lime as necessary to ensure that the hearing shall not exceed a total of one (1) clay. (ii1) The hearing officer shall consider the evidence presented at the hearing. In any hearing before the hearing officer, irrelevant, immaterial, repetitious, scandalous or frivolous evidence shall be excluded. All other evidence of a type commonly relied upon by reasonably prudent persons in the conduct of their affairs shall be admissible whether or not such evidence would be admissible in trial in the courts of Florida. The hearing officer may also require written summaries, proffers, affidavits , and other documents the hearing officer determines to be necessary to conclude the hearing and issue a final order within the time limits set forth by this section,. (iv) The hearing officer shall determine whether procedural due process has been afforded, whether the essential requirements of law have been observed, whether the decision was arbitrary, capricious, an abuse of discretion, in accordance with the law or unsupported by substantial evidence as a whole; substantial evidence means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. (v) Within ten (10) days from the date of the hearing, the hearing officer shall complete and submit to the City Manager, the City Attorney, any intervenor, the Chief Procurement Officer and the person requesting said hearing a final order consisting of his/her findings of fact and conclusions of law as to the denial or granting of the protest, as applicable. (vi) The decisions of the hearing officer are final in terms of City decisions relative to the protest. Page 25 of 65 605386 Any appeal from the decision of the hearing officer shall be in accordance with the Florida Rules of Appellate Procedure. (c) Compliance with filing requirements. Failure of a party to timely file either the notice of intent to file a protest or the written protest, together with the required Filing Fee as provided in subsection (f), with the Chief Procurement Officer within the time provided in subsection (a), above, shall constitute a forfeiture of such party's right to file a protest pursuant to this section, The protesting party shall not be entitled to seek judicial relief without first having followed the procedure set forth in this section (d) Stay of Procurements during protests, Upon receipt of' a written protest filed pursuant to the requirements of this section, the City shall not proceed further with the solicitation or with the award of the Contract until the protest is resolved by the Chief Procurement Officer or the City Commission as provided in subsection (b) above, unless the City Manager makes a written determination that the solicitation process or the Contract award must be continued without delay in order to avoid an immediate and serious danger to the public health, safety or welfare. (e) Costs. All costs accruing from a protest shall be assumed by the protestor. (I) Filing Fee. The written protest must be accompanied by a filing fee in the form of a money order or cashier's check payable to the City in an amount equal to one percent of the amount of the Bid or proposed Contract, or $5000.00, whichever is less, which filing fee shall guarantee the payment of all costs which may be adjudged against the protestor in any administrative or court proceeding. If a protest is upheld by the Chief Procurement Officer and/or the City Commission, as applicable, the filing fee shall be refunded to the protestor less any costs assessed under subsection (e) above. if the protest is denied, the filing fee shall be forfeited to the City in lieu of payment of costs for the administrative proceedings as prescribed by subsection (e) above. 1.74. SAMPLES -Samples of items, when required, must be submitted within the time specified at no expense to the City. If not destroyed by testing, Proposer(s) will be notified to remove samples, at their expense, within 30 days after notification. Failure to remove the samples will result in the samples becoming the property of the City. 1.75.. SELLING, TRANSFERRING OR ASSIGNING RESPONSIBILITIES i SuccessfulProposer shall not sell, assign, transfer or subcontract at any time during the term of the Contract, the Agreement itself or any portion thereof, or any part of its operations, or assign, sell, pledge, dispose , convey or encumber any portion of the Agreement or i.ts performance , t required by this contract, except under and by virtue of prior written permission granted by the City Manager, which may be withheld or conditioned, in the City Manager's sole discretion. As this Agreement is considered unique in nature such permission may be refused, withheld or conditioned by the City Manager. 1.76. SERVICE AND WARRANTY zWhen specified, the Successful Proposer shall define all warranty, service and replacements that will be provided, Proposer must explain on the Response to what extent warranty and service facilities are available. A copy of the manufacturer's warranty, if applicable, should be submitted with your response. 1.77. SILENCE OF SPECIFICATIONS -The apparent silence of these specifications and any supplemental specification as to any detail or the omission from it of detailed description concerning any point shall be regarded as meaning that only the best commercial practices are to prevail and that only materials of first quality and correct type, size and design are to be used. All workmanship and services is to he first quality. All interpretations of these specifications shall be made upon the basis of this statement. If your firm has a current contract with the State of Florida, Department of General Services, to supply the items on this solicitation, the Successful Proposer shall quote not more than the contract price; failure to comply with this request will result in disqualification of Proposal. Page 26 of 65 605386 1.78. SUBMISSION AND RECEIPT OF RESPONSES -Responses shall be submitted electronically via the Oracle System and additionally, responsesshali be submitted in hardcopy format to the City Clerk, City Hall, 3500 Pan American Drive, Miami, Florida 33133-5504, at or before, the specified closing date and time as designated in the IFB, RFP, RFQ, or RFLI. NO EXCEPTIONS. Proposers are welcome to attend the solicitation closing; however, no award will be made at that time. A. Hardcopy responses shall be enclosed in a sealed envelope, box package, The face of the envelope, box or package must show the hour and elate specified for receipt of responses, the solicitation number and title, and the name and return address of the Proposer. Hardcopy responses not submitted on the requisite Response Forms may be rejected. Hardcopy responses received at any other location than the specified shall be deemed non -responsive. Directions to City Hall: FROM THE NORTH: 1-95 SOUTH UNTIL IT TURNS INTO US1, US1 SOUTH TO 27TH AVE., TURN LEFT, PROCEED SOUTH TO SO. BAYSHORE DR. (3RD TRAFFIC LIGI-IT), TURN LEFT, 1 BLOCK TURN RIGHT ON PAN AMERICAN DR. CITY HALL IS AT THE END OF PAN AMERICAN DR. PARKING IS ON RIGHT. FROM TI-IE SOUTH: US1 NORTH TO 27TH AVENUE, TURN RIGHT, PROCEED SOUTH TO S0. BAYSHORE DR, (3RD TRAFFIC LIGHT), TURN LEFT, 1 BLOCK TURN RIGHT ON PAN AMERICAN DR. CITY HALL IS AT THE END OF PAN AMERICAN DR. PARKING IS ON RIGHT. B. Facsimile responses will not be considered. C. Failure to follow these procedures is cause for rejection of bid/proposal. D. The responsibility for obtaining and submitting a response on or before the close date is solely and strictly the responsibility of Successful Proposer. The City of Miami is not responsible for delays caused by the United States mail delivery or caused by any other occurrence. Responses received after the solicitation closing date and time will be returned unopened, and will not be considered for award. E. Late or rnis-delivered or incorrectly addressed responses will be rejected. F. All responses are subject to the conditions specified herein. Those which do not comply with these conditions are subject to rejection. G. Modification of responses already submitted will be considered only if received at the City before the time and clate set for closing of solicitation responses. All modifications must be submitted via the Oracle System or in writing. Once a solicitation closes (closed date and/or time expires), the City will not consider any subsequent submission which alters the responses, H. If hardcopy responses are submitted at the same time for different solicitations, each response must be placed in a separate envelope, box, or package and each envelope, box or package must contain the information previously stated in 1.82.A. 1.79. TAXES -The City of Miami is exempt from any taxes imposed by the State and/or Federal Government. Exemption certificates will be provided upon request. Notwithstanding, Bidders/Proposers should be aware of the fact that all materials and supplies which are purchased by the Successful Proposer for the completion of the contract is subject to the Florida State Sales Tax in accordance with Section 212,08, Florida Statutes, as amended and all amendments thereto and shall be paid solely by the Successful Proposer. 1,80. TERMINATION - The City Manager on behalf of the City of Miami reserves the right to terminate this contract by written notice to the Successful Proposer effective the date specified in the notice should any of the Page 27 of 65 605386 following apply A. A Successful Proposer is determined by the City, to be in breach of any of the terms and conditions of the contract. B. The City has determined that such termination will be in the best interest of the City to terminate the contract for its own convenience; C. Funds are not available to cover the cost of the goods and/or services. The City`s obligation is contingent upon the availability of appropriate funds. 1.81. TERMS OF PAYMENT -Payment will be made by the City after the goods and/or services awarded to a Successful Proposer have been received, inspected, and found to comply with award specifications, free of damage or defect, and properly invoiced. No advance payments of any kind will be made by the City of Miami. Payment shall be made after delivery, within 45 days of receipt of an invoice and authorized inspection and acceptance of the goods/services and pursuant to Section 218.74, Florida Statutes and other applicable law, 1.82. TIMELY DELIVERY -Time will be of the essence for any orders placed as a result of this solicitation. The City reserves the right to cancel such orders, or any part thereof, without obligation, if delivery is not made within the time(s) specified an their Response. Deliveries are to be made during regular City business hour's unless otherwise specified in the Special Conditions. 1.83, TITLE -Title to the goods or equipment shall not pass to the City until after the City has accepted the goods/equipment or used the goods, whichever comes first. An exception may be made for "trade secrets.' If the Response contains information that constitutes a "trade secret all material that qualifies for exemption from Chapter 119 must be submitted in a separate envelope, clearly identified as "TRADE SECRETS EXCEPTION," with your firm's name and the Solicitation number and title marked on the outside. Please be aware that the designation of an item as a trade secret by you may be challenged in court by any person. By your designation of material in your Response as a "trade secret" you agree to indemnify and hold harmless the City for any award to a plaintiff for damages, costs or attorney's fees and for costs and attorney's fees incurred by the City by reason of any legal action challenging your claim. 1.84. UNAUTHORIZED WORK OR DELIVERY OF GOODS -Neither the Successful Proposer(s) nor any of his/her employees shall perform any work or deliver any goods unless a change order or purchase order is issued and received by the Successful Proposer. The Successful Proposer(s) shall not be paid for any work performed or goods delivered outside the scope of the contract or any work performed by an employee not otherwise previously authorized. 1.85. USE OF NAME -The City is not engaged in research for advertising, sales promotion, or other publicity purposes. No advertising, sales promotion or other publicity materials containing information obtained from this Solicitation are to be mentioned, or imply the name of the City, without prior express written permission of the City Manager or the City Commission. 1.86. VARIATIONS OF SPECIFICATIONS -For purposes of solicitation evaluation, Proposers must indicate any variances from the solicitation specifications and/or conditions, no matter how slight. If variations are not stated on their Response, it will be assumed that the product fully complies with the City's specifications. Page 28 of 65 605386 2. SPECIAL CONDITIONS 2.1. PURPOSE The purpose of this Solicitation is to establish a contract(s), for the provision of Third Party Claims Administration and/or Managed Care Services, with a Third Party Claims Administrator, hereinafter referred to as "Successful Proposer", as specified herein, from a source(s), fully compliant with the terms, conditions, and stipulations of the solicitation, 2.2. DEADLINE FOR RECEIPT OF REQUEST FOR ADDITIONAL INFORMATION/ Any questions or clarifications concerning this solicitation shall be submitted by email or facsimile to the Procurement Department, Attn: Yadissa Calderon; fax: (305) 400-5369 or email: ycadderon@ci,miami.fl.us, and a copy filed with the Office of the City Clerk at clerks@miamigov.com, pursuant to Section 1.20. Cone of Silence. The solicitation title and number shall be referenced on ali correspondence. All questions must be received no later than Tuesday, November 1, 2016 at 5:00 PM, All responses to questions will be sent to all prospective Proposers in the form of an addendum, NO QUESTIONS WILL BE RECEIVED VERBALLY OR AFTER SAID DEADLINE. 2.3. VOLUNTARY PRE -PROPOSAL CONFERENCE Proposers are strongly encouraged to attend theVoluntary Pre -Proposal Conference, which will occur on Wednesday, Octoher 12, 2016, at 2:00 PM (local time), at 441 SW 2nd Avenue, 6th Floor South Conference Room, Miami, Florida. A discussion of the requirements of the Solicitation will occur at that time. Each Proposer is required, prior to submitting a Proposal, to acquaint themselves thoroughly with any and all conditions and/or requirements that may in any manner affect the work to be performed. No allowances will be made because of lack of knowledge of these conditions, The purpose of the Pre -Proposal Conference is to allow Proposers an opportunity to present questions to staff and obtain clarification of the requirements of the Solicitation documents. Because the City considers the conference to be critical to understanding the solicitation requirements, attendance is highly recommended. 2.4. DEFINITIONS "City Manager" shall mean the City Manager of the City of Miami who is the Chief Administrative Officer of the City. Whenever the word "City" is used, unless another body or board or commission is mentioned by name in decisions made by the City relative to this Agreement, the City shall mean the "City Manager." "Director" for purposes of this Agreement shall mean the Director of the City of Miami Risk Management Department. The City' Project Manager, may at her discretion consult with the Director about any matter regarding the Agreement, and the Director will provide. her input if so requested. "City Commission" shall mean the Miami City Commission, the municipal legislative body, who will consider the award of this Agreement and would be required to approve this Agreement. The City Commission is the only entity who may increase the funding, the budget or the moneys paid under this Agreement. 2.4.TERM OF AGREEMENT Page 29 of 65 605386 The Proposer(s) qualified to provide the services requested herein, shall be required to execute a Professional Services Agreement ("Agreement") with the City, which shall include, but not be limited to, the following terms: 1)The term of the Agreement shall he for three (3) years, with an option to renew for two (2) additional one (1) year periods. 2)The City Nlanager shall have the option to extend or terminate the Agreement, Continuation of the Agreement beyond the initial three (3) year period is a City prerogative: not a right of the Successful Proposer(s). This prerogative will be exercised only when such continuation is clearly in the best interest of the City. 3)The City Manager may cancel the Agreement for convenience on thirty (30) clays prior written notice to the Successful Proposer(s), and the Successful Proposer(s) will have no recourse except to be paid its direct fees and casts incurred prior to the effective date of cancelation. 4)The Hold Harmless, Duty to Defend, Indemnity and Insurance terms and requirements provided for in this RFP. 2.5. EXECUTION OF AN AGREEMENT The Successful Proposer(s) evaluated and ranked in accordance with the requirements of this Solicitation, shall be awarded an opportunity to negotiate a Professional Services Agreement (Agreement) with the City. The City reserves the right to execute, or not execute, as applicable, an Agreement with the Successful Proposer(s) in substantially the same form as the draft Agreement attached to the Header Section of this Solicitation, Such Agreement which will be furnished by the City, will contain certain terms as are in the City's best interest, and will be subject to approval as to legal form by the City Attorney. 2.6, CONDITIONS FOR RENEWAL Each renewal of the Agreement is subject to the following: 1) Continued satisfactory performance compliance with the specifications, terms and conditions established herein, 2) Ava.ilabiIity of funds 2.7.NON-APPROPRIATION OF FUNDS In the event no funds or insufficient funds are appropriated and budgeted or are otherwise unavailable in any fiscal period for payments due under this Agreement, then the City, upon written notice to the Successful Proposer(s) or his assignee of such occurrence, shall have the unqualified right to terminate the Agreement without any penalty or expense to the City. No guarantee, warranty or representation is made that any project(s) will be awarded to any firm (s). 2.8. MINIMUM QUALIFICATION REQUIREMENTS Proposer(s) shall satisfy each of the following requirements cited below. Failure to do so will result in the Proposal being deemed non -responsive. Page 30 of 65 605386 A,Workers` Compensation Claims and Liability Claims Administration Proposer shall: 1)Be authorized (licensed) as a Claims Administrator by the State of Florida, as of proposal clue date; 2)Have dedicated/clesignated adjusters in the State of Florida with a minimum of three (3) years' experience, directed bya dedicated Supervisor, with at least five (5) years' recent experience. 3)Be approved by all of the City's excess carriers; 4)Be compliant throughout the life of the Agreement and must be compliant at the time of proposal submittal, in Statement on Auditing Standard No. 70 (SAS70)/ Statement on Standards for Attestation Engagement 16 (SSAE16); 5)l-lave a minimum of five (5) continuous years of experience, handling Florida municipal claims, with at least one (1) client having a minimum of 1500 employees; 6)Be in full compliance with the federally -mandated State Children's Health Insurance Program (SCHIP) and Florida Electronic Data Interchange (EDI) requirements; 7)Have electronic capabilities to provide electronic reporting, transfer of data to any/all platforms as directed, and connectivity to Proposer's information system; 8)Have no record of judgments, bankruptcies, pending lawsuits against the City, criminal activities involving moral turpitude, and not have any conflicts of interest that have not been waived by the City Commission; and 9)Not be in arrears or in default of any debt or contract involving the City (as a party to a contract, or otherwise); nor have failed to perform faithfully on any previous contract with the City, This requirement applies to Proposer's principals, officers, or stockholders. B.ldianaged Care/Meclical Bill Review/Audit Services Proposers shall: 1)Adnninister one or more national Preferred Provider Organizations (PPO) that have negotiated contract rates with hospitals and providers, in an order or priority acceptable to Risk Management. Risk Management may, at its sole discretion, disallow the use of any PPO; 2)Have a National pharmacy network; 3)Have the ability to interface with Risk Management Information System (RMIS) 4)Be available twenty-four (24) hours, seven (7) days a week; 5)Proposer's staff nurses (telephonic and ansite) shall have a minimum of five (5) to seven (7) years of experience; 6)Must comply with Florida Agency for Health Care Administration guidelines; Rule Chapter 59A-23; 7)Be required to have Utilization Review Accreditation Commission (URAC) accreditation, as of the proposal due date; 8)Telephonic Case Manager (TCM)/Nurse Case Manager (NCM)are subject to continuing education; 9)Own, management and control PPO networks (can add, remove provider at will); 10)l-lave a mechanism to oversee physician/provider performance via scorecard; 11)Official Disability Guidelines (ODG)/American College of Occupational and Environmental Medicine ( ACOEM) schedules must be integrated into the rule engine of the Proposer; and Page 31 of 65 605386 12)Own, manage, and control Utilization Review (UR) services. 2.9.FAILURE TO PERFORM Should it not be possible to reach the Successful Proposer or representative, and/or should remedial action not be taken within 48 hours of any failure to perform according to specifications, the City reserves the right to declare Successful Proposer in default of the contract or make appropriate reductions in the contract payment. 2.10.INSURANCE REQUIREMENTS INDEMNIFICATION Successful Proposer shall pay on behalf of, indemnify and save City and its officials harmless, from and against any and all claims, liabilities, losses, and causes of action, which may arise out of Successful Proposer's performance under the provisions of the Agreement, including all acts or omissions to act on the part of Successful Proposer, including any person performing tinder this Agreement for or on Successful Proposer's behalf, provided that any such claims, liabilities, losses and causes of such action are not attributable to the negligence or misconduct of the City and, from and against any orders, judgments or decrees which may be entered and which may result from this Agreement, unless attributable to the negligence or misconduct of the City, and from and against all costs, attorneys' fees, expenses and liabilities incurred in the defense of any such claim, or the investigation thereof, The Successful Proposer shall furnish to the City of Miami, c/o Procurement Department, 444 SW 2nd Avenue, 6th Floor, Miami, Florida 33130, Certificate(s) of Insurance which indicate that insurance coverage has been obtained which meets the requirements as outlined below: The Successful Proposer shall, at its own cost and expense, acquire and maintain during the term of the Agreement, with carriers having an AM Best Rating of A-VII or better, sufficient insurance to adequately protect the respective Interests of the parties, including the Successful Proposer's indemnity obligations. Specifically, the Successful Proposer must carry the following minimum types and amounts of insurance on an occurrence basis or in the case of coverage that cannot he obtained on an occurrence basis, then coverage can be obtained on a claims -made basis with a three (3) year tail following the termination or expiration of this Agreement: a) Commercial General Liability:Written on an occurrence form, including but not limited to premises -operations, broad form property damage, products /completed operations, contingent and contractual exposures, personal injury and advertising injury, with limits of at least $1,000,000 per occurrence and $2,000,000 general aggregate, This coverage should be written .on a primary and non-contributory basis, and should list the City as an additional insured; b) Workers' Compensation Insurance:Statutory Workers' Compensation Insurance and Employers' Liability Insurance in the minimum amount of $1,000,000 each employee by accident, $1,000,000 each employee by disease and $1,000,000 aggregate by disease with benefits afforded under the laws of the state or country in ,vhich the services are to be performed. Policy will include an alternate employer endorsement providing coverage in the event any employee of the Successful Proposer sustains a compensable accidental injury while on work assignment with Company. Insurer for Vendor will be responsible for the Workers' Compensation benefits due such injured employee: c) Commercial Automobile Liability: If an automobile is used by the Successful Proposer in connection with the performance of its obligations under this Agreement, then Comprehensive Automobile Liability Insurance for any owned, non -owned, hired, or borrowed automobile used in the performance of Successful Proposer's obligations under this Agreement is required in the minimum amount of $1,000,000 each accident combined for bodily injury and property damage. City of Miami should be listed as an additional insured; d) Professional Errors and Omissions Liability: Insurance in the minimum amount of $10,000,000 per claim and Page 32 of 65 605386 policy aggregate, protecting the City against Successful Proposer's professional negligence, failure to perform professional duties and breach of contractual obligations under this Agreement, including but not limited to, coverage for claims services and certification that there is no security breach or unauthorized use exclusion on this policy; e) Network Security/Privacy Liability (Cyber Liability): Insurance in the minimum amount of $5,000,000 per occurrence including but not limited to protection of private or confidential information whether electronic or non -electronic; network security and privacy liability; protection against liability for systems attacks; denial or loss of service; introduction, implantation or spread of malicious software code; security breach; unauthorized access and use; including regulatory action expenses; cyber extortion coverage; and notification and credit monitoring expenses f) Employee Dishonesty/Fidelity: Insurance including 3rd Party Liability in the minimum amounts of31,000,000 each occurrence for acts of all Staff; and g) Excess Umbrella Liability (Excess Follow Form):Minimum limits of $10,000,000 per occurrencelaggregate. This coverage is excess over all applicable liability policies. The above insurance limits may be achieved by a combination of primary and umbrella/excess liability policies. 1. Prior to the execution of this Agreement (or seven (7) calendar days prior to the start of work under this A greement) and annually upon the anniversary dates) of the insurance policy's renewal date(s), the Successful Proposer will furnish the City with a Certificate of Insurance evidencing the coverages set forth above and naming the City, its subsidiaries. affiliates, authorized distributors, directors, officers, employees, partners and agents as an "Additional Insured" on the Successful Proposer's Commercial General Liability and Commercial Auto Liability policies listed above and name the City, its subsidiaries, affiliates, authorized distributors, directors, officers, employees, partners and agents as a "Loss Payee" on the Successful Proposer's Fidelity policy. 2. The Successful Proposer shall provide the City thirty (30) calendar days written notice of any cancellation, non -renewal, termination, material change or reduction in coverage. 3. The Successful Proposer's insurance as outlined above shall be primary and non-contributory coverage, 4. The coverage territory for the stipulated insurance shall be on a worldwide basis. 5. The Successful Proposer must ensure that any subcontractors or other service providers the Successful Proposer engages to provide the services required under this Agreement, acquire anti maintain at all times, with insurance companies with a minimum A.NI, Best Rating A-VII, the same levels of insurance coverage as are outlined above. The Successful Proposer and subcontractors of the Successful Proposer, will cause their insurance companies to waive their right of recovery against the City. 6. The stipulated limits of coverage above shall not be construed as a limitation of any potential liability to Company, and failure to request evidence of this insurance shall not be construed as a waiver of the Successful Proposer's obligation to provide the insurance coverage specified. BINDERS ARE UNACCEPTABLE. The insurance coverage required shall include those classifications, as listed in standard liability insurance manuals, which most nearly reflect the operations of the Successful Proposer. All insurance policies required above shall be issued by companies authorized to do business under the laws of the State of Florida, with the following qualifications: Certificates will indicate no modification or change in insurance shall be made without thirty (30) days written advance notice to the certificate holder. Page 33 of 65 605386 NOTE: CITY RFP NUMBER AND/OR TITLE OF RFP MUST APPEAR ON EACH CERTIFICATE, AND THE CITY NIUST BE LISTED AS THE INSURED AND/OR ADDITIONAL INSURED. Compliance with the foregoing requirements shall not relieve the Successful Proposer of his liability and obligation under this section or under any other section of this Agreement. --If insurance certificates are scheduled to expire during the contractual period, the Successful Proposer shall be responsible for submitting new or renewed insurance certificates to the City at a minimum of ten (10) calendar clays in advance of such expiration, --In the event that expired certificates are not replaced with new or renewecl certificates which cover the contractual period, the City shall: (a) Suspend the Agreement until such time as the new or renewecl certificates are received by the City in the manner prescribed in the RFP, (b) The City may, at its sole discretion, terminate this Agreement for cause and seek re -procurement damages from the Successful Proposer in conjunction with the General and Special Terms and Conditions of the solicitation. The Successful Proposer shall be responsible for assuring that the insurance certificates required in conjunction with this Section remain in force for the duration of the contractual period; including any and all option terms that may be granted to the Successful Proposer. 2.11.PROJECT MANAGER, CITY MANGER, DIRECTOR, CITY COMMISSION Upon award, Successful Proposer shall report and work directly with Ms. Angella Breadwoocl, Claims Manager, Risk Management Department, who shall be designated as the City Project Manager, for purposes of day to day administration of this Agreement. 2.12.SUBCONTRACTOR(S) OR SUBCONSULTANT(S) A subconsultant, herein referred to as subcontractor, is an individual or firm contracted by the Successful Proposer or Successful Proposer's firm to assist in the performance of services required under this Solicitation. A subcontractor shall be paid through Successful Proposer or Successful Proposer's firtn and not paid directly by the City, Subcontractors are allowed by the City in the performance of the services delineated within this Solicitation. Proposer must clearly reflect in its Proposal the major subcontractor(s) to be utilized in the performance of required services, The City retains the right to accept or reject arty subcontractor(s) proposed at time of proposal submittal or prior to contract execution. Any and all liabilities regarding the use of subcontractors shall be borne solely by the Successful Proposer and insurance for each subcontractor must be maintained in good standing and approved by the City throughout the duration of the Agreement. Neither Successful Proposer nor any of its subcontractors are considered to be employees or agents of the City. Failure to list all subcontractors, and provide the required information, may disqualify any proposed subcontractor(s) from perfortning work under this Solicitation. Proposers shall include in their proposal the requested subcontractor(s) information and include all relevant information required of the Proposer, In addition, within five (5) working days after the identification of the award to the Successful Proposer(s), the Successful Proposer(s) shall provide a list confirming the subcontractors that the Successful Proposer(s) intends to utilize in the Agreement, if applicable. The list shall include, at a minimum, the name, location of the place of business for each subcontractor, the services subcontractor will provide relative to any contract that may result from this Solicitation, any applicable licenses, references, ownership, and other information required of Successful Proposer(s). 2.13.TER>VIINATION Page 34 of 65 605386 A. FOR DEFAULT If the Successful Proposer defaults in its performance under the Agreement and does not cure the default within thirty (30) days after written notice of default, the City Manager may terminate the Agreement, in whole or in part, upon written notice without penalty to the City of Miami. In such event the Successful Proposer shall be liable for damages including the excess cost of procuring similar supplies or services: provided that if, (1) it is determined for any reason that the Successful Proposer was not in default or (2) the Successful Proposer failure to perform is without his or his subcontractor's control, fault or negligence, the termination will be deemed to be a termination for the convenience of the City of Miami, B. FOR CONVENIENCE The City Manager may terminate this Agreement, in whole or in part, upon thirty (30) days prior written notice, when it is in the best interest of the City, If the Agreement is for supplies, products, equipment, or software, and so terminated for the convenience by the City the Successful Proposer will he compensated in accordance with an agreed upon adjustment of cost To the extent that the Agreement is for services and so terminated, the City of Nliami shall be liable only for payment in accordance with the payment provisions of the Agreement for those services rendered prior to lerrni.nation. 2.14. PRIMARY CLIENT (FIRST PRIORITY) The Successful Proposer(s) agree upon award of this Agreement that the City shall be its primary client, and shall be serviced first during a schedule conflict arising between this Agreement, and any other contracts Successful Proposer(s) may have with any other cities and/or counties to perform similar services, as a result of any catastrophic events such as tornadoes, hurricanes, severe storms or any other public emergency impacting various areas during or approximately the same time, 2.15, UNAUTHORIZED WORK The Successful Proposer(s) shall not begin work until a Purchase Order and/or a Notice to Proceed is received. 2.16.CHANGES/ALTERATIONS Proposer may change or withdraw a proposal at any time prior to proposal submission deadline: however, no oral modifications will be allowed. Written modifications shall not be allowed following the proposal submission deadline. 2.17. COMPENSATION PROPOSAL Price must be submitted on the Price Proposal Form, Attachment B, as provided. See Header Section of the RFP for the form. Proposer(s) may submit a proposal for one and/or both category of services. Refer to Section 3.1, Background. In the event a Proposer is submitting a proposal for both categories of services, a separate Price Pro posal Form is required for each category of service. Proposer shall detail any and all fees and costs to provide the required services as listed below, and in accordance with the Submission Requirement for each of the category of service Proposer is submitting a proposal for. Part I - Third Party Claims Administration a.workers compensation claims b.liabilily claims including; i.Automobile (AL) ii. General liability (GL) ill. Employment practice liability iv. Law enforcement liability Page 35 of 65 605386 v. Public Officials liability Part II - Manac ed Care/Medical BiII Review Services Proposer shall additionally provide a detailed list of all costs to provide all services as detailed in Section 3, Scope of Services, as proposed. Failure to submit compensation proposal as required,may disqualify Proposer from consideration. Proposer shall submit a guaranteed, all-inclusive annual fee as previously detailed. This fee is to represent all claims, administrative, and loss data fees. Proposed rates are to be guaranteed annual fees for the initial three (3) years, and for the two (2) option to renew years, as opposed to per claim time and expense or any other fee proposal. Proposals not containing an alI-inclusive guaranteed annual fee for initial three (3) years anti two option to renew years, for all specified services, will not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's annual fee, Clearly indicate any charge not included in the proposed annual Fee. A flat rate is desirable, with no charges for duplicates and for bill review at fee schedule or UC only for reductions after. Proposer shall provide prices in U.S dollars for the required services. It is important that Proposer outline features of the Proposal, such as value-adclecl product(s) and/or service(s) that would not normally be addressed in a pricing evacuation, as they are of a non -monetary nature. As such, Proposer should include any relevant services or products that will be provided to the City which are not priced in its Proposal, but which will enhance the acquisition process. Proposer shall be responsible for indicating in its Proposal the cost, if any, of assuming these prior claims and data conversion and whether it is a one-time charge or an annual charge. As the current Proposer utilizes an on-line claim processing system where all data is maintained, updated and payments are issued, the Successful Proposer(s) must provide the City with a bank reconciliation tape and a tape to interface with the City's financial information, The Successful Proposer(s) will include in its costs for the provision of an enhanced system and for the conversion of any data necessary. The City's proposed performance guarantee may be negotiated with the City. Provide any and atl additional costs, item by item, as identified by Proposer in any other area not previously discussed and detail what those additional costs, if applicable, would entail. Include which entity (Proposer or City) that will be responsible for payment of those costs. 2.18.EVALUATIONISELECTION PROCESS AND CONTRACT AWARD The procedure for response evaluation, selection, and award is as follows: (1) Solicitation issued; (2) Receipt of proposals; (3) Opening and listing of all proposals received; Page 36 of 65 605386 (4) The Department of Procurement (Procurement) staff will review each proposal for compliance with the proposal submission requirements of the solicitation, including verifying that each proposal includes all documents required; (5) An Evaluation Committee, appointed by the City Manager, comprised of appropriate City staff and members of the community, as deemed necessary, with the appropriate technical expertise and/or knowledge, shall meet to evaluate each proposal in accordance with the requirements of this solicitation and based upon the evaluation criteria as specified herein; (6) The Evaluation Committee (Committee) reserves the right, in its sole discretion, to request Proposers to make oral presentations before the Committee as part of the evaluation process. The presentation may be scheduled at the convenience of the Committee and shall be recorded; (7) The Committee reserves the right to rank the proposals and shall submit its recommendation to the City Manager for acceptance. If the City Manager accepts the Committee's recommendation, the City Manager's recommendation for award of contract will be posted on the City of Miami Procurement Department website, in the Supplier Corner, Current Solicitations and Notice of Recommendation of Award Section, The notice of the City Manager's recommendation can be found by selecting the details of the solicitation and is listed as Recommendation of Award Posting Date and Recommendation of "Award To" fields, If "various" is indicated in the Recommendation of " Award To" field, the Proposer must contact the Procurement Contracting Officer for that solicitation to obtain the suppliers names. The City Manager shall make his recommendation to the City Commission requesting the authorization to negotiate and/or execute an Agreement with the recommended Proposer(s), No Proposer(s) shall have any rights against the City arising from such negotiations or termination thereof; (8) The City Manager reserves the right to reject the Committee's recommendation, and instruct the Committee to re-evaluate and make another recommendation, reject all proposals, or recommend that the City Commission reject all proposals; (9) The City Manager will negotiate a final Agreement with the Successful Proposer, which will be presented to the City Commission; (10) The City Commission may review, consider and approve the negotiated Agreement with the Successful Proposer(s). 2.19.ADDITIONAL SERVICES Services not specifically identified in this request may be added to any resultant Agreement upon successful negotiation and mutual consent of the contracting parties. The City reserves the right to add or delete any service(s), at any time. Should the City determine to add an additional service(s) for which pricing was not previously secured, the City shall ask the Successful Proposer to provide reasonable cost(s) for same. Should the City determine the pricing unreasonable, the City reserves the right to negotiate cost(s) or seek another firm/entity for the provision of said service(s). 2.20. RECORDS During the Agreement period, and for a least five (5) subsequent years thereafter, Successful Proposer(s) shall provide City access to all files and records maintained on the City's behalf. 2.21.AMENDMENTS TO THE CONTRACT The City Manager shall have the right and authority to amend and execute any necessary amendments and modifications to this Agreement on behalf of the City, in a form acceptable to the Office of the City Attorney, as may be necessary for said purpose, Page 37 of 65 605386 2.22. TRUTH IN NEGOTIATION CERTIFICATE Execution of the resulting Agreement by the Successful Proposer shall act as the execution of truth -in -negotiation certificate stating that wage rates and other factual unit costs supporting the compensation of the resulting Agreement are accurate, complete, and current at the time of contracting. The original contract price and any additions thereto shall be adjusted to exclude any significant sums by which City determines the contract price was increased due to inaccurate, incomplete, or non -current wage rates and other factual unit costs, All such contract adjustments shall be made within one (1) year following the end of the Agreement term. 2.23.ADDITIONAL TERMS AND CONDITIONS No additional terms and conditions included as part of your solicitation response shall be evaluated or considered, and any and all such additional terms and conditions shall have no force or effect and are inapplicable to this solicitation. If submitted either purposely, through intent or design, or inadvertently, appearing separately in transmittal letters, specifications, literature, price lists or warranties, it is understood and agreed that the General Conditions and Special Conditions in this solicitation are the only conditions applicable to this solicitation and that the Proposer's authorized signature affixed to the Proposer's acknowledgment form attests to this. If a Professional Services Agreement (PSA) or other Agreement is provided by the City and is expressly included as part of this solicitation, no additional terms or conditions which materially or substantially vary, modify or alter the terms or conditions of the PSA or Agreement, in the sole opinion and reasonable discretion of the City will be considered. Any and all such additional terms and conditions shall have no force or effect and are inapplicable to this PSA or Agreement. 2.2 4.ATTACHMENTS TO REF A.Exhibi.t 1: Third Party Claim Administration Contract with current Claim Administrator, Gallagher Bassett Services, Inc. (Gallagher); and B.Exhibit 2: Labor Agreements with the following: 1 (a) Fraternal Order of Police (FOP): 1(b) International Association of Fire Fighters (IAFF) ; 1(c) American Federation of State, County and Municipal Employees 79 (AFSCNIE): 1(d) American Federation of State County and Municipal Employees (AFSCNIE), All attachments can be found in the Header Section of this Solicitation. Page38of65 605386 3. Specifications 3.1. SPECIFICATIONS/SCOPE OF WORK 3.1BACKGROUND The Department of Risk Management (Risk Management) provicles optimum service to employees and the public through a variety of interrelated health, safety and liability/loss control programs, The provision of these crucial prevention -oriented programs greatly enhances the working environment and serves as an incentive for employee recruitment, retention ancl satisfaction, while protecting the City's assets, employees and citizens. Its objectives include goals to eliminate, where possible, the threat of accident and other forms of liability, and where it is passible to eliminate the risk, to at the very least, reduce the possibility of an accident or risk occurring. Currently, the City has approximately 4,141 full time employees, which include Law Enforcement officers, fire personnel, solid waste collectors, parks personnel, and does not include seasonal employees. There are four (4) Labor Unions in the City; 1)Fraternal Order of Police (FOP); 2)American Federation of State County and Municipal Employees (AFSCME); 3)International Association of Fire Fighters (IAFF); and 4)American Federation of State, County and Municipal Employees 79 (AFSCME). Labor Unions represent eighty-five percent (85%) of the City's workforce. The City has created and maintains a Self -Insurance program which provides protection to the City for all property and casualty loss exposures, workers' compensation claims, and provides group health benefits to active and retired employees. In addition, Risk Management monitors the City's injured workers. Attention is focused in the areas of safety awareness, prevention, treatment of injured workers, rehabilitation, job placement, education, and communications with the employees and the departments, Guidelines for the treatment and care of injured employees are based on Chapter 440, Florida Statutes, which governs the State's requirements for the provision of Workers' Compensation benefits. However, as a result of bargaining agreements, additional benefits may be due depending on the bargaining unit. The Successful Proposer(s) must become familiar with the existing labor agreements (attached in the Header Section of this Solicitation). The City's current Third Party Claims Administrator, Gallagher Bassett Services, Inc. (Gallagher), utilizes Risx Facs claim processing system where all data is maintained, updated, and payments are issued, The adjudication of workers' compensation medical bills and payments to the City's providers are performed through this system. Claims administration under this RFP, will include the takeover of current claims from Gallagher. The City seeks a Claims Administrator to provide the best quality claims services and the most reliable and valid data possible using the most useful, user-friendly claim systems available, The City uses in-house counsel on all litigated claims, as necessary. Risk Management works closely with the City's Attorney Office in a best -practices approach to manage litigated claims, The City is focused on the management of all claims, but has a laser focus on Workers Compensation claims as they represent approximately 80% of the City's annual claims cost. A Return to Work program is being implemented as the City recognizes that prompt return to work aids in controlling claims costs, Individual department heads are directly responsible for claims occurring in their departments, as claims cost are allocated by department. Therefore, each department is highly motivated to support effective loss control, safety, and liability and workers compensation claim management. Page 39 of 65 605386 The City utilizes a 24/7 claims intake center. This type of system facilitates expedited handling, in order to process and close claims in the most efficient manner, for the benefit of the employees. Due to the City's Fire and Police operations, the City has devoted significant resources and has been and remains focused on managing presumption -related Workers Compensation claims. The City has never lost a litigated presumption case, and the rate of presumption claim denial is eighty-five percent (85%). Close attention is also paid to closure rates and sound reserving practices. The partnership between Risk Management, the City's legal department, and outside counsel where needed, is unique and also quite effective. Case law is closely monitored and utilized to most effectively handle each situation. The City experiences approximately 756 claims per year on average. The ratio of medical only to loss time case is 40:60, i.e. forty percent (40%) medical only, and sixty percent (60%) loss time, 0f the approximate 4,141 full-time City employees, the following generally represents the location of their residences: REGION 1 REGION 2 COUNT (") Broward FL 606 Collier FL 1 Lee FL 2 Leon FL 1 Martin FL 1 Miami -Dade FL 3509 Palm Beach FL 16 Seminole FL 1 St, Lucie FL 3 Bronx FL 1 The City is soliciting for two (2) Category of Services: Part I - Workers' Compensation Claims and Liability Claims Administration: and Part II Managed Care/Medical Bill Review. Proposers may submit a proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration, and/or Part II - Managed Care/Medical Bill Review. Proposals will receive a separate score, in each Category of Service for which a proposal is submitted. Proposals will be ranked on a Category of Services basis. For example, proposals submitted for Part I, Workers' Compensation Claims and Liability Claims Administration, will only be ranked against other proposals submitted for the Workers' Compensation Claims and Liability Claims Administration. 3.2 CITY'S CLAIM EXPERIENCE Below is the City's Claims experience by years: Page 40 of 65 605386 Table No. 1 Policy Year GL Auto BI/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 300 355 113 8 821 42 1639 10/1/11 - 9/30/12 410 421 84 2 748 39 1704 10/1/12 - 9/30/13 419 433 87 0 795 34 1758 10/1/13 - 9/30/14 412 355 109 3 680 26 1585 10/1/14 - 0/30/15 351 270 68 1 765 14 1469 2010 - 2014 (Average) 378 367 92 4 762 31 1633 Table No. 2 Policy Year GL Auto BI/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 $566,237 $659,129 $201,201 $818,715 $6,848,127 $2,490,514 $11,383,923 10/1/11 - 9/30/12 $712,157 $1,725,636 $147,499 80 $6,215,610 $235,809 S9,036,711 10/1/12 - 9/30/13 $1,154,438 $707,976 $134,866 50 $6,666,574 $512,050 $9,175,903 10/1/13 - 9/30/14 $664,788 $610,034 5218,272 $38,000 $6,435,261 $331,468 $8,297,820 10/1/14 - 9/30/15 $546,951 $1,052,972 $122,527 $1,000 $4,773,880 $101,680 $6,599,010 2010 - 2014 (Average) $728,914 $951,1.49 $164,873 $164,420 $6,187,890 $734,304 $8,898,673 Table No. 3 Policy Year Indemnity Medical Total 10/1/10 - 9/30/11 447 374 821 10/1/11 - 9/30/12 444 304 748 10/1/12 - 9/30/13 549 246 795 10/1/13 - 9/30/14 445 235 680 10/1/14 - 9/30/15 504 261 765 2010 - 2014 (Average) 478 284 762 3.3 PART 1 - WORKERS COMPENSATION CLAIMS AND LIABILITY CLAIMS ADI4IINISTRATION 3.3.1:WORKERS COMPENSATION CLAIMS ADMINISTRATION The Successful Proposer(s) shall be responsible for performing at a minimum, the following services: 1, Establish reporting procedures which are compatible with the needs and organizational structure of the City as determined by Risk Management. Notice of injury report will be submitted by the City, to the Successful Proposer in paperless format (i.e. internet or email). 2. Establish claims acknowledgement procedures to the City's satisfaction. 3. Provide all necessary forms and instructions for use. Such forms shall include appropriate first reports of injury with mailing address of claim administrator pre-printed thereon. These forms shall be provided electronically if requested. The cost of providing these forms shall be included within the proposed price. 4. Develop a cost effective staffing structure to include the number of adjusters, designated to appropriately Page 41 of 65 605386 handle the City's claims. The City reserves the right to negotiate and approve the final staffing plan and any cost associated with the changes. In addition, the City will have the right to request removal of personnel assigned to the City's Agreement. Removal will take effect within thirty (30) days of written request by the City. 5. Provide a dedicated Claims Supervisor to be assigned exclusively to the City's contract. 6. Receive and examine on behalf of the City all reports of employee injury claims. 7, Establish and maintain complete files on each claim. 8. Accept or deny all reported claims for employees' injuries on behalf of the City in accordance with the applicable workers compensation law. The decision to controvert a claim must first be discussed with and approved by Risk Management and/or the Office of the City Attorney. 9. Conduct the required investigations deemed necessary, as it relates to Workers Compensation, including scene investigations, and personal claimant contact on all lost time or light duty cases. Contact with claimants must be attempted within twenty-four (24) hours of the Successful Proposer's receipt of the claim, Field investigations and claimant contact must be performed by employees of the Successful Proposer, Independent adjusters shall not be used to provide this service. 10, Perform job site visits, to become familiar with exposures unique to the City, 11. Provide a report to the City's Project Manager, every thirty (30) days, indicating all employees who are losing time or working in a light duty or restricted capacity. 12. Submit a full summary to Risk Management andlor the office of the City Attorney [where legal review or litigation has commenced', every ninety (90) days. on all claims of the following types; a.any claim in which an employee is not working full duty; b.total incurred claim value exceeding $2,000; c.potentially controverted cases; d.cardiovascular claims; and e.claims in which settlement (washout) is recommended. 13, Prepare, and maintain files necessary for legal defense of claims and/or other litigation (such as actions for subrogation), or other proceedings. 14. Pay in a timely fashion(within 30 days) all claims and expenses from the loss fund account established by the City, which will be maintained by the Successful Proposer. Fees and civil penalties for late payments are to be paid by the Successful Proposer unless caused due to late reporting by the City. 15. Pursue all possibilities of subrogation from third parties and recovery from Special Disability Trust Fund [SDTF] and report such activities in the time, manner and method, as deemed necessary by the City and/or the Office of the City Attorney [where legal review or litigation has commencecil. 16. While the Office of the City Attorney will designate the attorney(s) that provide the defense of claims, as well as litigation strategy, the Successful Proposer shall provide the City's defense attorney(s) a complete copy of the file in question and monitor and actively participate in the activities of the City's defense attorney(s). 17. The Successful Proposershall attend Workers Compensation hearings, mediations, and pension board hearings involving work -related injuries, as requested by the City, 18. Make written recommendations to Risk Management regarding any procedures or condition that should be examined to prevent future claims, which are revealed during the Successful Proposer's investigation of a • claim. 19. Contact Risk Management by telephone on all claims where the compensability or the relatedness of the medical expenses on the claim is in question, and conduct such investigation, or such additional investigation, as deemed necessary by Risk Management or the Office of the City Attorney. Page 42 of 65 605386 20. Contact employees who experience loss time at least every two (2) weeks, for the duration of temporary tetai disability payments. When an employee is represented, the City attorney shall be contacted when appropriate. If City attorney contact is appropriate, that contact should be on a sixty (60)-day basis. 21. Report all lost time and/or questionable cases to the Index Bureau. All lost time shall be re -indexed every six (6) months. 22. Establish initial reserves within ten (10) days of the first report of the claims being reported. A11 files must be reserved adequately to extend through the expected life of the claim, Although all the necessary facts may not be available at the onset of a claim, reserves should be adjusted when medical information or investigation indicates the existing reserve is inadequate or overstated. The following factors shall be considered when establishing reserve: a.ihe injury; b.the investigation; c.meclical treatment and costs; d.projected temporary total disability benefits to be paid; e.projected permanent partial disability and impairment benefits; and f.potential use of outside experts (rehabilitation service providers, attorneys, etc.).; 23. The Successful Proposer shall review the adequacy of reserves at least every three (3) months, and document the file accordingly. 24. Present in writing all settlements to Risk Management and the Office of the City Attorney for approval, regardless of the amount. The injured employee will not be contacted regarding settlement until approval of proposed settlement is obtained from Risk Management and/or the Office of the City Attorney. 25, Follow all Division of Workers' Compensation (DWC) rules when compensation, medical, or other benefits are being controverter. The case must be discussed with Risk Management before the claim is denied and/or the Office of the City Attorney, where legal review or litigation has commenced. 26. Obtain medical reports as necessary, in such manner as approved by Risk Management and the Office of the City Attorney to determine the status of the employee's injury and to verify disability. 27. Report all claims involving a fatality to Risk Management and the Office of the CityAttorney immediately. Payments on these and all other Workers' Compensation matters shall be made in accordance with the Florida Workers' Compensation law ancl or governing contractual agreements. Periodic activity/status checks shall be performed to ensure that dependents who receive survivor's benefits are still eligible to receive them, and notify Risk Management regarding those activity checks, The Office of the City Attorney shall be notified on litigated cases, or cases where legal review has commenced. 28. Prepare and file with the appropriate State agency all applications required for the City's qualification as a self -insurer, 29. Prepare, maintain and file all records and reports as may be required by legal authorities (State, local and Federal), Attach copies of reports. 30. Prepare, maintain and file statistical information required by Workers' Compensation Rating Bureaus, including all required data necessary for the promulgation of experience modifications. 31. Review for accuracy and approve the appropriateness of State assessments, prior to the due date of the assessment. 32. Establish an interest bearing bank account to make claim, indemnity, expense, and legal payments on checks drawn from this account. It is understood that all funds in this account are City funds and shall be returned upon the City's request or the termination of the Agreement. Regarding this account, the Successful Proposer shall: Page 43of6a 605386 a.Recencile on a monthly basis, the account and provide all monthly bank statements to the City, along with a request for a deposit from the City to maintain the balance needed in the account, as determined by the City. b.Ensure that any interest earned on the account be applied to reducing the subsequent monthly deposit by the City. c.Submit a monthly statement including the following; 1. balance at inception; 0. total disbursements by date and claimant; 10. balance at closing; and iv. amount of deposit required. d.List all checks along with all statements supplied to the City. 33. Successful Proposer shall provide to the City, bank account transactions and other information, additionally or in lieu of, on-line or via other means for "real-tinm.e" access by the City 34. Ensure that all adjusters handling City's cases are kept abreast of the Workers' Compensations Statutes, DWC rules, and applicable laws. 35. Ensure that the minimum standards of performance of Successful Proposer's personnel conform to the Florida statutes and administrative rules or future changes, if any. 36. Ensure all DWC filings, including compromise settlement agreement payments, are made in a correct and timely manner, 37. Provide notification of suit being filed against the City for any reason, to the Office of the City Attorney, and to Risk Management with twenty-four (24) hours of suit being filed. 38. Aggressively pursue recoveries to the satisfaction of the City, including recoveries based on subrogation and SDTF. As regards to subrogation recoveries involving injuries to the claimant caused by third parties. the Successful Proposer acknowledges that such recoveries may include redactions in future workers' compensation benefits as provided by Florida Workers' Compensation Law based on formulas provided in Chapter 440 and case law interpreting such law, and shall be responsible for documenting and collecting such recoveries from health care providers and the claimant as mutually agreed upon by the claimant and the City upon the claimant's recovery from the third party[ies]. 39. The Successful Proposer will pursue, track, and provide quarterly reports on all SDTF, as well as subrogation recoveries in such manner as deemed necessary by the City Attorney or designee. 40. Be responsible for data integrity. This includes properly inputting all cause codes, location codes, loss description, and other claims information. If a data conversion is involved the Successful Proposer must attest to the integrity of the combined data. 41, Obtain the approval of Risk Management and/or the Office of the City Attorney [where legal review or litigation have commenced] to hire experts in connection with claims against the City, Experts include, but are not limited to, accident reconstruction engineers and experts, medical and rehabilitation vendors and private investigators. 42. Provide the means for the City to perform claims status inquiries. 43. Provide training for supervisory personnel of the City for those individuals responsible for Workers Compensation activities. 44, Comply with all applicable laws and regulations regarding the administration of Workers Compensation benefits. 45. Provide and integrate successfully, an online claims management system that interfaces with all other existing systems to be utilized in the performance of this scope of work. Page 44 of 65 605386 46. Work closely with the "safety team" to enhance the Safety Program to reduce claims on an annual basis. 47. Assist in the implementation of the City's Return to Work Program, 48. Provide to the City a performance guarantee, to be negotiated with the City. A.HEARINGS CONFERENCES/TRIALS The Successful Proposer shall ensure that the following requirements for hearing conferences/trials are followed: 1, Pre -hearing or pre-trial reports shall be submitted by the Successful Proposer to the Office of the City Attorney at least two weeks prior to the hearing conference/trial or whenever requested by the Office of the City Attorney. Periodic up-clates on ongoing litigation, as well as provision and inspection of File materials kept by the Successful Proposer by the City Attorney or designee, will be scheduled by the Office of the City Attorney as needed. 2. Reports must contain all information pertinent to the file including transcribed statements and depositions. 3. The Successful Proposer shall obtain settlement authority from the City' prior to any hearing conference/trial. 4. Any recommendations made by the Successful Proposer, pertaining to the file should be carried out or referred to Office of the City Attorney. E.REPORTJNG REQUIREMENTS 1. Successful Proposer shalt make an immediate report to the Risk Management Director or designee on: a.fatalities; and b.catastrophic occurrences with potential exposure $50,000 for more. 2. Submit "full captioned reports" within thirty (30) days of setting reserves at or above $25,000. The content of the "full captioned reports" shall include, not limited to, the following; a.coverage items; b.eniployee's background; c.dependents; d.etnployee's job description; e,occurrence; (.injury; g.mecli.cal management; h.wage and compensation rates; i,dates and periods of disability; j.rehabilitation; k,other employee benefits; i,litigation; m.index/state filings; n.subrogation; o,remarks and/or recommended actions; and p.strategy for resolution. 3. Submit "full -captioned report" on all files in litigation. Provide copies of all pleadings along with the report. 4. Ensure that follow-up reports are received within ninety (90) days of the "full -captioned report", 5. Submit monthly experience/statistical reports which shall include, but are not limited to, a summary of experience by department stating cause of accident, frequency and cost, Open and closed claims shall include specific information on the accident date, claimant's name, cause of accident, injury type, amount paid and reserved, and state if the claim is open or has been finalized. These reports must be delivered by the 10th of each month, and must provide summary information by department, by participant, and by total program. Page 45 of 65 605386 6. Become familiar with existing labor agreements, and report all activities pursuant to those Agreement to the Risk Management Director or designee as requested, at Ieast on a monthly basis, or as required by the City, 7, Provide the necessary reports and/or data to satisfy Florida's self-insurance requirements. Required forms shall be completed by the Successful Proposer and sent to the City for review and appropriate signatures. Required self-insurance reports shall be provided on a timely basis so that the City will have sufficient time to review and execute the documents before the due date, 8. Provide any report(s) requested by the Risk Management Director, Successful Proposer's system shall have the ability to run ad hoc queries. C. "BAD FAITH" PROCEDURES The following procedures shall he followed to avoid potential actions for breach of good faith and fair dealings: 1. Termination of weekly benefits: Weekly benefits may be terminated only upon written or verbal notification by the treating physician or the City when employee returns to work. If return to work information is obtained verbally, the Successful Proposer must follow up in writing with a request for written verification. If treating physician releases the employee to modified work, the Successful Proposer must promptly determine if modified work is available and offered to the employee before benefits are terminated. 2. Controverting claims: The Successful Proposer shall contact the City prior to formally denying a claim. This will not be necessary when controverting the reasonableness and necessity of medical bills. 3. Judgments/settlements: Judgments/settlements should release potential future "bad faith" actions. 4. Penalties and fines: Penalties and fines assessed by the DWC shall be paid by the Successful Proposer if such fines and penalties result from negligent performance of its duties D, PERFORMANCE STANDARDS: WORKERS' COMPENSATION 'The City performs annual performance standards audit based on the following: 1. Successful Proposer will document all new claim information received front the City, and this information will he available within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business clay, if received less than one (1) hour before the close of a business day. File shall include First Report of Injury form, 2. A minimum of "three (3) attempts" by the Successful Proposer, to contact the appropriate parties, will be considered a "contact", if followed with the appropriate correspondence within the measurement period, For a workers' compensation claim, three (3) point contacts will be required (cla.i.mant, supervisor and treating provider). For a liability claim, two (2) point contacts will be required (claimant and reporting City Supervisor, if applicable). 3. Successful Proposer shall document, and provide Risk Management written notice of,subrogalion, contribution, and/or coordination of benefits recovery potential, as they develop. If a Successful Proposer decides not to pursue any such recovery, Successful Proposer must give written notice to Risk Management of its decision within fourteen (14) days of claim receipt. - 4. For Workers' Compensation claim, within fourteen (14) days of receipt of the claim, the claims adjuster will perform a three point contact, send appropriate notification packages to the claimant, as required by Chapter 440, review the claimant's pre -employment physical, and document the Successful Proposer's analysis of the compensability of the claim. Page 46 of 65 605386 For liability claims, within fourteen (14) days of receipt of the ,claim, the Successful Proposer will document appropriate specific directions for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim, initial reserves for the file will be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a.30 days from 72 hour review; b.30 days from 30 day review; c.60 days from last 60 day review; and d.Every 6 months thereafter, Increase or decrease of reserves by $10,000 or more, requires notification to Risk Management. Subsequent to notification, Risk Management reserves the right to discuss the case and request a reconsideration of the reserve of the Successful Proposer. 6.Successful Proposer shall "address" litigation within two (2) days of receipt of litigation notification, or less than two (2) clays as requested by the Office of the City Attorney if a shorter deadline is deemed legally necessary by the Office of the City Attorney. This will mean notice of to Risk Management, and referral to the Office of the City Attorney for assignment, within two (2) days, or perhaps less than two (2) days, if requested by the Office of the City Attorney. 7. Required status reports shall be provided to the Risk Management Administrator or designee. Required status reports are outlined in Attachment A, Proposer Supplemental Questionnaire. 8. Settlement evaluation shall be provided to the Office of the City Attorney and Risk Management 30 clays prior to mediation. The Successful Proposer shall evaluate, ar cause, a third party expert, as deemed necessary, to evaluate the need for a Medicare Set Aside [MSA], and this shall be determined and documented in all settlement evaluations, 9. File/System documentation shall include documentation of return phone calls to injured worker and the City within twenty-four (2 I) hours or the next business day. 10. File/System documentation shall include documentation that referral appointment was made for a claimant to a network provider specialist (i.e.; Diagnostic testing, Neurologist, Orthopedic) so that claimant was seen by specialist within two (2) weeks of the date of receipt of the referral from the primary treating physician, unless it is clearly documented that, despite Successful Proposer's best efforts, no specialist was available to see claimant within the requisite two weeks period. 3.3,2:LIABILITY CLAIMS ADMINISTRATION Upon receipt of all liability claims, the Successful Proposer, on behalf of the City, shall perform, at a minimum, the following services: 1. Review all first notices of claim reports received from the City, which will consist of lass reports, claim letters and suits, or claims that are phoned, mailed, or faxed in by the City, prior to an assignment to the Successful Proposer's adjuster, approved by the City, 2. Designate the necessary number of outside field adjusters to handle all City claims and also designate an alternate in their absence. The designation of these persons is subject to the approval of the City. Page 47 of 65 605386 3. Conduct a thorough and complete investigation of the accident, according to the requirements of the City. Investigations shall include, but not limited to, the following: a)Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the Successful Proposer. In the case of underrepresented claimants, personal contact is required the same day We claim is received. All claim files must contain adjuster's logs documenting all contact and activity, b)Obtain recorded statements from the claimant, witnesses, and the City personnel. Personal contact of all underrepresented claimants by outside adjusters is required. c)Complete a timely scene investigation consisting of photos and diagrams. This is required within two (2) days of receipt of any serious AL or GL, claim assignment, d)Obtain the police and/or fire rescue report. e) Obtain and review all medical reports and bills submitted by the claimant or their attorney. f)Obtain and review all estimates and appraisals for property damage claims. g)Establish appropriate reserves on all claims, and revise the reserves as needed, h)Submit a report to the City within 30 days of receipt of the claim, summarizing: i,Date/time/location of loss; ii.Claimant information; iii.Description of accident; iv.Injuries or damages; v.Witnesses' version; vi.Liability analysis;and vii.Evaluation of claim (i.e, amount of recommended settlement, denial, reserves, attorney demand), If a settlement recommendation cannot be made at this initial report (due to lack of information), indicate same and reason, However, remainder of investigation should be completed. 4. Submit a status report every 90 days thereafter to the City until the claim is resolved. The City prefers the above reporting requirements to be accomplished via the on-line claims management system for "real-time" viewing. 5. The Successful Proposer has the authority to settle cases on behalf of the City up to $3,000 per claim for property damage and $3,000 for bodily injury. For any settlement in excess of the above, the Successful Proposer must receive authorization from the City. The request for this authorization must be presented in writing, including the adjuster's evaluation and recommendation in a format required by the City. After authorization is granted, the Successful Proposer will settle the claim and obtain the appropriate release. Additionally the Successful Proposer shall provide a quarterly report to the City on all settlements above and below $10,000, 6. The City will assign an attorney for the legal defense of any claims that goes into suit. The Successful Proposer will assist the City's attorneys with any additional investigations, as deemed necessary by the City or its attorneys. The Successful Proposer will continue to monitor the file in litigation.Successful Proposer will provide a monthly report of all litigated claims in the format specified by the City. 7. Upon notification from the City, the Successful Proposer shall forward a copy of the file in suit, to the City's attorney with a transcription of all settlements. 8. The Successful Proposer shall attend all mediations and trials as requested by the City. With respect to claims with impending trial elates, the designated Successful Proposer's Supervisor or designee, shall take an active and aggressive role in settlement or preparation for trial. 9. The Successful Proposer, after approval of the City, can assign the necessary auto appraiser for properly damage claims. These expenses shall be paid as an allocated expense by the Successful Proposer from the City's loss fund. Page 48 of 55 605386 10. Any other claim expense must be approved by the City prior to being incurred, However, expenses for normal claim activities, such as photographs, tapes, supplies, postage, etc., are the responsibility of the Successful Proposer. 11. The Successful Proposer shall meet quarterly (or more frequently if required by the City) with the City Manager, and/or authorized representative, to review all large exposure (over $25,000) incurred cases and report on their status. 12. All claim files are at all times the property of the City. The City has the right to inspect any and all files whenever the City deems necessary. If the Agreement is terminated, the City will receive all original claim files. 13. The Successful Proposer shall make recommendations to the City as to actions that can be taken to prevent future claims. These loss prevention recommendations can be included in the status report. 14. Ail work must be performed by the employees of the Successful Proposer. The use of any contracted or independent adjuster is prohibited, unless prior approval is granted by the City. 15. The Successful Proposer shall reimburse the City far payments made in error that are non -recoverable from third parties by the Successful Proposer. 16. The Successful Proposer shall provide to the City a performance guarantee, to be negotiated with the City in the provision of Managed Care/Medical Bill Review (Part II services) as cited herein, to improve its effectiveness and efficiency while maximizing City resources. 17. The Successful Proposer shall continue to monitor the file in litigation, and obtain updates from the City Attorney's office, in an effort to prepare reports to the City's excess carriers as required. A.PERFORMANCE-STANDARDS: LIABILITY The City performs annual performance standards audit based on the following: 1. Successful Proposer shall document all new claim information received from the City, and this information will be available electronically within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one {1) hour before the close of a business day. File will include First Report of injury form. 2. A minimum of "three (3) attempts" by the Successful Proposer's ciainhs adjuster to contact the appropriate parties will be considered a 'contact'',if' followed up with appropriate correspondence within the measurement period. 3. Successful Proposer shall document, and give City's Project Manager, written notice of, subrogation, contribution, and/or coordination of benefits recovery potential. If Successful Proposer decides not to pursue any such recovery, it must give written notice to Risk Management of its decision within fourteen (14) days of claim receipt. 4. For liability claims, within fourteen (14) days of receipt of the claim, the Successful Proposer shall document appropriate specific direction for the investigation and handling of the case. 5, Within 72 hours of receipt of the claim, initial reserves for the file shall be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a.30 days from 72 hour review; b.30 days from 30 day review; c.60 days from last 60 day review; and cLEvery 6 months thereafter. 6. SuccessfuI Proposer shall "address" litigation within two (2) days of receipt of litigation notification. This will mean notice to Risk Management, and referral to the City Attorney's office for assignment, within two (2) days. 7. Required status reports are outlined in Attachment A, Proposer Supplemental Questionnaire. Page 49 of 65 605386 The City desires prompt, personal contact of all claimants. Evaluations of each claim shall be made as soon as the necessary information is received by the Successful Proposer, The investigation and evaluation of all claims should be completed prior to suit being filed, since F.S. 768.28 (sovereign immunity statute) requires the claimant provide six months' notice of intention to file suit. The Successful Proposer must have up-to-date policy and procedure manual(s) on hand in the work place. These manual(s) shall describe and discuss the day to day procedures for adjusting files, and shall be kept in accordance with statutory requirements. The Successful Proposer shall provide adequate toll -free telephone access to the claims office. The Successful. Proposer shall provide claims personnel, who shall be available on a 7 clay, 24 hour basis, for investigating claims, and must have an maintain an 800 or toll -free number for emergency service. The Successful Proposer shall provide its own office space or facility(s) for its adjuster or staff of adjusters. The Successful Proposer must agree to be responsible to manage liability claims to be opened within the year(s) following contract execution, along with the current inventory of open files. The Successful Proposer shall provide claims administration on a "life of relationship basis." 3.5 STAFFING, QUALITY CONTROL, AND SUPERVISION The Successful Proposer shall render high -quality claims:management and adjusting services throughout the term of the Agreement. The Successful Proposer's personnel shall have, as a minimum, the following levels of experience and licensing: 1. Supervisor or Supervising Adjuster shall have five to seven (5-7) years of related experience: 2. Adjusters shall have three (3) years of experience: 3. Medical -only processor(s) shall have one (1) year of experience, and must hold a current Florida Adjuster License; 4. The Successful Proposer's files must reflect evidence of supervisory direction and involvement at every level. All files must be kept current. File review should be performed on 30, 60, 90 or 120 clay cycles, as appropriate. Periodic review by the handling adjuster and all supervisors should be reflected in the file. 5. Successful Proposer's Supervisors shall receive all First Reports of Injury and outline investigative needs for the adjusters to follow through. Supervisors should assign the most difficult files to the most qualified adjuster. 6. Successful Proposer shall perform monthly claims review with Risk Management, to include the adjusters, and City Attorney. 7. It is the City's claims management philosophy that the proper and most. cost-effective method to handle claims and thereby reduce and control the City's self -insured loss payments, is to ensure the Successful Proposer hires and retains the appropriately qualified professionals to handle the City's claims. Additionally, the adequate number of adjusters and a manageable caseload enables qualified adjusters to perform the required services, The City therefore requires that the Successful Proposer agree to staffing, qualifications, and caseload criteria established by the City, 8. The City reserves the right to the final prior approval of the hiring and/or assignment of the claims manager, supervisors, and adjusters that will handle the City's claims. 9. The Successful Proposer agrees to add staff as necessary, to maintain these maximum pending caseload levels. The Proposer in its response to the RFP, must explain how its office or unit will be staffed, and the level of supervision that will be provided. Page 50 of 65 605386 10. Claims personnel must be employees of the Successful Proposer. The use of independent adjusters, sub contractors, or temporary adjusters will not be acceptable without prior approval of the City. Successful Proposer's Adjuster trainees are not acceptable for handling of the City's claims. The Proposer must submit with its proposal, the resumes of all claims professionals specifically to be assigned to this account. All Successful Proposer's claims professionals must possess a current Florida adjuster's license. 11. In addition to those services previously discussed, the Successful Proposer will additionally perform the following related services: a.State required filings; b.Loss fund management; c.Computer generated Loss runs and other management reports, preferably on-line; and d.Provide en annual SAS 70 audit report. 12. The Successful Proposer shall have the ability to provide full customer service to English, Spanish, and Haitian -Creole speaking individuals, when needed, 13. The Successful Proposer shall make available to the City an individual with management authority to meet with the Risk Management Director, or the designee, upon reasonable notice. This individual shall have the authority to make "agreed to changes." The Successful Proposer's employees shall meet with Risk Management on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be given by Risk Management to allow adequate preparation and data collection. The Successful Proposer's personnel, including the adjuster or Supervisor, roust also be available to attend mediation conferences, as necessary. 3.6 PART II: MANAGED CARE/MEDICAL BILL REVIEW/AUDIT SERVICES The City supports management of the medical component, which is key to returning employees back to work and facilitation of Workers' Compensation claim resolution, The City has the following expectations relating to medical: •A provider who actively and aggressively manages medical, .A network of physicians specializing in Return to Work •A claims management team approach whereby the team understands and works as partners in the RTW/Transitional-duty efforts, The City is very interested in the Successful Proposer's philosophy an utilization of TCM & FCM within their claims management model with the understanding that the City may elect to use a separate managed care vendor, The City's current Claims Administrator (Gallagher), utilizes on-line claims processing system where all data is maintained, updated, and payments are issued. The adjudication of Workers' Compensation medical bills and payments to the City's providers are performed through this system. On a monthly basis, Gallagher provides the City with a bank reconciliation report to interface with the City's financial system, The Successful Proposer shall be responsible for the provision of an on-line claim processing system and the conversion of any data necessary for successful integration with arty and all other systems, including following the termination of the Contract. Any procedures, equipment, and/or costs necessary to connect with Gallagher's hardware and software, shall be the sole responsibility of the Successful Proposer. A. MANAGED CARE SERVICES The Successful Proposer shall render high -quality claims management services throughout the entire Contract term. The Successful Proposer's personnel shall have, as a minimum, the following levels of experience and licensing: a)Supervisor shall have five to ten (5-10) years of relevant experience; Page 51 of 65 605385 b)Nurse Case Manager shall have five to seven (5-7) years of relevant experience; c)Account Representative shall be fully qualified and responsible for the performance of Provider's responsibilities under the Agreement. The Account Representative's responsibilities include, but are not limited to: i.Act as Successful Proposer's representative on any claims issue or problems; ii.Act as a liaison between the City, medical network, Successful Proposer, and any other parties as deemed necessary by the City; and iii.Participate with and assist the Risk Management in the performance reviews, as required under the Agreement, and review other claims as requested by Risk Management under the Agreement. d)The Successful Proposer's files must reflect evidence of supervisory direction and involvement at every level. All files must be kept current. File review should be performed on 30, 60, 90, 120 day cycles as appropriate. Periodic review by the handling Nurse Case Manager and Supervisors should be reflected in the file, e)Successful Proposer's Supervisor(s) shall receive all First Report of Injury and outline investigative needs for the Nurse Case Manager to follow through. Supervisor(s) should assign the most difficulty files to the most qualified Nurse Case Manager. OSuccessful Proposer shall perform monthly claims review with Risk Management, to include the adjusters, Risk Management and City Attorney. g)The City reserves the right to the final prior approval of the hiring and/or assignment of the Nurse Case Manager, and Supervisor(s) to handle the City's claims, h)The Successful Proposer agrees to add staff, as necessary, to maintain the maximum pending caseload levels. The Proposer, in its response, shall explain how its office, or unit will be staffed, and the level of supervision that will be provided, i)Claims personnel must be employees of the Successful Proposer. The use of Nurse Case Manager, subcontractor, or temporary Nurse Case Manager,will not be acceptable without prior approval of the City. The Proposer must submit with its proposal, the resumes of all Proposer's claims professionals specifically to be assigned to this account. All claims professionals must possess a current Florida adjuster's license. j)The Successful Proposer shall have the ability to provide full service to English, Spanish, and Haitian - Creole speaking indivicluals, when needed. k)The Successful Proposer shall make available to the City, an individual with management authority, to meet with Risk Management Director or the designee upon reasonable notice, This individual shall have the authority to make "agreed to changes." The Provider will meet Risk Management or the designee on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be given to allow adequate preparation and data collection. The Successful Proposer's personnel, including the Case Manager or supervisor, must be available to attend mediation conferences as necessary. B. MEDICAL BILL REVIEW AND AUDIT SERVICES Proposers are requested to provide the following medical bill review and audit services: A)Medical Bill Review; 1. Promptly review medical/surgical bills (in and out of network) for accuracy, including, but not limited to, as they relate to the following: a) Duplicate billings; b) Unbundling of charges; c) Up -coding of charges; and d) Approval and appropriate pre -certification Page 52 of 65 605386 2. Review all medical bilis that: a)Are not subject to fee schedule coding; b)Are for services not specifically addressed in the fee schedule; c)Need an in-depth medical interpretation of the rules and regulations; ancl d)in the exercise of professional judgment, specifically warrant review 3. Process, pay, and mail bills within 20 days of receipt. 4. Reimburse the City for any overpayments made in the bill review process, within 30 days of identification of overpayment. Reimburse the City for any penalties ancl/or interest associated with inaccurate payments. B)Medical Auditing Services: 1. Audit -in network and out -network hospital/provider bills: a)Exceeding $5,000; b)Where a departmental charge exceeds 10% of the total bill, excluding room and board charges; and c)Others at the Successful Proposer's direction or specific request by the City for accuracy and appropriateness. 2, Develop and follow written policies on how late charges, no show charges, and special arrangements shall be handled. 3.Develop and provide communication materials to explain the policies and procedures of the Medical Bill Review and Audi Services to the City of Miami's Medical providers. 4. Process, pay and mail bills within 20 days of receipt. 5. Develop and follow written grievance procedures for provider concerns. C. PHARMACEUTICAL MANAGEMENT SERVICES The City currently uses Cypress Care PBM services for claims that are administered in-house, The City desires to retain this relationship, Successful Proposer shall pursue subrogation recoveries pursuant to Workers Compensation lien recovery settlement agreement. Details regarding the PBMS's services should be provided, including access, utilization review services, coordination of claims data and reporting, Some physicians were dispensing drugs directly to injured workers; the City's current Claims Administrator (Gallagher), has taken steps to curtail excessive costs, and will reprice the prescriptions. Fees for pharmaceuticals or pharmaceutical services shall be reimbursable at the applicable fee schedule amount (F.S> 440,13(12c), except where the employer/carrier has contracted for a lower amount. Where the employer/carrier has contracted for such services and the employee elects to obtain them through a provider not a party to the contract, the reimbursement shall be at the scheduled, negotiated, or contract price, whichever is lower. Successful Proposers are requested to address the issue of physician dispensing and the high cast of repackaged drugs. D. LOSS CONTROL SERVICES When requested by the City to do so, the Successful Proposer shall consult with the City, its employees, agents and others, concerning workplaces, operations, work procedures, and equipment owned or operated by the City, and make recommendations to the City regarding same, for the purpose of establishing toss control systems to mitigate and/or control losses, damage, and claims; provided, however, it is understood and agreed, that neither the rights of Page 53 of 65 605386 the Successful Proposer to make inspections, nor its recommendations or reports as to loss control, shall constitute an undertaking on behaIf of, or for the benefit of the City, or its employees or others, to determine, warrant, or guarantee that such work places, operations, procedures, or equipment are free and safe from defects and/or hazards. E. IRS FILING REQUIREMENTS OF CLAIMS ADMINISTRATOR (SUCCESSFUL PROPOSER) The Successful Proposer shall: 1. Furnish required tax information for the Internal Revenue Service including 1099s with a copy of the 1099s submitted to the IRS. 2. Prepare, maintain and file all records and reports as may be required by legal authorities (State, local and Federal) , 3. Prepare, maintain and file statistical information required by the Division of Workers' Compensation and Rating Bureaus, including all data necessary for the promulgation of experience modification, and as required by any other legal entity(s). F. STATE REQUIRED FILINGS At a minimum, the Successful Proposer shall be required to provide the following services: 1. Prepare and file, on behalf of the City, with the appropriate state agency, all applications required for the City's continued qualification as a self -insurer, Prepare, maintain, and file all records and reports, as may be required by legal State or Federal. 3. Prepare, maintain, and file statistical data, records, or reports, as required by excess insurers, City actuaries, and the State. 4. Prepare, maintain, and file statistical information required by worker's compensation rating bureaus, including all data required for the promulgation of the City's experience modification and state assessment. 5. Prepare and file any other reports as required by the City and the State relating to claims experience, payments, etc. (such as DWC-51, etc.) G. LOSS FUND MANAGEMENT 1. The Interest Bearing Account will be maintained at the City's commercial. banking institution. The account will be classified as part of the analysis group of the City's accounts. The City will pay all service fees that are normal and customary in this account, All interest earned or service credits generated will accrue to the benefit of the City. 2. The Successful Proposer is required to follow Florida law concerning public deposits, Specifically, the Successful Proposer shall adhere to F.S. 237.211(6) and F.S. 280 Security of Public Deposits. Failure to comply with these laws is sufficient cause for the City to terminate the Agreement with the Successful Proposer. 3. All claims, expense and legal payment will be made by the Successful Proposer on checks drawn on an Page 54 of 65 605386 account set up by the Successful Proposer, and funded monthly by the City. It is understood that all funds in this account are City Funds, and shall be returned to the City upon request or at termination of the contract. The Successful Proposer is responsible for the monthly reconciliation of this account and shall provide bank statements to the City monthly, along with a request for a deposit from the City to maintain the monthly balance in the loss fund, as determined by the City. 5, The monthly reconciliation statement submitted by the Successful Proposer to the City shall, at minimum, include the following; a.Balance at inception of statement period; b.Total disbursements which cleared, by date and claimant/payee; c.Bala.nce at close of statement period; d.Amount of deposit required; and e.A list of all checks shall be submitted on a monthly basis. H. COMPUTER LOSS INFORMATION All charges related to these services are to be included in the annual claims administration fee, Any costs associated with programming changes that are necessary to create a report required by the City are the responsibility of the Successful Proposer. In its proposal, Proposer should indicate any fees to be charged for the creation of any special reports requested by the City, as necessary. All reports currently provided to the City are required from the Successful Proposer. 1. Successful Proposer must ensure conductivity with the current system and software used by Risk Management and the Department of Finance, and all other involved departments. Successful Proposer shall continue to ensure, at its cost, that its system remains a viable solution for on-line claims administration, should the City upgrade or replace any aspect of its risk and/or financial system throughout the terra of the Contract. 2. All claims data is the property of the City and any data and media will be provided to the City upon request and/or upon termination of the contract All computer notes will be printed out and placed in the files prior to file transfer to a successor Claims Administrator. 3, The Successful Proposer, at its own expense, shall ensure all claims and payment data is included in their loss runs, by a date as determined by the City. Historical data from the current Claims Administrator's database cannot be purged. Claims data for all open and closed claims must be transferred. 4. Loss runs shalt be provided by the Successful Proposer, on a monthly basis, sorted separately by line of coverage (WC, GL, AL), policy year, and department/location, Loss runs should list each claim separately. Specific summary reports must also be provided. This requirement may be satisfied by utilizing the Successful Proposer's on-line system. The following reports, at a minimum, are required: a.Clairns list (lists all claims alphabetically); b.Check register; c.Cumulative report byline of coverage by year; d.Annual summary reports; e.Locatian report; (.Large loss or severity report; g.Safety report h.Excess insurance report Page 55 of 65 605386 i.Litigation report j,Legal payments report Ic.SAF 200 (OSHA log) 5. Workers Compensation claims, involving no payment or no medical treatment, are reported by the City for inclusion in the database as reporting purpose only (RPO) or first aid or no pay cases and should be identified in the system that same way. 6. The Successful Proposer shall provide the City access via internet to the system for file review, e-mail, or other purposes, at no additional cost to the City. An 800 or other toll -free number is necessary for on-line connections and faxes if the call is outside Miami -Dade County. I. FEE BILLING The City desires to pay claims administration fees monthly in arrears for claim files established in the previous month, A summary invoice should be broken down by line of coverage and tie to month -end figures as shown on the loss runs. Page 56 of 65 605385 4. Submission Requirements 4.1. CMIA Submission Requirements 4.1. SUBMISSION REQUIREMENTS The following documentation shall he included, as a minimum, in the Proposal and submitted to the City. Instructions to Proposers: Proposers should carefully follow the format and instructions outlined below, observing format requirements where indicated. Proposals should contain the information itemized below and in the order indicated. This information should be provided for the Proposer for the work contemplated by this RFP. Proposals submitted which do not include the following items, may be deemed non -responsive, and may not be considered for contract award. ALL RESPONSES WILL BE SUBMITTED IN HARD COPY FORMAT ONLY TO INCLUDE ONE ORIGINAL AND SIX (6) COPIES, NO ON-LINE SUBMITTALS WILL BE ACCEPTED. The response to this Solicitation shall be presented in the following format. Failure to do so may deem your Proposal non -responsive. Proposers may submit a Proposal for either Part 1: Workers' Compensation Claims and Liability Claims Administration, and/or Part II - Managed Care/Medical Bill Review,Proposers must clearly indicate for which Part(s) Proposer is submitting its Proposal for, and must provide all of the following for each Part, in addition to the Supplemental Proposer Questionnaire (Attachment A), which is attached in the Header Section of this Solicitation. Proposals will be ranked on a Category of Services basis. For example, Proposals submitted for Part I, Workers' Compensation Claims and Liability Claims Administration, will only be ranked against other Proposals submitted for the Workers' Compensation Claims and Liability Claims Administration. 1. COVER PAGE The Cover Page should include the Proposer's name; Contact Person for the RFP; Firm's Liaison for the Contract; Primary Office Location; Local Business Address, if applicable; Business Phone and Fax Numbers; Title of RFP; RFP Number; Federal Employer Identification Number or Social Security Number. 2. TABLE OF CONTENTS The Table of Contents should outline, in sequential order, the major sections of the proposal as listed below, including all other relevant documents requested for submission. All pages of the proposal, including the enclosures, should be clearly and consecutively numbered and correspond to the table of contents. 3. EXECUTIVE SUMMARY A signed and dated summary of not more than two (2) pages containing the Proposer's Qualifications and Experience, Ability to Perform Required Services, and Overall Approach and Methodology to Scope of Work as contained in the submittal. Include the name of the organization, business phone and contact person. Provide a Page 57 of 65 605386 summary of the work to be performed by Proposer. Proposer must meet all requirements and/or criteria in Section 2.6, Minimum Qualification Requirements, and elsewhere in the RFP, including responding to and the following information in Sections 4 through 9, and providing all documents as required, with Proposer's response to this RFP. Attachment A, Proposer Supplemental Questionnaire must also be completed in its entirety. Failure to comply with the above, may deem your proposal non -responsive. 4.PROPOSER'S GENERAL EXPERIENCE, PAST PERFORMANCE, AND EXCEPTIONS 1) Describe the Proposer's past performance and experience and state the number of years that the Proposer has been in existence, the current number or employees, and the primary markets served. 2)List all contracts which the Proposer has performed for the City of Miami, describe all work performed for the City and include for each project: (i) name of the City Department which administers or administered the contract, (ii) description of work, (iii) total dollar value of the contract, (iv) dates covering the term of the contract, (v) City contact person and phone number, (vi) statement of whether Proposer was the prime contractor or subcontractor, and (vii) the results of the project. 3)Provicle information concerning any prior or pending litigation, either civil or criminal, involving a governmental agency or which may affect the performance of the services to be rendered herein, in which the Proposer, any of its employees or subcontractors is or has been involved within the last five (5) years. Provide letters of reference from law firms which currently handle your litigation. Provide contact person and phone number for each, 4)Identify if Proposer has taken any exception to the terms of this Solicitation. If so, indicate what alternative is being offered and the cost implications of the exception (s). 5. PROPOSER'S CATEGORY SPECIFIC EXPERIENCE PAST PERFORMANCE Note: Any Proposer submitting a Proposal for both categories of Service, Part I- Workers' Cornpensation Claims Administration AND Part II: Medical Bill Review and Audit Services (Part I and II) must provide in its proposal, complete and separate responses for applicable Items 5 through 15 below for each Part (Part I or II), 5)Describe Proposer's past performance and experience with regard to the particular service category (Part I anchor Part II), and state the number of years that the Proposer has worked in this area providing a similar type of service, the current number of employees working in this area, and the primary markets served, Provide organizational history and structure, and indicate whether the City has previously awarded any contracts to the Proposer (a list of these City contracts shall be provided in item 2 above). 6)Provide a detailed description of five (5) comparable contracts (similar in scope of services to those requested Page 58 of 65 605386 herein), which the Proposer has either ongoing or completed within the past five (5) years in the capacity as a Third Party Claims Administrator, The description should identify for each project: (i) client, (ii) client contact person, phone number and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Include the Proposer's role and any value added. (viii) Specify if the scheduled completion time and budgets approved by the client were met for each of the Iisted projects. Where possible, list and describe those projects performed far government clients or similar size private entities (excluding any work performed for the City). In the event that the Proposer has not performed five (5) comparable contracts in the particular category (Part I or Part II), the Proposer should provide information that demonstrated its ability to perform the required services. 7)Describe any relevant industry/subject matter expertise, including any experience in the particular services, and any unique or proprietary project methodologies relevant to the requested services. 8)Provide a list of clients that have, for whatever reason, discontinued the use of your services within the past two (2) years, and indicate the reasons for the same. The City reserves the right to contact any clients Iisted as part of the evaluation process. 9)Provicle two (2) Letters of Reference, on letterhead, from two different, similar sized governmental entities (as the City), and for which similar services (Part I or Part II) have been performed within the past five (5) years, This information is subject to verification as part of the evaluation process. 10)Provide a complete list of all current Florida clients for which Proposer administers claims in a Workers' Compensation, self-insurance, or retention program. The description should identify for each client: (i) client, and type of entity: (ii) client contact person, phone number, and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Specifically identify clients for whom a similar service has been provided, particularly to governmental entities similar in size to the City, Trust, or other similar type as the City, Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. 11)Discuss in detail Proposer's qualifications and experience to provide general Liability and automobile liability claims administration. Include, in the description, the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed. 12)Discuss in detail Proposer's qualifications and experience to provide managed care services. Include the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed, Page 59 of 65 605386 13)Provide detailed background on the Proposer's proposed Manager/Supervisor to be assigned the City's account throughout the duration of the contract term, and whether Proposer agrees to City's terms For approval of future Manager/Supervisor, should proposed representative leave Proposer's firm during the contract term. Provide copies of current applicable licenses for work to be performed in the State of Florida. 14)Describe the experience, qualifications and other vital information, including relevant experience on previous similar projects (Part I or Part II), of all key personnel, who will be assigned to the City's contract. This information shall include the functions to be performed by the key individuals, and the caseload of each person assigned to service the account. Inclucle copies of all licenses held by each individual, as all claims professionals must possess a current Florida adjuster's license. Provide copy(ies) of each adjuster's and Supervisor's Florida Adjusting License, or any other relevant licenses, if applicable. In addition, provide resumes, if available, with job descriptions and other detailed qualification information on all key personnel who will be assigned to the City contract, 15)Provicle a complete list of all licensed claim's personnel that will handle City's claims, and/or managed care services, including the Proposer's proposed Manager/Supervisor, Supervising Adjuster, Adjusters, Supervising nurse Case Manager, Case Manager, Medical -only processors, or other individuals including clerical and or support staff detailing education, experience in the area of workers' compensation claims, in the area of managed care, and type of Iicense(s). Include copies of all licenses held by each individual, Note: After qualification subtnission, but prior to the award of any contract or work order issued. as a result of this REP, the Proposer has a contintting obligation to advise the City of any changes, intended or otherwise, to the key personnel in its proposal submission. 6. PROPOSER'S ABILITY TO PERFORM REQUIRED SERVICES 16)Provide a complete list of all claims office locations and territory(ies) serviced with Proposer's current personnel, indicating the number of personnel of Proposer, and Proposer's ability to provide required services to the City. 17)Describe where your main office is located, and the location where the primary work will be performed. Indicate location where the Successful Proposer, the Successful Proposer's Manager/Supervisor will be located. 18)Discuss how the Proposer's office or unit will be staffed, and the level of supervision that will be provided. Discuss case assignments, including pending case load for each designated Adjuster and current number of monthly new assignments to each Adjuster, if.appl.icable. Discuss case assignments, including pending case load for each designated nurse Case Manager and current number of monthly new assignments to each nurse Case Manager, if applicable. 19)Describe how Proposer will ensure managed care services by City employees residing in Miami -Dade, Page 60 of 65 605386 Broward, Palm Beach, and Monroe Counties, among other locales. 20}Discuss whether the award of this contract necessitates an increase in Proposer's staff size to meet the City's staffing and caseload requirements, and whether staff will be in place by the start of the contract, which is estimated to be February 1, 2017. 21)Explain the percentage of time the Proposer's proposed Adjusters will be out of the office doing field work. If all of Proposer's proposed Adjusters are telephone Adjusters, indicate as such. Explain whether Proposer will utilize independent contracted Adjusters, and under what circumstances. Provide the name, address, phone, and contact person for independents you currently utilize. 22)Identify language capabilities (spoken or written) of Proposer's employees and those of the subcontractors or subconsultants. 7. PROPOSED OVERALL APPROACH TO PERFORMING THE SERVICES 23)Discuss in detail Proposer's overall approach to the work to be performed. Describe Proposer's specific project plan and procedures to be used in providing the services, and how Proposer has applied the proposed project approach in comparable contracts.\ 24)Describe Proposer's ability to perform the services described in the Scope of Services, and describe Proposer 's specific policies, plans, procedures or techniques to be used in providing the services requested. The Proposer shall describe its approach to project organization and management, responsibilities of Proposer's management and staff personnel that will perform work in this Solicitation, 25)Previde projected caseloads per employee of Proposer assigned to City account, 26)Describe Proposer's staffing plan to demonstrate that Proposer can be adequately staffed with trained personnel to handle the City's full caseload and have the capability to recruit such staff. 27)Include a statement that at east thirty (30) days prior to replacement of key personnel, Proposer will notify the City's Project Manager, in writing, that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. 28)Provide a detailed timetable identifying significant milestones for the smooth transition of the operations. Proposer shall identify the necessary support that shall be required from City staff during that transition. 29)Discuss in detail exactly how all services reflected in the Scope of Work will be accomplished. Include a complete approach Proposer will Lake to meet all responsibilities expected of Proposer by the City. Include any and ail information regarding affiliated physicians, other medical personnel, locations to provide said services, and other related information regarding the provision of such services for the City. Page 61 of 65 605386 30)Provide a description of the standard loss reports, as well as provide a sample and descriptions of any additional reports to be utilized. 31)Explain whether Proposer currently' file state and excess insurance forms on behalf of Proposer's clients, and attach copies of the forms used. 32)Describe Proposer's methodology for evaluating and determining savings as expected within this RFP. Include in detail the mechanisms Proposer would use to track whether proposed savings goal has been met, and methods to meet those goals. Indicate if Proposer is willing to accept the incentive or penalty as indicated, should savings not result. 33)ff proposed, describe in detail Proposer's computerized on-line claims management system and software to be utilized during the performance of the scope of work reflected herein. Detail functionality, transition from current system, and if a cost is proposed, indicate in Proposer's Fee Proposal. 341)Detaii any procedures, equipment, and/or costs necessary to connect with the City's hardware and software, particularly related to conductivity with Risk and Finance, at the time of this RFP and shoulct the City's system be modified or replaced during the Contract term. Should there be associated costs; indicate those costs, the reasons for the same, and who will pay those costs. Costs, if any, shall be detailed in the Fee Proposal Section, 35)Estimate Proposer's minimum start-up time from elate of contract award to the date Proposer's network would be available to Risk Management. What specific requirements does the Proposer have to initiate set-up, and please explain any additional costs involved. 36)Explain any options which the Proposer's system has that will permit the City to generate reports from, and to make direct inquiries into the Administrator's data base by on-Iine access, Proposer must clearly identify in its Proposal the costs of providing any special conversion systems, Iicense and software costs for accessing the system, and the party(s) responsible for the payment of those costs, if any. (Costs shall be fully detailed in Fee Proposal Section). 37)Provide sample reports describing information such as type of accident, accident site, department, date and time, cause of accident, injury, and part of body. Proposer shall describe in detail any safety/loss control reports that are provided by the system, and shall submit a listing of the variety of claims reports available, and provide sample copies of formats that may be requested by the City, 38)Provide the methodology and fist of allocated or anticipated expenses to employ outside professionals such as surveillance, rehabilitation, experts, attorneys and others to assist in the investigation and adjustment of claims. Page 52 of 65 605386 39) Provider shali provide its most recent audited certified business financial statements (or unaudited if audited is not available) as of a date not earlier than the end of the Proposer's preceding official tax accounting period, together with a statement in writing, signed by a duly authorized representative, stating that the present financial condition is materially the same as that shown on the balance sheet and income statement submitted, or with an explanation for a material change in the financial condition. A copy of the most recent business income tax return will be accepted if certified financial statements are unavailable. 8. FEE PROPOSAL (Provide prices in U.S dollars) 40)Submit a guaranteed, all-inclusive annual fee as previously detailed in Section 2.17. This fee shall represent all claims, administrative, and loss data fees, and shall be guaranteed annual fees for the initial three (3) years, arid the two option to renew years, as opposed to per claim time and expense or any other fee proposal. Proposals not containing an all-inclusive guaranteed annual fee for three (3) years, and the two option to renew years, for all specified services, will not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's Annual Fee. Clearly indicate any charge not included in the proposed annual fee. 41)As the City is interested in a program which will generate savings over the current expenditures in the workers' compensation area, the proposed fee structure should address the mechanism for achieving a minimum of 15% net savings with an escalating incentive bonus for savings that exceed the minimum and a penalty for a shortfall in the desire net savings. 42)Submit a separate quote(s) for existing claims, and a separate quote(s) for prospective claims; pricing on a "per claim" basis for both existing claims and prospective claims, and a breakdown of the cost between Lost tin-ie vs. medical. In addition, provide a per claim cost vs. flat dollar cost. Include any other charges not included in pricing. Price Proposal must contain rates based on the "Iife of relationship basis," namely for those prospective claims, and the City's inventory of open files, Provide separate quotes for the assumption of prior claims and for prospective claims commencing on the commencement date of the Contract, 43)h1clude any relevant services or products that will be provided to the City which are not priced in Proposer's Proposal, but which will enhance the acquisition process. 44}Indicate the cost, if any, of assuming prior claims and data conversion and whether it is a one-time charge or an annual charge. Include in Proposer's proposed price, costs for the provision of an enhanced system and for the conversion of any data necessary. 45)Provide a performance guarantee (may be negotiated with the City). 46)Provide any, and all additional costs, item by item, as identified by Proposer, in any other area not previously discussed herein, and detail what those additional costs, if applicable, would entail. Include whether Proposer, or the City will be responsible for payment of those additional costs. Page 63 of 65 605386 5. Evaluation Criteria 5.1. CMIA Evaluation Criteria 5.1. EVALUATION CRITERIA Proposals will be reviewed to determine if the proposal is responsive to the submission requirements outlined in this Solicitation. A responsive proposal is one which follows the requirements of this Solicitation, includes all documentation, is submitted in the format outlined in this Solicitation, is of timely submission, and has the appropriate signatures as required. Failure to comply may result in the Proposal being deemed non -responsive. Proposals will be evaluated by an Evaluation Committee (Comrnittee) which will evaluate and rank proposals based upon the following criteria and weight. The Committee will be comprised of appropriate City personnel and members of the Community, as deemed necessary, with the appropriate experience and knowledge. The criteria are itemized with their respective weight for a maximum total of one -hundred (100) points, per Committee member. CRITERIA PERCENTAGE Technical Criteria and Points l.Proposer's General Experience, Qualifications, and Past Performance 2. Proposer's Category Specific Experience, Qualifications, and Past Performance 10 3. Proposer's and Proposer's Key Personnel's Ability to Perform Required Services 4. Proposer's Methodology and Overall Approach to Scope of Price Criteria and Points 5, Fee Proposal 25 20 20 25 Total: 100 Proposals will receive a separate score in each category of service (Part I or Part II), for which proposal is submitted. Proposals will be ranked in a category by category basis. For example proposals submitted for Part I, will only be ranked against other proposals submitted for Part I. 5.2Oral Presentations Upon completion of the technical criteria evaluation indicated above, rating and ranking, the Committee may choose to conduct an oral presentation with the Proposer(s) which the Committee deems to warrant further consideration. Upon completion of the oral presentation(s), the Committee will re-evaluate, re -rate and re -rank the proposals remaining in consideration, based upon the written documents combined with the oral presentation. 5.3Price Evaluation Page 64 of 65 605386 After the evaluation of the technical proposal, in light of the oral presentation(s) if necessary, the Committee will evaluate the price proposals of those Proposers remaining in consideration, The price proposal will be evaluated subjectively in combination with the technical proposal, including an evaluation of how well it matches Proposer's understanding of the City's needs described in this Solicitation, the Proposer's assumptions, and the value of the proposed services. The pricing evaluation is used as part of the evaluation process to determine the highest ranked Proposer. The City reserves the right to negotiate the final terms, conditions and pricing of the contract as may be in the best interest of the City. Page 65 of 65 City of Miami, Florida Contract No. RFP 605386 EXHIBIT B SCOPE OF WORK THIRD PARTY CLAIMS ADMINISTRATION SERVICES 23 Third Party Claims Administration Services City of Miami, Florida Contract No. RFP 605386 EXHIBIT B SCOPE OF SERVICES THIRD PARTY CLAIMS ADMINISTRATION SERVICES 1. OVERVIEW The City of Miami (City) is contracting with USIS, Inc. (TPA) to provide third party claims administration services for full time employees. The TPA shall provide the best quality claims services for Workers' compensation and liability claims and the most reliable and valid data possible, using the most useful and user-friendly claims system available. 2. BACKGROUND The City's Department of Risk Management (Risk) provides optimum service to employees and the public through a variety of interrelated health, safety and liability/loss control programs. The provision of these crucial prevention -oriented programs greatly enhances the working environment and serves as an incentive for employee recruitment, retention and satisfaction, while protecting the City's assets, employees and citizens. Its objectives include goals to eliminate, where possible, the threat of accident and other forms of liability, and where it is possible to eliminate the risk, to at the very least, reduce the possibility of an accident or risk occurring. Currently, the City has approximately 4,141 full time employees, which include Law Enforcement officers, fire personnel, solid waste collectors, parks personnel, and does not include seasonal employees. There are four (4) Labor Unions in the City: 1) Fraternal Order of Police (FOP); 2) American Federation of State County and Municipal Employees (AFSCME); 3) International Association of Fire Fighters (IAFF); and 4) American Federation of State, County and Municipal Employees 79 (AFSCME). Labor Unions represent eighty-five percent (85%) of the City's workforce. The City has created and maintains a Self -Insurance Program, which provides protection to the City for all property and casualty loss exposures, Workers' compensation claims, and provides group health benefits to active, and retired employees. In addition, Risk monitors the City's injured workers. Attention is focused in the areas of safety awareness, prevention, treatment of injured workers, rehabilitation, job placement, education, and communications with the employees and the departments. Guidelines for the treatment and care of injured employees are based on Chapter 440, Florida Statutes, which governs the State's requirements for the provision of Workers' Compensation benefits. However, as a result of bargaining agreements, additional benefits may be due depending on the bargaining unit. The TPA must become familiar with the existing labor agreements). The City's current Third Party Claims Administrator, utilizes Risx Facs claim processing system where all data is maintained, updated, and payments are issued. The adjudication of Workers' compensation medical bills and payments to the City's providers are performed through this system. Claims administration under this Contract, will include the takeover of current claims from the current Third Party Claims Administrator. The City uses in-house counsel on all litigated claims, 1 Third Party Claims Administration Rev. 3122/17 City of Miami, Florida Contract No. RFP 605386 as necessary. Risk works closely with the Office of the City Attorney in a best -practices approach to manage litigated claims. The City is focused on the management of all claims, but has a laser focus on Workers' Compensation claims as they represent approximately eighty percent (80%) of the City's annual claims cost. A Return to Work program is being implemented as the City recognizes that prompt return to work aids in controlling claims costs. Individual department heads are directly responsible for claims occurring in their departments, as claims cost are allocated by department. Therefore, each department is highly motivated to support effective loss control, safety, and liability and Workers' compensation claim management. The City utilizes a 24/7 claims intake center. This type of system facilitates expedited handling, in order to process and close claims in the most efficient manner, for the benefit of the employees. Due to the City's Fire and Police operations, the City has devoted significant resources and has been and remains focused on managing presumption -related Workers' Compensation claims. The City has never lost a litigated presumption case, and the rate of presumption claim denial is eighty-five percent (85%). Close attention is also paid to closure rates and sound reserving practices. The partnership between Risk, the Office of the City Attorney, and outside counsel where needed, is unique and also quite effective. Case law is closely monitored and utilized to most effectively handle each situation. The City experiences approximately 756 claims per year on average. The ratio of medical only to loss time case is 40:60, i.e. forty percent (40%) medical only, and sixty percent (60%) loss time. Of the approximate 4,141 full-time City employees, the following generally represents the location of their residences: REGION 1 REGION 2 COUNT (*) Broward FL 606 Collier FL 1 Lee FL 2 Leon FL 1 Martin FL 1 Miami -Dade FL 3509 Palm Beach FL 16 Seminole FL 1 St. Lucie FL 3 Bronx FL 1 3. CITY'S CLAIM EXPERIENCE Below is the City's Claims experience by years: Table No. 1 Policy Year GL Auto BI/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 300 355 113 8 821 42 1639 10/1/11 - 9/30/12 410 421 84 2 748 39 1704 10/1/12 - 9/30/13 419 433 87 0 795 34 1768 10/1/13 - 9/30/14 412 355 109 3 680 26 1585 10/1/14 - 9/30/15 351 270 68 1 765 14 1469 2010 - 2014 (Average) 378 367 92 4 762 31 1633 2 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Table No. 2 Policy Year GL Auto BI/PD APD POL & ELL WC LEL Total 10/1/10 - 9/30/11 $566,237 $659,129 $201,201 $618,715 $6,848,127 $2,490,514 $11,383,923 10/1/11 - 9/30/12 $712,157 $1,725,636 $147,499 $0 $6,215,610 $235,809 $9,036,711 10/1/12 - 9/30/13 $1,154,438 $707,976 $134,866 $0 $6,666,574 $512,050 $9,175,903 10/1/13 - 9/30/14 $664,786 $610,034 $218,272 $38,000 $6,435,261 $331,468 $8,297,820 10/1/14 - 9/30/15 $546,951 $1,052,972 $122,527 $1,000 $4,773,880 $101,680 $6,599,010 2010 - 2014 (Average) $728,914 $951,149 $164,873 $164,429 $6,187,890 $734,304 $8,898,673 Table No. 3 Policy Year indemnity Medical Total 10/1/10 - 9/30/11 447 374 821 10/1/11 - 9/30/12 444 304 748 10/1/12 - 9/30/13 549 246 795 10/1/13 - 9/30/14 445 235 680 10/1/14 - 9/30/15 504 261 765 2010 - 2014 (Average) 478 284 762 4. WORKERS' COMPENSATION AND LIABILITY CLAIMS ADMINISTRATION A. THIRD PARTY CLAIMS ADMINISTRATION SERVICES The TPA shall be responsible for performing at a minimum, the following services: 1. Establish reporting procedures which are compatible with the needs and organizational structure of the City as determined by Risk. Notice of injury report will be submitted by the City, to the TPA in paperless format (i.e. Internet or email). 2. Establish claims acknowledgement procedures to the City's satisfaction. 3. Provide all necessary forms and instructions for use. Such forms shall include appropriate first reports of injury with mailing address of claim administrator pre-printed thereon. These forms shall be provided electronically if requested. The cost of providing these forms shall be included within the proposed price. 4. Develop a cost effective staffing structure to include the number of adjusters, designated to appropriately handle the City's claims. The City reserves the right to negotiate and approve the final staffing plan and any cost associated with the changes. In addition, the 3 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 City will have the right to request removal of personnel assigned to the City's Agreement. Removal will take effect within thirty (30) days of written request by the City. 5. Provide a dedicated Claims Supervisor to be assigned exclusively to the City's contract. 6. Receive and examine on behalf of the City all reports of employee injury claims. 7. Establish and maintain complete files on each claim. 8. Accept or deny all reported claims for employees' injuries on behalf of the City in accordance with the applicable Workers' compensation law. The decision to controvert a claim must first be discussed with and approved by Risk and/or the Office of the City Attorney. 9. Conduct the required investigations deemed necessary, as it relates to Workers' Compensation, including scene investigations, and personal claimant contact on all lost time or light duty cases. Contact with claimants must be attempted within twenty-four (24) hours of the TPA's receipt of the claim. Field investigations and claimant contact must be performed by employees of the TPA. Independent adjusters shall not be used to provide this service. 10. Perform job site visits, to become familiar with exposures unique to the City. 11. Provide a report to the City's Project Manager, every thirty (30) days, indicating all employees who are losing time or working in a light duty or restricted capacity. 12. Submit a full summary to Risk and/or the Office of the City Attorney [where legal review or litigation has commenced], every ninety (90) days, on all claims of the following types; a. any claim in which an employee is not working full duty; b. total incurred claim value exceeding $2,000; c. potentially controverted cases; d. cardiovascular claims; and e. claims in which settlement (washout) is recommended. 13. Prepare, and maintain files necessary for legal defense of claims and/or other litigation (such as actions for subrogation), or other proceedings. 14. Pay in a timely fashion (within 30 days) all claims and expenses from the loss fund account established by the City, which will be maintained by the TPA. Fees and civil penalties for late payments are to be paid by the TPA unless caused due to late reporting by the City. 15. Pursue all possibilities of subrogation from third parties and recovery from Special Disability Trust Fund [SDTF] and report such activities in the time, manner and method, as deemed necessary by the City and/or the Office of the City Attorney [where legal review or litigation has commenced]. 16. While the Office of the City Attorney will designate the attorney(s) that provide the defense of claims, as well as litigation strategy, the TPA shall provide the City's defense attorney(s) a complete copy of the file in question and monitor and actively participate in the activities of the City's defense attorney(s). 4 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 17. Attend Workers' Compensation hearings, mediations, and pension board hearings involving work -related injuries, as requested by the City. 18. Make written recommendations to Risk regarding any procedures or condition that should be examined to prevent future claims, which are revealed during the TPA's investigation of a claim. 19. Contact Risk by telephone on all claims where the compensability or the relatedness of the medical expenses on the claim is in question, and conduct such investigation, or such additional investigation, as deemed necessary by Risk or the Office of the City Attorney. 20. Contact employees who experience loss time at least every two (2) weeks, for the duration of temporary total disability payments. When an employee is represented, the Office of the City Attorney shall be contacted when appropriate. If City's attorney contact is appropriate, that contact should be on a sixty (60)-day basis. 21. Report all lost time and/or questionable cases to the Index Bureau. All lost time shall be re -indexed every six (6) months. 22. Establish initial reserves within ten (10) days of the first report of the claims being reported. All files must be reserved adequately to extend through the expected life of the claim. Although all the necessary facts may not be available at the onset of a claim, reserves should be adjusted when medical information or investigation indicates the existing reserve is inadequate or overstated. The following factors shall be considered when establishing reserve: a. the injury; b. the investigation; c. medical treatment and costs; d. projected temporary total disability benefits to be paid; e. projected permanent partial disability and impairment benefits; and f. potential use of outside experts (rehabilitation service TPAs, attorneys, etc.).; 23. Review the adequacy of reserves at least every three (3) months, and document the file accordingly. 24. Present in writing all settlements to Risk and the Office of the City Attorney for approval, regardless of the amount. The injured employee will not be contacted regarding settlement until approval of proposed settlement is obtained from Risk and/or the Office of the City Attorney. 25. Follow all Division of Workers' Compensation (DWG) rules when compensation, medical, or other benefits are being controverted. The case must be discussed with Risk before the claim is denied and/or the Office of the City Attorney, where legal review or litigation has commenced. 26. Obtain medical reports as necessary, in such manner as approved by Risk and the Office of the City Attorney to determine the status of the employee's injury and to verify disability. 27. Report all claims involving a fatality to Risk and the Office of the City Attorney 5 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 immediately. Payments on these and all other Workers' Compensation matters shall be made in accordance with the Florida Workers' Compensation law and or governing contractual agreements. Periodic activity/status checks shall be performed to ensure that dependents who receive survivor's benefits are still eligible to receive them, and notify Risk regarding those activity checks. The Office of the City Attorney shall be notified on litigated cases, or cases where legal review has commenced. 28. Prepare and file with the appropriate State agency all applications required for the City's qualification as a self -insurer. 29. Prepare, maintain and file all records and reports as may be required by legal authorities (State, local and Federal). 30. Prepare, maintain and file statistical information required by Workers' Compensation Rating Bureaus, including all required data necessary for the promulgation of experience modifications. 31. Review for accuracy and approve the appropriateness of State assessments, prior to the due date of the assessment. 32. Establish an interest bearing bank account to make claim, indemnity, expense, and legal payments on checks drawn from this account. It is understood that all funds in this account are City funds and shall be returned upon the City's request or the termination of the Agreement. Regarding this account, the TPA shall: a. Reconcile on a monthly basis, the account and provide all monthly bank statements to the City, along with a request for a deposit from the City to maintain the balance needed in the account, as determined by the City. b. Ensure that any interest earned on the account be applied to reducing the subsequent monthly deposit by the City. c. Submit a monthly statement including the following: i. balance at inception; ii. total disbursements by date and claimant; iii. balance at closing; and iv. amount of deposit required. d. List all checks along with all statements supplied to the City. 33. Provide to the City, bank account transactions and other information, additionally or in lieu of, on-line or via other means for "real-time" access by the City 34. Ensure that all adjusters handling City's cases are kept abreast of the Workers' Compensation Statutes, DWC rules, and applicable laws. 35. Ensure that the minimum standards of performance of TPA's personnel conform to the Florida statutes and administrative rules or future changes, if any. 36. Ensure all DWC filings, including compromise settlement agreement payments, are made in a correct and timely manner. 37. Provide notification of suit being filed against the City for any reason, to the Office of the City Attorney, and Risk with twenty-four (24) hours of suit being filed. 6 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 38 Aggressively pursue recoveries to the satisfaction of the City, including recoveries based on subrogation and special disability trust fund (SDTF). As regards to subrogation recoveries involving injuries to the claimant caused by third parties, the TPA acknowledges that such recoveries may include reductions in future Workers' Compensation benefits as provided by Florida Workers' Compensation Law based on formulas provided in Chapter 440 and case law interpreting such law, and shall be responsible for documenting and collecting such recoveries from health care TPAs and the claimant as mutually agreed upon by the claimant and the City upon the claimant's recovery from the third party[ies]. 39. Pursue, track, and provide quarterly reports on all SDTF, as well as subrogation recoveries in such manner as deemed necessary by the City Attorney or designee. 40. Be responsible for data integrity. This includes properly inputting all cause codes, location codes, loss description, and other claims information. if a data conversion is involved the TPA must attest to the integrity of the combined data. 41. Obtain the approval of Risk and/or the Office of the City Attorney [where legal review or litigation have commenced] to hire experts in connection with claims against the City. Experts include, but are not limited to, accident reconstruction engineers and experts, medical and rehabilitation vendors and private investigators. 42. Provide the means for the City to perform claims status inquiries. 43. Provide training for supervisory personnel of the City for those individuals responsible for Workers' Compensation activities. 44. Comply with all applicable laws and regulations regarding the administration of Workers' Compensation benefits. 45. Provide and integrate successfully, an online claims management system that interfaces with all other existing systems to be utilized in the performance of this scope of work. 46. Work closely with the "safety team" to enhance the Safety Program to reduce claims on an annual basis. 47. Assist in the implementation of the City's Return to Work Program. 48. Provide to the City a performance guarantee, to be negotiated with the City. B. HEARINGS CONFERENCES/TRIALS The TPA shall ensure that the following requirements for hearing conferences/trials are followed: 1. Pre -hearing or pre-trial reports shall be submitted by the TPA to the Office of the City Attorney at least two weeks prior to the hearing conference/trial or whenever requested by the Office of the City Attorney. Periodic up -dates on ongoing litigation, as well as provision and inspection of file materials kept by the TPA, by the Office of the City 7 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Attorney or designee, will be scheduled by the Office of the City Attorney as needed. 2. Reports must contain all information pertinent to the file including transcribed statements and depositions. 3. The TPA shall obtain settlement authority from the City prior to any hearing conference/trial. 4. Any recommendations made by the Office of the City Attorney, pertaining to the file should be carried out or referred to the TPA. C. REPORTING REQUIREMENTS The TPA Shall: 1. Make an immediate report to the Risk Director or designee on: a. fatalities; and b. catastrophic occurrences with potential exposure $50,000 for more. 2. Submit "full captioned reports" within thirty (30) days of setting reserves at or above $25,000. The content of the "full captioned reports" shall include, not limited to, the following; a. coverage items; b. employee's background; c. dependents; d. employee's job description; e. occurrence; f: injury; g. medical management; h. wage and compensation rates; i, dates and periods of disability; j. rehabilitation; k. other employee benefits; I. litigation; m. indexlstate filings; n. subrogation; o. remarks and/or recommended actions; and p. strategy for resolution. 3. Submit "full -captioned report" on all files in litigation. Provide copies of all pleadings along with the report. 4. Ensure that follow-up reports are received within ninety (90) days of the "full -captioned report". 5. Submit monthly experience/statistical reports which shall include, but are not limited to, a summary of experience by department stating cause of accident, frequency and cost. Open and closed claims shall include specific information on the accident date, claimant's name, cause of accident, injury type, amount paid and reserved, and state if the claim is open or has been finalized. These reports must be delivered by the 10th of each month, and must provide summary information by department, by participant, and 8 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 by total program. 6. Become familiar with existing labor agreements, and report all activities pursuant to those agreement to the Risk Director or designee as requested, at least on a monthly basis, or as required by the City. 7. Provide the necessary reports and/or data to satisfy Florida's self-insurance requirements. Required forms shall be completed by the TPA and sent to the City for review and appropriate signatures. Required self-insurance reports shall be provided on a timely basis so that the City will have sufficient time to review and execute the documents before the due date. 8. Provide any report(s) requested by the Risk Director. TPA's system shall have the ability to run ad hoc queries. D. "BAD FAITH" PROCEDURES The following procedures shall be followed to avoid potential actions for breach of good faith and fair dealings: 1. Termination of weekly benefits: Weekly benefits may be terminated only upon written or verbal notification by the treating physician or the City when employee returns to work. If return to work information is obtained verbally, the TPA must follow up in writing with a request for written verification. If treating physician releases the employee to modified work, the TPA must promptly determine if modified work is available and offered to the employee before benefits are terminated. 2. Controverting claims: The TPA shall contact the City prior to formally denying a claim. This will not be necessary when controverting the reasonableness and necessity of medical bills. 3. Judgments/settlements: Judgments/settlements should release potential future "bad faith" actions. 4. Penalties and fines: Penalties and fines assessed by the DWC shall be paid by the TPA if such fines and penalties result from negligent performance of its duties E. PERFORMANCE STANDARDS: WORKERS' COMPENSATION The City will perform annual performance standards audit based on the following: 1. TPA will document all new claim information received from the City, and this information will be available within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File shall include First Report of Injury form. 2. A minimum of "three (3) attempts" by the TPA, to contact the appropriate parties, will be considered a "contact", if followed with the appropriate correspondence within the measurement period. For a Workers' compensation claim, three (3) point contacts will be required (claimant, supervisor and treating TPA). For a liability claim, two (2) point contacts will be required (claimant and reporting City Supervisor, if applicable). 9 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 3. TPA shall document, and provide Risk written notice of, subrogation, contribution, and/or coordination of benefits recovery potential, as they develop. if a TPA decides not to pursue any such recovery, TPA must give written notice to Risk of its decision within fourteen (14) days of claim receipt. 4. For Workers' Compensation claims, within fourteen (14) days of receipt of a claim, the claims adjuster will perform a three point contact, send appropriate notification packages to the claimant, as required by Chapter 440, review the claimant's pre -employment physical, and document the TPA's analysis of the compensability of the claim. For liability claims, within fourteen (14) days of receipt of the claim, the TPA will document appropriate specific directions for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim, initial reserves for the file will be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a. 30 days from 72 hour review; b. 30 days from 30 day review; c. 60 days from last 60 day review; and d. Every 6 months thereafter. Increase or decrease of reserves by $10,000 or more, requires notification to Risk. Subsequent to notification, Risk reserves the right to discuss the case and request a reconsideration of the reserve of the TPA. 6. TPA shall "address" litigation within two (2) days of receipt of litigation notification, or less than two (2) days as requested by the Office of the City Attorney if a shorter deadline is deemed legally necessary by the Office of the City Attorney. This will mean notice of to Risk, and referral to the Office of the City Attorney for assignment, within two (2) days, or perhaps Tess than two (2) days, if requested by the Office of the City Attorney. 7. Required status reports shall be provided to the Risk Management Administrator or designee. 8. Settlement evaluation shall be provided to the Office of the City Attorney and Risk 30 days prior to mediation. The TPA shall evaluate, or cause, a third party expert, as deemed necessary, to evaluate the need for a Medicare Set Aside [MSA], and this shall be determined and documented in all settlement evaluations. 9. File/System documentation shall include documentation of return phone calls to injured worker and the City within twenty-four (24) hours or the next business day. 10. File/System documentation shall include documentation that referral appointment was made for a claimant to a network TPA specialist (i.e.; Diagnostic testing, Neurologist, Orthopedic) so that claimant was seen by specialist within two (2) weeks of the date of receipt of the referral from the primary treating physician, unless it is clearly documented that, despite TPA's best efforts, no specialist was available to see claimant within the requisite two weeks period. F. LIABILITY CLAIMS ADMINISTRATION 10 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 Upon receipt of all liability claims, the TPA, on behalf of the City, shall perform, at minimum, the following services: 1. Review all first notices of claim reports received from the City, which will consist of loss reports, claim letters and suits, or claims that are phoned, mailed, or faxed in by the City, prior to an assignment to the TPA's adjuster, approved by the City. 2. Designate the necessary number of outside field adjusters to handle all City claims and also designate an alternate in their absence. The designation of these persons is subject to the approval of the City. 3. Conduct a thorough and complete investigation of the accident, according to the requirements of the City. Investigations shall include, but not limited to, the following: a) Contact the claimant or the claimant's attorney within 24 hours of the time the accident report is received by the TPA. In the case of underrepresented claimants, personal contact is required the same day the claim is received. All claim files must contain adjuster's logs documenting all contact and activity. b) Obtain recorded statements from the claimant, witnesses, and the City personnel. Personal contact of all underrepresented claimants by outside adjusters is required. c) Complete a timely scene investigation consisting of photos and diagrams. This is required within two (2) days of receipt of any serious AL or GL claim assignment. d) Obtain the police and/or fire rescue report. e) Obtain and review all medical reports and bills submitted by the claimant or their attorney. f) Obtain and review all estimates and appraisals for property damage claims. g) Establish appropriate reserves on all claims, and revise the reserves as needed. h) Submit a report to the City within 30 days of receipt of the claim, summarizing: I. Date/time/location of loss; II. Claimant information; III. Description of accident; IV. Injuries or damages; V. Witnesses' version; VI. Liability analysis; and VII. Evaluation of claim (i.e. amount of recommended settlement, denial, reserves, attorney demand). If a settlement recommendation cannot be made at this initial report (due to lack of information), indicate same and reason. However, remainder of investigation should be completed. 4. Submit a status report every ninety (90) days thereafter to the City until the claim is resolved. The City prefers the above reporting requirements to be accomplished via the on-line claims management system for "real-time" viewing. 5. The TPA has the authority to settle cases on behalf of the City up to $3,000 per claim for property damage and $3,000 for bodily injury. For any settlement in excess of the above, the TPA must receive authorization from the City. The request for this authorization must be presented in writing, including the 11 Third Party Claims Administration Rev, 3/22/17 City of Miami, Florida Contract No. RFP 605386 adjuster's evaluation and recommendation in a format required by the City. After authorization is granted, the TPA will settle the claim and obtain the appropriate release. Additionally the TPA shall provide a quarterly report to the City on all settlements above and below $10,000. 6. The City will assign an attorney for the legal defense of any claims that goes into suit. The TPA will assist the City's attorneys with any additional investigations, as deemed necessary by the City or its attorneys. The TPA will continue to monitor the file in litigation. TPA will provide a monthly report of all litigated claims in the format specified by the City. 7. Upon notification from the City, the TPA shall forward a copy of the file in suit, to the City's attorney with a transcription of all settlements. 8. The TPA shall attend all mediations and trials as requested by the City. With respect to claims with impending trial dates, the designated TPA's Supervisor or designee, shall take an active and aggressive role in settlement or preparation for trial. 9. The TPA, after approval of the City, can assign the necessary auto appraiser for property damage claims. These expenses shall be paid as an allocated expense by the TPA from the City's loss fund. 10. Any other claim expense must be approved by the City prior to being incurred. However, expenses for normal claim activities, such as photographs, tapes, supplies, postage, etc., are the responsibility of the TPA. 11. The TPA shall meet quarterly (or more frequently if required by the City) with the City Manager, and/or authorized representative, to review all large exposure (over $25,000) incurred cases and report on their status. 12. All claim files are at all times the property of the City. The City has the right to inspect any and all files whenever the City deems necessary. If the Agreement is terminated, the City will receive all original claim files. 13. The TPA shall make recommendations to the City as to actions that can be taken to prevent future claims. These loss prevention recommendations can be included in the status report. 14. All work must be performed by the employees of the TPA. The use of any contracted or independent adjuster is prohibited, unless prior approval is granted by the City. 15. The TPA shall reimburse the City for payments made in error that are non -recoverable from third parties by the TPA. 16, The TPA shall provide to the City a performance guarantee, to be negotiated with the City in the provision of Managed Care/Medical Bill Review, as cited herein, to improve its effectiveness and efficiency while maximizing City resources. 17. The TPA shall continue to monitor the file in litigation, and obtain updates from the City Attorney's office, in an effort to prepare reports to the City's excess carriers as required. 12 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 G. PERFORMANCE STANDARDS: LIABILITY The City performs annual performance standards audit based on the following: 1. TPA shall document all new claim information received from the City, and this information will be available electronically within one (1) hour of receipt, if received during normal business hours, or within the first business hour of the next business day, if received less than one (1) hour before the close of a business day. File will include First Report of Injury Form. 2. A minimum of "three (3) attempts" by the TPA's claims adjuster to contact the appropriate parties will be considered a "contact", if followed up with appropriate correspondence within the measurement period. 3. TPA shall document, and give City's Project Manager, written notice of, subrogation, contribution, and/or coordination of benefits recovery potential. If TPA decides not to pursue any such recovery, it must give written notice to Risk of its decision within fourteen (14) days of claim receipt. 4. For liability claims, within fourteen (14) days of receipt of the claim, the TPA shall document appropriate specific direction for the investigation and handling of the case. 5. Within 72 hours of receipt of the claim, initial reserves for the file shall be set, thereafter, reserves will be reviewed on an on -going basis, as follows: a. 30 days from 72 hour review; b. 30 days from 30 day review; c. 60 days from last 60 day review; and d. Every 6 months thereafter. 6. TPA shall "address" litigation within two (2) days of receipt of litigation notification. This will mean notice to Risk, and referral to the Office of the City Attorney for assignment, within two (2) days. 7. Submit required status reports as outlined by the Risk Management Director or designee. The City desires prompt, personal contact of all claimants. Evaluations of each claim shall be made as soon as the necessary information is received by the TPA. The investigation and evaluation of all claims should be completed prior to suit being filed, since F.S. 768.28 (sovereign immunity statute) requires the claimant provide six months' notice of intention to file suit. The TPA must have up-to-date policy and procedure manual(s) on hand in the work place. These manual(s) shall describe and discuss the day to day procedures for adjusting files, and shall be kept in accordance with statutory requirements. The TPA shall provide adequate toll free telephone access to the claims office. The TPA shall provide claims personnel, who shall be available on a 7 day, 24 hour basis, for investigating claims, and must have an maintain an 800 or toll -free number for emergency service. The TPA shall provide its own office space or facility(s) for its 13 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 adjuster or staff of adjusters. The TPA must agree to be responsible to manage liability claims to be opened within the year(s) following contract execution, along with the current inventory of open files. The TPA shall provide claims administration on a "life of relationship basis." H. STAFFING, QUALITY CONTROL, AND SUPERVISION The TPA shall render high -quality claims management and adjusting services throughout the term of the Agreement. The City relied upon the TPA's proposal to determine that the TPA's personnel shall have, as a minimum, the following levels of experience and licensing: 1. Supervisor or Supervising Adjuster shall have five (5) to seven (7) years of related experience; 2. Adjusters shall have three (3) years of experience; 3. Medical -only processor(s) shall have one (1) year of experience, and must hold a current Florida Adjuster License; 4. The TPA's files must reflect evidence of supervisory direction and involvement at every level. All files must be kept current. File review should be performed on 30, 60, 90 or 120 day cycles, as appropriate. Periodic review by the handling adjuster and all supervisors should be reflected in the file. 5. TPA's Supervisors shall receive all First Reports of Injury and outline investigative needs for the adjusters to follow through. Supervisors should assign the most difficult files to the most qualified adjuster. 6. TPA shall perform monthly claims review with Risk, to include the adjusters, and City Attorney. 7. It is the City's claims management philosophy that the proper and most cost-effective method to handle claims and thereby reduce and control the City's self -insured loss payments, is to ensure the TPA hires and retains the appropriately qualified professionals to handle the City's claims. Additionally, the adequate number of adjusters and a manageable caseload enables qualified adjusters to perform the required services, The City therefore requires that the TPA agree to staffing, qualifications, and caseload criteria established by the City. 8. The City reserves the right to the final prior approval of the hiring and/or assignment of the claims manager, supervisors, and adjusters that will handle the City's claims. 9. The TPA agrees to add staff as necessary, to maintain these maximum pending caseload levels. 10. Claims personnel must be employees of the TPA. The use of independent adjusters, subcontractors, or temporary adjusters will not be acceptable without prior approval of the City. TPA's Adjuster trainees are not acceptable for handling of the City's claims. All TPA's claims professionals must possess a current Florida adjuster's license. 14 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 11. In addition to those services previously discussed, the TPA will additionally perform the following related services: a. State required filings; b. Loss fund management; c. Computer generated loss runs and other management reports, preferably on-line; and d. Provide an annual SAS 70 audit report. 12. The TPA shall have the ability to provide full customer service to English, Spanish, and Haitian -Creole speaking individuals, when needed. 13. The TPA shall make available to the City an individual with management authority to meet with the Risk Director, or the designee, upon reasonable notice. This individual shall have the authority to make "agreed to changes." The TPA's employees shall meet with Risk on a quarterly or as -needed basis to discuss claims of interest. Sufficient advance notice will be given by Risk to allow adequate preparation and data collection. The TPA's personnel, including the adjuster or Supervisor, must also be available to attend mediation conferences, as necessary. 14. The City will provide office space in its Risk Department to house two (2) claim adjusters. At the City's discretion, the City may increase or decrease the number of stations provided. I. FEE BILLING The City will pay fees monthly in arrears for claim files established in the previous month. A summary invoice should be broken down by line of coverage and tie to month -end figures as shown on the loss runs. 15 Third Party Claims Administration Rev. 3/22/17 City of Miami, Florida Contract No. RFP 605386 EXHIBIT C PROPOSAL AND COMPENSATION 24 Third Party Claims Administration Services City of Miarni, Florida RFP No.605386 EXHIBIT C THIRD PARTY CLAIMS ADMINISTRATION SERVICES PRICE SCHEDULE The prices shown below are the charges for Workers' Compensation Claims and Liability Claims Administration Services only, as stated in the Scope of Services (Exhibit C). The prices shall remain firm and fixed for the first two (2) years of the Contract. The City reserves the right to negotiate the rates for Year 3 of the initial term, and for renewal and/or extension periods. 1. INITIAL TERM (Years 1 through 3) A. Total Fees and Costs for Initial Term (Years 1 through 3): The total fees listed below include all fees and costs, including one-time and recurring fees, and value added options. $5,154.575 (Years 1 through 3) B. Breakdown of Total Fees and Costs for Initial Term (Years 1 through 3) The break down list below is for the aggregate price in Section 1A above. 1. Staffing Positions FTE Annual Salary Total Annual Salary* 1 Supervisor 1 $103,935 $207,870 2 Lost Time Adjuster 1 $88,560 $165,909 3 Lost Time Adjuster 1 $88,560 $165,909 4 Lost Time Adjuster 1 $88,560 $165,909 5 Lost Time Adjuster 1 $88,560 $165,909 6 Lost Time Adjuster 1 $88,560 $165,909 7 Medical Only Adjuster 1 $61,500 $109,785 8 Liability Supervisor 1 $110,700 $211,400 9 Liability Adjuster 1 $86,100 $172,200 10 Liability Adjuster 1 $86,100 $172,200 Total Annual Salary *Total Annual Salary column includes all costs associated with performance services. $1,703,000* 1 Third Party Claims Administration Rev, 3/20/2017 2. Total Breakdown of Annual and One -Time Costs (inclusive of staffing costs) Base Annual Cost Projected Annual Increase (%) Total Annual Costs Year 1 $1,703,000 0% $1,703,000 Year 2 $1,703,000 0% $1,703,000 Year 3 $1,703,000 2.5% $1,745,575 One -Time Implementation Cost for Data Transfer $3,000 Grand Total Costs (Years 1-3) $5,154,575 2. OPTION TO RENEW YEARS (Years 4 and 5) The prices shown below are the charges for Workers' Compensation Claims and Liability Claims Administration Services for two (2), one (1) year option to renew periods only, as stated in the Scope of Services (Exhibit C). A. Total Fees and Costs for Option to Renew Years (Years 4 and 5): The total fees and costs include all fees, and value added options, for Workers' Compensation Claims and Liability Claims Administration Services. $3,623,159 (Years 4 and 5) B. Breakdown of Total Fees and Costs for Option to Renew Years (Years 4 and 5) The break down list below is for the aggregate price in Section 2A above. 3. Staffing Positions FTE Annual Salary Total Annual Salary* 1 Supervisor 1 $113,572 $227,145 2 Lost Time Adjuster 1 $96,771 $166,768 3 Lost Time Adjuster 1 $96,771 $166,768 4 Lost Time Adjuster 1 $96,771 $166,768 5 Lost Time Adjuster 1 $96,771 $166,768 6 Lost Time Adjuster 1 $96,771 $166,768 7 Medical Only Adjuster 1 $67,202 $119,623 8 Liability Supervisor 1 $120,964 $231,930 9 Liability Adjuster 1 $94,083 $188,168 10 Liability Adjuster 1 $94,083 $188,168 Total Annual Costs *Total Annual Salary column includes all costs associated with performance services. $1,789,214* 2 Third Party Claims Administration Rev, 3/2072017 City of Miami, Florida RFP No.605386 4. Total Annual Breakdown Costs (inclusive of staffing costs) Base Annual Cost ($) Projected Annual Increase (%) Total Annual Costs Year 1 $1,789,214 0,0% $1,789,214 Year 2 $1,789,214 2.5% $1,833,944 Grand Total Costs (Years 4 and 5) $3,623,159 3. Additional Services Not -to -exceed hourly rates listed below will apply to future City requests for any additional services; modifications, or changes outside of the Scope of Services, for personnel who will be assigned to this Contract. 5. Additional Services Personnel Not -To -Exceed Hourly Rates Loss Control Consulting Services $120.00 Appraisal Services To be determined and negotiated A. Other Services: The not -to -exceed charges for each service itemized are listed: 6. Other Services Services Charges On-line Access No Charge GB International Claims Services NA Consultative Services Loss Control Consulting Services $120.00 per hour Appraisal Services To be determined and negotiated Fraud Prevention Special Fraud Investigations $85 per hour, plus expense Surveillance Investigations $75 per hour, plus expense Targeted Field Investigations $80 per hour, plus expense Targeted Database Investigations Rate per report MSA Workers Compensation (WC) Medicare Set -Aside (MSA) Allocation $2,200 per allocation Rush Fees (MSA completed within 7 days) $450 per case Revisions 3 — month free, $1501hour Liability Medicare Set -Aside Allocation $2,000 Fee MSA Submission to Centers for Medicare and Medicaid Services $500 Fee Compliance Services Conditional Payment Research $125 Flat Fee Conditional Payment Negotiations $250 Flat Fee 3 Third Party Claims Administration Rev. 3/20/2017 Secure Final Demand for Settlement $0 if included in CPR or CPN Otherwise $350 Bundled CP Resolution Services $500 Flat Fee Benefit Coordination & Recovery Contractor Notification $45 Flat Rate Medicare Eligibility Inquiry $50 Flat Rate Social Security Disability Income Verification $50 Flat Rate Release / Settlement Agreement Review $125/hour max $375 Lien Resolution (Advantage Plan, Medicaid, Part D) $500 Flat Rate per Lien Resolution Notes: 1. The prices above in Sections 1A, shall be fixed and firm for the first two (2) years of the initial term of the Agreement. The prices for the third (3rd) year of the initial term, and any extensions, and option to renew years, in Sections 2A, may be negotiated; at the sole discretion of the City. Any extensions to the Agreement beyond the five year period, will be at the then current term's rates. 2. All out-of-pocket expenses, including employee travel, per diem, and miscellaneous costs and fees, are included in the price, as they will not be reimbursed separately by the City. Refer to CH.112.061 of the Florida Statutes regarding adherence to travel expenses. 3. Notwithstanding the hourly rates in Sections 3, Additional Services, above, the City reserves the right to negotiate the not -to -exceed pricing on a year by year basis, at the City's sole discretion. 4. The positions identified in the table above shall be the same as the key positions identified in the Third Party Claims Administrator's proposal. The City expects that the personnel in those positions will be performing the services. 5. Taxes (All applicable taxes will be added to the service fees where required). 4 Third Party Claims Administration Rev. 3/20/2017 Request For Proposal's: PART I: WORKERS' COMPENSATION CLAIMS AND LIABILITY CLAIMS ADMINISTRATION RFP #605386 Opening November 30th, 2016 at 2:00 p.m. EST ...uS IS §IWILiiyc)isu..) THE' (.:Orktiii:ACT USIS, Inc, Contact Person: Ron Warble, Executive Vice President Firnfs Liaison: Tern Snapp 5728 Major Blvd., Suite 450 Orlando, Florida 32819 Phone: 800.444.9098 ext. 6503 Fax; 407.949.3140 Federal Employer identification. Number: 204580645 Part I — Workers' Compensation Claims and Liability Claims Administration ITEM PAGE/ATTACHMENTS Executive Summary Pages 1-2 • Insurance Certificate Page 3 Certification Statement Page 4 Certifications Pages 5-6 Proposer's General Experience, Past Performance, and Exceptions Pages 7-9 • Brown & Brown, Inc. Annual Report Attachment 1 Proposer's Category Specific Experience, Past Performance Pages 10-27 • Cardiac -Exposure Protocol Attachment 2 • Innovative Programs Attachment 3 • USISiNet and AmeriSysiNet Attachment 4 • USIS Sample Reports Attachment 5 • Reference Letters Attachment 6 • Resumes/Licenses, Job Descriptions Attachment 7 Proposer's Ability to Perform Required Services Pages 28-30 Proposed Overall Approach to Performing the Services Pages 31-47 • SSAE 16 excerpt Attachment 8 • Transition Plan Attachment 9 • Implementation Check List Attachment 10 Fee Proposal Pages 48-49 Supplemental Proposer Questionnaire Attachment A Pages 50-166 • myMatrixx Attachrnent 11 • Risk and Insurance, Revitalizing the Program - Teddy Award Winner Attachment 12 • Claims Handling Practices and Liability Claim Procedure Manual Attachment 13 Clahns Administration Price Proposal Schedule Attachment B1 JIUsrs November 28, 2016 Yadissa A. Calderon, CPPB Procurement Contracting Manager City of Miami Procurement Department 444 SW 2 Ave, 6th Floor Miami, Florida 33130 Reference: Third Party Claims Administration — RFP #605386 Executive Summary Dear Ms. Calderon: PO Box 616648 Orlando, Florida 32861 800.444.9098 ext. 6503 Ron Warble USIS is interested in and excited about the opportunity of providing Third Party Administrator services to and on behalf of the City of Miami. We believe our experience dealing with public entities for the core services requested makes USIS an excellent potential partner for the City and its injured employees. We are prepared to begin working with you and your team to design a workers' compensation program plan that meets the unique needs and requests of the City. We recognize that each employer/insured is unique in systems and philosophies and we stand ready to customize our services to best complement the cunTent program. We also recognize that these services and programs are dynamic and require ongoing assessment, evaluation and modifications to remain current with statute and rule as well as technology, medical advances and other efficiency -related information and techniques. As an organization we understand and are ready to implement all services that are necessary to meet all of the components identified and required as a part of this RFP. Having provided services to you previously as your Managed Care Partner from 2003 — 2011; AmeriSys, USIS' Medical Management division, is familiar with your various Agencies and Departments. AmeriSys worked closely with the City's Fire and Police with excellent satisfaction expressed. We are familiar with the number of Presumption claims the City historically incurred which represents a significant part of your overall exposure. We have developed unique Case Management programs for first responders covered under the Presumption Bill. We believe our BADGE program will assist the City in minimizing exposure to future costs of expensive cardiac events. • Our flexibility allows us to deliver a complete claims administration program that will be tailored to the unique needs of the City of Miami. Page 1 • There is a commitment in our organization to security. Our software system as well as our firewalls protect both medical provider information and claimant protected health information in accordance with HIPAA standards (even though Workers' Compensation claims are not subject to HIPPA compliance). Our organization is subject to Sarbanes-Oxley and as a result we have developed highly secured systems and protocols. Our systems are frequently audited and reviewed, both internally and by third party reviewers including annual SSAE16 (formerly SAS-70) audits. Though this process seems expensive and burdensome at times, we believe that it provides our customer partners confidence that we will handle their resources with great care. • Innovation and efficiencies are critical to any successful program and as a result USIS encourages new ideas from employees and sets improvement goals annually. Our primary office of operation will be in the Orlando area which has a rich labor pool allowing us to recruit and maintain exemplary staffing for this program. Ron Warble, Executive Vice President Authorized to legally bind and authorized to make representations in regard to this procurement on behalf of USIS, Inc. USIS Inc. PO Box 616648 Orlando, FL 32861 ron.warble@usis-tpa.com 407.949.3150 We are able to provide all Core services internally, partnering with PGCS to provide certain specialty liability claims services, in accordance with the requirements of the RFP. USIS and PGCS are both wholly owned organizations of Brown & Brown, Inc., operating within the same division (Services) that specializes in the services requested under this RFP. We understand that the services we would be providing on your behalf are for your employees, your colleagues, your citizens and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also making sure that we protect the financial and human resources that are paid for by the hard earned tax dollars of your City's citizens. We have a stewardship obligation and commitment to the injured employees and the City of Miami. We look forward to oral presentations where we can provide additional information and/or answer any questions about how our organization can assist you in providing a superior workers' compensation claims program for City of Miami. Respectfully, Ron Warble Executive Vice President USIS, Inc. Page 2 BROWN-3 OP ID: .IW ACC> CERTIFICATE OF LIABILITY INSURANCE DATE IISW7DONTIYI 1118812&16 THIS CERTIFICATE IS ISSUED AS A MAI LIzIA OF INFORMATION ONLY AND CONFERS NO .RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES HOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE :POLICIES BELOW. THIS t.-i.ii.csIFICATE OF INSURANCE DOES NOT CONSTITUTE: A CONTRACT BETWEEN THE ISSUIPPG. INSURER/S), AUTHORIZED REPRESENTATIVE OR PRODUCER,: AND THE CERTIFICATE HOLDER IMPORTANT,z It the nertificale. holder is an ADDITIONAL INSURED, the poliOyfies) Faust be .endoned. ff SDBROGAT/ON IS WAIVED, subject to the terms and .coos ot the:policy, •certain policies may;require. an endorserneit A .statemerif on this certificate does oot.00rffer rights to tfie ttertiftrte balder in lieu. of such enclicrsemengsl. PFISTABBER 2,59:gai LAURIE KOHLER #'16G95 Grown & Brown of Florida, Iron, Daytona Beath Office PHONE Wt. Mk, nil. 366-239-T242 I at, Nm 386-323,9159. P.O. Box 2412 Beack, FL 3211I5-2412 Una*, tkolderabbdaytana.corn oria Iteefettoutrim NB TENBANSI AFFORDINB ODBERABa NAM" altBREIR A :Trail derfl Prop & Ca Or Amer 25674 MINED BROWN & BROWN :r ,C ETAL lApAmE9 a : Continental Castiaity Co 20443 P 0 Box 2412 DA.YTORIA BEACH, FL 32115 inia/gER.D :Traveters indemnity 25666 INIAIPER D..:XL Specialty ins lac.: 371105 INIURER E : WILMER P : COVERAGES CERTIFICATE NUMBER: REVISPCN: NUMBER: TH;3 IE. TO CEraltil-Y THAT THE POLICES CF itrILIANCE LISTED Ham PAVE BEEN ISSUED TO THE iNgaPEI3 NAMED ABOVE:FOR THE!POLJCY PERIOD ICED. NOTWITI-0TAND4140 ANY REQUIREMENT, TERM DR CCNYTION OF ANY OCNTRACT OR OTHER DCCIAENIT WITH RESPECT TO Wi-IKIR NG CERTIFICATE MY BE MI-ED C:R MAY PERTAIN, TEE INSLEAJIICE .AFFORCED BY THE POLICES DESGREF_D I MEIN IS StIREGT TO ALL TEE TERMS, EXIIISICINS MID CONOMONS. OF SUCH Foams, uma6 sHDAN, MAY RAVE BEEN REDUCED EY PAID CLANS. 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I N Nt S A TC2JURS517B560,18 010161,I2016 1:11R1112017 El. aAcH Accoam- iSitAII:lia ,... L. OFRUEVYBI,AER IMAABNEry io mt. TRKUB9-51037C116 otioaole 0ta1l2017 E.L. DIZEABE -EA EMPLOYEE ILA CORM CleC,Rtel. Cllt. und.ex OEWBIPTION OF BPEFIATIOBJ Wow El INSEAM. - POLIOY LINT 1,4fikt,0/50 INS. AGENTS Eget ELU1424.65-tG €11P1lalItS ONE11/2017 LIMIT 5,01MOCO AGGREGATE 25,004,000 VEIMBIPTIBNI BF DAIEPATIOVIIILOCATIONt d 1EHECLE3 PoCCBIT, IIIL AlltIttizentiBmark‘ SaPetelats, Amy bp altanIF.All II:AFara Apase is Amps bed!, NAMED: INSURED:US/5, INC RFP NUMBER 665366 WORKERSCOMPENSATION CLAWS AND LIABILITY CLAIMS ADMINISTRATION RTIFICATE ROWER CANCELLATION CITYM-1 CITY OF MIAMI PROCUREMENT DEPARTMENT, SHOOLD, ENV OF 1HE AE1OVE DESCREBED POLICIEZ BE CANCELLED B:EFORE TIE EXPMATION BATE 11-FEREOF,, NOTICE WILL BE DELIVERED IN ALCOREIANCE WITH THE POLICY PROVISIONZ, 444 FLW„ 2ND.AVE. 6TH FLOOR MIAMI, FL 3i3136 AUTBDRIZEBREPREfoOTTA TINE i ID 19 i,i!.-7(144 ACORD. CORPORATION. AR rights reserved ACORD 25 pei4i614 The he °RD Dame and loon are registered marks. of ACCIFID Page 3 Certification Statement Please quote on this form, if applicable, net prices for the item(s) listed. Return signed original and retain a copy for your files. Prices should include all costs, including transportation to destination. The City reserves the right to accept or reject all or any part of this submission. Prices should be firm for a minimum of 180 days following the time set for closing of the submissions. In the event of errors in extension of totals, the unit prices shall govern in determining the quoted prices. We (I) certify that we have read your solicitation, completed the necessary documents, and propose to furnish and deliver, F.O.B. DESTINATION, the items or services specified herein. The undersigned hereby certifies that neither the contractual party nor any of its principal owners or personnel have been convicted of any of the violations, or debarred or suspended as set in section 18-107 or Ordinance No. 12271. All exceptions to this submission have been documented in the section below {refer to paragraph and section). USIS has no exceptions to this submission. We (I) certify that any and all information contained in this submission is true; and we (I) further certify that this submission is made without prior understanding, agreement, or connection with any corporation, firm, or person submitting a submission for the same materials, supplies, equipment, or service, and is in all respects fair and without collusion or fraud. We (I) agree to abide by all terms and conditions of this solicitation and certify that I am authorized to sign this submission for the subrnitter. Please print the following and sign your name: PROPOSER NAME: USIS, Inc. ADDRESS: 5728 Major Blvd., Suite 450 PHONE: 800.444.9098 FAX: 407.949.3140 EMAIL: ron.warb.le0),usis-tpa.com CELL(Optional): 407.810.2684 SIGNED BY: TITLE: Executive Vice President DATE: November 28, 2016 FAILURE TO COMPLETE, SIGN, AND RETURN THIS FORM SHALL DISQUALIFY THIS RESPONSE. Page 4 Certifications Legal Name of Firm: USIS, Inc. FEIN No.: 204580645 Entity Type: Partnership, Sole Proprietorship, Corporation, etc. - Corporation USIS, Inc. is a wholly owned subsidiary of Brown & Brown, Inc. Year Established: Established in 1982. Business Address: 5728 Major Blvd., Suite 450 City, State, and Zip Code: Orlando, Fl.orid.a 32819 Telephone Number: 800.444.9098 Fax Number: 407.949.3140 E-mail Address: ron.warble@usis-tpa.corn Office Location: City of Miami, Miami -Dade County, or Other Orlando, Florida Business Tax Receipt/Occupational License Number: Orlando #500-0520375 W-- Case Number BUS0000795-016 Business Tax Receipt/Occupational License Issuing Agency: City of Oviedo, City of Orlando, Orange County �. P4rs:ifl C rr zre Onxwo Hrh§pn ja Sfi'NE'+d�'F"i BBk�4ttw�ssG. �y.�6YYC¢5 ll391RL 0iliNMIIX�IEC[ ate. '.�w'saw Business Tax Receipt/Occupational License Expiration Date: 9/30/2017 Page 5 Will Subcontractor or Sub consultant (s) be used? Sub consultant shall mean the same thing as a Subcontractor in these documents. (Yes or No) (if yes for what and what percentage of such work) USIS may partner with Preferred Governmental Claim Solutions, Inc. (PGCS) to provide certain specialty liability claims services. USIS and PGCS are both wholly owned organizations of Brown & Brown, Inc., operating within the same division (Services) that specializes in the services requested under this RFP. Will furnish and provide professional services to the City, at minimum, in compliance with all contract documents and in compliance with all applicable laws, rules and regulations. USIS agrees. Certifies that neither the Proposer nor any of its principal owners or personnel or any subsidiary of the Proposer, have been convicted of any of the violation(s) or crimes or actions and conduct involving moral turpitude as defined by applicable laws, or debarred or suspended as set forth in Section 18-107, City Code, or as provided by 287.133, Florida Statutes. The Proposer further certifies that the Proposer has not been debarred or suspended by the United States Government, the State of Florida, any political subdivision of the State of Florida or any Special District or Public School Board in the State of Florida. USIS certifies to the above statement. Proposer understands that exceptions not timely or correctly taken are waived. USIS understands that exception not timely or correctly taken are waived. Please list and acknowledge all addendum/addenda received. List the addendum/addenda number and date of receipt (i.e. Addendum No. 1, 7/1/07). If no addendum/addenda was/were issued, please insert N/A. Addendum No., 1 10/13/2016 Addendum No., 2 10/17/2016 Addendum No., 3 .10/24/2016 Addendum No., 4 10/26/2016 Addendum No., 5 10/28/2016 Addendum No., 6 11/2/2016 Has Proposer reviewed the attached Sample Professional Services Agreement (PSA)? Yes, USIS has reviewed the attached Sample Professional Services Agreement. Does the Proposer acknowledge that the attached PSA is an example of the standard Agreement used in conjunction with the services related to this Solicitation and shall not be amended? Yes, USIS acknowledges and agrees to above. Page 6 Proposer's General Experience, Past Performance,; and Exceptions 1) Describe the Proposer's past performance and experience and state the number of years that the Proposer has been in existence, the current number of employees, and the primary markets served. USIS, Inc. was established in Orlando, Florida, in June of 1982. USIS is a full service Third -Party Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Total Care Management Systems and Loss Prevention Services. AmeriSys is the medical management division of USIS, Inc. and is a dba of USIS. (USIS, Inc. dba AmeriSys) USIS is a wholly owned subsidiary of Brown & Brown Inc., one of the nation's largest insurance agency/brokerage organizations. The financial and management depth and resources afforded by our affiliation with Brown & Brown assures our customers that we will be there for them even during the most troubling times. Please reference Attachment 1-- Brown & Brown, Inc. Annual Report. USIS provides services throughout the Southeast while Florida and Georgia are the primary markets served. We provide our services to commercial carriers, self-insurance funds, risk pools and trusts, as well as self -insured employers in the private and public sectors of the market. USIS management and claim technical teams are composed of high level, dynamic claim and medical professionals. These teams thoroughly understand the challenges related to the unique operational needs of individual clients. Our staff of almost 250 personnel includes a dynamic and experienced leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. The culture statement for B&B is as follows: "Brown & Brown is a lean, decentralized, highly competitive sales and service organization comprised of people of the highest integrity and quality, bound together by clearly defined goals and prideful relationships." Although we are decentralized by design, that culture permeates USISIAmeriSys. Page 7 AmeriSys is a regional medical management/managed care organization founded in 1985, and operated under its previous name ERS until 1995, a regional disability management company which had built a ten year success in Florida, Georgia, the Carolinas, and other southeastern states. As of April 1, 2000, AmeriSys was acquired by Brown & Brown Insurance Services, Inc., and folded into USIS, Inc. as its medical management division. AmeriSys is URAC Workers' Compensation Utilization Management certified. URAC is the nationally recognized certifying body for these programs and services. ACCREDITED Workers'Comv osatprym USIS, the claims handling side of our organization, is completely integrated with AmeriSys. AmeriSys is a division of USIS rather than a separate company. As such, we have common executive leadership assuring continuity and compliance, while having separate technical leadership making certain that we excel professionally in all aspects of the claims adjudication service to our customer partners. Our organization is customer -centric. Our excellent reputation comes from recognizing that each employer/insured is unique in systems and philosophies. We stand ready to customize our services to best complement the current program by designing unique and customized service programs that allow our customers to "own" their claims service program. This incorporates our customers' strengths while augmenting their programs with design, support and expertise in the areas that will drive the greatest improvement in outcomes. We also recognize that these services and programs are dynamic and require ongoing assessment, evaluation and modifications to remain current with statute and rule as well as technology, medical advances and other efficiency -related information and techniques. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. Our innovative, quality administrative services include: r Multi -Line Claim Administration > Progressive Claim -Reporting Procedures Medical Management and Certified )- Cost Containment/Medical Bill Auditing Managed Care Programs and Review/EDI transmission. Third Party Recoveries > State -of -the -Art Information Systems Full Spectrum Risk Management r 1Muiti-State Capabilities With a solid reputation borne of commitment to service, our team is dedicated to serving the client. Our focus is on quality, professional, superior service. This service -driven philosophy, conveyed throughout the organization, means dedicated individuals with the client's best interests at heart, constantly reinforcing the corporate mission Service Beyond the Contract°O. We have a team of talented, responsive people with a desire to share their knowledge and understanding of the insurance arena for the client's benefit -- experienced in all types of Workers' Compensation claims. We establish designated and/or dedicated teams to each account allowing for maximum customization to the needs of our customer partners. Our approach is inventive and creative with the client's needs in mind. Page 8 Our goal is to keep the employee at work. But if that is not possible, the adjuster and the employer work as a team to facilitate a quick return -to -work in a modified/transitional duty position as soon as a release to Return to Work (RTW) and restrictions are received. We have found that RTW in a modified duty position helps keep the employee's morale high and the claims costs low. The ultimate goal is to bring the claim to conclusion in the most economical way possible while still providing quality medical care for the injured employee. Internal claims handling guidelines are essential to providing excellent claims administration services. Our flexibility allows us to deliver a complete claims administration program that is tailored to the unique needs of the client. All or part of our services may be utilized, depending on the client's individual requirements. We understand that the services we would be providing on your behalf are for your employees, your colleagues, and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also .making sure that we protect the financial and human resources that are paid for by the hard earned tax dollars of your City's citizens. We have a stewardship obligation and commitment to the City of Miami and its injured employees. 2) List all contracts which the Proposer has performed for the City of Miami, describe all work performed for the City and include for each project: (1) name of the City Department which administers or administered the contract, (ii) description of work, (iii) total dollar value of the contract, (iv) dates covering the term of the contract, (v) City contact person and phone number, (vi) statement of whether Proposer was the prime contractor or subcontractor, and (vii) the results of the project. USIS, Inc., through its medical management division ArneriSys, contracted with the City of Miami for Managed Care services from 2003 — 2011. Name of the city of department Risk Management Description of work Workers' Compensation Managed Care Services Total dollar value of the contract Approximately $200,000 annually Dates covering the term of the contract 2003-2011 City contact person and phone number Angella Breadwood, 305.416.1751 Prime contractor or Subcontractor Prime Contractor Results of the project Successfully completed 3) Provide information concerning any prior or pending litigation, either civil or criminal, involving a governmental agency or which may affect the performance of the services to be rendered herein, in which the Proposer, any of its employees or subcontractors is or has been involved within the last five (5) years. Provide letters of reference from law firms which currently handle your litigation. Provide contact person and phone number for each. USIS/AmeriSys has not been party to lawsuits, administrative actions or litigation related to fraud, theft, breach of contract, misrepresentation, safety, or wrongful death. Ilowever in the notrrral course of doing business related to workers' compensation claims handling, USIS/AmeriSys was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor, and one is current and pending. Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of its business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. 4) Identify if Proposer has taken any exception to the terms of this Solicitation. If so, indicate what alternative is being offered and the cost implications of the exception(s). USIS has no exceptions to this submission. Page 9 oposer.'s Category Specific Experience, Past Performance Note: Any Proposer submitting a Proposal for both categories of Service, Part I- Workers' Compensation Claims Administration AND Part II: Medical Bill Review and Audit Services (Part I and II) must provide in its proposal, complete and separate responses for applicable Items 5 through 15 below for each Part (Part I or II). USIS, Inc. is submitting two proposals; Part I is proposed under USIS, Inc. and Part II is proposed under USIS, Inc. dha AmeriSys. 5) Describe Proposer's past performance and experience with regard to the particular service category (Part I and/or Part II), and state the number of years that the Proposer has worked in this area providing a similar type of service, the current number of employees working in this area, and the primary markets served. Provide organizational history and structure, and indicate whether the City has previously awarded any contracts to the Proposer (a list of these City contracts shall be provided in item 2 above). USIS, Inc. is a full service Third -Party Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Medical Management Systems/Programs and Loss Prevention Services and Programs. USIS provides services throughout the Southeast while Florida and Georgia are the primary markets served. USIS, Inc. has been in business for 34 years and was established in June of 1982 as a division of Brown & Brown, Inc. In April of 2006 USIS was incorporated as a wholly owned subsidiary of Brown & Brown, Inc. (NYSE stock symbol BRO). B&B is one of the nation's largest insurance brokerage organizations. This provides our organization with the size and economic strength, stability and resources to handle a program such as the City of Miami's Workers' Compensation program. Our staff of almost 250 personnel includes a dynamic and experienced leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. USIS, Inc. (corporation) dba .AmeriSys is a wholly owned subsidiary of Brown & Brown Inc., one of the nation's largest insurance agency/brokerage organizations. The financial and management depth and resources afforded by our affiliation with Brown & Brown assures our customers that we will be there for them even during the most troubling times. USIS is dedicated to long-tertn client satisfaction. Most of our customers have been with us for many, many years and even through mandated-RFP processes, still remain with USIS, With Service Beyond the Contract its motto, USIS has a team approach, a partnership with our clients that will ensure there is always someone looking out for your best interests. Beyond the day to day claims handling by the adjuster, the following team members own the relationship. The Management/Supervisory team (30) has been with USIS an average of 13 years. The Management team (l 1) has been with USIS an average of 17.6 years. The leadership philosophy at USIS is a customer -centric team approach and always one of respect. From the top down, leaders are always expected to behave in a respectful, courteous manner across all ranks of Page 10 the team, up and down. We expect that of our teammates and it is expected of our leaders. We strive to offer our teammates a pleasant place to work which passes through to our customers. All leaders are an active part of the team we do not develop managers; we develop leaders. We strive to ensure that our teammates are fully trained and part of the team — from the initial "Welcome" posting to the introductions around the office to detailed training in customer service, and constant check -ins to strive to keep happy, engaged teammates. Company leaders eschew the vertical pronoun "I," encouraging their teams to opt for the encompassing "we." RCN WARIK EXECLITNE VICE PRESt 1I NT (��9aRD-�SFpY:: %d�6tsr MamaH'aT f:'. Cillvtft $70-.4ttfACER A fit toFf:041r^9. �le�it! Mein. 5uoarW € 10€ODmx 9rzPa.a9Bws 1 otttlAttft 130A+ uaeaf Chirer4i llafiaw4 4 tetplft 7vnnv t a� iiprtral€BiiAf �,IiAAGWGpY work lafftp.4tit UmfF A9 17Re.Pcwai aac2'', USIS, Inc. has not been previously awarded any contracts to the City of Miami for Workers' Compensation Claims Administration. USIS was awarded a contract for Workers' Compensation Managed Care Services (2003 — 2011) through its Medical Management division AmeriSys. Page 11 6) Provide a detailed description of five (5) comparable contracts (similar in scope of services to those requested herein), which the Proposer has either ongoing or completed within the past five (5) years in the capacity as a Third Party Claims Administrator. The description should identify for each project: (i) client, (ii) client contact person, phone number and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Include the Proposer's role and any value added. Mil) Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Where possible, list and describe those projects performed for government clients or similar size private entities (excluding any work performed for the City). Client Palm Beach County Sheriffs Office (PBSO) Client contact person Hilda Gonzalez Phone number 561.688.3550 Email address gonzalezli@pbso.org Description of work WC Claims TPA, Medical Bill Review, Medical Management Total dollar value $800,000+ annually Dates covering the term of the contract Established 2000 and remains active Prise contractor or subcontractor Prime Contractor Proposer's role and any value added. Weekly staffing on cardiac claims. Dedicated Adjusters. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met. Client : Orange County Public Schools (OCPS) Client contact person Regina Cochrane Phone number 407.317.3918 Email address regina.cochrane(ocps.net WC Claims TPA, Medical Bill Review, Medical Management Description of work Total dollar value $400,000+ annually Dates covering the term of the contract Established 1.995 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added. Monthly and yearly claim reviews. helped. establish a Return to work program. Yearly review of physician panel. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed proj ects. Active contract with performance standards being met. Page 12 Client Orlando Health Client contact person Richard Tunno Phone number 321 841 8641 Email address richard.tunno@orlandohealth.com orlandohealth.com Description of work WC Claims TPA, Medical Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1996 and remains active Priine contractor or subcontractor Prime Contractor Proposer's ..role and any value added. Quarterly claim reviews. Assisted with choice of vendors. Specify if the scheduled completion time and budgets approved by the client were met for each of the listed .. projects. Active contract with performance standards being met. Client : Volusia County School Board Client contact person Sandra Higginbotham, Phone number 386.734.7190 Email address skhiggin@volusia.k12.f1.us Description: of work: WC Claims TPA, Medical Bill Review, Medical Management Total dollar value $250,000+ Dates covering the term of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Proposer's role and any value added.' Return to work program. Assisted with physician panel. Specify if the scheduled completion approved by the client were met for projects. time and budgets each of the listed Active contract with performance standards being met. Client Columbus Consolidated Government Client contact person : Anne -Marie Arniel Phone number 706.225.3113 Email address aamiel@columbusga.org Description of work WC Claims TPA, Bill Review, Managed Care Organization Total dollar value $350,000+ annually Dates covering the term of the contract Established 2014 and remains active Prime contractor or subcontractor : Prime Contractor Proposer's role and any value added. Helped establish a Return to Work program and saved CCG approximately $1,000,000 per year in Workers' Compensation expenses Specify if the scheduled completion time and budgets approved by the client were met for each of the listed projects. Active contract with performance standards being met. Page 13 In the event that the Proposer has not performed five (5) comparable contracts in the particular category (Part I or Part II), the Proposer should provide information that demonstrated its ability to perform the required services. N/A 7) Describe any relevant industry/subject matter expertise, including any experience in the particular services, and any unique or proprietary project methodologies relevant to the requested services. USIS has built an outstanding reputation as a claims administrator for Workers' Compensation programs. Our clients appreciate our philosophy of personal service, dedicated commitment and team approach. • Properly licensed, experienced multi -line claims professionals • Case counts below the industry average allow for proper claim management and personal service • Rapid assessment and investigation of claims to help control medical and indemnity costs, and discourage attorney involvement • Timely, successful conclusion of claims, with strict diary system control • Focus on claim -reserving practices — initial reserve determined only after careful review by the licensed adjuster and the claims supervisor • Timely vocational case -management intervention, as necessary, to enhance successful file closure and reduce exposure to prolonged disability payments • Licensed specialists review each claim file for subrogation potential, seeking maximum recovery of client claim expenses with a track record of reaping substantial recoveries • Although opportunities to recover from SDTF are rapidly disappearing, we maintain a dedicated claims unit to assure recovery to the extent possible from the various Trust Funds • Aggressive investigation of potentially fraudulent claims • Progressive claim -reporting procedures May be reported online using the USIS web site, or via email, fax or telephone. One contact from the employer establishes a record of the claim and initiates all required State filings and review procedures • Ability to electronically register each claim with a national claims index service It is our understanding that the City has first responders/badged officials that are in your employment which experience presumption and cardiac claims. Please reference BADGE Program Attachment 2 - Cardiac -Exposure Protocol. We believe that the Heart/Lung public presumption claims represent one of the most significant economic exposures to closing claims and the anticipation that most of those claims will deteriorate as the employee ages. David E. Perloff, MD, FACC, FACP, is the AmeriSys BADGE Program Cardiac Medical Director. He has many years of experience in Cardiology and over 10 years of that in dealing with workers' compensation related to the Heart/Lung Presumption Bill. It is also our assumption that the City has injured employees who are prescribed opioids. Please reference Attachment 3 Innovative Programs for information related to the SECURE program, AmeriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. The program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. Page 14 It is this position and approach of innovation and efficiency that characterizes our organization. Whether it is unique types of claims, unusual working conditions or locations with special information needs, we strive to customize our program to address those unique and individual needs. Our commitment to innovation and efficiency is also coupled with 30+ years of proven experience in providing cost effective and quality -oriented medical care management. It is the careful blend of innovation with proven, tested experience and success that allows for the best in functional and economic outcomes. USIS stands ready to work with your leadership team to identify, develop and implement a program that is best suited to your claims and informational needs. The City of Miami will have real-time access to our USISiNet Web Portal. Upon registration, users may have access to claims, reports, notes, payment information, dashboards, and more depending on assigned level of access. There is no charge for access. Access is granted to clients based on authority level and permissions dictated by the client via user ID/password. Please reference Attachment 4 — USISiNet and AmeriSysiNet. Please reference Attachment 5 - USIS, Inc. Sample Reports which are available at any time through the web -portal. We have 8 on staff and on -site programmers who will be able to build ad hoc reports and/or data extracts that you desire in a reasonable time frame. If the report is available, you can customize dates, etc. We host and control source code and all of the data files that make up the workers' compensation application. Reports may be downloaded in Excel and can be customized upon request. 8) Provide a list of clients that have, for whatever reason, discontinued the use of your services within the past two (2) years, and indicate the reasons for the same. The City reserves the right to contact any clients listed as Bart of the evaluation process. Miami Jewish I-Iealth Systems Loss of account due to a complete changeover in 5200 NE 2nd Avenue leadership and the new leadership moved in a Miami, Florida 33137 different direction. Shaniqua Smith, 305.762.1526 Florida Roofers and Sheet. Metal Association SIF FRSA is a Self -Insured Trust which made a 4099 Metric Drive decision to create its own Claims Department and Winter Park, Florida 32792 began administering claims in-house. Brett Stiegel, 407.671.3772 The Medical Management portion of FRSA went to a third party for one year and came back to USIS/AmeriSys. 9) Provide two (2) Letters of Reference, on letterhead, from two different, similar sized governmental entities (as the City), and for which similar services (Part 1 or Part 11) have been performed within the past five (5) years. This information is subject to verification as part of the evaluation process. Please reference Attachment 6 — Reference Letters. 10) Provide a complete list of all current Florida clients for which Proposer administers claims in a Workers' Compensation, self-insurance, or retention program. The description should identify for each client: (i) client, and type of entity; (ii) client contact person, phone number, and email address, (iii) description of work, iv) total dollar value of the contract, (vi) dates covering the term of the contract, (vii) statement of whether Proposer was the prime contractor or subcontractor. Specifically identify clients for whom a similar service has been provided, particularly to governmental entities similar in size to the City, Trust, or Page 15 other similar type as the City. Indicate whether Proposer assisted in disability, safety program, light duty 1 return -to -work program, etc. Client Bay County Board of County Commissioners Type of Entity Public Client contact person Eve Tooley Phone number 850.248.8231 Email address etooley@baycountyfl.gov Description of work WC Claims TPA Medical Bill Review Total dollar value $15,000+ annually Dates covering the term of the contract Established 1993 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW Client Broward County BOCC Type of Entity Public Client contact person Jeff O'Connor Phone number 954.357.7230 Email address JCOCONNOR@broward.org Descriptionof work Network Access/Bill Review/Intake Total dollar value $50,000+ annually Dates covering the tern" of the contract Established 2007 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, . etc. Client City of Cocoa Type of Entity Public Client contact person John Titkanich Phone number 321.433.8686 Email address jtitkanich@cocoa:ll.org Description of fwork WC Claims TPA, Medical Bill Review Total dollar value $50,000+annually Dates covering the term of the contract Established 2009 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, iighht duty / return -to -work program, ete. RTW Page I6 Client City of Jacksonville Type of Entity Public Client contact person Twane Duckworth Phone number 904.630.2777 Email address twaned@coj.net Description of work Network Access, Medical Bill Review and Medical Only Claims Handling on an as needed basis Total dollar value $275,000+ annually Dates covering the tern;: of the contract . Established 2013 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc: Client Orange County Public Schools Type t fEntity Public Client contact person Regina Cochrane Phone number 407.317.3918 Email address regina.cochrane[uocps,net Description of work WC Claims TPA, Bill Review and Medical Management Total dollar value $400,000+ annually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty, Loss Control Client Palm Beach County Sheriff's Office Type of Entity Public Client contact person Hilda Gonzalez Phone number : 561.688.3550 Email address gonzalezH@pbso.org Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value $750,000+ annually Dates covering the term of the contract Established 2000 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether . Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Page 17 Client State of Florida (DRM) Type of Entity Public Client contact person Candy Janes Phone number 850.413.4827 Email address Candy.Janes@rnyfloridaefo.com Description of work Intake/Triage Medical Management Total dollar value $9,000,000+ Annually Dates covering the term of the contract Established 2014 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Volusia County Public Schools Type of Entity Public Client contact person Sandra Higginbotham Phone number .. 386.734.7190 Email`address skhiggin@volusia.k12.fl.us Description of work ` WC Claims TPA, Bill Review, Medical Management Total dollar value $250,000+ Annually Dates covering the term of the contract Established 2007 and remains active Prixne contractor or subcontractor . Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return to -work program, etc. RTW, Light Duty Client Preferred Governmental insurance Trust Type of Entity Public Client contact person Ann Hansen Phone number 3 321.832.1510 Email address ahansen@publicrisk.com Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value C Confidential Dates covering the term of the contract : Established 1999 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp TPA Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Page 18 1 Client Brevard County BOCC Type of Entity Public Client contact. person Julie Jones Phone number 321.637.5446 Email address Julie,Jones@brevardcounty.us Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Total dollar value $250,000+ annually Dates covering the term of the contract Established 2003 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Cornp TPA Indicate whether Proposer assisted in disability, safety.. program, light duty / return -to -work program,: etc. Client ::: Charlotte County Type of Entity Public Client contact. person. Raymond Carter Phone number 941.743.1334 Email address Raymond.Carter@charlottecountyfl.gov Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $40,000+ annually Dates covering the term of the contract Established 2010 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, ;,safety program, light duty / return -to -work program, etc. Client City of Delay Beach Type of Entity Public Clientcontact person : Eddie DeMicco Phone number :.:.. 561.243.7150 Email address demicco@amydelraybeach.com Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Cornp TPA (PGCS) Total dollar value : 550,000+ annually Dates covering the term of the contract Established 2013 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Page 19 Client Leon County BOCC Type of Entity Public Client contact person Karen Melton Phone number 850.606.5120 Email address Meltonk@leoncoLntyll.gov Description of work Medical Bill Review, Medical Management (USIS /ArneriSys) Liability and Work Comp TPA (PGCS) Total dollar value $50,000+ annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Coinp Indicate whether Proposer assisted ::in :'disability, safety program, light . duty / return -to -work program, etc. Client _ Preferred Governmental Claims Services Type of .Entity Private Client contact person Ken Picton Phone number 800.237.6617 Email address kpicton@pgcs-tpa.com Description of work Medical Management, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2005 and remains active Prime contractor or subcontractor Prime Contractor for Medical Bill Review and Medical Management Indicate whether Proposer assisted in .disability,. safety program, light duty / return -to -work program, etc. Client :...: Ferman Motor Car Company Type of Entity Private Client contact person Webb Bond Phone number 831.251.2765 Email address webb.bond@ferman.com Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prune contractor or subcontractor Prune Contractor Indicate whether Proposer . assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Page 20 Client Halifax Health Type of Entity Private Client contact person Terry Martin Phone number 386.254.4048 Email address Terry.rnartin@halifax.org Description of work WC Claims TPA, Bill Review Total dollar value $75,000+ Annually Dates covering the term of the contract Established 2012 and remains active Prune contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Health First, Inc. Type of Entity Private Client contact person Nancy Johnson Phone number 321.868.7248 Email address Nancy.johnson@health-first.org Description of work WC Claims TPA., Bill Review Total dollar value $125,000+ Annually Dates covering the term or the contract Established mid 1980's and remains active Pririne contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Orlando Health Type of Entity P Private Client contact person Christy Pearson Phone number 321.841.6104 Email address christy.pearson@orhs.org Description of work WC Claims TPA, Bill Review Total dollar value $175,000+ Annually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor :' Prime Contractor Indicate whether Proposer assisted in. disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Page 21 Client Parrish Medical Center Type of Entity Private Client contact person Roberta Chaildin Phone number 321.268.6333 Email address roberta.chaildin@parishined.com Description of wort WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. RTW, Light Duty Client Ring Power Corporation Type of Entity Private Client contact person Cindy Acosta Phone number 904.73 7.773 0 Email address Cindy.Acosta@ringpower.com Description of work WC Claims TPA, Bill Review Total dollar value $40,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prune Contractor Indicate whether Proposer assisted in. disability, safety program, light duty / return -to -work program,:. etc. RTW, Light Duty Client . FHM insurance Company Type of Entity Private Client contact person Jack Lemine Phone. number : 800.329.4340 Email address jlernine@ihmic.com Description of. work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract Established 2003 and remains active Prime contractor or subcontractor Prune Contractor Indicate whether ' Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Page 22 Client Florida Citrus, Business Industries Fund Type of Entity Private Client contact person Jim Emerson Phone number 863.660.5943 Email address jim.emerson48 a gmail.com Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract. Established 2002 and remains open Prime contractor or subcontractor Prune Contractor Indicate whether Proposer assisted in disability,: safety program, light duty / return -to -work program, etc. Client : Florida Rural Electric Self Insurers Fund Type of Entity Private Client contact person William Willingham Phone number 850.877.6166 Email address Bil1(a),FECA.Corn Description of work WC Claims TPA, Bill Review, Medical Management Total dollar value Confidential Dates covering the term of the contract Established 2002 and remains active Prime contractor or. subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Florida Workers' Compensation Insurance Guaranty Association Type of Entity Private Client contact person . : Sandra Robinson Phone number 850.386.9200 Email address sobinson@agfgroup.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1998 and remains active Frime contractor or subcontractor - Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Run off claims Page 23 Client Sujar Cane Growers Cooperative of Florida Type of Entity Private Client contact person Cau nen Abercrombi Phone number 561.996.4751 Email address cabercrombi@cscgc.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the tenn of the contract Established 2010 and remains active Prime contractor or subcontractor Prince Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. 11) Discuss in detail Proposer's qualifications and experience to provide general liability and automobile liability claims administration. Include, in the description, the Proposer's thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed. USIS will partner with Preferred Governmental Claim Solutions, Inc. (PGCS) to provide some specialty liability services. We are a single organization (Brown & Brown, Inc.) operating within the same division that specializes in the services requested under this RFP. .PGCS has been licensed to operate as a third party claims administrator since 1956 (60 Years). PGCS was formed in 1956 in Miami, Florida under the name of Insurance Servicing and Adjusting Company (ISAC). The governmental entity division of ISAC later changed its name to Preferred Governmental Claim Solutions, PGCS has been located in central Florida for twenty- four 24 years and is currently located in Lake Mary, FL and maintains a dedicated claim unit at the Risk Management Department of Palm Beach County. PGCS was acquired by the Public Entity Division of Brown & Brown, Inc. in 2001 PGCS provides third party claims administration service to thirteen (13) self -insured municipalities. In addition, PGCS administers claims for over one -hundred (100) municipal members of the Preferred Governmental Insurance Trust (PGIT) With 60 years of Florida claims administration experience, PGCS has a thorough knowledge of all State Statutes and other applicable .laws governing this RFP. Page 24 12) Discuss in detail Proposer's qualifications and experience to provide managed care services. Include the Proposers thorough knowledge of all State Statutes and other applicable laws governing this RFP, to demonstrate a complete understanding of the work to be performed. ArneriSys is the medical and cost containment division of USIS. AmeriSys provides a complete selection of medical management and managed care programs. Our experience in handling large public entity employers, such as your own organization, the City of .Miami (2003 — 2011), as well as the Palm Beach County Sheriff's Office, Broward County Government and the State of Florida, makes us uniquely qualified to assist the City with its managed care program. Our experience providing the Occupational Medical Management program for Preferred Governmental Claim Services and Preferred Governmental Insurance Trust brings over 200 Florida public entity employers into our service program. Each of these customers has benefited from highly customized approaches developed by AmeriSys to meet its unique occupational medical management needs. AmeriSys has a thorough knowledge of all State Statutes and other laws governing this RFP from its 30 years of experience in the Florida Medical Management marketplace. 13) Provide detailed background on the Proposer's proposed Manager/Supervisor to be assigned the City's account throughout the duration of the contract term, and whether Proposer agrees to City's terms for approval of future Manager/Supervisor, should proposed representative leave Proposer's firm during the contract term. Provide copies of current applicable licenses for work to be performed in the State of Florida. Jenny Ross, will be the Account Executive. She will be the City's main point of contact for Claims Reviews and Service Issues ensuring a high quality of service and support. It will be the responsibility of the Account Executive, Jenny Ross, to identify and resolve any issues brought forth during the project duration. The Account Executive has been responsible for multiple large clients and is experienced in dealing with and resolving any issues. She will be accessible to the City by keeping the lines of communication open. USIS strives for an excellent customer service relationship. If . there are any concerns, they will be immediately handled. Our goal is to build and ensure excellent rapport between our staff and the City's for a superior working relationship. The Account Executive will remain fully involved in the day to day claims handling process in order to ensure that all critical decisions being made by the staff are in the best interest of the City and its injured employees. Any concerns will be discussed with .Risk Management as needed. Jenny Ross, Account Executive, Ext. 6302 jenny.ross(abusis-tpa.com Jenny Ross has been in the claims industry for over 20 years. Joining USIS 16 years ago, Jenny has been steadily promoted throughout her career. She started as an adjuster, handling a large volume of workers' compensation claims, conducting client visits and claims reviews; and has become an integral part of our claims management team. Jenny's customer service, declicat.io.n and commitment to our clients, along with claims knowledge and analysis, make her a top notch Project Manager. Prior to joining USIS, Jenny was employed at Executive Risk Consultants as a lost time claims adjuster. Jenny was the proud recipient of the 2011 Nationwide Brown & Brown Claims Professional of the Year Award, as well as USIS's Employee of the Year in 2007. Page 25 Terri Snapp, WC Claims Manager, Ext. 6409 terri.snappcusis-tpa.com Terri Snapp has over 28 years of experience in the workers' compensation insurance claims industry. Beginning her career as a file clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS, supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which are public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USIS as a TPA. Yarixa Eliason, Liability Supervisor, Yarixa.eliason rx,usis-tpa.com Yarixa Eliason has over 20 years of experience in the liability insurance claims industry. Beginning her career in Miami with John's Eastern as a liability adjuster, she was steadily promoted within the industry. She has her all lines adjuster license with experience in handling claims for commercial auto, general liability, employment liability and governmental entities. One key component of her job is dealing directly with public entity clients. Please reference Attachment 6 - Resumes/Licenses, Job Descriptions. Since USIS will be the employer and USIS/Brown & Brown could potentially be at risk for any perceived liability of wrongdoing in the hiring process, it would not be standard practice to accept an outside entity into our hiring processes. It is our intent to positively ensure that our equal employment opportunity philosophy, in accordance with federal, state, and local law, applies to all aspects of employment with USIS including recruiting, hiring, training, transfer/promotions, compensation and benefits, and termination. At USIS, handled through our own Human Resources Department we must ensure that our employment practices are free of discriminatory practices and that employment decisions are made on the basis of job -related qualifications, experience, including personal competence and potential for advancement. With that stated, we will be open and pleased to strongly consider any recommendations or referrals of properly qualified staff that the City might provide or request. We will also be willing to share the resumes of the employee(s) hired or transferred internally to handle the City of Miami account. Once into the contract, should there be any staffing changes necessary, USIS would communicate with the City of Miami as soon as known. It should be noted that at USIS we are committed to ensuring equal employment opportunity for all employees and applicants for employment. It is our goal to recruit, hire and develop the best employees using only job -related qualifications. We know that our people are the heart and soul of our enterprise and we recognize that our continued success depends on the full and effective recruitment, hiring and development of the very best employees, taking into consideration only job -related qualifications, regardless of race, color, religion, sex, age, national origin, marital status, disability, veteran status, genetic information and any other category protected by state or federal laws. AmeriSys strives to recognize the talents and job performance of all employees, and values the contributions that come from people with different backgrounds and perspectives. It is AmeriSys' desire to promote an environment that maximizes the potential of all of our employees, and to promote diversity throughout the Company because we believe that diversity is important to our ability to continue to excel in an increasingly diverse and dynamic marketplace. Page 26 The Company does not permit discrimination or retaliation against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training, or other terms, conditions, and privileges of employment. The Company will reasonably accommodate qualified individuals with a temporary or long-term disability so that they can perform the essential functions of a job. A job applicant who can be reasonably accommodated for a job, without undue hardship, is given the same consideration for that position as any other applicant. 14) Describe the experience, qualifications and other vital information, including relevant experience on previous similar projects (Part I or Part II), of all key personnel, who will be assigned to the City's contract. This information shall include the functions to be performed by the key individuals, and the caseload of each person assigned to service the account. Include copies of all licenses held by each individual, as all claims professionals must possess a current Florida adjuster's license. Provide copy(ies) of each adjuster's and Supervisor's Florida Adjusting License, or any other relevant licenses, if applicable. In addition, provide resumes, if available, with job descriptions and other detailed qualification information on all key personnel who will be assigned to the City contract. Jenny Ross Account Executive Teixi Snapp Claims Manager Yarixa Eliason Liability Supervisor Please reference Attachment 7 - Resumes/Licenses, Job Descriptions. 15) Provide a complete list of all licensed claim's personnel that will handle City's claims, and/or managed care services, including the Proposer's proposed Manager/Supervisor, Supervising Adjuster, Adjusters, Supervising nurse Case Manager, Case Manager, Medical -only processors, or other individuals including clerical and or support staff detailing education, experience in the area of workers' compensation claims, in the area of managed care, and type of license(s). Include copies of all licenses held by each individual. Jenny Ross Account Executive Terri Snapp Work Comp Claims Manager Yarixa EIiason Liability Supervisor TBD* Work Comp Supervisor TBD* (5) Lost Time Adjusters TBD* (1) Medical Only Adjuster TBD* (2) Liability Adjusters Please reference Attachment 7 — Resumes/Licenses, Job Descriptions*. Note: After qualification submission, but prior to the award of any contract or work order issued, as a result of this RFP, the Proposer has a continuing obligation to advise the City of any changes, intended or otherwise, to the key personnel in its proposal submission. USIS agrees to the above statement. Page 27 Proposers. Ability to Perform Required Services;. 16) Provide a complete list of all claims office locations and territory(ies) serviced with Proposer's current personnel, indicating the number of personnel of Proposer, and Proposer's ability to provide required services to the City. Brown & Brown, Inc. PO Box 2412 Daytona Beach, FL 32115 # of Employees: 8,600 USIS, Inc. PO Box 616648 Orlando, FL 32861-6648 Previously operated under United Self Insured Services # of Employees: 88 USIS provides services in Florida, Georgia, South Carolina, North Carolina, Virginia, Kentucky and Alabama. USIS currently provides the required services to Florida Public Entity clients. USIS has the ability to provide the required services to the City of Miami. 17) Describe where your main office is located, and the location where the primary work will be performed. Indicate location where the Successful Proposer, the Successful Proposer's Manager/Supervisor will be located USIS main office which is listed below is the location where the primary work will be performed. The Account Executive will also be located at the main office. USIS, Inc. 5728 .Major Blvd,, Suite 450 Orlando, Florida 32819 18) Discuss how the Proposer's office or unit will be staffed, and the level of supervision that will be provided. Discuss case assignments, including pending case load for each designated Adjuster and current number of monthly new assignments to each Adjuster, if applicable. Discuss case assignments, including pending case load for each designated nurse Case Manager and current number of monthly new assignments to each nurse Case Manager, if applicable. USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Cornp Adjusters (5 Lost Time and 1 Medical Only). The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit. Lost Time adjusters will handle a maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the Lost Time caseload below the maximum, USIS would move non -litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. Page 28 The Liability adjusters will have a maximum caseload of 160 claims. Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The City can access this report through USISiNet. This report is a tool that allows the supervisor to make ease load adjustments as necessary. .::;;::rva:; ::;:p r>r rl °�w.. w•.<:::::,e :_ ,: `aso oa m. ..::::::..::..:::T,:m,:-:..:::::::.::::qry: r=rn ry W ;: =.:::e :::e ' : : ; e::....:. Perrsla x ,, s i d ;:w . i;.;:::. eel m eem e:e e:;::::: :: .a e.:: ' °e ww €a �e eW:e:e:ese.:,:�e.e.:.�......,d........:.:::::�.;, ....w:. ,;..., Asp .: r ent e� 1 .mm. Lost Time Adjuster 127 l0 Medical Only Adjuster 294 152 WC Supervisor WC Supervisors do not handle a caseload The following staffing assumes USIS, Inc. dba AmeriSys receives the Medical Management contract. Under the overall direction of the Vice President of AmeriSys, the City of Miami will be directly supervised by a registered nurse who is also a certified case -manager. The Program Manager/Supervisor is responsible for the day to day activities on all claims. She is also responsible to ensure the standards set forth by the AHCA are upheld and maintained. Some of the standards include but are not limited to the monitoring of caseloads and ensuring diary protocols are followed. The supervisory duties also include the reviewing of internal audit scores, identifying issues pertinent to the City of Miami that require education and need reporting to the quality assurance committee. She will also track and trend the activity involved in the quality initiatives in which the City of Miami is participating. The Program Manager/Supervisor acts as an advisor and mentor to her staff members, and is the direct point of contact for both the claims adjusting team and the City of Miami Risk Management Departm.ent for any issues that are escalated and require an immediate response. It is our intention to staff the City of Miami designated unit with two (2) registered nurse case -managers. The team lead nurse case -manager will handle Medical Only and Lost Time files assigned by the adjusters. The second case -manager will be the cardiac case -manager, assigned to the oversight and management of the claims covered by the Heart and Lung Bill, specifically following the protocol of the BADGE program. The Telephonic Case Manager caseload average is 72 files and their maximum is 80 files, These numbers are dependent on severity and complexity. While it is our intention to maintain this.number of cases for the City of Miami case -.managers, we understand this may fluctuate at times dependent on seasonal activity as well as any incidents involving multiple claims at one time. AmeriSys averages 10-12 new files opened per Telephonic Case Manager per month. We also recognize that the number of new monthly assignments is directly affected by the number and type of newly reported injuries each month. We will distribute each type of elaim to the appropriate case -manager. Page 29 19) Describe how Proposer will ensure managed care services by City employees residing in Miami -Dade, Broward, Palm Beach, and Monroe Counties, among other locales. AreriSys, USIS' Medical Management division, currently has approximately 200 employees who service our customers, Those customers include Broward County Government and Palm Beach County Sheriff's Department as two large self -insured employers in the south east Florida area. In addition, the State of Florida is a customer with a large southeast Florida presence. We also have a number of smaller public entities as well as several insurance companies and three self-insurance funds, all of which have claims within the counties identified above. 20) Discuss whether the award of this contract necessitates an increase in Proposer's staff size to meet the City's staffing and caseload requirements, and whether staff will be in place by the start of the contract, which is estimated to be February 1, 2017. USIS will need to lire staff to meet the requirements of the City of Miami's RFP. The staff will be in place by the start of the contract. 21) Explain the percentage of time the Proposers proposed Adjusters will be out of the office doing field work. If all of Proposer's proposed Adjusters are telephone Adjusters, indicate as such. Explain whether Proposer will utilize independent contracted Adjusters, and under what circumstances. Provide the name, address, phone, and contact person for independents you currently utilize. Liability — We intend to hire one of the two adjusters in the Greater Miami area as an adjuster whomwill perform field work. Based on information provided by the City of Miami, it is assumed that the adjuster would spend 20% of his/her time doing field work. 22) Identify language capabilities (spoken or written) of Proposer's employees and those of the subcontractors or subconsultants. USIS will have employees within the unit who are bi-lingual. Page 30 Proposed Overall Approach to Perfor*ning ;theServices' 23) Discuss in detail Proposer's overall approach to the work to be performed. Describe Proposer's specific project plan and procedures to be used in providing the services, and how Proposer has applied the proposed project approach in comparable contracts. Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami will work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your" program. It is essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional limitations rather than blanket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared to evidenced based guidelines. It is our goal to have and maintain an excellent rapport with the provider community. USIS utilizes peer to peer contact to help resolve any issues regarding medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs. While ATP' s treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. USIS has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and performance guarantees to ensure the guidelines are being adhered to. Finally, our bill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule.. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored to the special needs of the client. Page 31 • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN • In-house programmers are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of injury reporting; check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost- effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes- Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case -managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case - manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, .Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 d.ays will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. Page 32 The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to a.ccomrodate the injured employee's restrictions. USIS is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with limitations is •noted in compariso.n to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor may be called upon to opine on the situation. • Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. • Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when :necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion an.d service to that employee and his/her family. Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: Page 33 A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis, It is policy that all reported claims will be investigated to fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information from the claimant, the account, witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: 1. Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. 2. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be Obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6, Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Page 34 24) Describe Proposer's ability to perform the services described in the Scope of Services, and describe Proposer's specific policies, plans, procedures or techniques to be used in providing the services requested. The Proposer shall describe its approach to project organization and management, responsibilities of Proposer's management and staff personnel that will perform work in this Solicitation. Be authorized (licensed) as a Claims Administrator by the State of Florida, as of proposal due date; USIS, Inc. is authorized as an administrator in the State of Florida — current annual update through February 28, 2017. Ali3'Ai171,R 63:Yrii OFV100. Fubmary 7.7,WI ltArx Warbia Mirllleo.Prealidrtm MIN., Run, Po.4 C31t{rc Rnti 6136f✓1x. Orlando, Cloridu'.VAG!-664% Fta: Quufi.Rcd6'4wrviung kthrity A rouraS Roport Ikar Mr.'Wurl>2o: Thu-Qvatiflod &e;¢iaiag L'milly Aonual. Roar, Fame. for your compuoy her ixon reemived. I Itm reciowtd thl; roper NW lug your cnm}wny is in cwnpl'+aneu with Ride 69f,S.12U(11Y g,A.C. (€leruitdng Authorization as a QuuI fad Sczvirdasg plolryy Ili is 3enar wilt marry Iti yoar twri Jay has buun riaatitio Mr the.partod Nfatrelt 1„'Ei114 Elrrvor,,h Ylq:iarrtary 24, 2017. Attached is a anpy ni1°urm DFST2 S1,25 (Quaittieil Sirevicog Lrnrlly Aorm>if ftupnrt laonn), to he us r 1i r &Vona filing na SW nm longer mall it, form pouruo dos due data. Ai.me at mb. d i P t eolry oY Lorna INS-172 SI-29 (Cort:flcalluo uY Saeadoing for Half=tnsusoa}, dole;ot= 1m ba aomplmled thirty (3a) Jay or amcaitrg Satin a can{r1.111 11m yarvioitt(}. Your oust ann ull rrtxni la.due .in ant ufficn.nu lukr than ildurcle .f, 3011. Should you.haro any gwuctfoin cm nuaa foliar etsslgurta:c,.pl4'uaatxinlaat.too at(& » 4.l.34716& otely, lnsuranuo at ulononta 61.:1,1tiiU.9.2aE'rAiCT: OR'01",14 MANCIAI; 93IIVRtY.Z Do4.11P.lanafng.-MvputacAtiao m [trial o dt`NE laa. 3apataaim a rhitOna114111.. 3.AnxnundaSiNy MO MA Caw &LW m 'liflalamm, elacia 314'1`,411. TO. $50411.1-/M, Y°a. 8ee.4 40244. -.@nrsit • awge al a xiiapOtArttaddantu am • Have dedicated/designated adjusters in the State of Florida with a minimum of three (3) years' experience, directed by a dedicated Supervisor, with at least five (5) years' recent experience. We hire adjusters with a minimum of 3-5 years of experience; most of our adjusters have 10+ years of experience. We require them to have extensive knowledge of accepted industry standards and practices including case law; the ability to successfully negotiate the settlement and disposition of serious claims; those who are technically competent with systems, etc. We seek out those adjusters who have come highly recommended by trusted attorneys, successful employees, etc. Experience, capabilities and work ethic are checked with as many sources as possible. The dedicated supervisor will have a minimum of five (5) years' experience. Page 35 • Be approved by all of the City's excess carriers; USIS is approved by all of the City's excess carriers with the exception of State National. USIS has not had any issues getting approvedby excess carriers and expects to be approved by State National. • Be compliant throughout the life of the Agreement and must be compliant at the time of proposal submittal, in Statement on Auditing Standard No. 70 (SAS70)/ Statement on Standards for Attestation Engagement 16 (SSAE16); USIS undergoes an annual SSAE 16 audit (formerly known as SAS 70) and is currently in compliance with all items. A copy of the report can .be provided upon completion of an executed contract between USIS and Sarasota County Schools. Please reference Attachment 8 - SSAE 16 excerpt. • Have a minimum of five (5) continuous years of experience, handling Florida municipal claims, with at least one (1) client having a minimum of 1500 employees; USIS has provided Florida public entity claims services for more than (5) continuous years to Bay County, Palm Beach County Sheriffs Office, Orange County Public Schools and Volusia County Public Schools, the latter 3 who have in excess of 1,500 employees. (current clients) • Be in full compliance with the federally -mandated State Children's Health Insurance Program (SCHIP) and Florida Electronic Data Interchange (EDI) requirements; USIS reports all claim data to the State of Florida via electronic data interchange (EDI) according to and complying with the standards of IAIABC current requirements, Claim forms are transmitted to the State daily. The adjusters review the State forms the next business day in the online data warehouse. Any rejected forms are resubmitted immediately. USIS has not had any major deficiencies or issues with State audit compliance. USIS currently provides CMS reporting in compliance with MMSEA 111. This reporting is identified for Medicaid (State Benefits) and Medicare (Federal Benefits). Currently there are no guidelines or directives for Medicaid reporting, but we are reporting to CMS for Coordination of Benefits Center (COBC) for those individuals receiving or likely to receive Medicare and/or Social Security benefits. Our system contains a COBC\CMS module that allows for direct data reporting for the Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA). • Have electronic capabilities to provide electronic reporting, transfer of data to any/all platforms as directed, and connectivity to Proposer's information system; USIS has the capability to provide and to receive electronic data to any/all platforms as directed by the City. • Have no record of judgments, bankruptcies, pending lawsuits against the City, criminal activities involving moral turpitude, and not have any conflicts of interest that have not been waived by the City Commission; and USIS has not been party to lawsuits, administrative actions or litigation related to fraud, theft, breach of contract, misrepresentation, safety, or wrongful death. However in the normal course of doing business related to workers' compensation claims handling, USIS was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor, and that one is recent and still pending. Page 36 Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of its business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. In the normal course of doing business related to workers' compensation claims handling, USIS has been occasionally named in individual suits, however has not been found at fault or apportioned liability. • Not be in arrears or in default of any debt or contract involving the City (as a party to a contract, or otherwise); nor have failed to perform faithfully on any previous contract with the City. This requirement applies to Proposer's principals, officers, or stockholders. USIS and Brown & Brown, Inc., USIS' parent company, are not in default on any contract or financing agreement with any bank, financial institution or other entity. USIS is unaware of any team member that is in default on any contract agreement or financing agreement with any bank, financial institution or other entity. 25. Provide projected caseloads per employee of Proposer assigned to City account. Lost Time adjusters will handle a .maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the caseload below the maximum, USIS would move non -litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. The Liability adjusters will have a maximum caseload of 160 claims. Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The City can access this report through USISiNet. This report is a tool that allows the supervisor to make case load adjustments as necessary. 26) Describe Proposer's staffing plan to demonstrate that Proposer can be adequately staffed with trained personnel to handle the City's full caseload and have the capability to recruit such staff. USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Comp Adjusters (5 Lost Time and 1 Medical Only). The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit USIS is experienced in recruiting and adequately staffing large accounts in a short period of time. In .late 2014, USIS/AnneriSys was awarded the State of Florida Medical Management contract. Within a 2 month period USIS/ArneriSys hired and trained approximately 70 employees. 27) include a statement that at east thirty (30) days prior to replacement of key personnel, Proposer will notify the City's Project Manager, in writing, that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. USIS will notify the City's Project Manager at least thirty (30) days prior to replacement of key personnel, in writing, that replacement employees will possess qualifications and experience equal to or greater than personnel being replaced. 28) Provide a detailed timetable identifying significant milestones for the smooth transition of the operations. Proposer shall identify the necessary support that shall be required from City staff during that transition. USIS recognizes that the Transition Plan is an extremely important and complex process and therefore we have created an attachment to reference each phase of the implementation plan. Please reference Attachment 9 -- Transition Plan, Page 37 29) Discuss in detail exactly how all services reflected in the Scope of Work will be accomplished. Include a complete approach Proposer will take to meet all responsibilities expected of Proposer by the City. Include any and all information regarding affiliated physicians, other medical personnel, locations to provide said services, and other related information regarding the provision of such services for the City. Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami will work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your" program. It is essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional limitations rather than blanket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared. to evidenced based guidelines. It is our goal to h.ave and maintain an excellent rapport with the provider community. 'USIS utilizes peer to peer contact to help resolve any issues regarding medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs, While the primary treating physician's treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. 'USIS has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and perfoliriance guarantees to ensure the guidelines are being adhered to. Finally, our hill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored to the special needs of the client. Page 38 • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN • In-house programmers are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost- effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes- Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case -.managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case - manager (when assigned) and cost containment. AineriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall, cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. Page 39 The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with th.e injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. USIS is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with limitations is noted in cornparison to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor may be called upon to opine on the situation. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and hums. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case ManagementProviders and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized rna.ny times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Page 40 Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It i.s policy that all reported claims will be investigated to fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information .tuna the claimant, the account, witnesses, medical providers and experts. The adjuster will gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: 1. Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. 2. Verification of any physical injuries will he made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Page 41 30) Provide a description of the standard loss reports, as well as provide a sample and descriptions of any additional reports to be utilized. There are several types of loss reports. Loss reports can be generated by policy year, accident year, detailed version, summary version, by claim type, claim status, by an employer, or a particular location. Employer reports can be exported to Excel and to .PDF. Below is a .list of other reports to be utilized, but not limited to: i. Check Registers (Payments) 1. Full Detail (By Individual Cheek/Transaction) 2. Totals by Year 3. Totals by Unit ii. Employer's Reports (Claim Payment, Reserve, Incurred Totals) I. Full Detail (By Claim with Claim Details) 2. Totals by Year 3. Totals by Unit d. By Policy, Accident Year, Employer b. Claim Summary Reports c. Reserve Reports d. Payment Histories e. Interactive Grids exportable f. Claim Lists g. Presumption h. Litigation Please reference Attachment 5— USIS Sample Reports. Page 42 31) Explain whether Proposer currently file state and excess insurance forms on behalf of Proposer's clients, and attach copies of the forms used. USIS has a designated Excess Adjuster who is responsible for the reports to the excess insurers. She is assigned to report all claims meeting the criteria to the excess insurers. The handling adjuster refers the claim to the Excess adjuster who in turn files the initial report and all follow up reports based on the reporting requirements regarding frequency as set forth by the excess insurer until the conclusion of the file. Quarterly loss runs are provided to each excess reinsurer showing all claims .reported with paid to date, reserves and total incurred noted for each claim, Access to these reports can be obtained from the USIS website if needed on a more frequent basis once a username and password is requested and obtained by the excess insurer Eztx.rn (wrier anwrreR: bate at €kew+aacec PTO m of onvxxs po Wosxers' t`enrpaaset on Rettaeisgiwn 6hre nceriable Clown Canter Gran Yr Canptote1 by: Date: d.4(£, fsc� FO not 61.64 [& Ot1,Wdon 1$51415 dB7?i1'.,014 r 1,8419A.“..0 p3 Excess Carrier: atanreck ClainFanc Date of Occurrence; Employer: Ctasm Sf.'itEP3 aT W dote; PILJ as ot; 3ypplwPer tol Report Policy Peden: Claim ft: Carrier Ct§t€[n p. Policy#: Erpeeten RT.W tfate; Reaetvea Scarce I Patti. to P to mini hnlenutity Medical Expense Joao!. Total Offsnk to Weckeos' Cempensatton Rsttadllttntian sett anent Claimant coy 4uesthmatae G€n€m Wilt StR tte extoette6 Comments' Completed by. Date: UBF5,1k. Pdo t t Sl6145 1- orloydalt ,i2861i6J3 cea.Fune' Ex RP'_51ne' omllka.ts4 Page 43 32) Describe Proposer's methodology for evaluating and determining savings as expected within this RFP. Include in detail the mechanisms Proposer would use to track whether proposed savings goal has been met, and methods to meet those goals. Indicate if Proposer is willing to accept the incentive or penalty as indicated, should savings not result. To determine the potential savings achieved on behalf of the City, USIS/AmeriSys would first reference our Medical Bill Review Activity reports from 2011 when AmeriSys performed these services for the City. We would also reference performance reports for other clients in the same geographic area. We make every effort to achieve the highest level of savings possible within the Florida Statutes and Rules, while establishing and ensuring rapport within the provider community. We recognize the potential significance of the City's claims due to the occupational hazards the employees possess. Quality physicians must be available to render care. USIS is agreeable to accepting a mutually agreeable incentive or penalty as indicated, should savings not result. 33) If proposed, describe in detail Proposer's computerized on-line claims management system and software to be utilized during the performance of the scope of work reflected herein. Detail functionality, transition from current system, and if a cost is proposed, indicate in Proposer's Fee Proposal. US1SiNet is the on-line claims management system as USIS which will be fully available to the City of Miami. There is no charge for access, and it does not require special software. Access is granted to users based on authority level and permissions dictated by the client via user id/password. The web portal contains reports that be directly accessed by the client. The City of Miami will have 24/7 on-line access to claims information via the USISiNet. The USISiNet is available through the internet requiring no additional hardware or special software. The USISiNet has customizable dashboards which allow for real-time data detailing information that is important to track. Please reference Attachment 4 USISiNet and AmeriSysiNet Dashboard Claim S{gtils Trend ag ry a3t;YaM QW _ sL tue4 W rl Bbm"Y"Pm Kt e The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. New reports can also be requested and will be made available online as needed by the City. Our web interface is a true reflection of our claim system wherein clients have access to all claim data, The City will be provided full access to the financial information of all claims including reserve totals by reserve category, total payments by category, outstanding reserves, total incurred. Page 44 USIS works along with our in-house application, Risk Manager. Risk Manager is an integrated suite of programs designed for the day-to-day administration of workers' compensation, property & casualty, professional liability, and general liability claims. It is an Internet capable, multi -state, client -server application designed to maximize performance in high volume environments. It is supported by a Microsoft SQL database and a .NET platform. Our in-house staff uses ERIC and the transactions are available real-time on our web portal. Our team of programmers have experience with data conversions and are prepared to transition from the City's current system into our Risk Managers Database. As part of the transition, we ensure that all transactions are successfully converted to a test database, all documents are available, and all financials are fully balanced. 34) Detail any procedures, equipment, and/or costs necessary to connect with the City's hardware and software, particularly related to conductivity with Risk and Finance, at the time of this RFP and should the City's system be modified or replaced during the Contract term. Should there be associated costs; indicate those costs, the reasons for the same, and who will pay those costs. Costs, if any, shall be detailed in the Fee Proposal Section. Data interfaces are implemented as a means to connect to the City's system. There is no need for additional hardware. Interfaces are normally done in the form of data transfers uploaded/downloaded to a Secure FTP that USIS will. to provide. If the City changes system, USIS would be prepared to assist in the process by making any modifications necessary to the interfaces. There should be no cost associated. 35) Estimate Proposer's minimum start-up time from date of contract award to the date Proposer's network would be available to Risk Management. What specific requirements does the Proposer have to initiate set-up, and please explain any additional costs involved. USIS ideally requests 60 days minimum start up time from date of contract award to the date USIS' network would be available to Risk Management. USIS will submit a conversion, implementation plan which includes a list of required data elements for conversion. • Initial Load of Electronic data files matching all file layouts • Claim/ claimant demographics • Claim Detailed historical reserve / payment transaction • Claim notes data file/ attachments thru • EDI & CMS 111 Data • Claim level loss runs • Any other Files • Bill Review / EOB History Data In addition, please review Attachment I.0 — Irnplementation Check List. 36) Explain any options which the Proposer's system has that will permit the City to generate reports from, and to make direct inquiries into the Administrator's data base by on-line access. Proposer must clearly identify in its Proposal the costs of providing any special conversion systems, license and software costs for accessing the system, and the party(s) responsible for the payment of those costs, if any. (Costs shall be fully detailed in Fee Proposal Section). The City will have access to generate reports from USISiNet at their convenience, along with having the ability to make direct inquiry in various areas of the web portal. There is no cost for this service and no special software. The only requirement is a web -browser. Page 45 37) Provide sample reports describing information such as type of accident, accident site, department, date and time, cause of accident, injury, and part of body. Proposer shall describe in detail any safety/loss control reports that are provided by the system, and shall submit a listing of the variety of claims reports available, and provide sample copies of formats that may be requested by the City. The USISiNet application houses multiple printer -friendly stock and eustonl reports as well as data dumps into Excel format, all on demand, 7 days a week 24 hours a day. We currently staff 7 in-house programmers who can create client -defined purpose -specific reports or data extracts in a client -specified format. USIS can accommodate numerous report types as part of our web services site. Our user friendly site allows you to pull reports straight to your printer or download claims data directly to your PC. There is no special license or software to run these reports. They are part of the USISiNet portal. Please reference Attachment 5 - USIS Sample Reports. 38) Provide the methodology and list of allocated or anticipated expenses to employ outside professionals such as surveillance, rehabilitation, experts, attorneys and others to assist in the investigation and adjustment of claims. During the course of a claim the adjuster will need to employ outside professionals to obtain information that will assist in moving the claim closer to closure. Examples of items that would be allocated to the claim file, though not an exhaustive list, would be as follows: 4. Index Bureau Reporting Surveillance Transcripts 4 Vocational Services - Court Reporters 4 Investigators 4, Medical Records • Legal Services Translation Services for legal proceedings IMEs Expert Witnesses Life Care Plans 4� MSAs The City will be responsible for payment of these additional costs. Page 46 39) Provider shall provide its most recent audited certified business financial statements (or unaudited if audited is not available) as of a date not earlier than the end of the Proposer's preceding official tax accounting period, together with a statement in writing, signed by a duly authorized representative, stating that the present financial condition is materially the same as that shown on the balance sheet and income statement submitted, or with an explanation for a material change in the financial condition. A copy of the most recent business income tax return will be accepted if certified financial statements are unavailable. Please reference Attachment 1— Brown & Brown, Inc. Annual Report. Rof3RR.'r W. L.1.-OYD tax.:curtve Vice Pre,TfOn1 rl Gccrier^al Ccraasasei November 1 • Daniel J. Alfonso City Manager City of Miami 444 SW 24d. Avenue Miami, FL 33130 It : USLS, lt1c, - Recu* t far .Proposal Dear Mr. Alfonso: Brown & Brawn, .lac. 220 South Ridgewood d Avenue (2114) Pao 33 x 2412 q t7a,ytou313e c i, EL 32115 386/252-9601 1..F38623 -572'3 Diret:t: Ulwe; (386) 239,5752 : (8t7[» 877.27159 Ext. 5751 )ifect.Fait: (3146)'r39.1229:3 Pursuant to the RF P request, J SIa, a subsidies of Brown & 13rowrl, :Ina.., provides its current Financial stAinnont on www..hhinsnranee.com., in addition., we have p.rovid d -you With Brown.&,Brown, Inc.'s most recent Annual Report. This will confirm that the- present financial. con.ditiol cif the oor1 arty is i gateri tly. the Sarre E3 that shown on tici balance sheet arid income e .statement 1fyou have aay questions, please contact omitted, Page 47 40) Submit a guaranteed, all-inclusive annual fee as previously detailed in Section 2.17. This fee shall represent all claims, administrative, and Toss data fees, and shall be guaranteed annual fees for the initial three (3) years, and the two option to renew years, as opposed to per claim time and expense or any other fee proposal. Proposals not containing an all-inclusive guaranteed annual fee for three (3) years, and the two option to renew years, for all specified services, will not be considered. The pursuit of subrogation and recovery from the Special Disability Fund is to be included in the Proposer's Annual Fee. Clearly indicate any charge not included in the proposed annual fee. Please reference Attachment B1 Claims Administration Price Proposal. 41) As the City is interested in a program which will generate savings over the current expenditures in the workers' compensation area, the proposed fee structure should address the mechanism for achieving a minimum of 15% net savings with an escalating incentive bonus for savings that exceed the minimum and a penalty for a shortfall in the desire net savings. USIS is agreeable to accepting a mutually agreeable incentive or penalty as indicated, should savings not result. 42) Submit a separate quote(s) for existing claims, and a separate quote(s) for prospective claims; pricing on a "per claim" basis for both existing claims and prospective claims, and a breakdown of the cost between lost time vs. medical. in addition, provide a per claim cost vs. flat dollar cost, Include any other charges not included in pricing. Price Proposal must contain rates based on the "life of relationship basis," namely for those prospective claims, and the City's inventory of open files. Provide separate quotes for the assumption of prior claims and for prospective claims commencing on the commencement date of the Contract. USIS is not prepared to offer a quote on a per claim basis due to the size and complexity of the City of Miami's Claims Administration Program. Please reference Attachment B1 Claims Administration Price Proposal which includes Life of Contract pricing. 43) Include any relevant services or products that will be provided to the City which are not priced in Proposer's Proposal, but which will enhance the acquisition process. If USIS / AmeriSys is selected for both Part I and Part II, USIS will provide our BADGE and SECURE programs. It is our assumption that the City has first responders/badged officials that are in your employment which experience presumption and cardiac claims. Please reference BADGE Program Attachment 2 - Cardiac - Exposure Protocol. We believe that the Heart/Lung public presumption claims represent one of the most significant economic exposures to closing claims and the anticipation that most of those claims will deteriorate as the employee ages. David E. Perloff, MD, FACC, FACP, is the AmeriSys BADGE Program Cardiac Medical Director. He has many years of experience in Cardiology and over 10 years of that in dealing with workers' compensation related to the Heart/Lung Presumption Bill. It is also our assumption that the City has injured employees who are prescribed opioids. Please reference Page 48 Attachment 3 - Innovative Programs for information related to the SECURE program. AmeriSys has developed unique protocols and criteria for managing these complex and cost -driving claims. The program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. It is this position and approach of innovation and efficiency that characterizes our organization. Whether it is unique types of claims, unusual working conditions or locations with special information needs, we strive to customize our program to address those unique and individual needs. Our commitment to innovation and efficiency is also coupled with 30 years of proven experience in providing cost effective and quality -oriented medical care management. It is the careful blend of innovation with proven, tested experience and success that allows for the best in functional and economic outcomes. USIS stands ready to Work with your leadership team to identify, develop and implement a program that is best suited to your claims and informational needs. 44) Indicate the cost, if any, of assuming prior claims and data conversion and whether it is a one-time charge or an annual charge. Include in Proposer's proposed price, costs for the provision of an enhanced system and for the conversion of any data necessary. There is no additional cost beyond that proposed in Attachment BI Claims Administration Price Proposal. 45) Provide a performance guarantee (may be negotiated with the City). USIS is agrees to negotiate a mutually agreeable performance guarantee with the City of Miami. 46) Provide any, and all additional costs, item by item, as identified by Proposer, in any other area not previously discussed herein, and detail what those additional costs, if applicable, would entail. Include whether Proposer, or the City will be responsible for payment of those additional costs. Examples of items that would be allocated to the claim file, though not an exhaustive list, would be as follo ws: Index Bureau Reporting Vocational Services _, Medical Records Surveillance Court Reporters Legal Services IMEs Expert Witnesses MSAs The City will be responsible for payment of these additional costs. Transcripts 4- Investigators d Translation Services for legal proceedings 4, Life Care Plans Page 49 ATTACHMENT A Supplemental Proposer Questionnaire ATTACHMENT A SUPPLMENTAL PROPOSAL QUESIONNAIRE Proposer shall respond to each Section in its entirety, in the same format presented. A copy of Attachment A may be requested in Word Format. 1. INFORMATION ABOUT THE PROPOSER Please include the following in your response: 1. Demonstrate your expertise and experience in claims handling that would relate directly to the City's operation. USIS, Inc. is a full service Third -Party Administrator (TPA) providing specialized, client designed, professional service programs for All -Lines Claims Administration as well as Medical Management Systems/Programs and Loss Prevention Services and Programs. USIS, Inc. has been in business for 34 years and was established in June of 1982 as a division of Brown & Brown, Inc. USIS has always been a technologically progressive company, as well as progressive in the development of programs for our clients and their injured workers. We are a regional TPA and Medical Management company that is diverse in the size and type of the clients with which we work. We are large enough to handle Workers' Compensation programs such as the State of Florida and State of Georgia, but also have smaller sized clients such as the City of Cocoa. We believe in a customer -centric model in which we will customize our services to meet the City of Miami's needs, values and culture. We will meet with the City during the transition phase to develop customized protocols and systems that will lead to quality care for your injured workers in a cost effective manner. USIS has a team of 8 programmers who are continually developing systems to meet the needs of our customer partners. The USIS web -portal, USISiNet, has customizable dashboards which allow for real-time data detailing information that is important to track. The web portal also has an analytics. module that will allow for detailed analysis - an important tool in the tracking and trending of your workers' compensation program. The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. USIS will meet with the City during the transition phase to develop customized dashboards and reports that will assist the City to best manage its Claims Administration program. Please reference Attachment 4 — USISiNet and AmeriSysiNet for screenshots of the customizable dashboards and reports. Page 50 USIS/AmeriSys has been proactive in developing specialized programs as the Workers' Compensation landscape continues to change. Below is information on three programs that have been developed to give additional cost containment benefits while providing excellent medical outcomes. SECUF&E* The SECURE program's goals are to improve/enhance return -to -work outcomes, reduce disability duration; prevent unnecessary, dangerous and costly consequences of inappropriate or prolonged utilization of opioid medications while reducing the costs of handling pain management claims. (Not included in the flat rate fee due to the specialized nature and costs associated with the SECURE program) AmeriSys 4C The ArneriSys 4C mission is to provide exceptional care in a cost-effective manner to severely injured or critically ill employees. USIS/AmeriSys will ease the burden of cost and management in dealing with these very challenging claims on behalf of employers and carriers. BADGE* AmeriSys developed a medical team and program approach in addressing the uniqueness and special needs of handling "Presumption" claims of the "Heart and Lung Bill". This program also addresses the exposures addressed in the bill. Please reference Attachment 3 -- Innovative Programs for information related to these programs. We have a history of becoming a seamless part of our customers' programs, sitting as advisors on their Boards, serving on their select committees and otherwise being recognized as part of their own organizations. When we are able to earn the trust and confidence of our customer partners, we are best able to assist them in identifying, designing and implementing systems and programs allowing them to more effectively meet their objectives and missions. Our partnership with contracted ancillary vendors is to ensure quality of service is being rendered following evidence based clinical guidelines along with competitive pricing for our customers. Every ancillary vendor is accountable to follow performance guarantees that focus on the delivery of quality medical care while using utilization review processes when needed to address medical necessity of requested treatment. By using the ancillary vendor network, we are able to capture cost savings, compliance with performance guarantees for services rendered, and compliance with billing practices. Our system is integrated with our PBM provider, myMatrixx. This integration allows the adjuster and Nurse Case -Manager real time access to injured workers' information, along with tools needed to control pharmacy costs. The USIS/my.Matrixx partnership has existed 10+ years since the inception of rnyMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. USIS/ArneriSys and rnyMatrixx, through their relationship, have joined forces to face multiple challenges in the Workers' Compensation arena, and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a • member of the rnyMatrixx pharmacy and therapeutics committee which establishes the general protocols and fo.r tnularies for this PBM. Please reference Attachment 11— myMatrixx. We understand that the services we would be providing on your behalf are for your employees, your colleagues, and very often friends. We recognize that we must treat each injured employee with respect and genuine interest in his/her well-being and recovery. We do this while also making sure that we protect the financial and human resources that are paid :for by the hard earned tax dollars of your city's citizens. We have a stewardship obligation and commitment to the injured employees and the City of :Miami. Page 51 2. List all external providers/vendors your company's partners with to provide adjusting, managed care, bill review, or other required services on an ongoing or occasional basis. Describe these services and the exact relationship between your company and those providers vendor. Liability Claims Administration Preferred Governmental Claims Solutions (PGCS) A Brown & Brown Company Since its founding in 1956, PGCS Claim Services has provided claims administration for public and private entities, carriers, and trusts. SIU Company Command Investigations, LLC is the preferred provider of Surveillance, SIU & Anti -Fraud Programming to P&C Carriers, Self -Insured Entities and Third -Party Administrators. Command is not a traditional vendor...but rather a strategic resource and committed investigative partner. Command has successfully blended the most sophisticated technology platforms with the finest staff to create a unique combination that leverages man, woman and machine. Their founding principles remain consistent with our 20 years of investigative experience: • Consistently deliver the best service and results • Develop, maintain and nurture rewarding customer relationships • Maintain a healthy, challenging, rewarding and fun work environment • Identify, develop and ,mentor new Command employees . Utilize and employ the finest technology available ■ Operate as a profitable and socially conscious business Managed Care External Providers: Preferred Provider Network USIS/AmeriSys is proposing DimensionComp for hospital and provider access, the AmeriSys Preferred Provider network for ancillary providers, and myMatri.xx as the Pharmacy Benefit Manager. In addition to using DirnensionComp as the primary network due to its South Florida specific geography; USIS/ArneriSys is prepared to offer the Coventry Preferred Provider network, which is a national provider, as a wraparound network to DimensionComp to capture the claims that do not fall within the primary network. USISIAmeriSys employs a Director of Provider Services who will work closely with the City, DimensionComp, the adjuster and the case -manager. The Director of Provider Services will make recommendations as to what outcomes would be monitored as well as work with the City to determine the criteria that are important. DimensionComp is an affiliate of Dimension Health, Inc. Dime.nsionCornp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Coventry health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. Page 52 Pharmacy Benefit Manager USIS/AmeriSys contracts with myMatrixx for PBM services. Matrix Healthcare Services, Inc., d/b/a myMatrixx, is a fall -service pharmacy benefit management (PBM) and ancillary services company focused on workers' compensation. Please reference Attachment 11— Overview of myMatrixx PBM Services. The AmeriSys/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. USIS/AmeriSys and myMatrixx through their relationship have joined forces to face multiple challenges in the Workers' Compensation arena such as the escalation of the need for cardiac medications (BADGE Program), and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and formularies for this PBM. Ancillary Network Access AmeriSys Preferred Provider network • The A.meriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. • Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, Physical Therapy, Diagnostics, Home Health and Durable Medical Equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. Page 53 AmeriSys Preferred Provider Network Spreemo Spreemo provides a diagnostic network through the AmeriSys Preferred Provider Network Orchid Medical Orchid Medical provides a Diagnostic, DME and Home Health .network services through the AmeriSys Preferred Provider Network Streamline Streamline provides a diagnostic network through the AmeriSys Preferred Provider Network One Call Care Management / Align Networks One Call / Align provides Diagnostic, DME and Home Health network and Physical Therapy services through the AmeriSys Preferred Provider Network Priority Care Solutions Priority Care Solutions provides DME and Horne Health network services through the AmeriSys Preferred Provider Network Speakeasy Translation & Transportation Speak Easy provides Transportation and Translation network services through the AmeriSys Preferred Provider Network ProCareProCare provides Transportation and Translation network services through the AmeriSys Preferred Provider Network ,INJ Services J&J provides Transportation and Translation.. network services through the AmeriSys Preferred Provider Network Intrepreters UnlimitedIntrepreters Unlimited provides Transportation and Translation network services through the AmeriSys Preferred Provider Network SPNet SPNet provides Physical Therapy services through the AmeriSys Preferred Provider Network Therapy Direct Therapy Direct provides Physical Therapy services through the AmeriSys Preferred Provider Network DentalWorks USA Dental Works provides dental network services through the AmeriSys Preferred Provider Network. NuQuest Bridge Point NuQuest provides Medical Set Aside services (a Brown & Brown, Inc. company) Field Case Management AmeriSys hires independent FCM subcontractors under the direction of AmeriSys' FCM Supervisor. All subcontracted FCM's are contracted to adhere to the standards of quality set forth by AmeriSys. Physician Advisor Services for UR Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhill@danestreet.com www.daneStreet.com :Dane Street provides Workers' Compensation Peer Reviews to .Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of .Insurance. Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state -specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Page 54 3. List all external providers/vendors/governmental organizations your company has electronic data systems interface with. Describe the system interface in detail. USIS reports all claim data to the State of Florida via electronic data interchange (EDI) according to and complying with the standards of IAIABC current requirements. Claim forms are transmitted to the State daily. The adjusters review the State forms the next business day in the online data warehouse. Any rejected forms are resubmitted .immediately. USIS has not had any major deficiencies or issues with State compliance. Additionally, USIS has electronic system interface with: • All ancillary vendors where we receive electronic bill records for adjudication and payment, and provide a File in return with the detailed data. • Several of our clients where we send/receive the following: claims data, bill data, electronic documents (pdf, and tiff files), eligibility files, case notes, and more. Some of these clients include the State of Florida, Broward County, Palm Beach Sherriff's Office, City of Jacksonville and more. • We currently have interfaces with the following RMIS platforms: Risk Master, Stars, Origami, Noss 4. Fully describe how your company perceives that your company's claims administration services differ and set your company apart from your companies' major competitors. Although USIS is located in the Greater Orlando area, USIS services many clients throughout Florida. We work with employers in the City of Miami area including State of Florida employees. The Claims Manager has worked at USIS for 28 years, most of this time handling self -insured public entity accounts. Terri is extremely involved in ensuring a culture of excellent customer service throughout the department. Terri and many of the adjusters have worked with Volusia County and Orange County school boards for over 20 years, taking great pride in their long term successful relationships. The adjusters handle each claim as though it is their money being spent. They live up to our motto "Service Beyond the Contract", and exemplify our S` T'E! campaign in the day to day claims handling process. S UPERIORITY �1 IMELINES S ESPONSIVENESS 1 NITIATIVE `iV IRTUE • NERGY BE BETTER THAN OUR COMPETITORS PROVIDE PROMPT CUSTOMER SERVICE SHOW SENSE OF URGENCY GO ABOVE AND BEYOND MAINTAIN ETHICAL COMPASS DEMONSTRATE PASSION AND ENTHUSIASM SERVICE BEYOND TIIE CONTRACT® Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. Page 55 An efficient claims system allows for effective claims administration. Software from leading vendors within the Claims Administration and medical management field, supplemented with programs and components developed by in-house programn.ers, provides an environment tailored to the special needs of the client. • Employers have online access to all claim information through database and document utilities. • Support services include all up-to-date office management tools • Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN • In-house programmers are able to develop customized reports where client special needs exist • Claims data is available via USISiNet for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse (USISiNet). All claim data within the system is viewable online and able to be downloaded into an Excel format directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and claimant statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall insurance costs and to provide cost-effective solutions best suited to the client's situation. Our service commitment is to make our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management when required as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the TCMs work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost tune days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City's overall economic outcomes. Employee Performance Management System Staff performance evaluations are done quarterly and annually. The Core Values of the company are `graded' on a quarterly basis, along with Key Performance Indicators relative to each position. A more in-depth performance evaluation is also done annually. Of course, any time more training or direction is required; it is handled at that time. USIS promotes a team atmosphere in which employees can talk freely with members of leadership. Employees are encouraged to openly discuss with their Department Leader any issues so that appropriate action can be taken. Page 56 5. Provide a list of your company's current client within the public entity sector. USIS has over 30 years of experience working with Florida governmental entities, Public entities make up 30% of USIS total clients. Our extensive experience with public entities such as, city and county governments, fire and police districts, school districts, and two state governments provide us with unique experience and expertise to handle the City of Miami's Workers' Compensation program. USIS currently provides services to the following Florida governmental entities. Client Services P'a ovided .:. Bay County BOCC WC Claims TPA Medical Bill Review Broward County BOCC Intake / Triage Network Access Medical Bill Review City of Cocoa WC Claims TPA Medical Bill Review City of Jacksonville Network Access Medical Bill Review Medical Only Claims Handling * * on an as needed basis Orange County Public Schools WC Claims TPA Medical Bill Review Medical Management Patin Beach County Sheriff's Office WC Claims TPA Medical Bill Review Medical Management Preferred Governmental Insurance Trust (200+ governmental members) Medical Bill Review Medical Management State of Florida Intake / Triage Medical Management Volusia County School Board WC Claims TP Medical Bill Review Medical Management Georgia Columbus Consolidated Government * WC Claims TPA Bill Review Managed Care Organization State of Georgia (DOAS) Triage Managed Care Organization *Reference Attachment 12— Risk and Insurance, Revitalizing the Program - Teddy Award Winner Page 57 PGCS currently provides services to the following Florida governmental entities, Client Brevard County BOCC Charlotte County City of Delray Beach Ci of Kissimmee City of Na .les City of Titusville Leon Coun BOCC Leon County School Board District School Board. of Pasco Coun Preferred Governmental Ins Trust Services Provided Liability Liability Liability Liability Liability Liability Liability Liability Page 58 6. Provide details including a brief summary and status of any pending claims, or lawsuits involving your company and/or its' subsidiaries, which may affect performance or bring about negative publicity for the City. USIS/AzneriSys has not been party to lawsuits, administrative actions or litigation related to fraud, theft, breach of contract, misrepresentation, safety, or wrongful death. However in the normal course of doing business related to workers' compensation claims handling, US.IS/AmeriSys was made party to litigation related to the servicing of workers' compensation claims (5) on behalf of its clients. All but one was resolved in our favor, and that one is recent and still pending. Brown & Brown, Inc. (the parent of USIS, Inc.) is publicly traded on the NYSE, is regularly subject to suits and claims that arise in the ordinary course of iits business, and is required by law to make periodic filings with the Securities and Exchange Commission, which are publicly available and which contain additional information concerning legal matters. 7. Provide a copy of your company's current SSAE 16/SOC 1 & SOC 2. USIS/AmeriSys receives an annual SSAE 16 audit and is currently in compliance with all items. A copy of the report will be provided upon completion of an executed contract between USIS and the City of Miami. Please reference Attachment 8 — SSAE 16 excerpt. soG 53, SAS'.1a vem 2. CLAIMS REPORTING The City desires Internet reporting capability, FAX, and a twenty-four (24) hour, seven (7) days -a- week, telephonic claims reporting service. Demonstrate your company's ability to meet the following criteria, detail how your company would meet the requirement, and any qualification or stipulation that applies to any response for the following: 1. Ability to answer a call routed from the City provided 1-800 number dedicated phone line with a customized the City script. USIS is able to have/provide a dedicated 1-800 for the City and it will be customized with the desired City script. 2. Capability for Internet, phone, and fax reporting. For your convenience, claims can be reported several different ways as outlined below: * Call a dedicated 1-800 Number and verbally report the claim to our intake specialists * Email a completed report to clairnreporting@usis-tpa.com * Report the claim on the web (with secured access) * Fax a fully completed first report to 407-352-5788 Below is a screenshot of claims reported by an individual through the USISiNet web portal. Page 59 Recently Reported Claims (Rep 100. ed by or Others, Last 30 Days) FL K. 199A99 9.Vt9rh4 1'11900 grgjekre 11'72P'9.9 el, I It93112 .0)14 ln9196 +Taalletxi 9tltnal-91?6G4"^A9 Edds?oct :9GGd1,211r61.frlpldP 1f14e'ootoa :-.':•'s-- �:»ice:»E��»^ OA, d Rl`:lU Tf3'9idiie9. &Iwawa '?WA.n`fl7&7ifi:PJFi?Y<¢tf 16Y015i9;0 r4t14 49 399911 T'h.:he911A' Pi. 9971932-11:flrt M060,149 ss s :; e•««cv:T.i'n. aim 9"99R9C19 599.1;p1JL➢e9 'Y6i121/9116 � yi.' 9i€!&4'91(11-'}4 F909991 3C,i9.9x7,;.G'999961ti15W ev9{969) 9z:d4.95'99'$4M06 3e,:�emaaagraT�.�'sax?a.:A:csw::x:cacnaw% i®yam. ew -- ...................... .. , ., ._ tilarkelo• ci^.»zzdnc=µMAC FS, iiF1S'P:'B.4i'&i nitas4 ;3561.71.:3II1.d{}U7P±?h'2 rnt4hp144,4a 19916.0:29AP U$V1i.NIEa Cflt{y.Rep tct y Me Las 0 Days I.�ccaa' OA TM meradaz.99 :a'xas p'R�St&9996'0..,'r<R111 3. Ability to utilize tape feed for: a) The City employee information and demographics, via secure FTP in the reporting system using employee ID. USIS .has the ability to transfer via secure FTP, the City employee infoimation and demographics, using employee ID. USIS is able to create reports for the City to retrieve this information if desired. b) Receive tape feed via FTP of the City (or related entity) vehicle information with the ability to look up vehicles by VIN, Tag or the City Number. USIS is able to receive and implement a data feed for the vehicle information. Reports, grid, anchor dashboards can be created to look up the vehicles, by VIN, Tag, or the City Number. c) Ability to provide the City immediate contact upon the receipt of claims involving certain criteria to be established by the City. During the implementation phase USIS and the City of Miami will establish Special handling instructions that would allow the City to be contacted immediately for claims involving certain criteria. Page 60 4. Ability to electronically send claim data to adjuster and nurse, no later than two hours after entry/receipt of claim, by any of the reporting methods outlined above. Upon receipt of the FROI, the supervisor and adjuster are automatically notified via diary and triggers of receipt of a new claim for review and handling. An emailcan also be submitted as an alternate method of notification to adjuster, nurse, supervisor, and anyone requiring to be notified. This system includes external system codes and allows for multiple levels of reporting. These location/employer records are an integral part of the FROI and claim creation process. The system will also capture the received date for claims reported to USIS. 5. Ability to provide automatic First Reports of Injury via e-mail, immediately after system entry to the City designated recipients. USIS has the ability to automatically send the First Report of Injury via e-mail to the city's designated recipients based by the injured workers' department or location. The City will receive a notification email with the claim assignment, and NOI attached. Immediately the claim will also be available on the USISiNet. 6. Ability to customize the intake screen to automatically inform the interviewer of the location's physician panel or recommended injury clinic, so the interviewer can inform the caller (Note: The City may wish to contract separately with a Preferred Provider): a) Ability to automatically notify the City regarding reserve updates that breach the Administrator's reserve level. USIS has the ability to create custom dashboards that allow for triggers. Reserve triggers can be setup up where notifications can be sent. b) System that can accommodate the use of form letters composed with input from the City. USIS would be able to add any letters from the City in our Claims Systems. c) Capabilities to provide various scheduled reports along with custom client -defined reports. Reports can be scheduled and delivered via our web portal to each user. d) Client access to create ad -hoc reports and standard reports. The USISiNet Portal provides various interactive grids that allows the client to filter the data and move it around. This would allow the City of Miami to create ad -hoc reports and export it to any format desired.. e) Ability to customize data fields as per the City requirements. Via the USISiNet web portal, the City will be able to select which data fields appear on a particular grid or report. 7. Describe your company's technology infrastructure for your company's first report system (claims intake, database management, application language, hardware, telephone, switch, etc.). Risk Manager V6R7 from ERIC Systems in Seattle, Washington -- Risk Manager is an integrated suite of programs designed for the day-to-day administration of workers' compensation, property & casualty, professional liability, and general liability claims. It is an Internet capable, multi -state, client -server application designed to maximize performance in high volume environments. It is supported by a Microsoft SQL database and a .NET platform. Risk Manager is a real-time design, meaning that there are no posting routines required at the end of day or to prepare for end of period reporting. Transactions affect financial. totals as soon as the entry is saved. End. of period closings can be completed without disrupting daily operations. Page 6 A web portal is available to clients 24/7 via the USISiNet, which is built on a MS .NET platform and MS -SQL database. There is not a charge for access, and it does not require special software. Access is granted to clients based on authority level and permissions dictated by the client via user id/password. The web portal contains reports that be directly accessed by the client. USISiNet is a highly customizable application that was built to directly meet the needs of our clients and partners. Unlike, the `out of the shelf tools, our web portal allows for client flexibility. The USISiNet has customizable dashboards which allows for real- time data that is important to track. The web portal also has an analytics module that will allow for detailed analysis. The USISiNet provides secured access to claims information, claim notes (including imaged documents), medical bills, financial reports, and more, via individual user security level. Our web interface is a true reflection of our claim system wherein clients have access to all claim data. The City will be provided full access to the financial information of all claims including reserve totals by reserve category, total payments by category, outstanding reserves, total incurred. Access is granted to clients based on authority level and permissions dictated by the client via user ID/password. The web portal and our ERIC back -end system are fully integrated in real-time. The claim intake is done on the web portal and once finalized by our processing department, it is then immediately available in ERIC for the adjusters and nurses. Hardware: USIS partners with NEC for its telephony solution. The SV8100 is a comprehensive NEC system which provides the necessary agility for today's ever -changing work environment. It enables 'USIS to tailor its communication needs to our specific business partners plus have total control over how, when and where you choose to be reached. This is a VOIP system with full redundancy built on the PBX as well as on the Voice Mail systems. In the event of a failure, USIS has the ability to fail over to one of our other redundant systems minimizing any down time. Our telecommunications vendors have a strong partnership which eliminates the need for USIS to deal with multiple vendors in the event of troubleshooting a problem. The SV8100 streamlines communication for the entire organization with its diverse suite of features and applications. It enables individuals, departments and locations to work more efficiently by ensuring seamless internal and external communications. PC Assistant — gives users the ability to manage and operate desktop phones from their PCs; and Softphones — provide convenient, cost- effective mobility for remote employees. Our systems are secured both externally with multiple firewalls and internally with Kaspersky Antivirus and multiple layer security on all software. We operate with firewalls, routers and server banks at each of our locations that are integrated via MPLS and Metro Ethernet. Our equipment is constantly evaluated and upgraded or replaced as needed and we audit compliance with all software licensing agreements. Our systems operate in Windows platforms with relational databases in MS SQL and Sybase SQL. Page 62 3. EMPLOYEE/LOCAL OPERATIONS COMMUNICATIONS Excellent employee and customer communications regarding reporting and process requirements, rights under workers' compensation, and recommended primary care providers, are paramount to an effective claims management program for the City. Please demonstrate your company's ability to meet the following criteria, and detail how your company would meet the requirement, and any qualification or stipulation that applies to any response for the following: 1. An effective process and framework for communication supported by state of the art technology. USIS will communicate with the City by phone, email, web portal and in person. During the transition phase, USIS will use a Gantt chart to manage the transition process. USIS uses its RMIS system, ERIC, and Medical Management system, Corrus, to manage the claims process through a diary system. 2. A process to provide and disseminate to the City and its locations, claims reporting media (i.e. posters, telephone stickers, employee cards, etc.,) to best communicate how to report claims under varying circumstances [Would prefer one central number that would accept all types of the City claims]. USIS will provide claims reporting instructions to the City to distribute to all locations. 3. Production and delivery of statutory posters for each location (New locations and changes in preferred providers would require new communications) USIS will produce and deliver statutory posters for each location. 4. Introductory and at least annual continuous improvement meetings with the City coordinated by the designated adjusters USIS agrees to at least an annual continuous improvement meetings with the City coordinated by the designated adjusters 5. Please describe how your company would meet the above requirements, and provide an outline of your company's proposal for communications. The USIS standard is that the adjuster is expected to have continual communication and interaction with the client and injured workers. Information is communicated in a number of ways, including: system documentation (viewing access available on the USISiNet), phone calls, letters, faxes, diaries and e- mails. USIS will provide weekly and/or monthly standard reports based on client criteria through the USISiNet. Often with large volume accounts, there would be daily communication. Each of our customers has specific preferences for contact. It is our intent and approach to assure that we provide service, and therefore, communication consistent with your organization's needs and preferences. All staff members are trained extensively in our culture, policies and procedures, specific client requirements, utilization of the computer system and various software programs. Our overall philosophy is customer -centric and excellent customer service is trained and re-trained at all levels. The adjusters are educated on client -specific policies and procedures to ensure constant communication with the client on all claims -related matters, as well as the USIS Quality Assurance•prograrn and auditing requirements. They are fully familiar with any Return -to -Work policy and procedure emphasizing communication with the customer, and with the medical providers, to assist the injured employees in returning to work as quickly as possible. Page 63 With a reputation borne of commitment to service, our competent team is dedicated to serving our customers. Our focus is on quality, professional, superior service. This service -driven philosophy, conveyed throughout the organization, means dedicated individuals with the client's best interests at heart, constantly reinforcing the corporate mission — Service Beyond The Contract. 6. Outline and provide samples of communication materials your company have that promote and facilitate injury management (i.e. posters, website etc.). All state required literature is mailed to the injured worker upon setting up and throughout the claim. The USISiNet also has a claims portal that provides basic claims information including indemnity payments to the injured worker. USIS can incorporate injury management information into the Claimant Portal upon request. in Notify your employer immediately to get the name of an approved physician. Workers' comp insurance may not pay the medical bills if you don't report your Injury promptly to your employer, it Notify the doctor and medical staff that you were injured on the job so that bilIs may be property filed. 3. if you have any problems with your claim or suffer excessive delays in treatment, contact the State of Florida's Division of Workers' Compensation at 1.-800-342-1.741, liVOPMKIVN<Fax ranrcar. Page 64 4. CLAIMS MANAGEMENT The City requires a team approach for quickly establishing and executing an aggressive claims resolution and injury management strategy on each claim. Individual members and The City have roles in reporting and investigating injuries, communicating with employees, claimants, and supervisors, and in returning employees to work. The City expects the Successful Proposer to facilitate a relationship with the City's locations, contacts, and resources and to work with them as a team in the claims management process. The Successful Proposer should understand and subscribe to the City's commitment to best practices and continuous improvement. Please respond to the following requests for information, demonstrate your company's ability to meet the outlined criteria, detail how your company would meet the requirement, and any qualification or stipulation that applies to any response: 1. Provide a flowchart of your company's claims management process, indicating in detail, the flow of information, decision points, supervisor intervention, etc. for all lines of business outlined in Section One. USIS/AmeriSys will develop, in consultation with the City, Claim Handling Requirements for workers' compensation claims assigned by the City to USIS. At a minimum, such requirements will include the Claim Handling Requirements set forth in the RFP. Once developed the requirements will be subject to revision and modification by the parties, provided that no such revisions or modifications are inconsistent with the Contract. Please reference the following Life of a Claim flow chart. me+ ical Only.: TCM ASSe6Sment Clcsdre:Of .' ..dical Only Acijiixfe Receives;New SaiUps i 24-Hour Contact. Irivestigalidn .Coiftp iiiax ljity: -'. De{eipnined''';,': Reviews.,.-. :-': oiscussiox ani Dispaeltiar"cf Buis,. Clasura Of Flf# Field Nurse Injury Occurs Report Injury via phone, wehsile, email or fax Intake Clahm Setup New Claim Diaried to Adjusters & Supervisor for Handling Triage 4 Is Claim Medical Only, Lost Time, Large/Catastrophic? Compensability Determined Evaluallon of Reserves — Adjuster & Supervisor File Reviews, Discussion, and Olsposition cf Bills Closure Of File "Field Nurse will be assigned to Medical Only/Lost Time claims based upon City triggers. **Nurse will be assigned to Medical Only claims based upon City triggers. Page 65 Our goal is to keep the employee at work (Stay at Work). But if that is not possible, the adjuster and the City of Miami work as a team to facilitate a quick return -to -work in a modified/transitional duty position, taking into account reasonable accommodations, as soon as a release to return to work (RTW) and restrictions are received. We have numerous customers with Stay -at -Work or Return -to -Work (SAW or RTW) programs in place. We can assist the City with designing and implementing a SAW or RTW program but in reality this must be "your" program. It is. essential that there is buy -in from the City of Miami at the top. The number of employees and job positions available overall within the City has a great deal to do with the program design and efficacy. USIS/AmeriSys prides itself on customization of programs to maximize utilization management. It begins with ensuring compensability of the injury and the treatments being prescribed are related to the reported injury. Once that has been determined, then all measures are taken to return the injured employee back to gainful employment. Is the disability time in accordance to ODG standards, if not, why? Questions are posed to the Authorized Treating Physician (ATP) regarding functional .limitations rather than b.l.anket off work statements. This allows employers to maximize modified duty positions by focusing on what the injured employee can do, rather than what they cannot do. All ATP's treatment requests are compared to evidenced based guidelines. It is our goal to have and maintain an excellent rapport with the provider community. USIS/AmeriSys utilizes peer to peer contact to help resolve any issues regarding medical necessity. It is in this way we ensure a strong relationship with the provider community that understands the intentions and goals of the City to provide an expedited and safe return to work for its employees, thereby lowering costs. While ATP's treatments are compared to evidenced based guidelines, so are ancillary services such as therapies and diagnostics. USIS/AmeriSys has put together a panel of preferred ancillary providers. These organizations have been put through a stringent process that includes providing services in accordance to evidenced based guidelines and performance guarantees to ensure the guidelines are being adhered to. Finally, our bill review process involves high levels of technology to allow for the deepest discounts that are compliance with state statute and rule. USIS prides itself on proactive claims management in a team approach with the injured worker, the employer, and medical case manager if applicable. Our promise is to work for you -- to manage your program effectively and efficiently by delivering the highest quality, most cost-effective service. We are constantly improving and implementing programs to help you contain costs and reduce fraud. An efficient claims system allows for effective claims administration. Software from. leading vendors within the Workers' Compensation and medical management field, supplemented with programs and components developed by in-house programmers, provides an environment tailored. to the special needs of the client. + Employers have online access to all claim information through database and document utilities. + Support services include all up-to-date office management tools + Comprehensive management reports are provided online or via email • Remote access from a client site is available by multiple portal protocols, such as internet or VPN Page 66 • In-house programmers are able to develop customized reports where special client needs exist • Claims data is available via the USIS website for use in client spreadsheets, word processing and/or database programs. • A web -based claim reporting system is in place for easy on-line access by clients • USIS developed and utilizes a secure, state-of-the-art web portal warehouse. All claim data within the system is viewable online and able to be downloaded into an Excel forinat directly from the website. Features include First Report of Injury reporting; check registers; loss reports; all account and injured worker statistical data under multiple search parameters. Our energetic staff is motivated to constantly search for ways to control overall costs and to provide cost-effective solutions best suited to the client's situation. Our service commitment is tomake our client's job easier. You will be able to rely on our licensed claims adjusters to handle all the details of each claim on your behalf. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. USIS has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. ArmeriSys is the medical management division of USIS and the telephonic case -managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and cost containment. AreriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Horne Health, etc.). These providers are contracted. not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. Ongoing Claims Management Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the .medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to Page 67 control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Utilization Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to full duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. USIS is acutely aware that an employee's status cannot remain at modified duty for an indefinite period of time. The treating physician is routinely asked to identify the injured employee's progress as it is related to the decreasing of functional limitations. Issues such as the decreasing of weight lifting restrictions are tracked, documented and communicated to the employer. When a failure to progress with limitations is noted in comparison to the guidelines, the treating physician is asked to address this area in the treatment plan, and a physician advisor .may be called upon to opine on the situation. Catastrophic or .large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. ArneriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to .maintain the highest degree of compassion and service to that employee and his/her family. Page 68 Liability The claims adjusters are responsible for providing thorough, accurate, timely communication and advice to the City in order to resolve any and all claim related issues. The claims adjuster will handle all cases professionally in order to assure a mutually beneficial resolution in a timely and cost effective manner. The handling of the claims will involve, but not be restricted to: A) Initial investigation to determine liability. B) Investigation to determine the damages. C) Identify and pursue any and all third party (subrogation) possibilities. D) Establish, monitor and assure the accuracy of any reserves. E) Notify the excess carrier of any claim that is catastrophic or has excess potential. F) Adhere to all recommendations provided through the claim review process. G) Prepare and manage all litigation. H) Adhere to the timely filing of any and all legal documents. I) Close all files as deemed appropriate on a timely basis. It is policy that all reported claims will be investigated to :fullest extent warranted. The adjuster will perform the investigation to include all available information from the claimant, the account, witnesses, medical providers and experts if warranted. All determinations of liability and the damages owed will be made in accordance with the laws The adjuster will perform all investigation warranted including obtaining information from the claimant, the account, witnesses, medical providers and experts. The adjuster will. gather documentation and obtain any estimates needed to properly evaluate the claim. This will include but not be limited to: l , Recorded statement where warranted by liability and / or damages. A summary of this statement should be included with the tape. 2. Verification of any physical injuries will be made. With any claim involving a physical injury, a medical release form will be obtained. 3. The police and incident reports will be obtained on all claims. 4. The fire department reports will be obtained on all property claims. 5. Photographs will be taken on all property claims. Photographs will be dated and carry a description. 6. Estimates and/or appraisals will be obtained on all automobile physical/property damage claims. Photographs will be obtained on all automobile claims. Page 69 2. Specifically detail the locations of your company's claim operations that would be handling the City claims, the number of employees in each office, the overall organizational structure of the office, and when the respective offices were established. USISS, Inc. PO Box 616648 Orlando, FL 32861-6648 Previously operated under United Self Insured Services # of Employees: 88 Established 1982 USIS management and claim technical teams are composed of high level, dynamic claim and medical professionals. These teams thoroughly understand the challenges related to the unique operational needs of individual clients. Our personnel includes a dynamic and experienced .leadership and management team, experienced adjusters in All Lines of claims management, RN medical case -managers and other support professionals to promote efficient, timely and technically -sound claims and medical management. RON WARBLE EXECUTIVE VICE PRESIDENT Leslie Whittemore Executive Assistant .,VIVIAidE RUI2 Y 'Bread of Business IrstagiatidA �. Programmer Analysts Network Support JS Supervisor Prograer Analysts Network Support CdR TCMfFCM Supervisors TCMsF (Rid RTV'FfCleric l ufd'saiioaeR14: =:msefi4�jie »Ent:sei uR Specialists (RN.). Clerical Support Cost Containment Supervisor Medical BIII Reviewers MDR Quality Controller Adminlstrallve Assistant t%;°oMia Ot Y�k19Artf Caen Management RN Supervisor TCMs(RNa) Clerical Support 'It�Cisl9saT�l`.Qe3 Provider Relations Coordinator Accounting/QC Claims Supervisor Adjusters Loss Control Consultants Claims Supervisor Adjusters MO Adjustor Claims Clerical Support Team Lead Clerical Support J o RVAfJ"STIiA$9URGi�lt. .Aldnager B esa'.D I p opk;:: ;Woat.,e.mp.eraim u2 Uni ' *. C . ias M -nas4p ^rClaFijrs Unie--; Claims Supervisors Adjusters MO Adjusters Subre Liability Adjusters ;hiFSi�GY 1 )FO P. 41e A Id rtt dieradoneartrtereart W rhiC, FeCi ni : unlfiki V€ce:PXEs tl b '.'. _._Claims unit..:;; Claims Supervisors Adjusters MO Adjusters HR Assistant Receptionists Clerical Assistant — Operations Administrative Assistant Page 70 3. Attach a map of your claims offices statewide, and list which offices handle what types of claims (workers' compensation or liability). Confirm if you have any plans to consolidate, reorganize, relocate any of these offices, or any personnel within these offices, to facilitate the administration of the City's claims. If so, please provide details to the extent they are known/available. USIS does not have plans to consolidate, reorganize, relocate any of these offices, or any personnel within these offices, to facilitate the administration of the City's claims. We may engage employees who live within the Miami area to work on this program and telecommute. ngaie Workers' CQ;upon. tion azrd 1 iut iihy Chino 4. Outline normal work hours and workdays, provide a list of your company's holidays, and discuss any optional/flexible work arrangements currently in use in your offices, or contemplated for administering the City's claims. Servicing Office - USIS, Inc. 5728 Major Blvd., Suite 450 Orlando, Florida 32819 8-5 p.m..Monday to Friday for Customer Service Unit Intake Unit for initial claim report 24/7 Normal business hours are 8-5 p.m. Monday to Friday. The USIS Intake Dept. operates 24/7/365. Upon policy verification, claim information will be entered immediately to the system while the person is on the phone. Claim team contacts will be available for management direction in emergency situations. Direct web claim reporting options are also available. USIS 2017 company holidays are listed below: New Year's Day (observed) Martin Luther King, Jr. Day Memorial Day Independence Day Labor Day Thanksgiving Christmas Day Page 71 5. Discuss your proposal for handling emergency issues during and/or after normal working hours, including identifying what personnel, by title, will be involved in those activities. 24/7 staffing — our claims management team is always available for consultation regarding emergency claim issues after hours. In a case of emergency, a field nurse case -manager would be expedited to the hospital. Account -specific handling requirements are followed. Jenny Ross will be the Account Executive. She will be the City's main point of contact for Claims Reviews and Service Issues ensuring a high quality of service and support. Page 72 6. Provide an organizational chart of those persons who would be involved in providing claim services to the City, listing the experience and qualifications of the key individuals who would be involved in the account by title, and identify those specific individuals if they are currently with your organization. All key personnel includes all principals, owners, parties, directors, managers, senior and other professional staff who will perform work and or serves in the specific category of services (Part 1 & II). Proposed Organizational Chart RON WARBLE EXECUTIVE VICE PRESIDENT MICHELLE COTTO Accounting Manager Supervisor TBD (5) Lost Time Adjusters cp9'1' at. tltlV (1) Medical Only Adjuster 1 1 I 1 1 1 1 YARIXA ELIASON LIABILITY UNIT Liability Supervisor (2) Liability Adjusters "US'S. VIV1ANE RUJIZ Vice President of Business Integration IT Department Programmers and Developers Dedicated Designated Page 73 Management Experience Ron Warble, Executive Vice President, Ext. 6503 ron.warble@usis-tpa,com Mr. Warble serves as Executive Vice President of USIS and is responsible for oversight of claims, medical management and overall operations within USIS. He has 33 years of experience in the Workers' Compensation arena. He previously owned and managed his own company which was acquired by USIS in April of 2000. That experience has allowed him to develop skills and expertise in many areas and is now being utilized to assist USIS' customers in providing quality and relevant programs on behalf of their injured employees. .Additionally, Mr. Warble has had the honor and privilege to serve on the Georgia Chairman's Advisory Council for Workers' Compensation since 2008 and currently serves as the Chaiuuan of the Medical Committee in that group. Jenny Ross, Account Executive, Ext. 6302 jenny.ross(ausis-tIDa.com Jenny Ross has been in the claims industry for over 20 years. Joining USIS 16 years ago, Jenny has been steadily promoted throughout her career. She started as an adjuster, handling a large volume of workers' compensation claims, conducting client visits and claims reviews; and has become an integral part of our claims management team. Jenny's customer service, dedication and commitment to our clients, along with claims knowledge and analysis, make her a top notch Project Manager. Prior to joining USIS, Jenny was employed at Executive Risk Consultants as a lost time claims adjuster. Jenny was the proud recipient of the 2011 Nationwide Brown & Brown Claims Professional of the Year Award, as well as USIS's Employee of the Year in 2007. Terri Snapp, Claims Manager, Ext. 6409 terri.snapp a,usis-tpa.cor Terri Snapp has over 28 years of experience in the workers' compensation insurance claims industry. Beginning her career as a file clerk with Leatherby Insurance Co., she was steadily promoted within the industry and has been with USIS, a leading Third Party Administrator, since 1988. Terri is currently a Claims Manager with USIS, supervising the work product of over 18 adjusters and supervisors. One key component of her job is dealing directly with clients, a lot of which are public entities, to ensure a high quality of service and support. Her knowledge and experience in the insurance claims industry has been significant in ensuring the continued success of USIS as a TPA. Yarixa Eliason, Liability Supervisor, Yarixa.eliasou usis-tpa.com Yarixa Eliason has over 20 years of experience in the liability insurance claims industry. Beginning her career in Miami with John's Eastern as a liability adjuster, she was steadily promoted within the industry. She has her all Iines adjuster license with experience in handling claims for commercial auto, general liability, employment liability and governmental entities. One key component of her job is dealing directly with public entity clients. Viviano Ruiz, MBA, MIS/HIS, Vice President of Business Integration, Ext. 3109 viviane.ruiz(ciusis-tpa.com Viviane Ruiz joined the Brown & Brown team in 2007 and is the Vice President of Business Integration for USIS. She is responsible for an IT staff of web developers, system analysts, database administrators, network administrators, technicians, and computer operators. Viviane has exceptional skills in Project Management and is an excellent liaison between the IS staff and the business staff She takes pride in meeting deadlines and sets a high priority on quality of work. Viviane is responsible for maintaining current systems, and ensuring the implementation of all state and medical rules guidelines, as well as leading new initiatives and keeping USIS/AmeriSys on the cutting edge of technology. Viviane has a Bachelor's Degree in Computer Information Systems, a Master's Degree in Business Administration, and a Master's Degree in Information Systems with concentration in Health Information Technology. Page 74 Prior to USIS, Viviane had nine years of experience teaching Information Systems as well as business courses for undergraduate and graduate students. She is fluent in Portuguese and Spanish. Michelle Cotto, Accounting Manager, Ext. 6213 nrichelle.cotto0),usis-tpa.com Michelle Cotto obtained a Bachelor of Science degree in Accounting from the University o:f Central Florida in 2007 and has been with USIS for 7 years. Responsibilities include Sarbanes-Oxley oversight for Accounting and IT environments, oversight of internal controls (SSAE 16), excess reimbursement filing, and interface with excess carrier representatives and auditors. Ms. Cotto's duties at USIS extend beyond accounting; she also leads a team dedicated to quality control and oversees the performance audit of each adjuster. Her department is also charged with th.e responsibility of maintaining bank accounts for each customer and securing funding from the customers for timely claim payments. TBD Work Comp Supervisor* TBD — Work Comp Adjusters* TBD - Liability Adjusters* Please reference Attachment 7 - Resumes/Licenses, Job Descriptions* PIease reference Attachment 1 - Brown and Brown, Inc. Annual Report for a complete list of officers and directors. 7. Describe your structural approach to claim services (i.e. dedicated unit, supervisor and unit manager, whether one adjuster will be assigned for the life of the claim or will the claim transition as the status changes). USIS proposes to provide a dedicated unit with (1) Work Comp Supervisor and (6) Work Comp Adjusters (5 Lost Time 1 Medical Only). The Work Comp Adjusters will be assigned for the life of the contract. The Liability Unit will have (1) working Supervisor and (2) Liability Adjusters. The designated Workers' Compensation Claims Manager will also manage the USIS Florida Independent Unit. 8. Provide the average caseload for your adjusters by line of business. a) Specify the caseload by BI/PD/Indemnity, Medical Only, and Record Only claims;, Lost Time adjusters will handle a maximum case load of 160 claims and the Medical Only adjuster 350 claims. To maintain the caseload below the maximum, USIS would move non litigated Lost Time files not receiving indemnity payments to the Medical Only adjuster. The Liability adjusters will have a maximum caseload of 160 claims. Incidents Report Only claims are set up in the system as reported, and documents are mailed to the employee and attached in the system; however not assigned to an adjuster unless the employee begins missing time or incurs medical treatment. At that point it is placed on the adjusters/supervisor diary for handling. b) Explain how the caseloads are monitored, noting the frequency with which managers review each level and/or category of claim; Caseloads are monitored via weekly claim count reports — system -generated for claim supervisors and managers. The County can access this report through USISiNet. This report is a tool that allows the supervisor to make case load adjustments as necessary. Page 75 c) State the average number of new claim assignments per adjuster per week/month; and :.:.:::.:3:e TJ Saseloa ................._......W. tl--m..:...........:::�::.:.:.::::.:r:.:...._..r 9;;�m.:.......,. ... :.....:e:.,�;........� rtm,:xa v.: nm e: =e:,_ T_::-:::: :m 1rn .C•ase1 -:; W ..............._.....:�..:��..,,. w:.:...:...: . eee _. e..:..:_s��g����ep�rr;,.....:�r�t_.m�..:: Lost Time Adjuster 127 10 Medical Only Adjuster 294 152 WC Supervisor WC Supervisors do not handle a caseload d) Provide statistics on your closing ratio and closing lag; USIS benchmarks: Lost Time closing ratio - 98% closed at 24 months Liability Closing Ratio — 1:1 9. Provide the average number of cases your supervisors adjust personally. USIS workers' compensation supervisors do not have a caseload and act strictly in a supervisory capacity, managing and directing the claims via supervisory reviews, etc. The Liability Supervisor's caseload will be determined by the number of files the 2 Liability Adjusters are handling at any one time, 10. Provide your current and average adjuster turnover ratio by level of examiner. USIS hires well .recommended, customer service -orientated individuals looking t17r long term commitments. We run background checks as part of our oversight to ensure the security of our clients' finances. Our policies and procedures focus on quality, professional, superior service; with numerous controls and safeguards in place to ensure compliance with State rules and regulations, client procedures and Sarbanes-Oxley standards. Our turnover in our claims operation is historically very minimal. Employees like working here? USIS/AmeriSys turnover for the past three years: 2013---17.83% 2014 —26.36% 2015 -- 21.76% USIS historically averaged turnover in the single digit range. Two factors are driving the increased turnover in the past three years. First, due to the large number of long term employees USIS has had many retirements. Second, USIS/AmeriSys was awarded the State of Florida Medical Management contract and hired approximately hire 70 employees in a short period of time. .A large part of our turnover in 2014-2015 has come from turnover on this account - approximately 5% relocation out of state; about 5% personal family issues; some had advancement opportunities that were not available with us in that short period of time, and some were not able to support our high standards and culture of excellent customer service and work ethic. The core group of initial new hires is still with us and exceling. The State of Florida is extremely satisfied with our work and we have maintained at 98% or higher score on the monthly performance standards every single month since January 2014, The Management/Supervisory team (30) has been with USIS an average of 13 years. The Management team (11) has been with USIS an average of 17,6 years. 11. Explain the career path provided for examiners. USIS standard career path. Upon hire, each adjuster will receive our Claims Procedure Manual for review and training. Experienced adjusters are trained in our eu.lture, policies and procedures, specific client procedures, utilization of the computer system and various software programs. Page 76 An entry level claim person would be placed in an assistant adjuster position. He/she will receive training for a Medical Only adjuster position and/or by assisting the adjuster making 3-point contacts, payment of compensation benefits, approving medical bills and filing State forms. He/she will either already have, or will study for the State exam and apply for the State license once passed. Once the adjuster and supervisor are confident that the trainee has complete knowledge of the job duties, State requirements, office and account procedures, he/she will then move to a Medical Only adjuster position. The time frame varies based upon the individual but does not occur until the supervisor feels confident that the trainee is capable of handling a case load and diary without constant supervision. Promotion to a Lost Time adjuster position will occur after more years of handling litigated Lost Time files with constant active supervision and training. Many of our senior level adjusters (Lost Time) have attained their current positions by internal promotions. Our training is geared to assist the adjusters in making the most prudent and cost effective claims decisions. USIS will hire Lost Time adjusters with 3 -S years of experience for the City of Miami unit. 12. Provide your current supervisor to adjuster ratio. Outline your protocol for supervisor involvement, including fixed diary requirements. The City of Miami supervisor ratio will be 6 adjusters to 1 supervisor. Claims are monitored by a diary system by each adjuster and the supervisor. The supervisory reviews include proper reserving, timely form filing, monitoring of compliance with all State regulations and statutes, direction and action plan — all with the goal to successfully return the injured worker to gainful employment and/or settle the claim to bring files to a successful closure. Supervisors will review claims after the initial review, every 30, 60 and 90 days thereafter and provide specific written instructions to the adjuster. This review will include appropriateness of reserves based on current status and exposure, any potential "red flags" that the adjuster should be aware of as well as any concerns that the file may become litigated. The supervisor will also review the quality of all documentation, paying close attention to the medical documentation to ensure that a treatment plan is in place, that the employee is compliant with appointments and testing and that the adjuster has a current action plan in place to bring the claim to closure, and that all state fillings have been handled timely. Any claim that cannot be closed after 90 days will be reviewed by the adjuster on either a biweekly or monthly diary and the supervisor every 90 days thereafter until the claim is closed. 13. Provide the average years of experience by position. Account Executive 26 years Claims Managers Claims Supervisors LT Adjusters MO Adjusters 29 years 27 years 21 years 11 years Page 77 14. Outline education and experience requirements by position. Claims Manager 7 years of Workers' Compensation claims handling experience with a consistent high level of performance and achievement. Claims Supervisor 3-5 years of Workers' Compensation claims handling experience with a consistent high level of performance and achievement. LT Adjuster MO Adjuster 3-5+ years in a claims environment handling lost time claims including litigated files 1-2 years of MO Claims handling experience in Florida WC law. Please reference Attachment 7 — Resumes/Licenses, Job Descriptions. 15. Outline adjuster diary schedule and requirements. All files/activities must be diaried in the computerized diary system. Diaries must be kept current. These are criteria monitored on supervisory reviews, quarterly scorecards and annual performance evaluations. All incoming mail and new claims (red) are diaried to the adjuster daily. Time - sensitive and any legal material is also monitored by the supervisor. All claim actions are placed on a computerized diary, according to company and client policy and procedure and statutory guidelines. Indemnity payments are placed on a bi-weekly diary. Each indemnity diary indicates the type of benefit (TTD, TPD, PPD), payment period and the dollar amount. The adjuster is responsible for setting PPD diaries to also indicate the number of weeks to which the employee is entitled, with a deduction of weeks each payment is made. This will ensure the correct amount of weeks are paid to avoid under and overpayments. The adjuster also places a note in the system documenting verification of benefits due. 16. Outline ongoing training and development programs. We provide in-house CEU classes on a variety of topics that an examiner/adjuster would handle on a desk. We generally offer 3 to 5 classes per month on law, ethics, fraud, medical terminology, etc. Classes are given by providers, physicians, specialty vendors and attorneys. Some examples of recent training classes include: • Insurance fraud • Knee injuries • Medicare Set Asides • Limiting PTD claims • Shoulder injuries • Case law issues and updates • Brain injuries • Changes to 440 rules • Vocational assessments • Adjuster ethics • Ethical issues of surveillance • MRSA (Methicillin Resistant Staphylococcus Aureus) • Pain management • Dental trauma Page 78 17. The City requests that your company's adjusters participate in periodic meetings with the City. Indicate your company's agreement. Yes, USIS representatives will be available to attend the City of Miami's periodic meetings to perform timely, review of all open cases to establish the status of disabled employees in order to assist in the appropriate action to be taken. 18. The City also requires quarterly loss reviews and periodic claim reviews on categories to be identified by the City. indicate your company's agreement to these requests and provide any additional charge for these reviews. It is USIS' recommendation to conduct claims meetings no less than once a quarter in person or by phone at no additional cost to the City. 19. The City requires dedicated/designated adjusters with a minimum of three (3) years' experience directed by a supervisor with at least five (5) years' experience. Indicate your company's agreement. USIS agrees to a minimum of three (3) years' experience directed by a supervisor and with at least five (5) years' experience. 20. Provide information and documentation regarding your company's current training program, available to your adjusters to further develop their knowledge base and adjusting skills. Specify what annual requirements your company has for continuing education beyond that required for the maintenance of their licenses. We provide in-house CEU classes on a variety of topics that an examiner/adjuster would handle on a desk. CEUs are available in excess of what is annually required. Training is also provided on industry trends as well as industry issues. We generally offer 3 to 5 classes per month on law, ethics, fraud, medical terminology, etc. Classes, which include webinars are given by providers, physicians, specialty vendors and attorneys. Some examples of recent training classes include: • Insurance fraud • Knee injuries • Medicare Set Asides • Limiting PTD claims • Shoulder injuries • Case law issues and updates • Brain injuries • Changes to 440 rules • Vocational assessments • Adjuster ethics • Ethical issues of surveillance • MRSA (Methicillin Resistant Staphylococcus Aureus) • Pain management • Dental trauma Page 79 21. Confirm your company's agreement to provide the company's claims staff to present and participate at claims workshops, and on -site injury management training throughout the year. USIS agrees to provide claims staff to present and participate at claims workshops, and on -site injury management training throughout the year. 22. The City may request that your company hire specified adjusters who are currently handling their claims. The City will need your company's written agreement that the City and/or any subsequent claims administrator, will also have the option to hire your company's adjusters at the termination of the agreement. Please provide your company's agreement. The City of Miami will have the option to hire the City of Miami Unit adjusters at the termination of the agreement. Regarding the City's request that USIS hire specified adjusters currently handling the Ci.ty's claims, USIS will interview those adjusters and follow USIS policy. Since USIS will be the employer and USIS/Brown & Brown could potentially be at risk for any perceived liability of wrongdoing in the hiring process, it would not be standard practice to accept an outside entity into our hiring processes. It is our intent to positively ensure that our equal employment opportunity philosophy, in accordance with federal, state, and local law, applies to all aspects of employment with USIS including recruiting, hiring, training, transfer/promotions, compensation and. benefits, and termination. At USIS, handled through our own Human Resources Department we must ensure that our employment practices are free of discriminatory practices and that employment decisions are made on the basis of job -related qualifications, experience, including personal competence and potential for advancement. With that stated, we will be open and pleased to strongly consider any recommendations or referrals of properly qualified staff that the City might provide or request. We will also be willing to share the resumes of the employee(s) hired or transferred internally to handle the City of Miami account. Once into the contract, should there be any staffing changes necessary, USIS would communicate with the City of Miami as soon as known. It should be noted that at USIS we are committed. to ensuring equal employment opportunity for all employees and applicants for employment. It is our goal to recruit, hire and develop the best employees using only job -related qualifications. We know that our people are the heart and soul of our enterprise and we recognize that our continued success depends on the full and effective recruitment, hiring and development of the very best employees, taking into consideration only job -related qualifications, regardless of race, color, religion, sex, age, national origin, marital status, disability, veteran status, genetic information and any other category protected by state or federal laws. USIS strives to recognize the talents and job performance of all employees, and values the contributions that come from people with different backgrounds and perspectives. It is USIS' desire to promote an environrnennt that maximizes the potential of all of our employees, and to promote diversity throughout the Company because we believe that diversity is important to our ability to continue to excel in an increasingly diverse and dynamic marketplace. The Company does not permit discrimination or retaliation against qualified individuals with disabilities in regard to application procedures, hiring, advancement, discharge, compensation, training, or other terms, conditions, and privileges of employment. The Company will reasonably accommodate qualified individuals with a temporary or long-term disability so that they can perform the essential functions of a job. A job applicant who can be reasonably accommodated for a job, without undue hardship, is given the same consideration for that position as any other applicant. Page 80 23. Commit that your company's employees, including but not limited to, the adjusters, will return all phone calls within twenty-four (24) hours. USIS Claims Handling Guidelines mandate a return phone call within 24 hours. Emails/written correspondence are to be responded to daily. Supervisor has access to adjuster ernails and voice mail to ensure compliance. It would be expected that the adjuster would respond within an hour since he/she would be dedicated to the City of Miami and be in continual communication. USIS has Key Performance Indicators (KPIs) for each adjuster, some of which include the above, and quarterly scorecard reviews are completed to ensure these KPIs are being met. 24. Agree that your company's adjusters will initiate three (3)-point contact within twenty-four (24) hours. Describe how your company currently monitors compliance, and how that monitoring will be done to assure compliance to this standard on an ongoing basis. Provide an example of a management report that measures this requirement. The claims supervisor monitors compliance by running a system report that identifies the date of (3) point contact to ensure timely contact. USIS has Key Performance Indicators (KPis) for each adjuster, some of which include the above, and quarterly scorecard reviews are completed to ensure these KPIs are being met. Upon claim report and set up of claim in the system, the adjuster makes contact within one business day after receipt of the claim. USIS will agree to contact within 24 hours. Contact with the physician and injured worker and defense attorneys, if applicable, are done bi- weekly, or more frequently if the claim/situation demands it. Files are maintained on diary and all contacts are documented thoroughly in the system. The claims supervisor reviews each new Lost Time claim on the day it is received and provides specific written instruction to the assigned adjuster within one work day of receipt. These instructions will assist the adjuster with information to determine compensability, possible "red flags", subrogation (or other offset potential), as well as any jurisdictional or claims management issues. The adjuster is then given a due date to return the claim to the supervisor within 7 days with the initial contacts (3 point contact) completed (within 24 hours) as well as a detailed claim review, thorough investigation, reserve recommendations and if possible the decision on compensability. The supervisor will follow up to verify that all criteria have been completed in a timely manner. Diaries are then set for follow up by the adjuster, the supervisor and the TCM if applicable. If a detailed investigation is needed in order to determine compensability, this is assigned with employer approval without delay. Medical records may also need to be obtained in an expedited manner in order to make a compensability decision within 14 days. Compensability investigations begin by reviewing the facts of each case. i.e.: • Was the employee injured while performing his regular duties within the course and scope of his employment? • Did the injury occur on the employer premises? • Idiopathic? • Are there any pre-existing conditions? • Is the injured worker a "repeat claimant"? Page 81 The adjuster will obtain most of this information during the initial 3 point contact. If further investigation is needed in order to make a decision, recorded statements may be taken. If USIS/AmeriSys recommends a denial of the claim based on the investigation results, the adjuster will discuss the claim and request approval of denial from the City. The City will have final authority to determine if the claim should be denied. If the City approves the denial recommendation, USISIAmeriSys will so notify the injured worker by DWC-12, and inform the City. The following is an excerpt of the 3-Point contact from our Procedure Manual: • PROMPT initial contact within one business day. Verify SSN and Date of Birth. Each attempt needs to be thoroughly documented in system notes. ■ Employer - Obtain all the details on the accident including subrogation potential and witnesses. Find out what type of employee he/she is. Inquire about light duty availability, • Employee - Details of the accident, any prior workers' compensation claims, auto accidents or other injuries. A detailed medical history is vital to determining major contributing cause and com.pensabi.lity of the claim. Explanation should be given to the employee to notify the employer when released to light duty to determine if suitable employment is available within the restrictions. (Contact must be done within 24 hours) • Medical provider — Contact with the medical provider to obtain a DWC-25 to document the diagnosis, prognosis, work status and future treatment plan. Explain that all authorizations should be approved by USIS/AmeriSys. A file is exported and sent to ISO at the initial. indemnity payment; any report received is scanned to the claim fi.le which diaries the adjuster. The adjuster has the ability to request an ISO search at any time. Contact with the physician and the injured worker and defense attorneys, if applicable, is done bi- weeldy or more frequently if the claim/situation demands it. Files are maintained on a color -coded diary to help the adjuster prioritize work. Page 82 25. Provide your company's definition of a BI/Indemnity case and Medical Only case. Detail how, and when, a Medical Only claim would escalate to an Indemnity case, and any fast track claims handling alternatives. Once a claim escalates from a Medical only to an Indemnity claim, advise how the City is able to see, and track the change. Incident Only is any claim wherein the injured worker returned to work with no time missed from work and did not receive medical treatment. This is for Report Only purposes; no adjuster is assigned. Medical Only is any claim wherein the injured worker did not lose more than 7 days from work and is treating for medical. Indemnity is any claim wherein there is lost time from work of 7 days or more, or a Medical Only claim reaches $5,000.00 in medical expense. We .may also classify a claim as Lost Time if there is a need for investigation to determine compensability, or the claim is litigated, regardless of lost time. Once a Medical Only claim reaches $5,000 in medical expense it is transferred to an indemnity file. It would also be transferred should the IW start to lose time from work and lost days exceed 7 days. The claim would also be transferred to lost time in the event it becomes litigated. An event is created and the City of Miami would see the claim reclassified on the web portal. A case note is also created documenting the change, which is also available for viewing in the portal. 26. Describe the current subrogation process. Provide sample reports of how your company monitors subrogationfSlTF activity and recovery. We carefully evaluate any and all subrogation possibilities and follow the claim to ensure the best recovery possible, Subrogation activities and recoveries are reported in the system. The supervisor monitors subrogati.on/SITF activity through the RMIS system. diary. USIS handles Subrogation claims in-house. The First Report is reviewed by the supervisor to identify any third party involvement on the claim. The supervisor will note this on his/her instructions to the adjuster in the system. The subrogation adjuster places the file on diary for review and initiates the investigation process. The initial review involves a thorough review of all volumes of the claim, including the claimant's recorded statement and other investigative material obtained. The adjuster monitors the file for liability or comparative negligence. Upon determination of these, the adjuster prepares a Subrogation package (all parties placed on written notice by certified mail) to submit to tort for recovery. The employer may agree to hire its own attorney to protect and enforce its lien, or it may hire the employee's attorney to also represent its lien interests, as long as the employee gives his/her consent. The selection of counsel should be decided on a case by case basis. Subrogation recoveries are important at USIS; with a Subrogation Specialist Adjuster on staff ptu-suing recoveries for the best possible outcomes for its clients. The claims adjuster will identify the potential for subrogation information gathered in the initial investigation of the claim, during which time contacts are made and available documentation such as police and medical reports are obtained. If the initial investigation indicates possible third party liability as a factor in the loss, the claim will be referred to the Subrogation Adjuster for further review, and if subrogation potential exists, lien letters will be sent by certified mail to the appropriate parties. The claim will be placed on a diary so that contact is maintained with all parties in regard to the status of our subrogation and applicable timelines. Success is determined when all Page 84 parties reach a consensus as to the amount of our lien recovery, with the Subrogation Adjuster pursuing a maximum .recovery in line with statute and case law, or by settling the Workers' Compensation claim with the incorporation of a full or partial wavier of the lien. In negotiating the lien recovery, the option of settling the Worlcers' Compensation claim is often a factor. In some cases, subrogation can be most effectively utilized by agreeing to waive all or part of the lien in return for a reduced settlement amount in the claim. USIS will ask for the City's consensus in pursuing subrogation. Recoveries are reviewed, logged and prepared for entry by the Administrative Assistant and then entered to the system by the Accounting Dept. After entry, an Exception Register is run to verify that the recovery check was entered properly. Recovery checks are then forwarded on to the attention of the designated representative at the client's location for deposit to the client's bank account. Each month, the Exception Register is reviewed by the Accounting Manager to verify all recoveries received have been entered properly. An Exception Register is sent monthly to the designated client representative detailing the recoveries received for that month. In addition, a copy of the recovery check and any supporting documentation is saved in the system claim file. Date: Adjuster: Subro Referral (Please note urgency of referral if settlement is pending) Claimant Name: SSN: Claimant Address: File Number: Open ❑ Closed Date of Accident: Fund/Carrier; Employer: Details of Accident/Loss: At Fault Party Name: Address: [nsurance Company: Address: Third Party Attorney: (if applicabie) Address: Police Report: ❑ Attached ❑ Ordered Other Report / Outside Investigation: Paid to Date: Indemnity: Medical: Comments/Remarks: Pagc 85 Date: Adjuster: Subro Changes (Please note urgency of change if settlement is pending) Claimant Name: SSN: Claimant Address: File Number: Open: ❑ Closed: ❑ Date of Accident: Fund/Carrier: Employer: **5ubro Changes** (please list changes below): New Attorney Additional Ins info Pending status of settlement Police Report: ❑ Attached Other Reports / Outside Investigation: Paid to Date: Indemnity: Medical: Comments/Remarks: 27. Describe your company's current process for identifying claims having fraud potential, including your company's process for referring those claims for investigation. Describe the parameters of that investigatory process. Describe how these claims and their related investigations are monitored, the parameters, and any proposed changes to that process for monitoring this activity and its performance. Provide sample reports. Our adjusters are well trained. in recognizing `red flag' indicators. If the adjuster suspects any fraudulent activity, he/she would contact the City to discuss and make recommendations for further investigation, such as surveillance or recorded statements. Claims would be assigned to a third party for surveillance documentation and/or further investigation. All suspected fraud would be pursued to the fullest extent availableunder the law. At the City's request, an attorney (City choice) will review all potential fraud cases. SIU assignments will be made upon approval from the City. The adjuster submits a complete copy of the file to the Fraud Division with the States Attorney's Office for review to determine if the State will pursue action. The adjuster continues to have communication with the State Attorneys' Office regarding further action or activity. Page 86 Subject to client approval, all new claims are sent through ISO search to determine if there were any pre-existing accidents and/or injuries. A new ISO search is done on an annual basis to ensure that any intervening accidents are noted as long as the file remains open. 28. Describe your company's quality assurance policy and procedures, Provide copies of your company's current policy. Include: (Sent to Ken) a) Internal Quality Control processes and current reporting designed to monitor Quality b) System prompts requiring supervisor attention c) Criteria for supervisor intervention related to QA deficiencies d) Criteria for measuring adjuster performance e) Discuss reports addressing Quality issues and proposals for improvement USIS is dedicated to ensuring quality control reviews measure timeliness, accuracy and compliance within a cost effective program, Internal audits done on a monthly basis ensure that claims handling processes and procedures are being followed on a day to day basis. If applicable, an action plan for improvement is written by the claims supervisor to address any necessary items. Claims are reviewed by the Supervisor on diary to ensure the quality of the adjusters' work and adherence to the USIS quality control standards and client -specific protocols, File reviews are also done by the USIS Quality Control Department. The Supervisor reviews are to ensure adjusters are working the claims appropriately and to provide direction/guidance to the adjuster as necessary. If an issue is identified the supervisor will address with the adjuster and place on a follow up diary to ensure it has been. handled. The adjuster will have continuous contact with Risk Management. If there are any issues they will be resolved immediately. It will be the responsibility of the Account Executive, Jenny Ross, to identify and resolve any issues brought forth during the project duration. The Account Executive has been responsible for multiple large clients and is experienced in dealing with and resolving any issues. She will be accessible to the City by keeping the lines of communication open. USIS strives .for an excellent customer service relationship. If there are any concerns, they will be immediately handled. Our goal is to build and ensure excellent. rapport between our staff and the City's for a superior working relationship. The Account Executive will remain fully involved in the day to day claims handling process in order to ensure that all critical decisions being made by the staff are in the best interest of the City and its injured employees. Any concerns will be discussed with Risk Management as needed. The following describes USIS' quality assurance and account management processes. QUALITY ASSURANCE of claim files is monitored by the Quality Control Analyst, a licensed adjuster, under the direction of the Accounting Manager. Every quarter, the A.ccounting Manager gives the QC Analyst a list of adjusters for claims audit. The selection is rotated to ensure all adjusters are audited throughout the year. Claim files are audited for compliance with company procedure and State rules and regulations — monitored by the QC Review Pori. The outcome of these audits is reviewed by the Accounting Manager, Claims Managers and Supervisors and submitted to our corporate internal audit staff as an internal control established for Sarbanes- Page 87 Oxley compliance. A Quality Control Survey is initiated to all employees by the Accounting Manager every month to comply with Sarbanes-Oxley protocol ACCOUNT MANAGEMENT PROGRAM: The claims will be handled by a Lost Time adjuster and a Medical Only adjuster under the review of a supervisor and manager, according to USIS Policy and Procedure, State rules and regulations, and client protocol. Claims are monitored by a diary system by each adjuster and the supervisor. The supervisory reviews include proper reserving, timely form filing, monitoring of compliance with all State regulations and statutes, direction and action plan — all with the goal to successfully return the injured worker to gainful employment and/or settle the claim to bring files to a successful closure. Internal quality control audits are performed on a regular basis; internal auditors verify controls placed in operation and test for operating effectiveness and that claims are handled per policy and procedure; audits are performed by the State for compliance with rules; external audits are performed by excess carriers and clients — all to verify proper claims handling. 29. Please provide a copy of your company's claim handling practices (Best Practices). These Best Practices should at a minimum, include your company's standards on: a) Initial Contact (3-point on WC and Auto); b) Recorded statements, including scripts that have been designed for various types of statements to be taken; c) Claim Investigation; d) Scene investigation; e) Follow-up Contact, including requirements for all parties; f) Diary requirements and requirements for the completion of claim strategy/action/resolution plans; g) SITF/Subrogation; h) Indexing; i) Reserving practices; j) Explain your reserving philosophy, policies, and practice. (i.e. ultimate probable exposure v. worst case); k) Outline the specific deadlines applicable to appropriate reserving; I) Describe any reserving software or modules that are used; m) Describe how you identify and report reserving performance and overall trends; n) Confirm if reserves are set on Medical -only files; o) Outline your company's controls to achieve consistent and appropriate reserving among various adjusters. Describe how your company's monitor reserving performance and overall reserving trends; p) Medical Management; q) Pre-Settlement/Settlement procedures; r) Confirm your company's agreement to obtain settlement authority prior to any settlement; s) Confirm your company's agreement to provide the City with a reserve advisory/consult on all claims that have a reserve set at $25,000 or greater or are changed/increased by $25,000 or greater and category claims with quarterly updates; t) Confirm your company's agreement to submit the proper filings to all required states on the City's behalf; u) Confirm your company's willingness to allow the City to select and/or approve defense counsel; v) Confirm your company's agreement to allow audits by the City or consultants with appropriate notice. Outline your company's audit protocol; Page 88 w) Confirm your company's willingness to provide regular stewardship/report cards to the City measuring your company's performance on their services and outcomes of their services. Provide a sample stewardship report; x) Confirm your company's agreement to adhere to the City's Client Service Instructions, and to adhere to your company's claim handling Best Practices with the City's Client Services Instructions, taking a primary position to any of your best practices; Following is an Excerpt from our Procedure Manual: • PROMPT initial contact — within one business day, Verify SSN and DOB. Each attempt needs to be thoroughly documented in system notes. • Employer - Obtain all the details on the accident including subrogation potential and witnesses. • Employee - Details of the accident, any prior workers' compensation claims, auto accidents or other injuries. A detailed medical history is vital to determining major contributing cause and compensability of the claim. Explanation should be given to the employee to notify the employer when released to light duty to determine if suitable employment is available within the restrictions. • Medical provider - Document the diagnosis, prognosis and future treatment plan, Explain that all authorizations should be approved by USIS. Request copies of any medical documentation to substantiate payment of benefits and treatment. If claim is Lost Time, the following should be done: • Initiate payment of indemnity benefits • File First Report of Injury with the State within 21 days. • Send Benefits letter along with appropriate attachments to the claimant • Send wage statement request to the employer • Determine if case has subrogation potential. If so, complete Subro Referral form in system and forward to Subro Specialist (email). Copy to file, copy to Accounting Mgr.) • Set appropriate diaries (future indemnity payments, etc.) • If investigation is needed (and denial is not to be filed immediately) and/or compensability is questionable; send WC-3 to claimant, State Board of Workers' compensation and assigned Field Adjuster for recorded statements and investigation. • Set appropriate reserves for potential exposure, according to client specifications • ALL the above to be documented in the system The supervisor/manager monitors the FROI handling to ensure compliance with the State timefiames. If claim is Medical Only, the following should be done: • Make contact with the employer to verify return -to -work date and whether working/paid at full wage. Please reference Attachment 13 — Claire Handling Practices and Liability Claim Procedure Manual. A copy of USIS, Inc. proprietary Claims Manual can be provided upon completion of an executed contract between USIS and the City ofMictmi. Page 89 5. LITIGATION MANAGEMENT USIS agrees to utilize the City of Miami's selection of counsel. As requested, USIS, Inc. has a relationship with the following South Florida law firms: :<: _:: ,::; _:�:.:.:.:«1YLlrft�,..�=ti��^�''�.t'A.E'is=:.':'de i:���:dCi•::-a::-::a _••::>:9:»:;:,«:.. Kip Lassner Christian Petrie Cole, Scott & Kissane, PA Conroy Simberg/West Palm Beach 954,343.3901 Office 561.478.6034 Lizette Francisco Francisco/Blanco, P.L. Alison Schefer 305.444.8336 Adelson, Testan, Brundo, Novell & Jimenez Stephanie Robinson 561.402.8924 Conroy Simberg Hollywood Office 954.518.1328 1. Confirm your company's agreement to notify the City of all legal dates including hearings, trial dates, settlement conferences, deposition, etc. with enough advance notice to allow attendance if desired. USIS agrees to no notify the City of all legal dates including hearings, trial dates, settlement conferences, deposition, etc, with enough advance notice to allow attendance if desired. 2. Confirm your company's agreement to maintain a litigation calendar to ensure all deadlines are met. USIS agrees maintain a litigation calendar to ensure all deadlines are met. The litigation calendar triggers a creation of litigation diaries to ensure that actions are scheduled. 3. Identify whether your company's claims handling system can generate alerts to internal and external persons related to specific deadlines. Yes, our claims systems generates alerts in the form of Diaries, creating Action items with deadline for different requirements. Reports for overdue diaries are also auto generated and reviewed by users and supervisors to ensure timely of action items completion. Litigation management occurs within the claims system, following policy and procedure of the company and any client requirements. The Litigation screens within the system are utilized for handling and monitoring all litigation practices, e.g. with receipt of a Notice of Appearance denoting the plaintiff counsel of record, our claims system "Litigation screen" is completed with the name and contact information of plaintiff counsel. Defense counsel, when assigned, is also noted on this screen as well as the date assigned to track lag days from date claim is received until date assigned to defense. All litigation paperwork that is received is attached in the claims system and a color coded diary is set for the adjuster and supervisor. It is the adjuster's responsibility to timely respond to all pleadings, and the supervisor will also set a "legal" diary to ensure that this is being done timely. All legal proceedings are noted on the docket of the litigation screen and the system will alert the adjuster of the upcoming legal proceeding via an alert from the claims system to ensure the adjuster is prepared. There are system triggers and alerts, some pre-set system -wide. There are automated features to assist the adjuster related to litigated claims. If an attorney is entered to a screen, an Alert subsequently pops up every time that claim is opened. There is also a litigation flag that stays red in the default screen. There is also the ability to run reports related to litigated claims based on specific criteria. There are specific procedures in place for legal documents that are scanned to the claim file with specific note and subject types, diaried to the adjuster and supervisor. Page 90 4. Describe and provide examples of the periodic status reports your company will provide to the City online/via e-mail. To, establish the proper and most accurate reserve the adjuster completes a reserve worksheet that breaks down into 4 categories — Indemnity, Medical, Other and Legal. 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The adjuster will maintain communication with defense counsel and the City determining strategy on a go forward basis to bring the file to fair and. equitable resolution for all parties. The adjuster maintains control of the file in an effort to control costs. The adjuster gives a synopsis of the claim to the defense attorney. The attorney generally handles the deposition of the claimant and any witnesses. The attorney handles the legal aspects of the case, i.e. work that has to be filed through the court system. The adjuster maintains control and direction of the claim, working as a part of a team with the defense attorney to bring the case to a rapid conclusion. Within the claims system, there are automated features to assist the adjuster related to litigated claims. If an attorney is entered to a screen, an Alert subsequently pops up every time that claim is opened. There is also a litigation flag that stays red in the default screen. There is also the ability to run reports related to litigated claims based on specific criteria. There are specific procedures in place for legal documents that are scanned to the claim file with specific note and subject types, diaried to the adjuster and supervisor. Page 92 6. Provide several Plans of Action (POA) examples, noting specific action -oriented goals. pA1rC AtxH� 98ttf 161/Agggit i�` �Sii�fdSSkb`.7i'diNtir•6�3ee3tf �g �'„", 9i f:R' 3'r"� %' f& t aq ClaP44. nit POI ttrVitik COOK Rom: WNW* ride" :WS 1,41 awr -04740.0rn awA'i #-,0*NtitftiS 4,VO°ais 141A mores Z. 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The City has the following expectations relating to medical: 1) a provider who actively and aggressively manages medical; 2) a network of physicians specializing in Return to Work; and 3) a claims management team approach whereby the team understands and works as partners in the RTWITransitional-duty efforts. The City is very interested in the Successful Proposer's philosophy on utilization of TCM & FCM within their claims management model, with the understanding that The City may elect to use a separate managed care vendor. USIS/AmeriSys has an integrated approach to claims management which involves Telephonic Case Management, when required, as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the telephonic case - managers work alongside the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, ease -manager (when assigned) and cost containment. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Horne Health, etc.). These providers are contracted not only for significant pricing reduction but also performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City of Miami's overall economic impact. The adjusters are well trained on when to recognize when a case is deteriorating and are instructed to control these claims as quickly as possible in any way we can in order to minimize litigation and lost time days and re-engage the injured worker and doctors. This may include use of Util.izatio.n Review and/or Independent Medical Examination or surveillance, if fraudulent activity is suspected. We may also consider use of tasking a RN Field Case -Manager to attend an appointment or conference with the doctor to question the treatment plan if applicable; this would be subject to City approval. Keeping in constant contact with the injured worker and employer is an extremely important part of adjusting and is strongly encouraged. USIS routinely works with physicians, employers, and injured employees to identify barriers that prevent an individual from returning to work. Once the barriers are identified, a plan is then formulated in conjunction with the employer, physician and injured employee, to facilitate removal of the barrier, return the employee to work and thus resolve the case. Our system, allows us the ability to accurately track the Return -to -Work milestones based on the Official Disability Guidelines. This includes the release to frill duty, restricted duty, and the employers' ability to accommodate the injured employee's restrictions. Catastrophic or large losses seldom occur but when they do they have a chilling impact on claims expense. Our experience with the construction industry and other industries has well acquainted us with serious claims involving traumatic brain injuries, spinal cord injuries, amputations and burns. These claims are complex from beginning to end. Rapid response in claims investigation, assignment of Catastrophic Case Management Providers and having a relationship with the facilities and providers likely to provide care for these claims is paramount to best outcomes. Page 94 AmeriSys, our medical management division, has relationships in place with facilities such as Shepherd Center, ancillary providers for home health, durable medical equipment, as well as therapies that have been utilized many times on large and catastrophic claims bringing the City of Miami the experience, when necessary, to handle these claims efficiently and effectively. We recognize that when these injuries occur, they are to your employees, your neighbors and often friends. We address these claims to offer not just the best economic outcomes but the best functional outcomes while striving to maintain the highest degree of compassion and service to that employee and his/her family. Recommendations for Assignments of Telephonic Nurse Case Management Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster (per client protocols), a referral for ease management is initiated. Serious injuries will be assigned for telephonic case management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of th,e initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the file, these can also be assigned. Telephonic case management is the systematic evaluation of medical services, procedures, facilities for medical necessity, appropriateness and efficiency. This promotes optimal. patient outcomes, reduce period of disability and assure high quality of care while controlling costs. A nurse facilitates the medical activity on a. file with the ability to individualize the plan of care and coordinate early return -to -work strategy with the employer and medical provider. The functions included • Coordination and referral to network medical providers • Coordination of the treatment plan with the provider • Working with the provider to establish functional abilities and conditional release to return to work • Discussion with the injured worker to clarify the worker's understanding of the diagnosis and treatment plan • Monitor the treatment compliance of the injured employee • Identify and assist in the resolution of problems with compliance to the treatment plan • Provide regular reports to the claims handler to assist them in the management of the claim • Recommend on -site case management and vocational services when needed • Work with the employer to identify a medically appropriate job Coordination and referral to network medical providers allows for the best network penetration. The channeling of the network providers will allow for the best network discounts. The Telephonic Case -Manager acts as the center point of contact ensuring delivery and communication to all approved providers of PBM and appropriate parties, forwarding appropriate issues to the utilization review department as necessary and reporting outcomes to the AmeriSys Quality Assurance Committee. Page 95 Case 1Vlana2ement Injured EinpEoyee' Medical :Case -Manage r Case Management Plg[l Assess Needs -• Develop Plan - Implement Plan:Items Manktor Progress ."Evaluate Outcomes...,..', Re-Evaluate Pan ;:TransporlstionC& ................................. .........tend..... ... iAttending Treating Physidan).:::::. Vooallona! and''. :;Field Case! -:: Management: 'CAT Supplier.. ' Utilization Review Prospective (PreCert) Concurrent '.-'.Refrospective.;- ....................................... We understand that it is imperative for both employee and customer satisfaction; we communicate promptly, which includes facilitating care and appointments properly. Prompt, accurate and complete communications are perfot ttmance standards and measurements for our case management team. Page 96 Recommendation for Assignments of Field Case Management 1. All catastrophic injuries, such as, but not limited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome - • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7. Difficult pre-existing medical or social problems • .Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism, and/or chemical dependency • Morbid obesity S. Cases not fitting an expected recovery time frame: • Not responding to provided care • Time delays in getting appointments • Irregular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planning for home health and/or durable medical equipment. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with .language barriers who know limited or no English) 13. All new claims with an initial reserve established of $50,000 or greater. Page 97 Please outline and discuss the following: 1. Organization and worklflow process for the provision of medical management care services including: a) Process of notification from reporting center; Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster, a referral for case management is initiated and approved by the City. Serious injuries will be assigned for telephonic case management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of the initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the file, these can also be assigned. b) Decision points for intervention; Early Intervention - The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case manager upon assignment by the adjuster; will within the first 24 hours of a reported injury conduct a 3 or 4-point contact. An assessment of the initial. medical treatment; evaluation of the treatment plan and the need for continued medical case management will be evaluated. This is the first step in the aggressive return to work coordination. A Telephonic Nurse Case -Manager will be utilized based on the approval criteria set by the City of Miami and USIS/AmeriSys, The Telephonic Nurse Case -Manager would provide Quality Care in a Cost Effective Manner focusing on early Return -to -Work. During the transitional phase USIS/AmeriSys will develop protocols with the Risk Management staff that would trigger triage and nurse case management. Early Intervention Criteria: • Severe lacerations, especially tendons and muscles • Server eye injuries • Back injuries with anticipated lost time exceeding statutory waiting period • Knee injuries with anticipated lost time exceeding statutory waiting period • Cumulative trauma (including carpal tunnel syndrome and tendonitis) • Concussion, severe head injuries • Chemical inhalation/poisoning • Severe sprains, strains (major body area such as ankle, shoulder or wrist) • Dislocations (major body area such as ankle, shoulder, wrist) • Rotator cuff injuries • Second/third degree burns not considered catastrophic • Injuries involving immediate inpatient hospitalization • Psychological claims/stress claims • History of protracted recovery from prior Indies or illnesses • Repeater claimants if prior claims involved the same body part and same or similar type of injury Page 9S • Any type of injury with lost time exceeding statutory waiting period • Cases with multiple providers • Crush injuries • Fractures • Amputations Aggressive Return to Work Coordination An early return to work after an illness or injury benefits a patient: physically, psychologically, financially, and socially, preserves a skilled and stable workforce for the employer. c) Frequency and duration of case manager intervention; The frequency and duration of case manager intervention will be based upon the City of Miami and AmeriSys agreed upon criteria. d) Decision points and process reflecting integration of pre -certification and utilization review with the case management process; Utilization Review Utilization review is the evaluation of appropriateness in terms of both the level and the quality of health care and health services provided a patient. UR is based solely on medically accepted standards. Utilization file review is the cornerstone of identifying potential quality assurance issues. Prospective, Concurrent and Retrospective reviews can be conducted. Ongoing utilization review throughout the process of adjusting health care billings is required to identify issues and initiate corrective action as early as possible. ACCREDITED Workers' Ctunnoeitasunee 13(it;<1u6+ra MAngoraeeat Ft,pirea mt3 i'i 017 Prospective Utilization Review This review is conducted prior to the delivery of the services requested. Prospective reviews may be for inpatient or outpatient services. Prospective review facilitates the prompt time.ly authorization of prescribed services and the documentation of authorized services which must be recorded in a consistent manner. Pre -Certification of Procedures Pre -certification is the timely authorization of medical/surgical services before treatment is rendered based on established third party guidelines, practice parameters and accepted standards in the medical community. An experienced nurse specialist completes all reviews and utilizes peer review physicians when the decision to certify cannot be made. Page 99 Pre -certification services address: • Appropriateness of setting (inpatient versus outpatient) • Appropriateness o surgica proce• ure, •'agnostic stu or treatment • rescribed Appropriate engt o stay or treatment pre -certification services • Pre -certification of hospital admissions • Reduce unnecessary hospitalizations • Re • uce t e engt o stay especia y w ere per • iem reimbursement is established for hos•itals ▪ Foster a shift from inpatient to outpatient care • Provi•e a mec anism or time y i•enti rcation o patients who re•uire dischar:e •Fannin: and case mana:ement A properly licensed nurse will obtain the demographic data and relevant information to the clinical conditions to be treated and procedures to be performed from the provider. The nurse reviewer will consult acceptable established guidelines — established and accepted Practice Parameters such as McKesso.n's InterQual, or the Length of Stay by Region. If the data provided meets these criteria the request for service will be determined as medically necessary. If the data does not meet the criteria, the request is referred to our medical director Or a physician advisor for a determination. All parties are notified of decisions by telephone, fax or mail and the carrier is kept informed at all steps. Concurrent Review for Continued Stay or Services Concurrent review is a review of the clinical information and coordination, assessment, planning and follow-up procedures during the course of treatment to determine medical necessity. This review is performed while the injured employee is still hospitalized andlor services are being provided. Concurrent review also occurs with the request for additional physical medicine. If the data does not meet the criteria, the request is referred to the USIS/Am.eriSys medical director or physician advisor. The medical director will review all available data from the provider and review the established criteria and may contact the attending physician requesting the services. The medical director may consult a peer physician of the same specialty as the requesting provider for further investigation and decision on the service. All parties are notified of decisions by telephone, fax or mail. Page 100 Retrospective Utilization Review This review is performed after the requested service or procedure has already occurred. This includes random and focused reviews, which are quantified and evaluated by senior staff and/or physician advisors. Problems identified from these reviews are addressed through an action plan in-house or with the provider. Utilization review is also conducted on medical billings to identify over -utilization of a particular service as well as review of multiple surgical procedures, questionable CPT coding, review of related to level of service, relatedness, as well as all Hospital billings over a pre -determined dollar amount. All Retrospective reviews are conducted by a Registered Nurse. Medical and hospital bill audit USIS/ArneriSys services are a combination of automation with manual oversight and verifications. Manual reviews are performed on multiple surgical billings and hospital bills over $5000 by a Utilization Review Nurse Specialist prior to entry. Bills are also reviewed against pre -determined criteria, which indicate that a more in-depth review is indicated. These criteria include: • Hospital bills which indicate inpatient stays for procedures normally performed on an outpatient basis • Hospital bills with lengths of stay which exceed the 50th percentile of the norm.a.l length of stay • Hospital. bills which show :multiple diagnostic tests or diagnostic tests not usually related to the injury • Hospital bills which contain unidentified detail charges • Hospital bills which contain duplicate charges, data entry errors, or unidentified charges posted after the discharge date • Hospital bills which note unrelated diagnosis or procedures on the UB-04 • Provider bills which meet the indicators of potential abuse (double billing, common referrals, cross billing, fragmented billing, missing modifiers, over -charging, over - itemization, over -prescribing, overutilization, prolonged follow-up, self -referrals, services not rendered, substandard care, or upcoding) • Provider bills which indicate more than two modalities of therapy per visit • Provider bills which show an excessive number of diagnoses for the same condition/inj ury • Provider bills accompanied by narratives which do not meet CPT guidelines, or appear to be duplicates or computer -generated • Provider bills which show an excessive amount of surgical or other supplies or medications Unbundling The UR Nurse Specialist identifies procedure codes that are individually billed that are included or should be billed using a single procedure code. The codes are verified if they are included in other CPT codes and should not be billed separately. This procedure is consistent with outpatient, surgical, laboratory and diagnostic procedures. If additional documentation is needed it is requested. Page 101 Peer Review Peer review is a process where a physician evaluates an individual physician's medical treatment of at least one patient in order to assess the quality of care provided by that physician. This will include documentation of care (medical audit), diagnostic steps used, conclusions reached, therapy given, appropriateness of utilization and reasonableness of charges claims. A specialized nurse will conduct a preliminary file review to assess appropriateness/cost-effectiveness of peer review service. Files may be reviewed for: The RN will obtain any missing medical records, prepare questions/issues to be addressed and coordinate referral to an independent, specialty -matched physician. The physician, acting as advisor to the RN, will decide upon the questions and issues arising from the chart review. The Peer physician will review all available medical records and will provide an unbiased, constructive opinion of all medical activity documented on the case. The Peer physician may contact the provider for further information, clarification or discussion of the case. A detailed written report will be prepared to include specific reasons supporting conclusions reached and suggested approaches to corrective action. e) Processes for bill review, approval and payment detailed in flowchart; Upon receipt of paper billings, the bills, along with any corresponding documentation, are scanned and attached to individual claimant files within the Corrus system. Medical bills may also be submitted electronically via HIPAA compliant X12 5010 standard files. A bill record is then created corresponding to the scanned/imported document/bill. Simultaneously the adjuster is diaried as to the presence of the bill for electronic review and approval. After approval by the adjuster, the bill record, along with scanned document/bill, is transferred to a user bill list for the bill reviewer to examine and prompt the syste:m adjudication to apply fee schedule limitations/rulings and MRA. As the adjudication systemvalidates data, the bill review analyst must respond to any "Review Messages" prior to finalizing the bill. During this process the bill review staff will also be alerted to any reimbursement issues identified from the adjuster review via Corrus notes that are accessible by all parties involved with the claim. The Corrus database maintains a complete history of all medical bill processing including the payment information and EDI results. The data stored within our database includes original Page 102 bill data as entered, plus scanned copies of the documents; vendor information; reduction information and EOBR codes assigned; allowed codes and amounts; payment date, amount and check number; all dates relevant to receipt, processing and external transmission; EOBR conninents from the bill reviewers; EDI control numbers and status. Please reference the Medical Bill Review Flow Chart below. We recognize that each client has unique needs, requirements and expectations. The utilization of USIS services will be tailored to the City of Miami's individual needs, expectations and requirements. Medical Bill Review Flow Chart Automatic Process Manual Process Claims Cost Containment Page 103 Cost Containment Analyties are also performed by an internal tool that allows USIS to view the historical trends by provider type, claimant demographics, and billing codes; or zoom in on a particular claim. It also allows us to review claim outcomes for over/under utilization or possible duplicates and to break out trends or review a particular claim by diagnosis or procedure codes. • i 93591temn 9 HX 933216331 939,11313,. > k1TaWl rvi4! A4Vic9 12977393 W7,44431 5,233,961.11 21562,767.69 d12 7,494,M,/6 1,42356655 1,069 12,392,362.12 9,1.1.7,329.12 21 354,035.37 71,555.74 13 33,319,22 :17,333,96 19,553 2331035,6-01.73 S2,232,12337 229 2,213,312.29 7933,63559 212 672,202.s? 31691953 ,132 1,aP3,b15.42 653,975,79 52 7,215, 993.07 1, 5341,195.33 29a zz f23072929.1S 59,13253295 1,015.61 2497190 7,393,13 336.90 29-16,362.42 325 9927 593,M 'S21 3,764,229,6? 1,211 12,00 439356 76 24,937.27 is 46,165,39 12,41 175,605,344.61 731 7,557,5,39 93 90 397,07. 97 114 1,251,95571 835,49765 15,529 321, 3,U96.40 2'. I Page 104 For the calendar year 2015, USIS/AaneriSys was able to offer its customers savings achieved by a variety of medical management approaches. As an organization we were able to demonstrate in excess of $27,082,651 in case management savings. Case management savings is achieved in variety of ways including, but not limited to, fee negotiation, directing treatment into the ancillary provider network to benefit from contracted rates, the recognition of non-compensable body parts or treatments ACCREBITER it'CR�K l�tl<ta�pyttryYlYtlii and reaching the Maximum Medical Improvement goals for the claim prior to the VclmicrerihforotYmeo fr:Al es G-Mbi,]uI7 benchmarks set by the approved guidelines. In addition to the case management savings we were able to document in excess of $9,534,227 in Utilization Review Savings by the identification of medically unnecessary procedures and/or procedures that are not causally related to the compensable injury. These reviews are done in compliance with the standards set forth by URAC and with the assistance of physician advisors in issuing non -certifications. There was an additional $5,823,500 in documented savings accomplished by returning the injured employee to work prior to the benchmarks set by the Official Disability Guidelines. Days saved are calculated in accordance with the injured employee's average weeklong wage. This also demonstrates the importance of a robust return -to -work program offering modified duty positions. In the processing of over 253,531 bills, the USIS/AmeriSys Bill Review Department in compliance with statute and rule, utilizing Pi 0 networks, the skills of seasoned bill reviewers and utilization review nurses who specialize in retrospective bill review, reviewed total submitted charges of $215,386,620. We saved 55% on those submitted charges. The Fee Schedule Savings were 40% of that number with the remaining ���"s��'r«�'`sue—zee�,M'�✓°-,m,,a=w¢°����r �a,Y°"a°°.'tl�'.�gme Mp..... °e:,., $32,529,040 resulting from our .:YS�y;�aY..a:k��..� ��?fi"1=="-�-m'a' :✓d'F P� ...:y � � �I •: �ij�. professional review and �rm�,:«s:;�'='•(5L %i :.aamx�-.'� -a�¢.,.e, 99 }gsx��3,�C "Y��'€-� contracted s savin{7. Our contracted savings average was 11.34% below Fee Schedule. All of this totaling more than $117,788,132 in documented savings collectively for our customer partners. US!S/AmeriSys Actual Results Based On 2015 Bill Volume of 253,531 Total Billed Charges: $215,386,620 Total Savings $117,788,132 Fee Schedule Savings H Other Professional Savings PPG Savings Below Fee Schedule is Total Allowed Page 105 f) Unique software and/or other knowledge resources utilized, and the value they add; Corrus is the primary Case Management and Bill Review/Cost Containment Information System at USIS. It is interactive with customer data imports and exports, and the extensive database provides the data for reports requested by a client. The application provides for detailed tracking of case notes, diaries, claim contacts, provider utilization and letters as well as a complete medical bill re -pricing system for efficient and effective adjudication of medical bills. Our computer system allows us to enter claim information based on dates of injury or occurrences and allows for multiple claims per claimant. Additionally, Risk Manager (ERIC) is used as the primary claims system at USIS. Corrus and ERIC are fully integrated systems which provide advanced claims handling capabilities in order to maximize technical efficiency. On a daily basis we exchange many different types of information with claim systems, ancillaries, and our customers, including EOBs, claims, invoices, and eligibility data via secured methods. Corrus and ERIC are synched via live data feeds. Adjusters primarily work out of ERIC for their daily functions, diaries, and case notes. The Cost Containment staff primarily works out of Corrus for the adjudication and review of bills. The authorization and/or denial of bills are done in Corrus by the adjusters and a business work flow is built into the system to move the bill to the next step. Vendors have access to the review the status of bills via our provider portal. The portal currently has the ability to track and display the status of each step of a bill. The portal shows if a bill has been approved, adjudicated, sent for payment, under review, denied, EDI and more. This allows providers, at their convenience, to view the current status of their bills. This feature significantly reduces medical provider phone calls seeking information regarding their bill status. EOB Search Tool Page 106 Cost Containment analytics are also performed by an internal tool that allows USIS to view the historical trends by provider type, claimant demographics, billing codes, or zoom in on a particular claim. It also allows us to review claim outcomes for over/under utilization or possible duplicates and to break out trends or review a particular claim by diagnosis or procedure codes. ,4417 Pk! 1115653 Rt! Yene G cowza m. Ta - ;ee zap {.At'; ,.--%w ?9 k. ,rar H, edWW. .__ i3 9dS, 39- 2170,131.31 1,646.35 V. 4.13,161,42-34,623.61 1E9 5,1126,%i.11 305124367.64 90.44.3t 325. 4,427,314.73 $A66,735.72. 113 3,496,770.36 7,403456r85 3,76359 121 1,364,9665.7 Y.'15,454,93 1, 54 13,261,163.13. 6, 11:7,5:44A5 9,.29:.06 2,112 33,021,3 3.66 4477.1,37144, 23 151,0%;@7 74,766.71- 3,13553 26 721,157;17 33,314,43 13. 23,31936 17,433.95i 713.43 19 46,155.33 3,636,36 1.1,639 134036,64113 36,142a233,12291,75 19,431 133,333,344.61 52,248,653.55 7a5 2,219,dl2,d4 1,a11,635,39 Y,BIS.X S3i. 3,36 ;556.57 1,441,932,34 PE® 67L 63.39 316,974.21- 1,415.3t 91 797,137.17 333.312.44 #'+3 SA43,33$,#3 663,943.74 1,297.40 134- fi391933,71 524,374,39 37 2,7J3223.67 1,34,3143.17 7,464,13 38 &35a-95535 313,346.43 14,62"s 373,4923.13 23,6S3,546,45 ,sa>1.13 13,528 a2i, , 4fi.6tl S'1 12.7A7..24 Listed below are some of the software capabilities (not exhaustive): • Software Availability Access to our system is available through several means: 1. Direct internet connection to our secured web site allows for viewing and entering of Case Notes and Diaries, viewing bills, running reports, and more. 2. TSWeb connection to a specified. computer via a VPN allows full access to the system 3. VPN/ODBC connection allows for full usage of the system if our software is installed at the remote site. • SFTP Site (Secure File Transfer Protocol) A FTP site will be hosted and maintained by AmeriSys to allow transfers of data and or/reports required by client. The site will be accessible by client and with proper authorizations. Page 107 g) Decision criteria for assignment and discontinuance of field case management and vocational rehabilitation; Field Case Management The purpose of Field Medical Case Management is to provide services that allow for more specific and detailed information regarding care, home situations, family dynamics and employee job site. This manner of delivery is important for establishing rapport with the injured worker and/or family, particularly with high risk or severe injury situations. Medical Case Management includes, but is not limited to, coordinating physical rehabilitation services such as medical, psychiatric, or therapeutic treatment for the disabled individual. These services have proven to be of assistance in the resolution of workers' compensation cases, auto, general and product liability cases, Long Term Disability and Catastrophic Case Management cases. Recommendation for Assignments of Field Case Management Recommendation for Assignments of Field Case Management 1. All catastrophic injuries, such as, but not limited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7. Difficult pre-existing medical or social problems • Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism and/or chemical dependency • Morbid obesity Page 108 8. Cases not fitting an expected recovery time frame: • Not responding to provided care • Time delays in getting appointments • Irregular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planning for home health and/or durable medical equipment. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with language barriers who know limited or no English) 13. All new claims with an initial reserve established of $50,000 or greater. Activities also include, but are not limited to: •Providing health training to the injured party and family •Monitoring the disabled individuals recovery •Consulting with treating physicians to develop an appropriate individual written rehabilitation plan *Gathering medical information if needed •Documentation of findings with recommendations on a monthly basis • Coordination of referrals and delivery of services • Home Assessments • Ergonomic Job Analysis Vocational Services Ergonomic Job Analysis & Job Description With the ever-increasing demands of today's occupations and new legislation governing the workplace, the ergonomic job analysis is necessary in the prevention and management of injury and disability. This is accomplished by snatching worker capabilities with occupational demands and providing this information in a mariner consistent with systems developed by the Federal Government. Our Nationally Certified Consultants visit each worksite to observe and gather data regarding the job being performed. This information can be utilized in the recruitment, promotion, job modification, training, performance evaluation and safety program development. Page 109 Providing these in an Essential Function format demonstrates the employer's understanding of the basics and the desire for compliance with guidelines of the ADA, Activities Include ✓ Essential Function Identification and Analysis ✓ Physical Demands Analysis ✓ Environmental Conditions Analysis ✓ Worker Characteristic Components Analysis Benefits ✓ Prevention of workplace injuries ✓ Facilitates early return to work ✓ Identification of transitional work opportunities ✓ Useful in the recruitment, placement and promotion of employees ✓ Identification of training needs ✓ Compliant with The Americans with Disabilities Act h) Management of provider networks, including utilization of credentialing and/or outcomes management; AmeriSys is proposing DimensionComp for hospital and provider access, Coventry PPO as the secondary or "wrap" network, the AmeriSys Preferred Provider network for ancillary providers, and rnyMatrixx as the Pharmacy Benefit Manager. USIS/AmeriSys employs a Director of Provider Services who will. work closely with the City, DimensionComp, the adjuster and the case -manager. The Director of Provider Services will make recommendations as to what outcomes would be monitored as well as work with the City to determine the criteria that are important. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Provider credentialing and monitoring — All providers must have privileges at a participating Dimension Hospital, hold a current license in the state of Florida, Must be Board -Certified or Board -Eligible, hold an unrestricted DEA certificate and comply with the State in maintaining malpractice coverage. The Florida License is verified to ensure it is active and clear of sanctions. DimensionComp also verifies malpractice history. It also ensures the DE.A license is current. Board Certification is verified through the American Board of Medical Specialties. Physicians agree to comply with all other provisions of Florida law applicable to a worker's compensation policy, plan, or program. Physicians have agreed to promote high standards of medical care and to control the cost and utilization of medical services, including, but not limited to, policies and procedures regarding quality assurance, utilization review, record keeping, billing, and grievances. Recredentialing is conducted every 3 years. Page 110 Under the 2003 -2011 managed care agreement, AmeriSys provided the City with a certified carve out version of Dimensions Health Care. The carve -out was modified to meet the specific needs of the City while meeting the requirements of the Agency for Healthcare Administration. The AmeriSys Network Manager established a strong rapport with Dimensions Healthcare; thus ensuring the prompt attention to specific provider needs of the City of Miami, including the recruitment of specialty physicians that are qualified to care for those individuals covered under the Heart and Lung Bill, Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. Ancillary Network Access AmeriSys Preferred Provider network • The AmeriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. • Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, Physical Therapy, Diagnostics, .Home Health and Durable Medical Equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. i) Utilization of physician review, IME, and other ancillary services; USIS/AmeriSys provides utilization/peer review services in accordance to the standards set forth by URA.C. Our accreditation period is current through .March of 2017. Utilization Review issues are identified and the file is referred to a Utilization Review Specialist. The UR specialist will conference with members of the case management and claims team to determine the issues to be addressed and the most appropriate utilization review approach. The UR specialists have access to mul.tipl.e third party guidelines, including, but not limited to, InterQual, Medical Disability Advisor and Official Disability Guidelines. The review can be performed as a Prospective, Concurrent or Retrospective Review. In the Prospective or Concurrent format, the UR specialists can review the issues requested and communicate their findings to both the case - manager and claims team. In the Retrospective format, the file can be reviewed and the UR specialists will formulate questions to be posed to a "peer" physician. Once the "peer review' is returned, the physician's determination is communicated to both the case -manager and claims team. The decisions are defended by confisaning the process was in compliance with URA.0 standards, the peer physicians are also functioning within URAC standards and the guidelines utilized have been approved. As always, it is the claims adjuster's decision to utilize the determination to best serve the claim and the injured worker. In conjunction with our performance standards for our Preferred Physical Therapy providers as it relates to adherence to evidenced -based guidelines, all providers have set up processes for Utilization Management. These processes are routinely utilized in the services provided for USIS/AmeriSys customers. Page Ill See an example below from one of our Preferred Partners: ALIGN mwrvisAmas AIAN NE}'WOltN$ GOLD STANDARD REv1EEW eeer.'..,...i.'1f1 ANAB.m[wntwab.w✓..aeasMmrot..wef. ,..£wYb,h,R6kwep,..� 61,51., ,. iYdNanrc: Wave W4t1.- Ohinl Wntdw, WAurx% 9,s1V.5.11. m,(/. sF.(M! ..4S .rmp r .. 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MWF.,F- .4,A_ Should the nurse reviewer determine that request for care or treatment is in variance to the evidenced -based guidelines or statutory guidelines, that request is forwarded to a peer of a like specialty to review. If resolution cannot be achieved by a non -physician reviewer, the review is escalated to a peer physician of a like specialty. Through our Physician Advisor organizations and as well as our physical therapy partners, non -physician review consultants are available for use for ambulatory care review, such as chiropractic and physical therapy specialists. AmeriSys works with Dane Street for Physician Advisor services. Physician Advisor Services for UR Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhill a,danestreet.com www.daneStreet.com Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance. Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state - specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Page 112 J) Methodology for tracking lost days (include your company's definition of lost days); measures the savings in comparison to ODG guidelines Third party guidelines and standards of care benchmarks are referred to validate the need for treatment or to confirm the disability status. The physician is contacted to verify discrepancies between the care being delivered and the established third party guidelines. The Official Disability Guidelines are referenced for disability management and Pressley Reed's Medical Disability Advisor is referenced for standard medical treatment including but not limited to diagnostics and therapies. McKesson's InterQual is utilized under the URAC guidelines for the pre -certification of invasive/surgical procedures. As stated earlier, the use of these guidelines allows the nurse case -manager to plan and benchmark the claim for appropriate treatment and anticipated return -to -work and MMI. Once the timeframes are set per the evidence -based criteria and variances occur in either treatment or disability, the nurse case -manager can then question the treating physician as to the medical necessity of either. If this does not resolve the discrepancy, the medical director or physician advisors will be consulted to opine and intervene. When the NCM identifies treatment that appears outside of guidelines or there is a delay in release to RTW, AmeriSys can and does utilize our Medical Director to provide a peer to peer telephone conference to discuss any issues of concern. Very often this is able to resolve any questions. If questions remain, we may choose to use IME's or formal Peer Review to address the issue. The following screen shot shows the NCM current Return -to -Work benchmark tracking. Page 113 k) Describe and provide an example of documentation of medical management within your company's notes system; Documentation of medical management is inclusive of all pertinent aspect of an injured employee's care, inclusive of functional limitations. The DWC-25 is reviewed, as well as any physician notes. Treatments and procedures are reviewed for medical necessity and causality. Once a determination is rendered, then the care is coordinated. All actions are documented in Corrus as well as the guidelines referenced. Office Visit - TCM Case Assessment Note Received by: 09/05/15 Dr. ='- Orthopedist LOV: 08/09/2015 NOV: after MRI DX: M54.41 Lumbago M96.1 Post-laminectomy syndrome, Lumbar Region Acute or chronic lumbar syndrome in previously operated spine with previous history of 1- ThIP L4-5 and stenosis L3-4 Work Status: OOW Anticipated MMI per ODG guidelines: 10/05/2013 Drs. Eval: INSPECTION: No swelling or bruising. No gross deformity. There is a healed lumbar incision. PALPATION: No midline tenderness. Diffuse bilateral paraspinal lumbar tenderness. There is no paraspinal spasm. There is no sciatic notch tenderness. There is no sacroil inc joint tenderness. RANGE OF MOTION: Marked restriction of forward flexion, extension, lateral bending and rotation to each side. There is more lower back pain with extension, There is no pain with hip range of motion. STRAIGHT LEG RAISING: Negative on the right. Negative on the left. She has lower back pain with bilateral straight leg raising and pulling into her thighs. MOTOR STRENGTH: 5/5 bilaterally in hip flexion (TI,2,3), hip extension (L5,I), hip abduction (L.5), hip adduction (1.2,3,4), knee extension (L2,3,4), knee flexion (L5,1), ankle dorsiflexion (L4), EHL (L5), plantarflexion (SI). The patient is able to stand on their toes and heels without difficulty. SENSATION: Intact to pin prick and light touch bilaterally. RELLEXES: Patellar (LA) 2+ bilaterally, Achilles (S1) absent bilaterally. There is no clonus or Babinski, GAIT: The patient walks with a slowed gait Imaging Orders: Three views with AP, Lateral and L5-SI spot of the lumbosacral spine were ordered, obtained and interpreted from an orthopedic standpoint Lumbosacral Spine X-rays: Lumbar x-ray shows a transitional L5-SI level, There is disc space narrowing throughout the lumbar spine. Drs. Treatment Plan: I had a long discussion and reviewed treatment options in detail, after reviewing the clinical findings and diagnostic studies with the patient. Due to the severe pain T would recommend an updated lumbar MRT scan with and without contrast. She has an appointment scheduled today with Dr. Epstein for medication management and will keep that appointment. No pain medications were prescribed from this office today. After the MRI scan I will be able to heifer determine whether not require surgery for lumbar spine and whether or not this is related to the pre-existing condition or this new accident on 7/3112013. MRl of the lumbar spine with and without contrast was ordered. The patient is to return when the result of MRI is available. A copy of the patient's note was sent to the adjuster. A copy of the patient's note was sent to the nurse case manager. Improvement noted: no Medications: Wellbutrin, Nabumetone 750mg Tab Oral Are there any medications concerns: no Average monthly medication cost: $63.25 per My Matrixx Treatment in compliance with MD Guidelines: yes Lumbar HNP Page 114 Based on clinical suspicion of a disc herniation, conservative treatment, which may range from simple rest to elaborate traction devices is recommended initially, except when signs of severe or progressive nerve compression (radiculopathy) are present. The individual is instructed to avoid aggravating activities such as heavy lifting, bending, twisting, or prolonged sitting. A corset may be worn during the day to provide support. For relief of pain and inflammation, treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs) and, if pain is severe, a narcotic or an anticonvulsant for its analgesic effects. Muscle relaxants are frequently prescribed for their sedative effects. Other treatments such as ice, heat, massage, and ultrasound therapy may help relieve pain and muscle spasm. As symptoms subside, an increase in activity is recommended, including physical therapy and/or a home exercise program to strengthen the lower back and abdominal muscles and improve aerobic capacity (walking). The individual may attend "back school" to learn correct posture and body mechanics. Many individuals recover completely; however, recurrences of back pain and sciatica are common. Therefore, preventive and maintenance measures such as exercise and proper body mechanics may be continued indefinitely. If little or no improvement is seen after 4 to 6 weeks of treatment, and if the pain is severe and debilitating, further evaluation is appropriate. If imaging studies have not yet been performed, MRI or CT/rnyelogram are indicated. Individuals who have leg pain (radicular pain) as the predominant symptom may gain relief through the administration of epidural corticosteroid injections. If non -operative measures are unsuccessful in relieving the individual's symptoms, surgery consisting of a laminectomy and disc excision or a minimally invasive disc excision, may be considered. Proper patient selection is the key to favorable surgical results, and good outcomes are more highly associated with correlation between clinical findings of radiculopathy and imaging studies. Central disc herniations generally present with low back pain and without radicular complaints; they, rarely benefit from a lumbar laminectomy and discectomy. Individuals who have persistent back pain as the predominant symptom usually do not benefit from surgery intended for disc herniation (discectomy). Individuals with chronic low back pain may benefit from a rehabilitation program, and/or pain management. Emergent disc excision (discectomy) is indicated in the patient with cauda equine syndrome, which presents with bilateral severe leg pain, saddle anesthesia, and bowel and/or bladder incontinence. Surgery is also indicated in the individual with progressive muscle weakness; severe unilateral leg pain with objective signs of nerve root compression (nerve tension signs and/or loss of neurological function) that has not improved during an adequate trial of conservative treatment, with an imaging study that correlates with the clinical findings for nerve root compression; or recurrent episodes of severe leg pain with objective signs of nerve root compression and a matching defect on imaging studies. Microdiscectomy or minimally invasive discectomy are alternative procedures that may be done on an outpatient basis and niay have shorter recovery periods. However, the indications for these procedures are the same as the indications for open laminectomy. Adjuster conference: per corrus notes Are there any red flags: pre-existing lumbar surgeries, complicating this claim Nurse Care Plan: coordinate MRI accordingly, results to provider, determination of exacerbation or new injury by Dr XXX. Monitor medicals. Field Case Manager update/report: Possible FCM request after, if surgery is indicated. :;$: ;rirmmw:RN BS Page 115 I) Ability to profile provider practice patterns and report on both clerical and financial outcomes on a case by case basis, as well as in aggregate; and AmeriSys has the ability to report on a providers practice patterns, both from a compliance with submitting of the correct documents as well as their billing practices. PCP A PCP B PCP C Comparison of Physician Outcomes for Claim Year 2015 at 12 months 20 Claim PT hays (.,.1 .5L7.61. 0 Avg Bill Cost Bill Count Avg Claim Cast Claim Count $205,19 $5:18,42 $1,1:30.36 0 200 400 600 800 1000 :1200 ti PCP C 111PCP El XiPCP A Claim Count Avg Claim Cost Bill Count !Avg Bill Cost Claim PT Days 11 $ 205.19 25 $ : 90.28 0 15 :$ 518.42 521 $ 149.54 11 36 : $ 1,130.36 1871 $ 217.61 .. ; 20 Page 116 Examples of medical cost containment reports (either ad hoc or standard) that have been generated from your company's system using a real blind client. USIS/AmeriSys has 8 on staff and on -site programmers who are able to build ad hoc reports and/or data extracts at your request for no additional charge. AluetiSys RTW Savino rt Roan To Work Niel 001 a t - 0,M40124 - :todami .w TCX C)p* d .) cle DOA Ciairo U44 Pro,teckiXINV Pt ti Nuns eta it> Claim Poet Tama taf #eta tit MUM 4C1.-ltiF 0,000il U1V140 4 8 d} eW1. 3"* $4,Me tlit / oro AA 3 irtn itreA,x±?iu trtit,rM3 nit 1a 14 *414 WS P °>t .8ai.5Gaea# 11a 855.35#_�r$°8L2?Iffi ?1,cianaf 11'm ,,,-1,1$R 1511411,L.4� � .;: G0..414..55 1 $§b ,,4;r7 tfOutdilbi Yril, ,I.K16 , 7 1 1kV0F1:P'a Stip.V % 'a KA'11'fib laJJ 6-:, O',OPO nsiE ,,..-.,.... At+ t4 ^ids 4A1) N. 14/ 44Y. 4i4 MO % Olt .,.:�. .,.�e60} 9 fa.:d :h.;19 MNPI ai4 r},$P 744oPt. t;`R4R,a.A .4......,1^_€.t±4RD SJ+3;s`4-V.F d"A Page 117 1; .1.34,575.71 41113,W4.37 725,772.34 2c:_na 85,78D.23 .550,054.J313 4,555 Ambulance 33,55: : AnglePeery 52rgical Center 3,015.1:5; 3.840 .55: Cent Regis. elerselAdaccuerl Norse Prectifiener ; :Duster 171,42025: :Durable Medical Equipment :liespies 2:l7.5M..54 i Lab 4.t.a2,22i :lndepenifent :Pharmacy 5.13; ; Physicei TheragIv 7,221.7.4; !Ceti Regis. Nurseatthisinced Nurse PresWidener .! '340..54 Dectlst 114.17; :Dociar !Durable: Maditca! Ecyjsenent Haspkai 4rszlegeneeet4 Leda :Pnennacy :Physica.4 Therapy Fee Schedule Reiuetions AmMeince knevleinty-fareizel Conte "111 IC4r4lAnYeltesi.: • OCeict ()nudge:Wel:se it.0.44.sint • liuMtll :Moven:Mei Lae ▪ Phomaty VW Physical 7huospy Network ReducOons mi Vert FletA- Nerserasteenceni..... Ottekn ▪ DULiG6 1111 Our4Wliestlicif:Estti0Lint41i uotzi Indsecneare Leh Floarineee INV Moailwy CON -Reductions 1,134,576,71 65%954.08 474,622.63 2. Detailed outline of medical management and medical cost containment fees for services proposed to the City to include the following: a) List all of the medical cost containment services included in your company's claim service fee. NA — Refers to Part II All medical cost containment services are priced separately from the claim service fee. b) List all of the medical cost containment services provided by your company or your company's vendor partners, that are not included in the claim service fee with the itemized charges. NA — Refers to Part II c) Outline all medical cost containment services provided to your company by an outside vendor, including PPO, Nurse Triage, Dedicated Nurse Case Manager and any other proposed services. Note: Proposers are requested to address the issue of physician dispensing and the high cost of repackaged drugs. AmeriSys is proposing DimensionComp for hospital and provider access, Coventry PPO as the secondary or "wrap" network, the AmeriSys Preferred Provider network for ancillary providers, and myMatrixx as the Pharmacy Benefit Manager. DimensionComp is an affiliate of Dimension Health, Inc. DimensionComp provides clients access to the one of the largest Workers' Compensation networks in South .Florida. By maintaining strong relationships with the provider community, DimensionComp is able to offer clients superior network savings and greater access. Under the 2003 -201 1. managed care agreement, AmeriSys provided the City with a certified carve out version of Dimensions Health Care. The carve -out was modified to meet the specific needs of the City while meeting the requirements of the Agency for Healthcare Administration. The AmeriSys Network Manager established a strong rapport with Dimensions Healthcare; thus ensuring the prompt attention to specific provider needs of the City of Miami, including the recruitment of specialty physicians that are qualified to care for those individuals covered under the Heart and Lung Bill. Coventry Health Care Workers' Compensation, Inc. Coventry provides clients access to the largest national provider network offering in the workers' compensation industry. By maintaining strong relationships with the provider community, Coventry is able to offer clients superior network savings and greater access. The AmeriSys Preferred Provider Network is made up of a select group of vendors to perform the services referenced below. Every three (3) years AmeriSys undergoes a very detailed RFP process for Ancillary Medical providers that include transportation, translation/languages, physical therapy, diagnostics, home health and durable medical equipment. These organizations undergo due diligence and are then contracted. Contracting includes indemnification for customers, insurance coverage verification as well significant discounting for services. We believe this provides our customers with the best protection at the best price, creating best value. Page 119 Matrix Healthcare Services, Inc., d/b/a myMatrixx, is a full -service pharmacy benefit management (PBM) and ancillary services company focused on workers' compensation. The AmeriSys/myMatrixx partnership has existed 10+ years since the inception of myMatrixx. Together we have provided quality medical management and pharmacy services to customers in the entire south-east region. AmeriSys and myMatrixx through their relationship have joined forces to face multiple challenges in the Workers' Compensation arena such as the escalation of the need for cardiac medications (BADGE Program), and currently we are working together on the AmeriSys Pain Management initiative called SECURE. The Vice President of AmeriSys is currently a member of the myMatrixx pharmacy and therapeutics committee which establishes the general protocols and formularies for this PBM. Physician Dispensing USIS' procedures adhere to Florida Statute and Rule requirements that the dispensing of medicinal drugs is limited to a pharmacist or a licensed dispensing practitioner and must billed under the original NDC (National Drug Code) number. The Florida Fee Schedule reimbursement for the dispensing of prescription medications is: Average Wholesale Price (AWP) + $4.1.8 = $ Reimbursement [Note: In order to properly reimburse repackaged medications, USIS requires both Original and .Repackaged NDC #] Through our PBM, myMatrixx, we are able to offer an extended network discount on repackaged physician -dispensed medications. For physicians who are willing to participate, the pricing is as follows: Average Wholesale Price (AWP) + $5 + $4.18 T $ Reimbursement which is a discount from the Florida Fee- Schedule allowance. This is a savings over the Florida Fee Schedul.e pricing for repackaged physician -dispensed medications which is: Average Wholesale Price (AWP) xl 12.5% of the original + $8 = $ Reimbursement Example: For non -repackaged drugs, whether from a pharmacy or a physician, payment is based on .Fee Schedule, unless a PBM contract is in place. If the physician has repackaged the drug, but there is no PBM in place, payment would be based on 112.5%, and both the repackaged code and the original code have to show. Dane Street, LLC - Physician Advisor Services for UR Dane Street provides Workers' Compensation Peer Reviews to Managed Care Organizations, Third Party Administrators, Utilization Review Organizations and Employers. Licensed in all mandatory UR states, with an active Regulatory and Compliance group which interfaces with the appropriate State workers' compensation Boards and Departments of Insurance. Dane Street is a URAC-accredited review organization and the reviews are delivered according to all URAC, jurisdictional and client requirements. They understand the importance of state - specific medical treatment guidelines, turnaround times, match requirements —and track any changes across these categories in their rules -based PeerAccess platform. Page 120 3. Provide the name, address and contact of the vendor and please also: Dimension Health, Inc. 5881 N.W. 151 Street Suite 201 Miami Lakes, Florida 33014 Contact: Creta Diehs (305) 823-7664 Provider hospital Network CO SENT Y Coventry Health Care Workers' Compensation, Inc. 4141 North Scottsdale Road Scottsdale, AZ 85251 Contact: Jennifer Cummings 615.854.0359 (Wrap) Provider Hospital Network n 5706 Benjamin Rd. Tampa, Florida 33634 Contact: Artemis Emslie 877.804.4900 Pharmacy Benefit Manager Dane Street, LLC Debbie Hill, MSN, RN, CCM, Director of Account Management 891 Centre Street • Boston, MA • 02130 951.543.1627 561.206.0659 (fax) dhill@da.nestreet.com www.daneStreet.com Peer Review Provider Page 121 AmeriSys Preferred Provider Network � .34F 111 4p" . -g 6.. ' i 8-#:<= ba.F r>»93 a 3 .r :-,:. 8.a..,. ffi.€.pa..9,. .E.::.....'[.°4.�»..�...,r..'_e=.<.__£:,...}}�.a.,.FaF..F .. <...E......».:...: �>.»•..;..,.... $...:>...§it..'...§:s.. x'r[tl yP5°� 0: &3'e.98..,>R:e .:.i:.t:....:.,.l.d.;.:, :° : 9.3,; gigC aia..< g:. 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Box 560370 Orlando, FL 32856 866.888.6724 407.893.7363 Priority Care Solutions 3802 Corporex Park Drive, Suite 100 Tampa, FL 33619 866.932.5779 877.212.9137 Page 122 One Call Care Management 841 Prudential Dr., Suite 900 800.848.1989 866.672.6807 Orchid Medical P.O. Box 560370 866.888.6724 407.893.7363 Priority Care Solutions .... 3802 Corporex Park Drive, Suite 100 Tampa, FL 33619 866.932.5779 877.212.9137 .a.d-q,doimd...F.daddhNii.flop,3,,,,,,F4d,i ;;;: . ; . ' "g5-;14-0,:itfthalh;t;Olioimoi Idii44mq.111014KigliTriltz,.N,E-NpNdnodid-dm.;idiinx.w.4.E.5.1,0. d be Otoli,dd d...,..„,,.„, -,,,t;;;;;:i-:;,:uaoi Therapy Direct PO Box 915 888.904.6776 678.298.6271 AlignNetworks 7785 Baymeadows Way, Suite 305 866.389.0211 904.998.0299 SPNet Clinical Solutions 22 Inverness Center Parkway, Suite 500 Birmingham, AL 35242 888.654.0049 205.995.1894 ' ''' ' ' 1' '' '''' ' 17114 rrtfileg'°tilf"ihIH'14414':%-"ih1H4ra '8'' :IgiLL:i4MtiLail4 ..... '" 11-q-''JG.Pth.NTr"-Ii'.226'''''4PYr.k,4ii'MP.khg:qii101P AVATBidhatrff'04iEMMMilii-PAPgiNi6RVoiniTAWN.8 ,-,,,,11-0,4644EN.$01 P.O. Box 10541 B Home Safe 5914 Jet Port Industrial Blvd. Tampa, FL, 33634 877.854.8897 877.854.8898 Orchid Medical P.O. Box 560370 866.888.6724 407.893.7363 One Call Care Management 841 Prudential Dr., Suite 900 Jacksonville, FL 32207 800.848.1989 ---"'"'"''''''""wraTlim5IVIRRY.1675,70u,P-H4g.,g,A,TiniiNogiff0:;:27M5nwmag 866.672.6807 ... 'FiNi'' P""EqPIPJ Express Doctors 2004 N. Flamingo Road 888-569-0577 888-539-0579 Dental Works USA 1408 N. Westshore Blvd. Suite 704 Tampa, FL 33607 855.443.9872 813.251.3850 Page 123 a) Confirm your company's willingness to allow the City to select and utilize a separate managed care vendor the City would like to utilize on the City's files; If it is the City of Miami's preference to utilize another vendor, USIS would be willing to work with that vendor. However, USIS prefers not to utilize a separate a managed care vendor as the USIS/AmeriSys systems and processes are wholly integrated which provides better economic outcomes for our clients. USIS has an integrated approach to claims management which involves Telephonic Case Management when required as well as integration of the cost containment components of the program. AmeriSys is the medical management division of USIS and the TCMs work with the claims adjusters. Systems are integrated allowing the sharing of case documentation between the adjuster, case -manager (when assigned) and the cost containment bill review team. AmeriSys also has contracts with Physician/Hospital networks as well as Ancillary Providers (Physical Therapy, Diagnostics, Home Health, etc.). These providers are contracted not only for significant pricing reduction but also for performance related to the speed of establishing appointments, supplying reports and other standards that impact the overall cost of the claim, including lost time days. We believe that the combination of aggressive claims handling, integration of cost containment and case management, preferred providers and strong experience dealing with public entities will positively impact the City's overall economic impact. b) Outline your company's philosophy on field medical case management versus telephonic case management; The Telephonic Nurse Case -Manager should provide Quality Care in a Cost Effective Manner focusing on early return -to -work. The purpose of Field Medical Case Management is to provide services that allow for more specific and detailed information regarding care, home situations, family dynamics and employee job site. This manner of delivery is important for establishing rapport with the injured worker and/or family, particularly with high risk or severe injury situations Telephonic Nurse Case Management will be utilized based on criteria set by the City of Miami and AmeriSys. AmeriSys recommends Field Case Management assignments if the triggers .listed below occur. We believe that Telephonic Case Management, when feasible, is the most cost effective method of providing case management services. Travel and related expenses are cost drivers for case management and should only be utilized where there is the need for face to face or direct contact such as Home Assessments, meetings with providers, etc. Page 124 Recommendation for Assignments of Field Case Management 1. All catastrophic injuries, such as, but not limited to: • Spinal cord injuries • Head injuries 2. Neck injuries (except for minor strains) • Burns of face, hands or greater than 9% of the body • Amputations • Loss of hearing • Electrical shock • Multiple fractures 3. Any potential serious back injury: • Failed back syndrome • Multiple fractures in the back • Herniated disc with radiculopathy • Positive neurological findings • Any back injury with any degree of paralysis 4. Chronic Pain Cases 5. Claims with high potential for PT rating including, but not limited to: • Fractures in or near major joints or weight -bearing body parts • Crush injuries • Hand injuries, particularly of the dominant hand 6. Injured employees with a previous history of workers' compensation injury or injuries. 7. Diff.cult pre-existing medical or social problems • Diabetes • Heart disease • Psychiatric problems • Illiteracy • Mental retardation • Alcoholism and/or chemical dependency • Morbid obesity 8. Cases not fitting an expected recovery time :frame: • Not responding to provided care • Time delays in getting appointments • irregular appointment attendance • Disagreement with the course of treatment • Questionable or experimental treatment recommendations 9. Injured employees who are approaching 60 days without returning to work. The need for Re-employment .Assessments is decided on a case -by -case basis. 10. Need for extended home care. 11. Hospital discharging requiring planing for home health and/or durable medical equipment. 12. Location or communications barriers. (Injured employees in small rural areas with limited local facilities, or with language barriers who know limited or no English) 13. All new claims with an initial reserve established of $50,000 or greater. Page 125 Recommendations for Assignments of Telephonic Nurse Case Manaement Upon receipt of the First Report of Injury, the claims adjuster reviews the nature and cause of the injury to determine the necessity for further intervention. At the direction of the claims adjuster (per client protocols), a referral for case management is initiated. Serious injuries will be assigned for telephonic case management immediately. The goal of early intervention is to provide aggressive case management with a focus on early return to work. The medical case -manager within the first 24 hours will make contact with the injured worker and complete an assessment of the initial medical treatment; evaluation of the treatment plan and assess the need for continued medical case management. If specific tasks need to be completed to assist the claims adjuster with the handling of the file, these can also be assigned. Telephonic case management is the systematic evaluation of medical services, procedures, facilities for medical necessity, appropriateness and efficiency. This promotes optimal patient outcomes, reduce period of disability and assure high quality of care while controlling costs. A nurse facilitates the medical activity on a file with the ability to individualize the plan of care and coordinate early return -to -work strategy with the employer and medical provider. The functions included • Coordination and referral to network medical providers • Coordination of the treatment plan with the provider • Working with the provider to establish functional abilities and conditional release to return to work • Discussion with the injured worker to clarify the worker's understanding of the diagnosis and treatment plan • Monitor the treatment compliance of the injured employee • Identify and assist in the resolution of problems with compliance to the treatment plan • Provide regular reports to the claims handler to assist them in the management of the claim • Recommend on -site case management and vocational services when needed • Work with the employer to identify a medically appropriate job Coordination and referral to network medical providers allows for the best network penetration. The channeling of the network providers will allow for the best network discounts. Page 126 The Telephonic Case -Manager acts as the center point of contact ensuring delivery and communication to all approved providers of PBM and appropriate parties, forwarding appropriate issues to the utilization review department as necessary and reporting outcomes to the AmeriSys Quality Assurance Committee. Diag,ostics' Physical T. het?. py; Case Management Injured Em:I.Yee Medical Case -Man ages;;`. Case Management; Plan s- Assess Needs':' Qev lop Plan Implement Plan Items Monitor Progress Evaluate Outcomes Re- Evaluate Plan Transrcr. #ion &.. Languages ATP [(Attending •-" ?Treating ` ;Physiiiah), UtiIization:Review ` PraspecR a (Pr Cart) Concurrent 9:Refrospecfive J.; r Vocational aid Field Case r= Management We understand that it is imperative for both employee and customer satisfaction; we communicate promptly, which includes facilitating care and appointments properly. Prompt, accurate and complete communications are performance standards and measurements for our case management team. Page 127 c) Provide a sample of quarterly reports detailing savings realized as a result of your company's cost containment/medical management programs; Performance Report Report Outcomes for Fiscal 41' Quarter: ApeUl —June 2,015 fi>ace6 Year End; July 2414 — June 2015 AntrrdSvs' fi%F%C 45 rc ara A tut 00,0 ErSSW7!�t a;Bx db8 Y9d•Bi i C� AteM>tea4 te:Rt axpm:xsC totrkm rheruy 0.01, ra sont00 weanwru hsar.:a tet.vatants 4aF € Q&E9, 8,4,k`l aa`Maaa, 6Nvb4lia$ 5rd t 000/ wah Mifmiwg b° Ppada»a .141.04,N .iura:. t aea exmgdatn .. dh khkti i Y s¢aa.avta saa5 En s:a. E�a�xPda�caatrs�. t..was a tour 01 OM 00x..0lad 00. tart :. 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M.4% 112 ktlga84l� FE75,Y9II3_& UAW,* f�.ir4 mb 4IQ5�C{N! �i.i 4Sf.Y1 04 ��• _ Sd.9ax.�a *..5.3 eq Ft3'?,394064 }LT3.937.1TF ak PxF 4.8SP Lk Sip Z.317 giAt/Vs S°6iS,itil,k+ FbCni�9'4E ,S,:A.W.6 ®,64A 6%26. . R9 ,i4 0 �-.P.-•�_4e.d. .,45 .3 3+Ft,.d SE ��j•�SAi ... dL6 0�7;mt m e 1.01U% 2:si5y1 i F9'-0ks :4'2'!2,'155,5 H13,6£45.,.,,,., Silr•Ar; JASm 1-c9'b �2[&S.r,r&.v97 fi3.Gx Z.Y, " $Y$4'3F„f.§ q.$4�•Y,�••Y $I°. k35FAal 3 YaFaafe LOCO'04S €" .ne<A0. 'OMR,9 U.B.t4 T9 iU&of l5,2i tw,t�m Page 130 d) Outline any association your company may have with a managed care organization or PPO including the network your company utilize; ArneriSys is the Medical Management division of USIS and is contracted with DimensionComp for utilization of the Hospital and Physician components of medical services and Coventry PPO as the secondary or "wrap" network. We are direct -contracted with providers for Ancillary (DME, Physical Therapy, Diagnostics, Transportation, Translations and Home Health) for preferred service, as well as better pricing. Providers from Dimensions as well as our direct -contracted providers are readily accessible in your area. e) Provide references of clients using these associated medical management services indicating detail of services purchased; Client - Bay County Board of County Commissioners Type of Entity Public Client contact person Eve Tooley Phone number 850.248.8231 Email address etooley@baycountyfl.gov WC Claims TPA Medical Bill Review Description of work Total dollar value $15,000+ annually Dates covering the term of the contract " Established 1993 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc: RTW Client Broward County 13OCC Type of Entity Public Client contact person Jeff O'Connor Phone number 954.357.7230 Email address J JCOCONNOR a}broward.org Description of work Network Access/Bil1 Review/Intake Total dollar value $50,000+ annually Dates covering the term of the Contract Established 2007 and remains active Prime; contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in. disability, safety program, light duty / return - to -work program, etc, Page 131 Client City of Cocoa Type of Entity Public Client contact person John Titkanich Phone number 321.433.8686 Email address jtitkanich@cocoafl.org WC Claims TPA, Medical Bill Review Description of work Total dollar value $50,000+annually Dates covering the term of the contract Established 2009 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, . light duty / return - to -work program, etc. RTW Client City of Jacksonville Type of Entity Public Client contact person Twane Duckworth Phone number 904.630.2777 Email address twaned cr coj.net Description of work Network Access, Medical Bill Review and Medical Only Claims Handling on an as needed basis Total dollar value $275,000+ annually Dates covering the term of the contract Established 2013 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program,light duty / return - to -work program, etc. Client Orange County Pubic Schools Type of Entity Public Client contact person Regina Cochrane Phone number 407.31.7.3918 Email address . ... regina.cochrane(ajocps.net Description of work : WC Claims TPA, Bill Review and Medical Management Total dollar value $400,000+ annually Dates covering the term of the contract Established 1996 and remains active Prime contractor. or subcontractor Prime Contractor Indicate whether - Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty, Loss Control Page 132 Client Palm Beach County Sheriff's Office Type of .Entity Public Client contact person Hilda Gonzalez Phone number 561.688.3550 Email address gonzalezH@pbso.org Description of work . WC Claims TPA, Bill Review, Medical Total dollar value $750,000+ annually Dates covering the tetiii of the contract Established 2000 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Client State of Florida (DRM) Type of Entity Public Client contact person Candy Janes Phone number 850.413.4827 Email address Candy.Janes@rnyfloridacfo.com Description of work . Intake/Triage Medical Management Total dollar value $9,000,000+ Annually Dates covering the term of the contract Established 2014 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted : in disability, safety program, light duty / return - to -work program, etc. Client ... Volusia County Public Schools Type of Entity Public Client contact person Sandra Higginbotham Phone number 386.734.7190 Email address skhiggincr,volusia.k12.fi.us Description of work WC Claims TPA, Bill Review, Medical Total dollar value $250,000+ Annually Dates covering the term of the contract Established 2007 andremains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc: RTW, Light Duty Page [33 Client Preferred Governmental Insurance Trust Type of Entity Public Client contact person Ann Hansen Phone number . 321.832.1.510 Email address ahansen@publicrisk.com Description of work Medical Bill Review, Medical Management (USIS /AtneriSys) Liability and Work Comp TPA (PGCS) Total dollar value Confidential Dates covering the term of the contract Established 1999 and remains active Prirne contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Cornp TPA Indicate whether Proposer assisted in disability, safety. program, light duty i return -to -work program, etc. Client Brevard County BOCC Type of Entity Public Client contact person Julie Jones Phone number 321.637.5446 Email address Julie.JonesAbrevardcounty.us Description of work Medical Bill Review, Medical Management (USIS /AxneriSys) Liability and Work Comp TPA (PGCS) Total dollar value $250,000+ annually Dates covering the term of the contract Established 2003 and remains active Prime contractor orsubcontractor, Subcontractor for Medical Bill Review, Medical Managemnent Prime Contractor for Liability and Work Cornp TPA Indicate whether Proposer assisted in disability, safety program, light duty / return -to -work program, etc. Client Charlotte County Type of Entity Public Client contact person Raymond Carter Phone number 941.743.1334 Email address Raymond.Carter(c4charlottecountyfl.gov Medical Bill Review, Medical Management (USIS /AneruSys) Liability and Work Comp TPA (PGCS) Description of work Total dollar value $40,000+ annually Dates covering the term of the contract Established 2010 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Comp Indicate whether Proposer assisted in. disability, safety • program, light duty i return -to -work program., etc. Page I34 Client City of Delay Beach Type of Entity Public Client contact person Eddie DeMicco Phone number 561.243.7150 Email address demicco@mydelraybeach.com Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Description of work Total dollar value $50,000+ annually Dates covering the termof the contract Established 2013 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Cornp Indicate .whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client Leon County BOCC Type of Entity Public Client contact person Karen Melton Phone number 850.606.5120 Email address Meltonk(rtleoncountyfl.gov Description of work Medical Bill Review, Medical Management (USIS /AmeriSys) Liability and Work Comp TPA (PGCS) Total dollar value $50,000+ annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Subcontractor for Medical Bill Review, Medical Management Prime Contractor for Liability and Work Cornp Indicate: whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client Preferred Governmental Claims Services Type of Entity . Private Client contact person Ken Picton Phone number : 800.237.6617 Email address kpictongpgcs-tpa.com • Description of work Medical Management, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2005 and remains active Prime contractor or subcontractor Prime Contractor for Medical Bill Review and Medical Management Indicate whether Proposer assisted . in disability, safety program, light duty / return - to -work program, ete, Page I35 Client Ferman Motor Car Company Type of Entity Private Client contact person Webb Bond Phone number 831.251.2765 Email address. webb.bond(ferman.com Description ofwork WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer . assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Client Halifax Health Type of Entity Private Client contact person Terry Martin Phone number 386.254.4048 Email address Terry.martin(rr7,halifax. org Description of wort WC Claims TPA, Bill Review Total dollar value $75,000+ Annually Dates covering the term of the contract _ Established 2012 and remains active Prime contractor or subcontractor Prime Contractor Indicate' whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc, RTW, Light Duty Client Health First, Inc. Type of Entity Private Client contact person Nancy Johnson Phone nurnber - 321.868.7248 Email address Nancy .jOl111SOn@llt;alth-frrSt. Q1'g WC Claims TPA, Bill Review Description of work ' Total dollar value $125,000+ Annually Dates covering the tearer of the contract Established raid 1980's and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted ': in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Page 136 Client Orlando Health Type of Entity Private Client contact person Christy Pearson Phone number 321, 841.6104 Email address christy.pearson cr,orhs.org Description of work WC Claims TPA, Bill Review Total dollar value $175,000+ Annually Dates covering the term of the contract Established 1996 and remains active Prime contractor or subcontractor Prune Contractor Indicate whether Proposer assisted in disability, safety program., light duty / return - to. work program, etc. RTW, Light Duty Client Parrish Medical Center Type of Entity Private Client contact person Roberta Chaildin Phone number 321.268.6333 Email address.' roberta.chaildin(c@parrishmed.com Description of work WC Claims TPA, Bill Review Total dollar value $20,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program; etc. RTW, Light Duty Client : Ring Power Corporation Type of Entity Private Client contact person _ Cindy Acosta Phone number 904.737.7730 Email; address ` Cindy.Acosta(airingpower.com Description of work WC Claims TPA, Bill Review Total dollar value .:.... $40,000+ Annually Dates covering the term of the contract Established 2011 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer . assisted in disability, safety program, light duty / return - to -work program, etc. RTW, Light Duty Page 137 Client FHM Insurance Company Type of Entity Private Client contact person Jack Lemine Phone number . 800.329.4340 Email address jleniine{atirnic.com Description of work WC Claims TPA, Bill Review, Medical Total dollar value Confidential Dates covering the term ofthe contract Established 2003 and remains active Primecontractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Client . Florida. Citrus, Business Industries Fund Type of Entity Private Client contact person Jim Emerson Phone number' 863.660.5943 Email address ':' jirn.ennerson48 cr,gnlail.com Description of work WC Claims TPA, Bill Review, Medical Total dollar vaIue Confidential Dates covering the term of the contract Established 2002 and remains open Prime contractor or subcontractor :. Prime Contractor Indicate whether Proposer assisted ` in disability, safety program, light duty / return - to -work program, etc: Client Florida Rural Electric Self Insurers Fund Type of Entity :: Private Client contact person William Willingham Phone number `: 850.877.6166 Email address Bill(caECA.Corn Description of work WC Claims TPA, Bill Review, Medical Total dollar value Confidential Dates covering the term of the contract Established 2002 and remains active Prime contractor or subcontractor Prime Contractor Indicate whether Proposer _ assisted, . in disability, safety program, light duty / return - to -work program, etc. Page 138 Client Florida Workers' Compensation Insurance Guaranty Association Type of Entity Private Client contact person . Sandra Robinson Phone number 850.386.9200 Email address srobinsonnagfgroup.org Description of work WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 1998 and remains active Prune contractor or subcontractor Prime Contractor Indicate whether Proposer assisted in disability, safety program, light duty / return - to -work program, etc. Run off claims Client Sugar Cane Growers Cooperative of Florida Type of Entity Private Client contact person Carmen Abercrombi Phone number 561.996.4751 Email. address cabercrornbii2l gc.org Description of work ':: WC Claims TPA, Bill Review Total dollar value Confidential Dates covering the term of the contract Established 2010 and remains active Prime contractor or subcontractor Prime Contractor Indicate . whether Proposer . assisted . in disability, safety program, light duty / return - to -work program, etc. . f) Outline the process for nominating physician/facilities to your company's provider networks; USIS/AmeriSys employs a Director of Provider Services who coordinates provider nominations with DimensionCornp. She will work closely with Risk Management, DirnensionComp, the adjuster and the Telephonic Case -Manager to meet the needs of the City of Miami. DimensionComp has a formal nomination process in place and encourages/welcomes client provider nominations for inclusion into the network. Dim.ensionComp may receive nominations via on-line website, e-mail and/or fax. When its client services team receives an eligible provider nomination, the provider is logged and forwarded to the network development team to begin the contracting process. DimensionCornp will make every effort to obtain a contract with the nominated provider. Dimension Health providers understand and respond to patients' concerns about being able to receive excellent medical care promptly and efficiently. At Dimension Health quality and access are emphasized. Dimension's local presence means that questions from insurers, employers and covered employees can often be answered on the spot. Page i39 g) Describe your company's attributes for physicians within your Outcome Based Network, if applicable; While we measure outcomes of our physicians, we do not have a network based solely on outcomes. The attributes we look for in the physicians that treat our injured employees are as follows. First that they are familiar with the Florida Worker's Comp requirements for physicians treating injured employees within the state. We ensure through our network that they are credentialed andcontracted below fee schedule to allow our customers savings. AmeriSys Director of Provider Services monitors the Ievel of quality service and care being provided through multiple quality initiatives, including but not limited to satisfactions surveys. We also provide direct education to providers when there are industry changes to ensure the providers are current with standards of care. h) Provide medical cost savings as a percentage for the State of Florida; Calendar year 2015: AmeriSys total Medical Cost Savings including Fee Schedule savings is 53.5%. AmeriSys total Medical Cost Savings below fee schedule is 13.1%. i) Indicate if savings accomplished by use of outside medical vendor. N/A 4. Provide the following information regarding your company's medical bill review offerings: a) Provide benchmarking data pertaining to your company's book of business bill review average savings per bill, per claim and return on investment; AmeriSys customizes benchmarking for each client based on the specific network, geographic location and business rules the client sets. b) Outline how duplicate bills will be charged; and No charges for duplicates c) Identify any states in which your company use, a third party vendor for medical bill review services, and provide any unique pricing arrangements. AmeriSys does not use a third party vendor for medical bill review services with the exception of Dane Street for Peer Review services. Page 140 7. RISK MANAGEMENT INFORMATION SYSTEMS Google Chrome -compatible or Firefox-compatible claims management system platform providing real-time interactive communication and claims management between nurses, adjusters, the City, and its business units. The City will determine the number of accesses by level of use dependent on your company's system capabilities in coordination with your company during this RFP process. www.USIS.iNet.com L USISiNet Portal Features a. Reports — 40+ standard reports i. Check Registers (Payments) 1. Full Detail (By Individual Check/Transaction) 2. Totals by Year 3. Totals by Unit Employer's Reports (Claim Payment, Reserve, Incurred Totals) 1. Full Detail (By Claim with Claim Details) 2. Totals by Year 3. Totals by Unit b. Intera.ctive Grids (Filter, Sort, Colunnr Customization, Export) i. Claims ii. Reserves iii, Payments iv. Notes v. Claims Totals by department, unit, location c. Complete Loss Control Module d. Claimant Module e. Security i. Ability to Customize what claims each user can see ii. Ability to Customize what features each user can use iii. Ability to Exclude specific claims or features on claims where User is also Claimant f. Report Export Types Supported i. Excel (XLS, XLSX, CSV ) ii. Word (HTML, MHT, RTF, Text ) iii. Rendered ( PDF, Image, XPS ) 2. Screearshots (See Below) 3. Customization a. Customizable Dashboards i, Choose the Dashboard Tiles that are right for you Customize Dashboard Tile Size and Position iii. Customize Settings/Filters to your needs (e.g. New Claim (Days), Recent Note (Days) ) iv. Additional New Custom Dashboard Tiles can also be created on Request b. Customizable Security i. For each Feature and per User ii. For Users who are also Claimants / Claimants in Litigation (e.g. removing notes from "my claims") Page 141 c. Branding 1• Custom "/Welcome/NC" Login/Landing page with Branding ii. Client Logo on Every Page d. Grids i• Add and .Remove columns ii. Filter by any column iii. Sort by any column iv. Add field v. Move field e. Reports i• New Custom Reports can be created on Request 4. System Requirements a. All Major Systems Supported: i• Desktop/Laptop (Windows, Apple, Linux, . • . ) ii. Tablet (Windows, iOS, Android, ... ) iii. Mobile Phone (Windows, iOS, Android, ...) * * Some Features may be more convenient on a larger screen, such as a Desktop, Laptop, or Tablet b. All Major Browsers Supported (Latest Recommended) Please reference Attachment 4 - USTSINet & AmeriSysiNet. Please respond in detail to the following: 1. Confirm your company's ability to establish an interface with a RMIS vendor of the City's choice with no fee to implement. USES has the ability of establishing an interface with a RMIS of the City's choice with no fee to implement. 2. Confirm that your company will provide a daily feed to a RMIS vendor of the City's choice at no cost. USIS is ready to implement a daily feed with the City at no cost. 3. Identify the access your company provides to the database: Internet, 1-800 or local call access. An absence of any one of these could cause the City to incur unreasonable costs for long distance calls for access. Please describe alternatives to direct long distance charges if applicable. USIS will provide a 1-800 number for the City of Miami to contact USIS. The USIS web portal can be accessed from any web browser. 4. State your company's current internal requirements for claim files updates. Discuss how often claims files are updated for: a) Adjuster/nurse notes Adjusters update the claim notes every 2 weeks if the injured worker is missing time, if the injured has returned to work and continues to follow up with medical care the claim notes are updated upon receipt of medical reports. Nurses update the case notes when medical notes are received with medical treatment plan and work status. b) Financial information Financials are reviewed on each diary date for accuracy. They are also reviewed upon any medical/legal changes that occur whether it be an increase or decrease. c) Resolution plans Adjusters input an action plan each diary date. The plan should include indemnity medical and legal updates. The notes also include any recommendations by the adjuster regarding settlement potential and or recommendations regarding the anticipated exposure. Page 142 5. Confirm that your company's system has scanning capability for all mail/correspondence pertaining to the claim file, and if so, whether the images can be accessed real time by the client or if there is a delay. Detail any delay. All mail/correspondence/bills are scanned, on the same clay of receipt, to the claim file. The images are scanned into a .pdf format and are accessible to the client via the USISiNet web portal real time. 6. Outline your company's system abilities to report on each specific claim line as opposed to gross reporting on the incident. USISiNet has a reports section where existing reports can be found and new reports can be added to meet the City's needs. Currently, the detail Employer's report would report on each specific claim line. Additionally, the portal offers interactive claim grids that allows for detail on a claim line level that can also be exported to Excel and be used a report. 4,3 L» aaaa; s 0i "lAtkr i uE iT3. .t:f 0.xGµeF1?nsV4?A^ S:Um � . : iSa4,31: �[3lasv i3 ::ipHR va 19 ES;d46:UF y;'l P;At2& :'d5es gFaRyQ 9flf.{E BrY WP G &ts''.XISS rin dqa 1?kd i�:9sfl4 `iA' -:91@ na : u:9Gxrcc4¢.Kga;;q c..?n - 33;33 14,34 3431; arwitw c ^tC7.' d hR 2 a entn :.4 &SVsaaaa Ida; 4" && .. iSY A::?5A<GUL%i'd11wFd:IF.�C! 9 lOIW' ,Ow i">rt. 0333 .f6R3eGirid C fi;+a':it74F2 kAY1 kOLa 4EFo- ir5Tti.2A34 - YFW334 'a <91- l9 S rasa L;w nW,iaaa;slai;O1`44; C Wa435 ut iFSa' raga 5f1+[Y1ka iSai .5 �`,3 -.17 'dt hH 35«b 6 _ aMrr ' aNx- 3 f4'33Cdtt C.t9(MABt Nhly' L' 3g;4;3-3 .5. - X3!B _ tab3 5(i41 R';a33Ra; a'ihn arBB xtl VYAhSfAC4}KiJ.?5§'4 F °dZr.AYd xi .t sa asEe. .'+/i?? + 34;a;434 an; 34: a; „V 31aEee3 saS ':.?'� sFL3R : Ydf3 jNrf KaS : n^49"93a S:Prn:nn Slak 15 ;§Sa 1 k3Ek: 33 lebn Om 4411033AA'341,3193,434t4C h"4.1.790.5 '., 381W 13's4a S.B&'.?')a 1.1.+F14,1iS4 .3,1G 43 aE &A .n.:rauerv} :a s (ss« om �.aac c c�ir:aFa _ r = ;.a ' 1>ariff s _ C+'�F1f fa''PrME'Y6 if3i' � :..pp. 11.9 : ,>.:xitlifKxl;:'i SIS'XEd Wm s -bba :Armen rma 43834e44m i. fi?i:CtUL1 M3 G©L8 1d#"P SI1St;L#9 °;'sP1d&ii srga ?3 iC P.1 - Acwa3 :.ofw I o No L.igr'M§+G. AmrTio4 C %1/tBf.X'34 lT Yfgt sT.?o:4 '. Cn9h ad ik`Fa' aax 48 3,44333.53$4X %i 5,'a0O.4 HAn Rt 5R%LYnF b"�Yu«�v ss: C 1,': 1tlFa 'pgt3 : YN.s, k3W 5f:!S?EF - +'t5&i:'R€d an; 3! Y :,3Kaa E4 M313d,3Y: -f..138SdifY a 'la .kSt�`. r'I sx4: #xa. C N '�EE8 h1f3 a"JiR• - ffdVRt _ afP a �94f3 .,m..4 7. State your company's policy on the ability of any outside entity to enter notes into your company's system and describe how this is managed. The ability for an outside entity to enter notes in the system is decided during the implementation process and very careful permissions would be applied to each user. A notification process is in place to allow the claim staff of a new note and for review purposes. 8. Outline how notes are categorized in your company's system (i.e. by type or subject] and your company's ability to select, or identify those notes pertaining to a particular category for review). Please explain the difference, if any, between Client access to notes vs. Adjuster access notes. Case Notes are categorized by a Case note type and also a subject. They can be grouped, and reported by any of the groupings available. The web portal grid allows to easy search of a particular set of notes via the advanced search feature. The clients have access via the web portal to the same notes the adjusters do. Page 143 9. Confirm that nurse's notes are included in the same system as the adjuster notes within your company's system. Confirm if client has access to all nurse notes, and if so, whether or not the notes are readable in real time, or if there is a delay. Detail any delay. Nurse notes are included in the same system as the adjuster's notes. Similar to the adjusters notes, they are made available to clients in real-time, however, sensitive notes containing confidential / medical information will not be made available on the web portal. 10. Confirm that your company's system incorporates e-mail for easy communication between users, permitting an email to be launched from the claim pages. US]SiNet allows the client to launch an email window from the claims page of the web portal. 11. Explain controls and requirements around version updates of software and any fees associated with them. Our RIVIIS ERIC system is maintained by ERIC Systems and version updates of software are maintained by the company. Once received we fully test it prior to implementation. Our USISiNet web portal is designed by an internal team of developers and also fully tested and documented by different developers prior to being released to production. Neither system have fees associated with them to the client. 12. Confirm your company's agreement for providing tapes or EDI transfer of data, loss runs, weekly transaction registers, claims updates, and 1099 reports on a timely basis and detail any additional charge. USIS confirms and agrees to provide tapes or EDI transfer of data, loss runs, weekly transaction registers, claims updates, and 1099 reports on a timely basis and detail any additional charge. 13. Confirm that your company's system allows for entry, tracking and reporting of: a. Claims data by Client specific coding (locations, departments, divisions, Employee Numbers, etc); Yes, USISiNet does allow for claims data by Client specific Coding. b. Policy Information and whether that information can be attached to the claim; and Yes, and yes, the policy information can be attached to the claim. c. Exposures. Yes 14. Confirm your company's ability for the City to manage location changes within the system (i.e. closing of facilities and/or adding new locations). At the eun-ent time, the ability to manage location changes is an internal process, however, we have the ability of automating the process via a data interface as we do with many of our clients. 15. Describe systems standard reporting capabilities. Please describe ad -hoc and custom reporting as well as the Clients ability to create, modify, and run reports in your company's system. Please provide examples of ad -hoc reports and describe the ability to run the following: The web portal contains several reports that be directly accessed by the client. For existing reports, parameters are available to allow the user to customize the end result. These reports cane be exported in various different formats. Reports can also be scheduled for delivery. USIS has 8 on staff and on -site programmers who will be able to build ad hoc reports and/or data extracts that you desire in a reasonable time frame. All custom reports can be made available on the web portal for future use by the City. If you have a standard monthly or quarterly spreadsheet that Page 144 monopolizes your time every month -end or quarter -end, there is likely a process that can be built for it to be downloadable to your desktop after any month -end. We host and control source code and all of the data files that make up the workers' compensation application. Reports may be downloaded in Excel and can be customized upon request. The number of data fields available depends on the data download need there is no limitation to the number of fields. u 5 I:5#1.t ET Schedule Repo Par Teter 'Enter &mum Number t [ €fit t t i y 3titts er cat leis ' . k %ir A 24fb iSa i fvT r itrrAt—cjS Enter Fla 1 Y D. 'tr r g? YYYY3 Gieq Loa C'A Page 145 The web portal offers powerful dashboards that have a number of ways for the users to customize it based on their needs. Below is an example of the dashboard also displaying how easy it is to customize. Claim Status Trend Ma,(i€;;^ tog TVII tHalwa The web portal also contains powerful, detailed, interactive grids that can be customized, filtered, sorted, and exported at the user's convenience. Preferred searches can also be saved on that particular user's profile for future use. Ckthn Status. Trend t�'nt3';r i,;:sx� r,Riv�Bv :.',M ':'a4'=. ..'4 �,. 3a CC,".4 p:RAG .12; sm.............. 2 tT 3 Eim°g'E,th4. Edit Tile - i i Status Trend (6 89uus5 S19dUv TA4 13/197s 22 9932 - 3432 idE4 19E3F, 29as _r/g„ygg99 7i22/9999 9t'e°4i8 & 4f1'WOW ., � MHur�in f isryn4E,'1'.�IC Page 147 The advanced filtering page is excellent for power users who are researching for specific analytical data. Various Total Grids are also available for quick management use. Here is an example. .rant ilt r 05/01M6C1 .r' i7,>i VV)i6 Ents.rprENE, Et9 Page 148 a. Run triangles by policy years; USIS currently provides Triangle reports. Below is an example. Lass Triangiee Repari • TQtaI Incurred FL.AR10A Apf 8egemiag 04.01.2O0e Summaries As O t241)74075 nonoti Ccwsai 12 Months 24 !tenths 36 Mo tlhn At£ kt 84 3imaim 72 !Rased. 'd1. Months IES k€psolh¢ Jan 1,:2006- Dec 31,7J1Ek? ••••,•ios 507336 .2,542464 �WV661,074 .(24A,004g (3427,721) t36" Yoso it.939! ,rm 1, TOp7-• Ckot Sl, 4E0 Rib 18.742138 413,623 242644 (14/1,62i17 (4,112y d1 1 co 13) 33.05i .Eon 1,:206.Dee 51,2465 $23 17;101,48.1 134,485 (96,8561 EISZIlid 134363. 381,24 248,711 0,664 Jan 1,2+ O•Doo31.MO 666 1.6`,059,164 07,233) 651,302 25S,757 211,004 371„833 134836 ,Ion 1,:11(1- Ono a1,26'PQ 6F5 24., f1.260,914 654d27 336:969 586350 .251.473 Jan 1.1011-€4431,2011 t,110 k8,343,406 013,0) 032,076 496.13O t"8".606) Jon 4;20a2s.04431,2$113 -1022,a5e, 0 1,633,i30 wan 61,307 Jut 1, M73, Vne 31, 31113 24142 3u,1193,927 '1,887,%,$ 701,827 • 1, 2014 Alec 31, 2U14 2,p@e 36,087,i38 -2t13,773 30 1,'2n15•Poo 3%2016 f,682 25,,0322547 C3aii116 11,043 erfterfffke Total b. Loss stratification; USIS can provide Loss Stratification reports from its RNIIS system. Tot'al 14,466066 tY„2sQ.546 $8,66,1,655 vuston 21,10.556 10,658,032 25,309.91s 30,493,63E 35,26.8.- 2 2603240 Page 149 c. Ability to create graphs within a report; Reports available on the web portal, USISiNet, do and can contain graphs. �E tiSam :L1 Claim S'M us tt RE � eycoW Page 150 d. Client's ability to create scorecard and dashboards; The web portal offers powerful dashboards that have a number of ways for the users to customize it based on their needs. Below is an example of the dashboard also displaying how easy it is to customize. Olwao.t. Daft Offiva 3wMetpeler0cea e. Automated import into Excel, Access, Microsoft Word etc.; As show below, reports can be exported in several formats. __..---, ® �`� o CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02/18/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Aon Ri sk Services Northeast, Inc. New York NY Office One Liberty Plaza 165 Broadway, Suite 3201 New York NY 10006 USA CONTACT NAME: E (A/CN No. Ext): (866) 283-7122 FAX No ): (800) 363-0105 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED USIS 6015 Resource Lane Lakewood Ranch FL 34202 USA INSURER A: Great American E & 5 Insurance Company 37532 INSURER B: Chubb Indemnity Insurance Co. 12777 INSURER C: Federal Insurance Company 20281 INSURER D: Great Northern Insurance Co. 20303 INSURER E: INSURER F: _� COVERAGES CERTIFICATE NUMBER: 570110902972 REVI3IOPf'IQUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURE IIIED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHE' I I.. ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCR' I EREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID: Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY P D YYY) LIMITS D X COMMERCIAL GENERAL LIABILITY 36045110 05/O1/202'.= 02S EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $1,000,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $100,000 GENII AGGREGATE LIMIT APPLIES PER: *(</ GENERAL AGGREGATE $2,000,000 POLICY ❑ PRO- JECT LOC O PRODUCTS - COMP/OPAGG $2,000,000 OTHER: ^ C C AUTOMOBILE LIABILITY (24)7364-18-57 / 05/01/2024 05/01/2025 COMBINED SINGLE LIMIT (Ea accident) $1, 000, 000 X ANY AUTO BODILY INJURY ( Per person) OWNED SCHEDULED A NON -OWNED AUTOS ONLY PROPERTY DAMAGE (Per accident) ��,0 C X UMBRELLA LIAB X OCCUR 56 05/01/2024 05/01/2025 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS -MADE ��� AGGREGATE $10,000,000 X DED RETENTION O Deductible $10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 2571763736 05/01/2024 05/01/2025 x PER STATUTE OTH- ER Y/ N ANY PROPRIETOR / PARTNER / EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $1,000,000 If Es, describe under DESCRIPTION DOF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 A E&O - Professional Liabi1i - Primary TER5325748 05/01/2024 05/01/2025 Limit Deductible $10,000,000 $150,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 01, Additional Remarks Schedule, may be attached if more space is required) City of Miami is added as Additional Insured as respects the General Liability as required by written contract. General Liability is primary and non-contributory to other insurance available to the certificate holder, but only to the extent required by written contract with the insured. CERTIFICATE HOLDER CANCELLATION Holder Identifier : 570110902972 Certificate No Si City of Miami 444 SW 2nd Ave. Miami FL 33130 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE eir ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From: Gomez Jr., Francisco (Frank) To: Gandarilla. Aimee Cc: Quevedo, Terry; Aviles, Yesenia Subject: RE: COI USIS Date: Thursday, February 20, 2025 10:15:52 AM Attachments: image002.pnq image003.pnq Hello Aimee, The COI is adequate. `r) 41/ Frank Gomez, PIAM, CPI I V (/ Property & Casualty Manager 1/ City of Miami Risk Management (�iO 14 N.E. lst Avenue end Floor �./ Miami, Florida 33132 (3o5) 416-1740 Office fgomez@Q (3o5) 416-176o Fax miamigov.com </ 0 Q Q Thanks, "Serving, Enhancing, and Transforming our Community" From: Gandarilla, Aimee <AGandarilla@miamigov.com> Sent: Thursday, February 20, 2025 10:14 AM To: Gomez Jr., Francisco (Frank) <FGomez@miamigov.com> Cc: Quevedo, Terry <TQuevedo@miamigov.com>; Aviles, Yesenia <YAviles@miamigov.com> Olivera, Rosemary From: Gandarilla, Aimee Sent: Wednesday, April 9, 2025 11:14 AM To: Hannon, Todd Cc: Olivera, Rosemary; Brown, Sadie; Reinike-Heinemann, Evelyn; Fossler, Thomas; Roberts, Frankeetha Subject: Executed Amendment USIS Inc. RFP 605386 (matter 24-394) Attachments: Amendment USIS Inc. RFP 605386 (matter 24-394).pdf Good morning Todd, Please find attached the fully executed copy of an agreement from DocuSign that will be considered an original agreement for your records. Evelyn/Frankeetha: Please close Matter 24-394. Thank you, Aimee) candartiltai Procurement Assistant City of Miami Procurement Department 444 SW 2nd Avenue, 6thfloor, Miami, FL 33130 P (305) 416-1906 F (305) 400-5073 E adandarilla@miami.gov "Serving, Enhancing, and Transforming our Community" i