CONTRACT 3882D CLOSEDAgreement No. 3882D
FOURTH AMENDMENT TO
AGREEMENT NO. 3882 BETWEEN
THE CITY OF EL SEGUNDO AND
YORK RISK SERVICES GROUP, INC.
THIS 4TH AMENDMENT ( "Amendment ") is made and entered into this 31 st day of December,
2014, by and between the CITY OF EL SEGUNDO, a general law city and municipal corporation
existing under the laws of California ( "CITY "), and YORK RISK SERVICES GROUP, INC.
incorporated under the laws of the State of New York and qualified to do business in the State of
California ( "CONTRACTOR").
Pursuant to Section 8 of Agreement No. 3882 ( "Agreement "), entered into the 1St day of
January, 2009, the term of the agreement is extended until December 31, 2015.
2. Section 1(C) shall be revised to provide that the annual fee for the period January 1, 2015
through December 31, 2015 shall be $97,749.00.
3. This Amendment may be executed in any number of counterparts, each of which will be an
original, but all of which together constitute one instrument executed on the same date.
4. Except as modified by this Amendment, all other terms and conditions, including all
Exhibits, of Agreement No. 3882 remain the same.
IN WITNESS WHEREOF the parties hereto have executed this contract as dated below
with the effective date hereinabove written.
CITY OF
Greg
City(
SEGUNDO
YORK RISK SERVICES GROUP, INC.
..
Jody
Senior Vice President
ATTEST..,
f
Taxpayer ID No. 13- 1963636
I
Ci Clerk- "
"
Agreement No. 3882D
Attachment A
§0098 0 rvtces CI rims A�minf,sba�lar►
The City of El Segundo is interested In obtalnIng a TPA who MI bo able to
favorably respond to the f0ll0in0 p+erforrrra activas and be
contractually 00mrritted to carrrplY 'Mtlr the follOYA09, lout not limited to,
perforrasne -e standards"
9.
Q422120" Each examiner shall have ,an average caseload not to
exceed 150 open indemnity clelaw. Open Indornnity (Aojrrw Irrcltado
future medlcal claims. Each dal aaaletant shall brave a caseload not
to oxceed 150 open medical only claims, The wpeni r shall have a
caseload not to excaed 30 open Indernnity olellms, The TINA shall
provide a aornputer generated monthly caseload report to the City of El
Segundo's Director of l umarr Resources for all omminers handing El
Segundo claims,
2. FQM: The TPA shall provide all forms nooessary for the pro ssing of
barreitts Or clalM8 Information Including the Employees Repod of injury,
OWC - Form-1- Return' tc W&k -Sli s, vouch j -mss, and ode_ .
r
related forms. These forms shall be provided alectrorrlr011y If requested,
The cost of providing these for n$ shall be included VAthirr the contract
Price,
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Agreement No. 3882D
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The exarr4nar will proAde on -site file reviews guartedy unless ctherMas
requested. Other periodic on -site file mfewr; will lie scheduled based
-- -- upon -ths -needs of-the City, of El Segundo, _..,. _.
Emoloveg w
employee s work, err Or Personal contact
be r, employee within one (1) working day of
claim, receipt of noflm of Suoh contact
least necessary, but at Me retums to Wok
ch contact Wth the emPloyea shall be documented In Me computer
notepad,
Return phone mils to employees will be awornplMod uAwn orre (1)
working day.
All correspondence from employees will be responded to within five (a)
days of receipt,
Probable Oost of each claim, All reserve vategodesshall be reviewed
on a regular bas)a but at least every ninety (90) days. Such review
shall Include an explanation for
A clefms assistant shell have auttrority to establish reserves not to
exceed $300. An examiner shall have authority to establish reserves
not to exceed $50,000. A senior examiner shell havo aUfority to
establish reserves not to exased $75,000, The supervisor shall have
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Agreement No. 3882D
authority to establlsh res0rVee rrot to ear $460,080. A claims
m8nager, vice president, or presidont of the TPA Mall review and
approve all reservas In excess of 1 O,00 ,
8, : The City of El Segundo has €rstabllshW a posIgve pay
sweep account, which shall at all tIMS contaln sufflalent french to
enable the TPA to make timoly poyaw nts of c4altr1g, allocaled loss
expenws, and other amunts the TPA Is authorized or retligred
make on behalf of the My of El Segundo, Tho TPA shall elactonloally
submit the Inf0trnallon required by the City of El Segundo °a linanc4ai
Institution on "a dally, weekly, or rant nfhly basle. The subnrlsslarts imil be
at no additional COM to the City of El Segundo,.
The plr +slrJOn's OMCO Will ba Contacted vrlthlrr five () days of noticc of
all now hido rrlty claims. Such contact wIII conilnue an needed dr dnq
the cOnflnuallorr Of tern %)taryr disobfilty to amro that troatrrrent is
rolatod to a corn,pensable Injury or Illness. All contact shall be
documented In the curnputer notepad,
.The - PA...sball maintain- ccrnaot Wft treating physiclans to_ ensure
employeas receive proper medloal treatment and are ratumed to full or
modl ed employment at the earliest possible date,
Tho TPA shall maintain direct Wntact with medical service providers to
ensure their reports are receiver! In a Umely manner.
The TPA small arrange roadicai evaluations whon needed, rearonable,
and/or requested In compliance �Mth the current Labor Code.
The TPA shall ensure that medical bills are reduced to the
r6wrnmOndOd rates established by the Administrative Clrector of
Worlcera' COmpensa#lon, The use of a S 106 contractor must be
approved by the City of FI Segundo. The City of 51 Segundo shall pay
for the uoe and benefits of the services provided,
The TPA shall ensure that utlllZatlOn review and/or p ..
managed care services v011 be provided on an as-noaded brasla
Injured employees by providers approved by the CRY Of El Segundo,
10- MW1231 Ed nts: ML-dlwl bills V411 be reviewed for correcti
-a—yment, and paid within Orne limits approved • .established w �.w
Code + r1 or part of i e; bill Is being disputed,
re provider on ., ♦ w r r
established time 11MIts by .► ..„
WE
Agreement No. 3882D
AN
12, its Thd TPA 811011 promptly Initiate investlgatim of Issues
Identified as material to potential lltlgatlon, The member $heii be
alerted to the need for an oatsl'de W68119 00M ao soon as pos ible and
the examinsr shall appoint are Investigator who Is a ptabl'o to tfle
rwmber, The msrmber shall be Inept informed on the scope and results
of all Investigations.
The TPA shall subscribe to the Index Bureau, fists to subscAbe to
this Index Bureau shall bs Included in propolsed Pffdrig strutlure, The
examiner shall request a report from the Index l ureau on all new
lndemnity claims, Subsequent requests should be made every sIx (6)
to twelve (12) months thereafter on all aotJve Indemnity claim.
13, The compensabillty dotermInatlon (a p t claim, deny
oy arxe ptance ponding the results of adctltloraai
Investigation) and the reasons for such determination will be ode and
clearly documented in the Corwuter notepad within tive (6) working
drays of the recelpt of the notifrcattion of the loss, relay or cierrlal of
benefit letters shall be ilejt in comliance wltlr the Division of
Industrfal_Relations'. guldellnes.— Tire -TIPA- small notify th$- mernber -of
delay or denial of any Bairn,
In no case shall a Vnal conVensablIfty i;:Me f be extended beyond
ninety (90) days from the member oWs knowledge of the daJm
! f Provide i f i
compliance Medical ben!effts in a timely manner and In
statutory requirements Gf the ! The TPA shall
compule and ,' temporary d1sabillity :'s employees
based i and ! perlods.
TPA shall MOM, compote, and Pay all Inf=ial ratings,
death
Findings and Awards, f w f; ;,,
settlements.
Agreement No. 3882D
_'; .
Late payments mint include the 40% *elf-ImPoaed penalty in
a=rdsnce wigs Laver Code section 4-050,
17, " Tho PA aallall provide asslstanob )c the CIEy at Fj
Segundo In raturrring injured ormployoeB to rrrodified duty while
reccaverfng and prior to Choir roturn to rrogulcrr dutles,
The TINA shall oon It freguantiy wills the oirector at Human Resources
In ftse oases where the Irajuary teslduala mfghf irrVr4ve porrrrerjord work
restrlollons andlar retlrernont Potential,
4$, r Tranap;ortstion relrnburaernent wfil be =11ad
WOO five (� days of the r6celpt of the olalm for ro) nboroement,
Mvgince travel a penso payments Will be rrialled to the Injured
employee ttert (")g) days prior to the aniWpat ct date of fravol,
9g; C The
employoes In compJatfng the
dirso llty rating,
TPA shall explaln and assist injured
nocessary forms to obtain a permanent
The TPA shall detorrnlne the nature and eXWnt of perrrranent dlsablMf
and arrange for an Informal disability rating whenever possible to avoid
WorkarW Compensation Appeals Dowd litigation,
All .pPrrr vent di_11011lty.bartefft MOWS shall be_seritto the employee aD
required by the Labor Code.
20, =ai$d Grass; The City of El Segundo shall be alorted to the need
for an outside courwl as soon as pusslbie, and the examiner shell
appoint an attorney who Is acoeptahie to the Clty of Ej Segundo,
When defense counsel is not necessary, the TINA shall work closely
with the applicant's attorney in Informal cllspOsitlon of litigated eases,
80ttlerwnt proposals directed to the MY of El Segundo shall be
forwarded by the TPA or defense counsel In a concise and dear Mteen
farm With a reason(s) for such recorrinxIndatfon,
All preparation for a trial small involve the City of E1 Segundo so that all
material evidence and witnesses are utilized to obtain a favorable result
for the defense.
The manager, supsrvispr, or examinOr shall attend Workers`
ComPensatlon APPOWs I0ard hearings, rehabilitation hearfngs,
rneatings with defense counsel, and meatings Mth mert*ar's staff,
depart nts, and employee groups as nocessary and as requested to
ado so,
29, 8 1 S' ThO TPA shall abtaln the Clty of E1 egundo's mitten
allthoOzagon on all settienvnts, AM requests for settlement authority
shall Include a written calm summary, current 'flnanc al Informatlaan,
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Agreement No. 3882D
estimate of penny nunt disability; ants dra dotenus courtw,s wMments
and (6 commendations,
:22. d In ail 0080 there a third party Is respotialble for the
Injury to the employee, the TPA shall contact the rrrernbet Indlcadtl
they will pursue sub o ation unless Instructed o frerv", by the City of
El Sa ur7dn, When subrogation Is to w pumue , the 'turd party shall
be Ontactedd Wthin tarn ( ) days of Iderrtilicati+orr, wltfi no ltcatlon of
the City of El egundo's right to► $Ubro otlon and the recOveryof wrt n
clalmr.e porn ev, If the titlyd party is a governmollial entity, a dwm $ball
be tiled With thagoverning board vA hiri six (8) rttonthe of tho Injirr r or
MOCO of IrrJUty,
Perlodia contact shall ba made with they re€=;pcmalble #arty acrd /or irtsurar
to pr"(ie noUnca " Of the MOM Of the estimated revery to whirh
the mombs r will be onfiged.
11 tine Injured worker l)rfrr a a civil acttarr a Ainrst the party m'%pon lblo
for the injury, tiro "i "m maii 00"Sult Oth VIO City of El SogUndo about
tho value of the subrogalloti claim, and other cortaldoratlons. lip*" the
City Of PI e utrdo's DuthodZaffon, subrogaflon aoUnsol shall tea
awggned'to file a Lion or a complaint In Intervention to the civil action,
Whariever practical, the TPA sitoUld take advantage of atty sattlerr rrt
In a civil action by atternpUng to settlo the yidotkars, Componealtos
Cialm by_ maarr of a Third Potty Compror lso and t eloatse ....if. su oh
attempt does not MICCOad, th0l) every effort should be rule thtoij9h
the Workers' CoMpen6ation Appeals ftard to offset Bairn expenses
throu h a credlt Sgalnst the Proceeds from the Injured warkor`s elvii
action,
3, VQ ' in a=rdonca with all appfirable CailfDMIa
laws In place at the date of Injury, the TPA stall:
'l. Deten"'he the Qualified 'nJured WOrkw ftn Quallhad Injured
Wo"r staters;
2, Advise It re InJured worker of Itlslher right to rehabilitation banentst
Provide appropriate vocational re'habilltatlon benefts;
onfrol rehabilitation vests; and
. Attempt to sea; re the prompt oonctuslon of vocational rehablilla#ion
bensfita,
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Agreement No. 3882D
M9, Oases that have
td % Of the City Of Si S99011d0's ., S4 retailtion P
should b o rep*rted 10 010 011Y Of El ti
Resourous, Any raw e4 the polantlol to exceed
50% of the CHY of El W
rt
M E Inauror In aWordance with the
the established E eltega aro to +rp1 s
of the day on y/alch it is known S cdtedorl is met,
sA
e Release agreements Wil . or sooner
r.
Workers'
Vr Board
appropriate, clactiment.
4
r » . tvIsOr medical
TPA,- x dale'0-01111Y by the Ion to Indemnity w Clalmstatus,
to and any claim open beyond C o I'D Of entry mUst bO f�
r +M w r ►
Placed on th
indemnity x sa»
Wil be closed within 3JxtY (60) daYS ot the final gnandal fm"action 0
final correspondence to the injured worker as
required
Indemnity v
open for tm (2;) Years from the loat payment of belleM and then, within sixty (60) closed will rm-nitor stipulated
C M m
"'" a :!
be reviewed !.. adjusted a=rdltiq to use,
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Agreement No. 3882D
31, CUMAW—P&M The TPA uhall maintain all loss Information as
required by the Workefs'UnTansatlort InguffinO Rating Bureau,
32, r All ORIM fifes shall be maintained In accordanoo
requframents and thei City Of El Segundo shall be
nothled prior 10 arly destrur'llon of Mau.
33. Q1QIM 9WWVJ2JQn1: The TPA strall provide oupi wvls o staff that Will
regularly review the work product of the clalmg examiners, The
supervisor shall review at least 10% of each examiner,s COOR104d each
month to ensure ea-ch exardner Is following the POrforMance Standards
ouflinad In Ifils document Such rovlewa shall be jabe,113d as
"Supervisor ftW and clearly documonted it) tho dalm flot9pad. In
addition, The supervisor Shall conduct a ragular, quarterly review of all
open Indarnnity claim with reserves in e)(oojg) of $100,000 and ail
problem or complex claims,
34. Am :l I :, The TPA shall ansure at 10061 ol)d (1) or mt.&
the exerr'Inors. assiOnOd to the City Of E-1 Segundo ore On-0110 Ohd
available to the City Of El Segundo and Ift memberg ev" b1jOjnOVA:
day (exclutgng holiday$ between the hours of 7,
30 aln), and 5:3D P,M.
throughM'' ut the term of the approved contract betwoor,
,9egun�do and the TPA The TPA shall provide a toll-free tolopf,)onoi
number.
35, gvn� jb�rbjw: The -rPA shall annuall cartity to ib
y city of!
Segundo that eadi Y. examiner handling mertibareV claIM Is
COMPORtIca With all legal and regulatory licensing and continul
educational requirements no Presently or In the fuhlre Shoji
promulgated and required by the, Mote of California, Where rmequlroWd p
law Or WOU18000, OoPles Of allsuch cercation S shall be provided
lenot annually by the VA to tho City ► Ef $0glindo, I
MeMOLAVIM. The rFA shall provide special on-,olte troini
services when requested bY the CMY Of FJ 889UMO to ensure the of
supervIsory slaff process woftra, compensailon cla�l
Ma Offectival
carr)ft out tha procedures required for a succesoful program,
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Agreement No. 3882D
The TPA shall require Orr dxOn i"r to be available and readily respond
to a Member's request for assfstarloo vWth probl&m cas es, Inoluding on-
alit vlslts fa the My of El 88911ndo.
Thad TPA shall provide the City of 11 Segundo v4th it1f0rrrra110r')
r890rdIng stetutes, proposed chong" to s ab.ttas, 411d oharrgea to tl19
roles and regulations affsotind the CRY Of V Sag,:Undo and Ito
respond lllty as a 1e9011y W- finsured workers' mpollootion public,
entity.
37.
The -rm shall prraVlde OnIlne ac«cas$ at no
additiono'l chorge for the City cif" :1 Segundo, err well ao addlllontil
aocsas frir selscWd vendors providing tejvloOv to the C Ity 01 El
Sagurtdo, The TINA shall provide fraInfog for use of tl7e computer
system at na.addlOonal ollarge.
38. e As required, the TPA will develop, for revlaw by
the City of El Segundo, rnaterlala wfrich will pr"rte Intorrrrr"allon and
guidance to the City of Ef 8a undo l lreator of Hu1nan l e$ouroes
regarding workers' compepsailon and the Self- Insuranc* program,
As required, fhe TPA will assist Injured omployeas Ira resolving
problems that arise from injury or fffness clalms,
39, Q121 of „I; leresL Tho TPA shall avold all Wrlfflctz of Interest or
— appearance of ronfifcte -of Interest In performance a of this cfommant; - If
the TPA receives compensation from f11e GUY of` El 8agundo for
sen4cas not Included in this document, such as f 111 review services,
managed rare, or Investigations, the TPA shall dfaclose all foes
received from the City of El ftundo. Such disclosure shell be in the
forrn of a letter and shall be received l >y thO City of El fturWo each
April 1 1.
4t1, ill � ' . eaj . Provide for comprehanslvv rredical bill review,
In- patient hospital and outpatient facillty bill revlaws, nego0ated faille, .
larafas*nal surgical fees, fine are a bills, duplicate bill,$, it, addltlon to
re- ev0luat3on*ovider fncluldes, experttostirrony In defense of reviews,
EDI ( lectrorlic gate frtforfaca), on -litre armass to the system and
MGM* reports, and resolution to disputes by providers,
41, ll �. ��� f�ra}vlde cornprberrefve ralf�orr review
servf s, Idenii ed in era approved iltlil afion Ftevlew Pion, lrr
campllan with Ubor Coda Sactlotr 413111, defined f ltlil�florl Review
f oufaarta and Tlmefines, and off tflPeotlY frcrn fbe Adrrrrfstrative
f;31rc r of #re f fvfsian of 1+Vcr€sere'errfpeneatfor�,
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