FAS Typically Performs the Following Services as an Employer’s Third Party Administrator:
a. Receives initial reports of injury from the client concerning client’s injured covered employees
b. Establishes an electronic file with respect to each injured employee
c. Obtains and reviews an ISO Claim Search report on each injured employee.
d. Assists the Client in determining the compensability of each claim based upon the facts of the incident and Plan provisions and initiates a claim denial where appropriate in accordance with Client’s instructions.
e. Contacts the injured employee and provides guidance to an approved medical provider.
f. Obtains from the treating physician the injured employee’s medical diagnosis, treatment plan and ability to return to work.
g. Monitors treatment and progress of injured employees until: employees have been authorized to return to work by their treating physicians, employees have exhausted all coverage and benefits under the Plan, or the claim exceeds Administrator’s authority.
h. Investigates claims to discover pertinent facts and circumstances.
i. Provides a written chronology in the claim file of actions taken with respect to the claim.
j. Maintains a record of medical charges, medical notes and other correspondence.
k. Reviews and audits medical bills or utilizes a third party to audit and review medical bills in an effort to ensure only reasonable and necessary medical charges, directly related to an occupational injury, are approved for payment.
l. Manages the payment of benefits according to the terms of the Plan.
m. Pays covered Plan benefits, except weekly indemnity (lost wages), out of a checking account funded by Client or provides Client with payment instructions for payment to providers in the form of an explanation of benefit (EOB) that identifies the employee, the service provided or benefit owed, the payee and the recommended amount of payment.
n. Computes or assists Client in computing weekly indemnity (lost wages) benefits under the Plan.
o. Recommends medical case management where appropriate to coordinate physicians’ treatment and activity plans.
p. Pays Additional Loss Adjustment Expenses out of a checking account funded by Client or provides Client with payment instructions for payment to vendors that provide Additional Loss Adjustment services. Additional Loss Adjustment Expenses include:
1. Expense of private investigators and adjusters (including but not limited to on-the-scene investigations, photos and surveillance).
2. Any fees or expenses related to the outside investigation or handling of a claim by a third party vendor or attorney.
3. Mediation or arbitration expenses.
4. Trial, hearing, mediation and arbitration attendance fees.
5. Travel expenses.
6. Testimony, opinions, appraisals, reports, surveys, and analyses of professionals and experts.
7. Court reporter and stenographic services and transcripts.
8. Automobile or property appraisals.
9. Reports from government agencies or branches.
10. Reports from attending or examining physicians.
11. Independent medical examinations of injured employees including necessary transportation expenses.
12. Peer review of the appropriateness, quality and cost of health care and health services provided a patient.
13. Medical case management.
14. Utilization review.
15. Any outside expense related to protecting subrogation rights or collecting monies owed by third parties.
16. Any other reasonable and necessary fees and expenses payable to a third party that are related to the handling, investigation or defense of a claim under the Plan.
q. Assists Client with recovering amounts paid by Client as benefits under the Plan when a third party is responsible for the injury sustained by the employee.
r. Recommends the engagement of legal counsel when appropriate.
s. Provides assistance and information to legal counsel as necessary.
t. Exercises reasonable efforts to manage the Services provided under this Agreement to ensure every employee of Administrator and every vendor utilized by Administrator that performs work on behalf of Client does so within the scope of this Agreement and in accordance with the Plan.
u. Prepares monthly, for filing by the Client, the DWC-7 Non-covered Employer’s Report of Occupational Injury or Illness as required by the Texas Department of Insurance Division of Workers’ Compensation.(Each non-subscribing employer must report all fatalities, all occupational disease claims and all on-the-job injuries resulting in more than one day’s absence from work no later than the 7th day of the following month).
v. Meets with Client in Administrator’s office at reasonable times and for reasonable periods to discuss any claim or process covered by this Agreement.
w. Provides a monthly loss summary report for Client showing the payment and reserve activity by individual employee.
x. Maintains records of all transactions.