HomeMy WebLinkAbout14-Human Resources
C CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
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From: LINN LIVINGSTON, DIRECTOR
OF HUMAN RESOURCES
Dept: HUMAN RESOURCES
Subject: RESOLUTION OF THE CITY
OF SAN BERNARDINO
AUTHORIZING THE EXECUTION OF
AN AGREEMENT WITH CORVEL TO
PROVIDE UTILIZATION REVIEW
SERVICES FOR THE CITY'S
WORKERS' COMPENSATION
PROGRAM.
MICC Meeting Date: Feb. 19, 2008
Date: February 8, 2008
Synopsis of Previous Council Action:
Recommended Motion:
Adopt Resolution.
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Contact person:
Phone:
Supporting data attached:
Ward:
FUNDING REQUIREMENTS: Amount: Not to exceed $100.000 annuallv
Source: (Acct. No.)
678-452-5163
(Acct. Description)
Finance:
Council Notes:
Agenda Item NO.~_
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C CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
Staff Report
Subiect:
Resolution of the City of San Bernardino authorizing the execution of an agreement with CorVel
to provide Utilization Review services for the City's Workers' Compensation Program.
Backl!round:
The City of San Bernardino is a self-insured agency, providing workers' compensation benefits
to 1800 plus employees annually. Senate Bill 228 mandates employers who are self-insured
administrators handling Workers' Compensation claims to establish a mandatory Utilization
Review (UR) process. A Utilization Review program provides several valuable services
including; managing costs associated with Workers' Compensation claims, evaluating patient
care using evidence-based guidelines, ensuring the delivery of appropriate and reasonable care as
well as channeling cases into the Preferred Provider Organization network.
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To maintain compliance with SB 228, the City went out to bid on September 18,2007 for a
vendor to provide Utilization Review services. Nine bids were received and reviewed by the
Workers' Compensation Committee, consisting of6 members. After review, all nine vendors
were invited to provide an overview of their services and answer questions from the selection
Committee. The top two vendors were invited back to the City to provide a detailed
demonstration of their Utilization Review services. CorVel was unanimously chosen by the
selection Committee to provide a Utilization Review Program for the City.
CorVel is a local vendor with an office in San Bernardino who specializes in applying advanced
communication and information technology to improve heaIthcare management. CorVel
Associates work side by side with their 1,500 customers nationwide to deliver innovative,
tailored solutions to manage risk and keep their customers ahead of their costs.
As part of the contract, CorVel will be responsible for communicating with bill review and
claims administrators regarding approved modified negotiated or denied services, auditing
hospital bills for appropriateness of medical services, negotiating rates not included in the
Official Medical Fee Schedule and will emphasize early return-to work goals. Utilization Review
is one of the many cost containment measures used by the City's Workers' Compensation
Division to control cost associated with claims handling.
The City additionally contracts with other cost containment providers who monitor and manage
ancillary costs associated with the Worker's Compensation Program; examples include
Occupational Clinics, Pharmacy programs, Durable Medical Equipment Programs and Medical
Case Managers.
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The City is proposing a one (I) year agreement with CorVel with two (2) one (1) year
extensions.
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Financial Impact:
The cost of the Utilization Review services will vary each year by case load. The Workers'
Compensation Division is anticipating increased cost for this year due to large case files. Cost of
services will not exceed $100,000 annually. The cost for these services is already incluqed in the
City's FY 2007-08 adopted budget.
Recommendation:
Adopt Resolution.
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Resolution No
RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AGREEMENT WITH CORVEL TO PROVIDE UTILIZATION
REVIEW SERVICES FOR THE CITY'S WORKERS' COMPENSATION PROGRAM.
BE IT RESOL YED BY THE MAYOR AND COMMON COUNCIL OF THE CITY OF
SAN BERNARDINO AS FOLLOWS:
SECTION I: The City Manager of the City of San Bernardino is hereby authorized and
directed to execute on behalf of said City an Agreement with CorVel to provide Utilization
Review services for a period of one (I) year with two (2) one (1) year extensions, a copy of
which is attached hereto, marked Exhibit "A" and incorporated herein by reference as fully as
though set forth at length.
SECTION 2: The Purchasing Manager is hereby authorized to issue a Purchase Order t
CorVel for Utilization Review services for the Workers' Compensation Division for a tota
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amount not to exceed $100,000.
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SECTION 3: The authorization to execute the above mentioned agreement is rescinded
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if the parties to the agreement fail to sign it within sixty (60) days of the passage of this
17 resolution.
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RESOLUTION OF THE CITY OF SAN BERNARDINO AUTHORIZING THE
EXECUTION OF AN AGREEMENT WITH CORVEL TO PROVIDE UTILIZATION
2 REVIEW SERVICES FOR THE CITY'S WORKERS' COMPENSATION PROGRAM.
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I HEREBY CERTIFY that the foregoing Resolution was duly adopted by the Mayor and
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the Common Council of the City of San Bernardino at a
meeting thereof,
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day of
, 2008, by the following vote, to wit:
held on
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ABSTAIN
ABSENT
COUNCILMEMBERS:
ESTRADA
BAXTER
BRINKER
DERRY
KELLEY
JOHNSON
MCCAMMACK
AYES
NAYES
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Rachel G. Clark, City Clerk
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The foregoing resolution IS hereby approved this
day of
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,2008.
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Patrick J. Morris, Mayor
. City of San Bernardino
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Approved as to form:
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JAMES F. PENMAN,
City Attorney
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1\genda Items:Reso.CorVe1.2008
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3 This Vendor Service Agreement is entered into this 1 st day of March 2008, by and between
4 CorVel ("VENDOR") and the City of San Bernardino ("CITY").
VENDOR SERVICE AGREEMENT
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6 WITNESSETH:
7 WHEREAS, the Mayor and Common Council has determined that it is advantageous and in
8 the best interest of the CITY to acquire Utilization Review Services; and
9 WHEREAS, the City of San Bernardino did solicit and accept proposals and bids from a
10 number of vendors for Utilization Review Services;
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13 1.
NOW, THEREFORE, the parties hereto agree as follows:
SCOPE OF SERVICES.
14 For the remuneration stipulated, San Bernardino hereby engages the services of VENDOR
15 to provide those products and services as set forth in Exhibit" A", attached hereto and incorporated
16 herein by this reference.
17 2.
COMPENSATION AND EXPENSES.
18 a. For the services delineated above, the CITY, upon presentation of an invoice, shall
19 pay the VENDOR the amount of monthly invoices for services rendered during the previous month.
20 Invoices shall include task description, the number of hours spent on each task, and applicable hourly
21 rate. Cost not to exceed $100,000 annually.
22 b. No other expenditures made by VENDOR shall be reimbursed by CITY,
23 3. TERM.
24 The term of this Agreement shall be for a period of one (1) year with two (2) one (1) year
25 extensions.
26 This Agreement may be terminated at any time by thirty (30) days written notice by either
27 party. The terms of this Agreement shall remain in force unless mutually amended. The duration
28 of this Agreement may be extended with the written consent of both parties.
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1 4. INDEMNITY.
2 Vendor agrees to and shall indemnify and hold the City, its elected officials, employees,
3 agents or representatives, free and hannless from all claims, actions, damages and liabilities of any
4 kind and nature arising from bodily injury, including death, or property damage, based or asserted
5 upon any actual or alleged act or omission of Vendor, its employees, agents, or subcontractors,
6 relating to or in any way connected with the accomplishment ofthe work or performance of services
7 under this Agreement, unless the bodily injury or property damage was actually caused by the sole
8 negligence of the City, its elected officials, employees, agents or representatives. As part of the
9 foregoing indemnity, Vendor agrees to protect and defend at its own expense, including attorney's
10 fees, the City, its elected officials, employees, agents orrepresentatives from any and all legal actions
11 based upon such actual or alleged acts or omissions. Vendor hereby waives any and all rights to any
12 types of express or implied indemnity against the City, its elected officials, employees, agents or
13 representatives, with respect to third party claims against the Vendor relating to or in any way
14 connected with the accomplishment of the work or performance of services under this Agreement.
15 5. INSURANCE.
16 While not restricting or limiting the foregoing, during the term ofthis Agreement, VENDOR
17 shall maintain in effect policies of comprehensive public, general and automobile liability insurance,
18 in the amount of $1,000,000.00 combined single limit, and statutory Workers' Compensation
19 coverage in accordance with the laws of the State of California. VENDOR shall maintain
20 professional malpractice insurance for professional negligence, including errors, omissions, or other
21 professional acts in the amount of$1 00,000.00. VENDOR shall file Certificate(s) of Insurance with
22 the CITY's Risk Manager prior to undertaking any work under this Agreement. CITY shall be set
23 forth as an additional named insured in each Certificate of Insurance provided hereunder. The
24 Certificate( s) of Insurance furnished to the CITY shall require the insurer to notify CITY of any
25 change or termination in the policy.
26 6. NON-DISCRIMINATION.
27 In the performance of this Agreement and in the hiring and recruitment of employees,
28 VENDOR shall not engage in, nor permit its officers, employees or agents to engage In,
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1 discrimination in employment of persons because of their race, religion, color, national origin,
2 ancestry, age, mental or physical disability, medical condition, marital status, sexual gender or sexual
3 orientation, or any other status protected by law, except as permitted pursuant to Section 12940 of
4 the California Government Code.
5 7. CONFIDENTIALITY.
6 VENDOR understands and agrees that CITY, as a public entity, can maintain VENDOR's
7 confidentiality only to the extent that doing so does not conflict with its duties under the California
8 Public Records Act, the Ralph M Brown Act or any other requirement oflaw, regulation, rule, or
9 court or other government decision.
10 8.
INDEPENDENT CONTRACTOR.
11 VENDOR shall perform work tasks provided by this Agreement, but for all intents and
12 purposes VENDOR shall be an independent contractor and not an agent or employee of the CITY.
13 VENDOR shall secure, at its expense, and be responsible for any and all payment of Income Tax,
14 Social Security, State Disability Insurance Compensation, Unemployment Compensation, and other
15 payroll deductions for VENDOR and its officers, agents, and employees, and all business licenses,
16 if any are required, in connection with the services to be performed hereunder.
17 9.
BUSINESS REGISTRATION CERTIFICATE AND OTHER REQUIREMENTS.
18 VENDOR warrants that it possesses or shall obtain, and maintain a business registration
19 certificate pursuant to Chapter 5 of the Municipal Code, and any other licenses, permits,
20 qualifications, insurance and approval of whatever nature that are legally required of VENDOR to
21 practice its business or profession.
22 10.
NOTICES.
23 Any notice to be given pursuant to this Agreement shall be deposited with the United States
24 Postal Service, postage prepaid and addressed as follows:
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TO THE CITY:
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Linn Livingston, Human Resources Director
300 North "D" Street, 2nd Floor
San Bernardino, CA 92418
Telephone: (909) 384-5161
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TO THE VENDOR:
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Sharon O'Connor
Director of Legal Services
2010 Main Street, Suite 600
Irvine, CA 92614
Leann Farlander,
Account Executive
600 City Parkway West, Suite 700
Orange, CA 92868
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11.
ATTORNEYS' FEES
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In the event that litigation is brought by any party in connection with this Agreement, the
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prevailing party shall be entitled to recover from the opposing party all costs and expenses,
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including reasonable attorneys' fees, incurred by the prevailing party in the exercise of any of its
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rights or remedies hereunder or the enforcement of any of the terms, conditions or provisions
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hereof. The costs, salary and expenses of the City Attorney and members of his office in
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enforcing this Agreement on behalf of the CITY shall be considered as "attorneys' fees" for the
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purposes of this paragraph.
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12.
ASSIGNMENT.
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VENDOR shall not voluntarily or by operation of law assign, transfer, sublet or encumber
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all or any part of the VENDOR's interest in this Agreement without CITY's prior written consent.
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Any attempted assignment, transfer, subletting or encumbrance shall be void and shall constitute
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a breach of this Agreement and cause for the termination of this Agreement. Regardless of
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CITY's consent, no subletting or assignment shall release VENDOR of VENDOR's obligation to
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perform all other obligations to be performed by VENDOR hereunder for the term of this
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Agreement.
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1 13.
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VENUE.
The parties hereto agree that all actions or proceedings arising in connection with this
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Agreement shall be tried and litigated either in the State courts located in the County of San
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Bernardino, State of California or the U.S. District Court for the Central District of California,
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Riverside Division. The aforementioned choice of venue is intended by the parties to be the
mandatory and not permissive in nature.
GOVERNING LAW.
This Agreement shall be governed by the laws of the State of California.
15. SUCCESSORS AND ASSIGNS.
14.
This Agreement shall be binding on and inure to the benefit of the parties to this
Agreement and their respective heirs, representatives, successors, and assigns.
14 16.
HEADINGS.
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The subject headings of the sections of this Agreement are included for the purposes of
convenience only and shall not affect the construction or the interpretation of any of its provisions.
17.
SEVERABILITY.
If any provision of this Agreement is determined by a court of competent jurisdiction to
be invalid or unenforceable for any reason, such determination shall not affect the validity or
enforceability of the remaining terms and provisions hereof or of the offending provision in any
other circumstance, and the remaining provisions of this Agreement shall remain in full force and
effect.
18. ENTIRE AGREEMENT; MODIFICATION.
This Agreement constitutes the entire agreement and the understanding between the
parties, and supersedes any prior agreements and understandings relating to the subject manner
IIII
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of this Agreement. This Agreement may be modified or amended only by a written instrument
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executed by all parties to this Agreement.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the day
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and date first above shown.
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ATTEST:
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8 Rachel Clark, City Clerk
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14 Approved as to form:
15 JAMES F. PENMAN
City Attorney
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CITY OF SAN BERNARDINO
Fred Wilson, City Manager
CORVEL CORPORATION
By:
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By: ~ ~./~
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EXIIIlIIT nAn
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CORVEL
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Table of Contents
Confidentiality Statement .... ...... ..... .......... .............. ... ......... ... ... ....... ........ .......... ... ............. ....3
Cover Letter ...........................................................................................................................4
Executive Summary........... ................ ......... .... .... ... ... .......... ........... ................. ...................... ..5
Technical Specifications........................................................................~............................... 7
Proposal Content and Forms................................................................................................13
Attachments ................ .... ... ................ ......... .............. .......... .......... ............................ ...........21
CorVel Corporation
Page 2 City of San Bernardino
Workers' Compensation Utilization Review
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CORVEL
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('onfidl'lIti:llit.\ Stutl'l11t"nt
Note: Prior to reviewing our RFP response, please read the following carefully.
CorVel Corporation is submitting this proposal to The City of San Bernardino. This
proposal is being submitted specifically to facilitate The City of San Bernardino's
evaluation of CorVel's Managed Care solutions. It is our understanding that this proposal
(which contains highly confidential and proprietary information) will be viewed only
by employees of The City of San Bernardino, for the purpose of such evaluation on a strict
need to know basis only and will not be shared with or used by any individuals other than
The City of San Bernardino employees without the express written consent of CorVel.
The City of San Bernardino agrees to hold in confidence any information obtained relating
to the business of CorVel, and agrees to instruct its employees to keep all information
strictly confidential in the same manner you maintain your own confidential and
proprietary information. The City of San Bernardino agrees that it will not directly or
indirectly disclose to any other person, firm or corporation, any of the information,
including but not limited to customer information, personnel information, fee schedules,
sales and pricing information, training programs and materials, manuals and procedures,
systems, methods, ideas or processes of any product or service provided by CorVel as
described in our proposal. In the event of any breach of this Confidentiality Statement by
The City of San Bernardino or any of its employees, CorVel will be entitled to seek
injunctive relief without being required to post any bond, as well as any other remedies
available to it.
Should The City of San Bernardino disagree with our understanding relative to the sharing
of information as contained in this document, please notify CorVel and immediately return
the CorVel information prior to the initiation of The City of San Bernardino RFP review
process. CorVel' s submission of this information to you is conditioned upon your
agreement to maintain the confidentiality of such information and to use such information
solely as provided in this Confidentiality Statement. Absence of The City of San
Bernardino contact with Leann Farlander, Account Executive, listed below, will indicate
full agreement with all aspects of this statement.
Leann Farlander
Account Executive
CorVel Corporation
600 City Parkway West
Suite 700
Orange, CA 92868
C 949 233 5303
F 866 434 3680
Leann3arlander@corvel.com
CorVel Corporation
Page 3 City of San Bernardino
Workers' Compensation Utilization Review
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<o,er Letter
September 19,2007
City of San Bernardino
300 N. "0" Street, 4th Floor
Attention: Deborah R. Morrow
San Bernardino, CA 92418 .
Thank you for considering CorVel as a strategic partner for the City of San Bernardino
for Utilization Review Services. CorVel is pleased to have the opportunity to deliver a
proposal for these services. We are confident that you will conclude that CorVel has the
experience and superior products and service delivery you are seeking.
CorVel provides a comprehensive program, which will address your needs and
requirements. CorV el does not use outside vendors or subcontractors, thereby providing
seamless, integrated services. CorVel offers a complete range of services required to
minimize claims costs, ensure appropriateness of care and expedite employee return to
work. Our financial stability allows CorVel to remain nimble in .our ever-changing
industry, while investing in state of the art technology.
CorVel offers the following strengths:
. Utilization Review
. Pre-Certification
. Concurrent Review
. Discharge Planning
CorVel recognizes this is more than an opportunity to deliver cost containment services.
Our team appreciates the importance of a partnership, which will result in a quality
service and a custom-tailored program that is fully integrated with the personnel and
claims processing systems of the City of San Bernardino.
Sincerel}!.
Leann Farlalider
Account Executive
CorVel Corporation
600 City Parkway West
Suite 700
Orange, CA 92868
C 949 233 5303
F 866 434 3680
Leannjarlander@corvel.com
CorVel Corporation
Page 4 City of San Bernardino
Workers' Compensation Utilization Review
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About CorVel
CorVel Corporation is a nat)onal provider of leading workers' compensation solutions to
employers. third party administrators. insurance companies and government agencies. CorVel
specializes in applying advanced communication and information technology to improve
healthcare management. Our associates work side by side with our 1.500 customers nationwide to
deliver innovative. tailored solutions to manage risk and keep our customers ahead of their costs.
CorVel Corporation is publicly traded company on the NASDAQ (CRVL). The Company has
more than 25 years of healthcare management experience and has been listed by Forbes as one of
the 200 Best Companies in America.
CorCase Overview
CorCase is CorVel' s suite of case management solutions. designed to combine quality care with
new technologies, offering the most comprehensive capabilities for patients. CorCase
offers early intervention,. utilization management through local branch offices and case
managers in your neighoorhood. Our case managers work side by side with patients to
assist them though their episode of care, working to achieve timely recovery and increased
savings.
The Advantage
CorCase services are provided by trained and certified professionals in nursing. CorVel's
program proactively focuses on reducing medical costs through the efficient medical
management of all claims. CorVel works to identify and categorize claims as soon as
possible to make sure the patient follows the most appropriate care path. Our nurses gather
and analyze medical treatment information, discussing with the employer current job
requirements of the injured worker. accommodations for modified work, and any further
relevant information. This service positively impacts patient cases by utilizing proactive
measures throughout the episode of care.
We have 18 distinct service types under the CorCase umbrella. By customizing service
delivery, we are able to create the perfect solution by knowing your needs. Our solutions
offer a f~ter return to work which means a decrease in claims costs. These services are
directed through our internally developed advanced application software, rules engine and
systems infrastructure. Our processes offer protocols to support decisions and are legally
compliant to offer litigation support.
CorVel offers web-enabled service delivery and reporting to interface with customers on a
virtual basis, 24 hours a dati 7 days a week. Once an employee is injured the claim is put
into our database in Care c and routed to the appropriate office and case manager.
Electronic case notes, updated daily, give you real time access to information and status on
a claim anytime, day or night. With a nationwide service delivery network CorVel is
where your claims are located.
CorVel Corporation
Page 5 City of San Bernardino
Workers' Compensation Utilization Review
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L,\\!\'uli\\! Summary
The Difference
The utilization of our innovative technology and leading medical expertise at the onset of a
claim will significantly reduce your claims, including administrative fees, medical costs
and indemnity reserves, From early intervention to advanced software and employee
return to work, CorVel's CorCase is the most comprehensive solution for your case
management needs, CorVel's innovative services help you manage your risk and stay
ahead of your costs,
CorVel Corporation
Page 6 City of San Bernardino
Workers' Compensation Utilization Review
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IV.TECHNIC,AL SPECIFICATIONS
SERVICES TO BE PROVIDED
Following is a desJ;ription of the required services for the Workers'
Compensation Utilization Review (UR):
Per the requirements of SB228, ad'minister Utilization Review for the City as
follows:
o Review treatment for medical necessity, appropriateness, and duration of care in
the following treatment categories, applying American College of Occupational
and Environment;ll Medicine (ACOEM) guidelines and other approved evidence-
based guidelines:
o Chiropractic;
o Physical Therapy and other physical treatment modalities;
o MRI and other major diagnostic test
o Hospitalization;
o Outpatient Surgery/Outpatient Procedures.
CorVel has a network that specializes in aU the Ancillary services listed above.
The City of San Bernardino can access this Information via CorVel's website
CareMC. "
The CareMC website (http://www.caremc.com) has been CorVel's proprietary,
healthcare management platform since 2000. CareMC is the application
platform for all of CorVel's primary services line and delivers immediate
access to customers. It offers customers direct access to CorVel's primary
services.
To view a screen shot of CareMC, please see Attachment A.
o Provided service requests within the applicable time standards and
provided medical advice as warranted.
CorVel adheres to California Labor Code in regards to Utilization Review
time frame.
CorVel's Utilization Review nurses are available during the hours of
8:00 a.m. to 5:30 p.m., Monday through Friday. CorVel also has the ability to
customize our staff/program to meet the needs of the City of San Bernardino.
CorVel Corporation
Page 7 City of San Bernardino
Workers' Compensation Utilization Review
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In accordance with labor Code 4610 all prospective and concurrent
decisions must be reviewed and a decision made within 5 working days from
receipt of information but not to exceed 14 days from the date of the treatment
recommendation by the physician.
The claims professional, provider, attorney's and claimant receive copies of
CorVel's recommendations for certification or non-certification within 24
hours of a determination being made. UR determination letters are entered
directly into CareMC and can also be e-mailed or faxed upon request. In the
case of a non-certification determination the claims payer is also notified via
phone at the time of determination.
Proposals for ser~ices shall include the following information:
o An overview of your company's experience in providing UR services for cities
and other clients.
CorVel has been performing Utilization Services since 1991, and has been
certified by the State of California since 1997 to provide managed care
programs/utilization review to injured workers in California.
CorVel's UR program is registered with the State of California and conforms
to all regulations. CorVel's utilization review department has been fully
trained on the regulations governing utilization review to ensure optimum
results. CorVel utilizes ACOEM guidelines, along with other nationally
recognized scientific based studies, during the utilization review process.
Since the State of California implemented mandatory UR in accordance with
ACOEM Guidelines in 2004, CorVel has seen significant savings that have
resulted from denial of unnecessary treatments, procedures and their
associated costs to all the services above.
o Minimum of three professional references.
Please refer to the Statement of Proposer's Qualifications and References
form on page 16 of this RFP.
o List of physicians/nurses who will be performing UR services, along with resumes.
CorVel utilizes more than 100 California licensed, board-certified physician
specialists that have practiced and have knowledge of California's Workers'
Compensation. All of CorVel's physician specialists are board certified in
CorVel Corporation Page 8 City of San Bernardino
Workers' Compensation Utilization Review
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their practice field. These physicians are educated in California's UR labor
code, including all medical guidelines pertaining to California's UR protocols.
Utilization Review Manal!er # '1
EDUCATION:
Mennonite Hospital School of
Nursing, Illinois
Diploma, 1961
WORK EXPERIENCE:
CorVel Utilization Review Nurse (2005-Present)
Case ManagerlUR Workers'
Compensation
(2004-2005)
Utilization Review Nurse
(1999-2004)
(1991-1999)
(1989-1991)
Telephonic Case ManagerlUR
Director of Nursing
PROFESSIONAL ORGANIZA TIONS/CERTIFICA TIONS:
CCM Certification Case
Management
Utilization Review Manal!:er # 2
EDUCATION:
Cerritos College, Norwalk
A.S. RN Nursing
WORK EXPERIENCE:
CorVel Telephonic Case (2004-Present)
Manager/Advocacy
Telephonic Case Manager (2003-2004)
Nurse Case Manager/Discharge (2003-2003)
PlannerlUR
UR Case Manager (1999-2003)
Staff/Labor Delivery Nurse
(1998-1999)
CorVel Corporation
Page 9 City of San Bernardino
Workers' Compensation Utilization Review
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I Labor/Delivery Nurse
(1985-1998)
- Experience and training of DR staff. including nurses who would will conduct
initial reviews.
Utilization Review Case Managers are responsible for handling the clinic:al '
review of the UR process are graduates of an accredited school of nursing and
hold a current RN license in California. CorVel's Utilization Review Case
Managers have a strong clinical background in orthopedics, neurology, or
rehabilitation. We require three or more years of recent clinical experience,
preferably in rehabilitation, and/or at least one year experience in Workers'
Compensation or STDIL TD case management.
As with all CorVel case management staff, corporate policy encourages
continuing eduCation and the company policy reimburses for those expenses.
Each locaVregionaVnational office is encouraged to host monthly meetings,
offer CEU programs, and solicit timely guest speaker CEU programs.
CorVel has a formal orientation and training program for Nurse Case
Management Reviewers and Physician Consultants. Topics included are:
. State Labor Codes and Other Standards
. UR Process and CorVel Methodology
. Software Used in Utilization Review
. ProtocolslGuidelines Used in Utilization Review
. Training Manual (includes Policies and Procedures)
. CorVel Customers
CorVel provides continuing education for its employees, including DR Case
management staff, through formal staff meetings and informal in-service
presentations to address company policy, DR processes, new customer
information, and staff needs as identified by the Quality Management
nrogram. CorVel posts notification of community based continuing education
programs.
D Your company's average-turn around time for UR requests.
CorVel's average turn around time for DR services is 2.5 days. Our internal
standards for turn around time are as follows:
. Prospective DR requests are completed within 5 business days, in most
instances they are completed within 72 hours.
CorVel Corporation
Page 10 City of San Bernardino
Workers' Compensation Utilization Review
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. Retrospective UR requests have an average turn around time of 5
days,
. Concurrent hospital UR requests are completed within 72 hours, in
most instances they are'completed within 24 hours.
. Appeal Reviews al'e completed within 5 days
. Denial letters are sent within 24 hours to the requesting physician,
facility, claims administrator and claimant.
The claims professional, provider, attorney's and c;laimant receive copies of
CorVel's recommendations for certification or non-certification within 24
hours of a determination being made via e-mail, fax or mail.
o Fee options and how fees are calculated.
Please refer to the Price Form on page 13 of this proposal.
o Samples of reports documenting claims review and action taken.
To view a copy of CorVel's Sample UR reports, please see Attachments B, C,
andD.
o Describe workflow and
exchanged between City's
performing UR services.
the method information is gathered and
medical providers and your company in
The CorVel Utilization Review Case Manager reviews injury, diagnosis,
t~tment plan and pertinent medical information and screens request against
guidelines to determine reasonable treatment. The UR Case Manager then
contacts and/or discusses treatment plan with providers. If the treatment plan
is deemed not appropriate by the Utilization Review Case Manager, then
request is referred to a physician advisor to verify or deny necessity of Medical
Treatment Plan.
The Physician advisor will contact provider to discuss the treatment plan as
necessary.
The claims professional, provider, attorney's and claimant receive copies of
CorVel's recommendations for certification or non-certification within 24
hours of a determination being made, CorVel prefers to transmit DR results
CorVel Corporation Page II City of San Bernardino
Workers' Compensation Utilization Review
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to the City via CareMC, our online Healthcare portal (caremc.com); however,
we are able to transmit via fax and hard copy. DR determination letters are
entered directly into CareMC and will be e-mailed or faxed upon request. In
the case of a non-certification determination, the claims payer is also notified
via phone or fax at the time of determination.
To view a copy of CorVel's DR work-flow, please see Attachment F.
o Any distinguishing or unique qualifications that your company possesses
or any other information that more fully documents your ability to provide
UR services,
CorVel can offer the City a 6:1 Return on Investment in the Patient
Management arena - that equals lower administration costs and improved
outcomes for your employees.
o
Price must be no more than 12 pages (not including City forms or contract)
CorVel's response to the City's Request for Proposal is no more than 12 pages.
excluding forms and contract.
CorVel Corporation
Page 12 City of San Bernardino
Workers' Compensation Utilization Review
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RFP F-07-54
STATEMENT OF PROPOSER'S QUALIFICATIONS AND REFERENCES
UTLIZA TIONREVIEW
The proposer is required to state the proposers' financial ability and a
general description of similar work performed.
Number of years engaged in providing the work included within the scope
of the specifications under the present business name: CorVel Corporation
List and describe fully the last three contr,acts performeil by your firm.
which demonstrate your ability to complete the work included with the
scope of the specifications. Attach additional pages if required. The City reserves
the right to contact each ofthe references listed for additionannformation
regarding your firm's qualifications.
Reference No.1
Customer Name: County of San Bernardino
Contact Individual: Nancv Rice. Suoervisinl! Workers' Como. Adiuster
Address: 222 West Hosoitalitv Lane Phone No: (909)386-9024
Contract Amount: Confidential Information Year: 1999
Description of Work Done:
Bill Review, Case Management, Utilization Review
Reference No.2
Customer Name: Countv of Los Anl!eles
Contact individual: Tami Omoto-mas
Address: 3333 Wilshire Blvd. Phone No: (213)639-6072
Contract Amount: Confidentiallnfonnation Year: 1998
Description of Work Done:
Bill review, Case ManagernentlUR Services
CorVel Corporation
Page 16 City of San Bernardino
Workers' Compensation Utilization Review
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CORV'EL
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'I,ll ",It, III and Forms
Reference No.3
Customer Name: City of Redding
Contact individual:: Gail Crowley
Address: 777 Cvoress Ave.
Contract Amount: Confidential Information
Description of Work Done:
Bill Review. Case Management. Utilization Review
Phone No: (530)225-4348
Year: 2006
Signature
Title:
CorVel Corporation
Page 17 City of San Bernardino
Workers' Compensation Utilization Review
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RFP F-07-54
STATEMENT OF PROPOSER'S PAST CONTRACT
DISQUALIFICATIONS
Pursuant to SectiolL 10162 of Public Contract Code, the proposer shall state
whether such proposer, any officer of employee of such proposer who has
proprietary interest in such proposer has ever been disqualified, removed, or
otherwise prevented from proposal on, or completing a Federal, State, or
local government project because of a violation of la~
or a safety regulation; and if so, explain the circumstances.
1. Do you have any disqualifications, removal, etc., as described in the
above paragraph to declare? No
2. If yes, explain the circumstances.
CorVel does not have any disqualifications, removal, etc., as described in the above
paragraph.
Executed on at , California.
I declare, under penalty of perjury, that the foregoing is true and correct.
Signature(s) of Authorized Proposer
Signature of Authorized Proposer
Title
Title
CorVel Corporation
Page 18 City of San Bernardino
Workers' Compensation Utilization Review
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C RFP F-07-54
WORKERS' COMPENSATION INSURANCE CERTIFICATE
Sections 1860 and 1861 of the California Labor Code require every
contractor to whom a public works contract is awarded to sign and file with the
awarding body the fQllowing statement:
.. I am aware of the Provisions of Section 3700 of the labor Code which
requires every employer to be insured against liability for Workers'
Compensation or to undertake self-insurance in:accord- ance with the
provisions of that code, and I will comply with such Provisions before
commencing the performance of the work of this Contract. ..
By:
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Date:
Title:
By:
Date:
Title:
RFP F-07-54
To view a copy of CorVel's Certificate of Insurance, please see Attachment H.
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Page 19 City of San Bernardino
Workers' Compensation Utilization Review
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CONTRACT BETWEEN THE CITY OF SAN BERNARDINO AND
CorVel Corooration FOR
WORKERS' COMPENSATION UTILIZATION REVIEW SERVICES
Please refer to Attachment G to view CorVel's San Bernardino Contract review.
CorVel Corporation
Page 20 City of San Bernardino
Workers' Compensation Utilization Review
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PRICE FORM
REQUEST FOR RFP:
DESCRIPTION OF RFP:
RFP F-07-54
Workers' Compensation Utilization Review
OFFEROR(S) NAME/ADDRESS:
CorVel COIl'oration 2010 Main Street, Irvine, CA 92614
The undersigned declares that he or she has carefully examined the
Request for Proposals and is thoroughly familiar with the contents thereof,
is authorized to represent the proposing firm, and proposes to provide to the City
of San Bernardino:
As described in said Request for Payment, which is made a part of this proposal,
quoted herein in full
Utilization Review
(a) Nurse (per hour or flat rate per claim) Per Hour fee of$90 per UR
referral/Flat Rate of$IOO for out-patient UR referral and $125 per In-patient UR
referral
(b) Physician (per hour or flat rate per claim) Peer review is Actual Provider
Charges OR $250 Per peer review
(c) Other Associated Costs (per hour or flat per claim)
Explain:
TOTAL COST:
Per hour $90 per hour
Flat Rate Per Claim Flat Rate of
$100 for out-patient UR referral and $125 oer
In-patient UR referral
Plus Deer review if needed not to exceed $250
**Please note we are providing the ootion of
either flat rate or hourlv charges.
THE ONLY EXCEPTIONS FROM THE SPECIFICATION ARE AS
FOLLOWS:
Please note that our pricing is quoted per UR referral.
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RFP F-07-54
Are there any other additional or incidental costs that will be required by your firm
in order to meet the requirements of the Technical Specifications? Yes / No
(circle one). If you answered "Yes", please provide detail of said additional costs:
Please indicate any elements of the Technical Specifications that cannot be met
by your firm. All technical specification can be met by CorVel.
Have you included in your proposal all informational items and forms as
requested? Yes / No. (circle one). If you answered "No", please explain:
This offer shall remain firm for 90 days from RFP close date.
Terms and conditions as set forth in this RFP apply to this proposal.
Cash discount allowable %
terms are: Net thirty (30) days.
days; unless otherwise stated, payment
In signing this proposal, Offeror(s) warrants that all certifications and documents
requested herein are attached and properly completed and signed.
From time to time, the City may issue one or more addenda to this RFP. Below,
please indicate all Addenda to this RFP received by your firm, and the date said
Addenda was/were received.
Verification of Addenda Received
Addenda No:
Addenda No:
Addenda No:
Received on:
Received on:
Received on:
AUTHORIZED SIGNATURE:
PRINT SIGNER'S NAME AND TITLE:
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CorVel Corporation
Page 21 City of San Bernardino
Workers' Compensation Utilization Review
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Attachment A
CareMC Screenshot
CorVel Corporation
Page 22 City of San Bernardino
Workers' Compensation Utilization Review
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Sample Report-DR Denial Letter
CorVel Corporation
Page 23 City of San Bernardino
Workers' Compensation Utilization Review
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CORVEL
Outpatient Non-Certification Recommendation
8-2-07
John Smith
101 Moffitt St.
San Francisco, CA 94131
CLAIM #: 12345
001: 09/02/1997
CLAIMANT: Smith, John
CORVEL #: 24566334-17
Provider:
Facility:
Pre-cert #:
Treatment being requested:
Treatment Non-Certified:
Treatment approved, if any:
Dear Mr. Smith:
INSURED:
CARRIERlTP
A:
ADJUSTER:
GB / United Airlines
G.II.gher Bassett
Sue Jones
Bob Bones, M D
Feel Good Physical Therapy
Additional Physical therapy I x 6 left elbow
Additional Physical therapy I x 6 left elbow
NONE
CorVel Corporation has been asked by Gallagher Bassett to review the above noted treatment request for
medical necessity and appropriateness. After careful review of the submitted medical information, our
Physician Advisor, Andrew Brooks MD - board certified orthopedic surgeon Lic # G6722 I was unable to
recommend the requested treatment. The Non-Certification determination was made on 8-2-07.
Guidelines used in the determination process: ACOEM, 000
The clinical ~asons regarding medical necessity, or lack of medical necessity, for non-certification:
Date of Report:
Level of Review:
08/02107
Initial
Patient Name:
John Smith
Date of Injury:
Diagnosis:
09/02197
Chronic progressive left cubital tunnel syndrome
Bilateral CTS
Cervical degenerative pain
Bilateral shoulder pain
CorVo' Cotporatlon
www.corvel.com
600 City Parkway West
Suite 700
Ora.... CA 92868
714.385.0J0
866.910.4423
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Surgery:
Left cubital tunnel release and subsequent revision
Bilateral CTR
ACDF
Requested Treatments:
1. Additional PT lx6
Determinations:
1. Non-certification
Medical documentation submitted with this request and reviewed in consideration of this request
includes: .
-07/26/07 PR-2 submitted by Mathias Masem, MD
-07/25107 Outpatient hand therapy discharge summary submitted by Olga Yuzhin, OT
_ 07/25107; Hand therapy evaluation data sheet submitted by Olga Y uzhin, OT
06/11107 ;
05/1 0/07
Data sheet notes consistent improvement in left grip and pinch strength. OT discharge report
notes that claimant has made progress with strength and is diligent and independent with a home
exercise program.
Report dated 07/26/07 notes that claimant is 16 weeks post op and his elbow symptoms have
subsided. Exam notes full elbow motion, slight left medial epicondyle tenderness, and persistent
left hand ulnar intrinsic atrophy. Grip strength is 32# on the left and 38# on the right. Provider
recommends c.ontinued therapy due to continued weakness.
Rationale for Determinations:
Claimant has progressed with motion and strength in 24 post op therapy visits. He is
noted as compliant with and independent in a home exercise program. The necessity of
additional skilled therapy intervention is not evident. Claimant can continue to progress
toward final goals through continued compliance with his home program.
Per ACOEM Guidelines. Chaoterls) 10 and below referenced medical evidence
I. Evidence citations for theraov
ACOEM Guidelines. Chapter 10 (Revised 2007). Page 15 notes that comfort is often a
patient's primary concern. Nonprescription analgesics will provide sufficient pain relief
for most patients with acute and subacute elbow symptoms. If the patient's response to
treatment is inadequate (i.e.. his or her symptoms and activity limitations continue),
pharmaceuticals, orthotics, or physical methods can be prescribed. Co-morbid conditions,
side effects, cost, and provider and patient preferences should guide the health care
professional's choice of recommendations.
CorYe. Col'pOl'atlon
www.corvel.com
600 Cil)' ParkWl)' West
SuilC700
Oranae. CA 92868
114.38S.8500
866.910.44D
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CORVEL
ODG-TWC Elbow Procedure Summary last updated 06/11/2007 provides best practice
physical therapy gu-idelines for ulnar nerve entrapment as that which allows for fading of
treatment frequency (from up to.3 visits per week to I or less), plus active self-directed
home PT, in 20 visits over 10 weeks for post-surgical treatment. To justify ongoing
treatment, even within these guidelines, patients should be formally assessed after a "six-
visit clinical trial" to see if the patient is moving in a positive direction, no direction, or a
negative direction (prior to continuing with the physical therapy). In addition to a "six-
visit clinical trial", every six visits thereafter the treating therapist should validate
improvement in function in order for treatment to continue.
Please note the utilization review process is mandatory and has been done in accordance with California
Labor Code ~4610. The American College of Occupational and Environmental Medicine Practice
Guidelines, second edition, have been utilized in the determination process, as required in Title 8,
California Code of Regulation 9792.6.
Any dispute shall be resol ved in accordance with the provisions of Labor Code section 4062, an objection
to the utilization review decision must be communicated by the injured worker or the injured worker's
attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of
the decision. The 20-day time limit may be extended for good cause or by mutual agreement of the
parties. You may file an Application for Adjudication of Claim and Request for Expedited Hearing,
DWe Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with
sections 10136(b)(I), 10400, and 10408
Should the requestiIlg medical provider have additional pertinent clinical information, which has not
previously been submit'Pod for review, he or she may submit the clinical information to the claims adjuster
for reconsideration of the non-certification determination. Requests for reconsideration need to be sent to
the claims adjuster within 10 days of this determination. Requests for reconsideration do not replace the
objection process noted above.
If you want further information, you may contact the local state Information and Assistance office by
calling the applicable information and assistance district office, numbers below, or you may receive
recorded information by calling 1-800-736-740 I.
You may also consult an attorney of your choice. Should you decide to be represented by an attorney,
you mayor may not receive a larger award, but, unless you are determined to be ineligible for an award,
the attorney's fee will be deducted from any award you might receive for disability benefits. The decision
to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to
receive your benefits.
In accordance with regulation 9792.9(k) should you wish to speak to the reviewing physician regarding
this determination, you can call 714-385-8500 from ]2:00 p.m. to 3:00 p.m. PST, Monday through
Friday. Should the reviewing physician be unable to speak with you, another reviewer who is competent
to evaluate the specific clinical issues involved in the medical treatment services will be made available.
The above noted determination does not release the provider from hislher patient care responsibilities.
This recommendation is for medical necessity and appropriateness and does not confirm or guarantee
C insurance coverage.
CorYe. Corpol'8t1on
WNW.corvel.com
600 City Parkway Well
SUilC700
0...... CA 92868
714.38S.8DJ
866.910.442:1
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Should you have any questions regarding this determination please call the number below between the
hours of 8:30 a.m. and 5:00 p.m. PST, Monday through Friday.
Sincerely,
Utilization Management Department
cc: Office File
Gallagher Bassett, Attn: Sue Jones, P. O. Box 255397, Sacramento. CA 95865
Bob Bones, M D, 101 South San Mateo Drive, Suite 200, San Mateo, CA 94401
Feel Good Physical Therapy 1600 Divisadero St. San Francisco CA 94120
Shari Levy 255 California St., #600 San Francisco CA 94111
Susan Borg 2015 Pioneer Ct. Suite A San Mateo CA 94403
ColVelCorponItIon
WWW.COfVeI.com
600 City Parkway West
5uice7oo
Om>ae. CA 92868
714.385.8SOO
866.910.4423
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Information & Assistance Unit. district offices
Anaheim, 92801
1661 N. Raymond Avenue. Suite 200
(714) 7J8-40J8
Fresno, 93721.2280
2550 Mariposa Street. Room 2035
,(559) 445-5355
,-.. "._--'---, -- .,-_..
! Long Beach, 90802.4460
: 300 Oceangate Street. 3rd Floor
1(562) 590-5240
----"'-"...
I'oxnard 93030
2220 E. Gonzales Rd. Suite 100
(805) 485-3528
Riverside, 92501
3737 Main Street. Room 300
(951) 782-4347
ISan Bernardino, 92401
1464 W. Fourth Street. Suite 239
(909) 383-4522
San Jose, 95113
100 Paseo De San Antonio. Room 240
(408) 277-1292
Bakersfield, 93.101
t800 30th Street. Suite 100
(661) 395.2514
,Grover Beach, 9343.\.2261
, 1562 Grand Avenue
.(805)481.3296
i Los Angeles, 90013
i ;<20 W. 4th St. 9th Floor
:(213) 576-7)89
.. -iP;mona;9i768-
.435 W. Mission Blvd. #300
1(909) 623-8568
----.--...---- - I - -..- ~-_.---..-
I Sacramento, 95825
j2424 Arden Way. Suite 230
(916) 263-2741 .
San Diego, 92102-4402
7575 Metropolitan Road. Suite 202
(619) 767.2082
Santa Rosa, 95404
50 "D" Street. Room 430
(707) 576-2452
CorYe' Corpono_
WWW.CXM.VeI.COfn
Santa Ana, 92701-4701
28 Civic Cenler Plaza, Room 451
(714) 558-4597
Stockton, 95202-2314
31 East Channel Street, Room 450
1(209) 948-7980
600 Cit)' Parkway West
Sui~700
Qranae. CA 92868
Eureka, 95501.0421
100 "W Street. Room 201
(707)441-5723
Goleta, 93117
6755 Hollister Avenue
(805) 968-4158
'Oakland,94612
! 1515 Clay Street6th Floor
1(510)622.2861
---- -I Redding, 96001-2796
12115 Akard, Room 21
(530) 225-2047
~alinas; 93906.3487
1880 North Main Street, Suite 100
(831)443-3058 .
San Francisco, 94102
455 Golden Gate Avenue, 2nd Floor
1(415) 703.5020
Santa Monica, 90405
2701 Ocean Park Blvd, Suite 222
(310) 452-1188
Van Nuys, 91401.3373
6150 Van Nuys BI vd.. Room 105
(818) 901-5367
1).4.385.8500
866.910.4423
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PROOF OF SERVICE
I am a citizen of the United Stares and a resident of the County of Orange; I am over the age of
eighteen years and not a party to the within entitled action; my business address is 600 City
Parkway West, Suite 700, Orange, CA 92868.
On 8-2-07, I served the within letter(s) on the parties in said action, by sending a true copy
thereof electronically on the following parties:
Gallagher Bassett, Attn: Sue Jones
EMAIL: Sue_Jones@gbtpa.com
Bob Bones, M D
FAX: (650) 342-2937
Feel Good Physical Therapy FAX: 0 -415-353-9643
Executed on 8-2-07, at Orange, Orange County, California.
I, Lauren Ott, declare under penalty of perjury, under the laws of the STATE OF CALIFORNIA,
that the foregoing is true and correct.
Signature
File: 2455337-17 Smith
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CORVEL
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Attachment C
Sample Report-Certification Letter
CorVel Corporation
Page 24 City of San Bernardino
Workers' Compensation Utilization Review
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CORVEL
Outpatient Certification Recommendation
01-21-07
Joe, MD.
12345 Me Bean Parkway Suite E-21
Valencia, CA 92222
Fax 800-555-5671
CLAIM #:
DOl:
CLAIMANT:
CORVEL #:
5555-00-05555
04/24/1997
Jess Smith
2461000-1
Pre-cert #:
Treatment requested:
Facility
Dear Dr. Joe, M 0:
INSURED:
CARRIER!TPA:
ADJUSTER::
Y ouDo
ABC Insurance Services
Joe Doe
2461000-1
Photodynamic therapy with Levulan
Aesthetic Surgery and. Laser Medical center
CorVel Corporation has been asked by ABC Insurance Services to review the above noted
treatment request for medical necessity and appropriateness. After careful review of the
submitted medical information, the requested treatment has been certified. The Certification
decision is summarized below:
ICD-9 Code:
Diagnosis:
CP-I' Code:
Requested Treatment:
Recommended Treatment:
Number of Visits approved:
Certification Valid From: .
702.0
Actinic keratosis
96567,J7308
Photodynamic therapy with Levulan
Photodynamic therapy with Levulan
I
01-21-07 To 02-28-07
To obtain a review for continued treatment after the above noted certification period, please call
CorVel Corporation at the number below. Our hours of operation are from 9:00 a.m. to 5:30
p.m. PST, Monday through Friday.
CcNY" Co......tlon
www.corveI.com
600 Cily Parkway West
Sutle 700
OraDF. CA 92868
714.385.8lOO
714.385.878'
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CORVEL
Please note this review has been done in accordance with California Labor Code Section 4610
and the American College of Occupational and Environmental Medicine Practice Guidelines,
second edition, have been utilized in the determination process.
Sincerely,
Utilization Management Department
cc: Office File
ABC Insurance Services, Attention: Joe Doe, POBox 14, Orange, CA 96541
***This recommendation is for medical necessity and appropriateness and does not confum or
guarantee insurance coverage.***
**NOTE**
Please attach a copy of this recommendation letter
with your bill; otherwise, payment may be
delayed.
CorVeI c:o.poratlon
WWW.corvel.com
600 City Parkway WeSI
Suite 100
Orans:e. CA 92868
714.)B5.8SOO
714.385.8785
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Attachment D
Information Request Letter
CorVel Corporation
Page 22 City of San Bernardino
Workers' Compensation Utilization Review
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CORVEL
8-14-07
Received from Intercare Insurance Services on 08/13/2007
John Doe, M. D.
I 2345Crenshaw Blvd., # I 00
Torrance, CA 90505
Fax 310-555-1817
Team Post op fax 7 I 4-434-6071
CLAIM #: 3000-008-01234
001: 0711511997
So we may expedite your UR request,
please attach copy of this letter with your
documentation & return within 48hours.
Your rom t res ose is a reciated..
INSURED: 390-Ffre Dept
CARRIER!TPA Intercare Insurance Services
CLAIMANT: J obn Doe
CORVEL#: 2467414-1
ADJUSTER:
Jane Doe
Dear Dr. Smith, M. D.:
We have been asked by Frank Tiongson of Intercare Insurance Services to provide utilization review of
your recent request for certification of Sling Shot 11, Game Ready Control Unit and Game ready
shoulder pad. Additional information is necessary to reach a determination of the medical necessity of
your request. Please submit reasonably necessary medical information as follows within 48 hours:
181 Most currenlPR2
o Hist"ry & physical
o Prior treatment/response
o Operative/procedure report(s)
o Laboratory results
o Any available diagnostic studies
181 Initial evaluationIProgress reports
o CPT and ICD9 codes
o Current treatment plan
o Plans for discharge
o Number of visits to date
o Start of care date
181 Op report?
o
The utilization review process cannot begin until we receive this requested information. To
expedite the review, you may fax directly to CorVeI at 866-434-3840.
This notificatfonis in compliance with Labor Code ~46 I O. If you have any questions or if we may be of
further assistance, please contact CorVel at the number below.
Sincerely,
Utilization Mamigement Department
cc: Office/Case File
Intercare Insurance Services, Attn: Frank Tiongson, POBox ] 4243, Orange: CA 92863
Team Post Op 2909 Tech Center Drive Santa Ana CA 92705
Co"'.I~
www.corvel.com
600 City Parkway West
SuillC 100
0...... CA 92868
714.385.8500
866.910.4423
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CORVEL
8-14-07
John Doe
1234 Street Trail Street
Ontario.CA 91761
CLAIM#:
001:
3000-98-01214
0711511997
INSURED:
CARRIER/TPA
390-Fire Dept
Interc~re Insurance Services
CLAIMANT:
CaRVEL #:
John Doe
2467414- I
Frank Tiongson
ADJUSTER:
Dear Mr. Doe:
We have been asked by Frank Tiongson of Intercare Insurance Services to provide utilization review of a
recent request by your provider for Sling Shot 11, Game Ready Control Unit and Game ready
shoulder pad. . Please be advised that there will be a delay in ~ur determination as to the medical
necessity of this request while we await additional reasonably necessary medical information from Joe
Smith. M. DI Team Post op.
No further action can be taken on this request until this information is received. Once submitted, the
utilization review process will begin. This notification is in compliance with California Labor Code
~461O.
Sincerely.
Utilization Management Department
cc: Office/Case File
Intercare Insurance Services. AUn: Frank Tiongson. POBox 14243. Orange. CA 92863
Team Post Op 2909 Tech Center Drive Santa Ana CA 92705
CorY" Corporation
www.corvel.com
600 City Pad;.way West
Suitt: 700
Orance. CA 92868
714.38S.85OO
866.910.4423
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CorVel Corporation
Attachment F
DR Work-flow
Page 27 City of San Bernardino
Workers' Compensation Utilization Review
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No Peer Review
or Delay
1-5 Days
~
- Meets
=-;, Guidelines
_.':~', Certified
DR Workflow
Q
Proper Medical
Records
Meets I I
Guidelines I:: c....
Certified ::-'"'
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Certification
or Denial
E1J ~nt
G Day of Request from Provider
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Review Referral
.
Day I
Review records
D..
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Refer to
Peer Review
I-I Denied
=-.
Medical ReCOprdS ~.
Needed '.,
,.,.-' ;Slr
FaxlMail request to
Provider - email to
.': ::1 adjuster 'MJ
Review Medical
~ Records
G)
Peer Review
& or Delay
1-5 Days
II Meets
=-.'", Guidelines
-"..." Certified
. Refer to
_. Peer Review
~
I
Meets I I
Guidelines =- '.
Certified ::",\
i
I ~ilr:-nied
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UJ#'- .,
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Certification
or Denial
~nt
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Attachment G
The City of San Bernardino Contract Review
CorVel Corporation
Page 28 City of San Bernardino
Workers' Compensation Utilization Review
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City of San Bernardino
Request for Proposal F-07-54
Workers' :Compensation Utilization Review
CorVel's Contractual Exceptions
Section III. General Conditions: Insurance l(d) CorVel ("Contractor")
can provide insurance,certificate and any endorsements, but cannot
provide any form of the insurance policy.
Terms CorVel ("Contractor") would like included'in contract:
REPRESENTATIONS, WARRANTIES AND COVENANTS OF THE CITY
A. Authority. The City represents and warrants thai (i) it has all necessary corporate power and
authority to enter into this Agreement and to perform its obligations hereunder, and the execution
and delivery of this Agreement and the consummation of the transactions contemplated hereby
have been duly authorized by all necessary corporate actions on its part, (ii) this Agreement
constitutes a legal, valid and binding obligation of The City, enforceable against it in accordance
with its terms, and (iii) the execution. delivery and performance of this Agreement will not
constitute a violation of any judgment, order or decree or a breach of a material agreement that
would materially impair or prevent The City from complying with its obligations under this
Agreement.
B. Authorizations. The City represents and warrants that (i) it has obtained or shall obtain such
authorizations or approvals as are required for Contractor to perform the services described in this .
Agreement, irdnding but not limited to receiving and disclosing patient-specific data ~.
contemplated hereunder, (ii)- it shall maintain the compliance of its workers' compensation
program under all applicable laws, (iii) it has obtained and shall maintain during the Term any
regulatory approval needed in order for Contractor to perform its obligations hereunder, and (iv)
it shall promptly notify Contractor if any such approval is terminated, suspended or otherWise
materially limited. .
C. Non-Solicitation. The City agrees that during the Term of this Agreement and for a period of
one (I) year after any expiration or termination thereof, The City shall not, directly or indirectly.
recruit or- solicit for employment, employ or in any manner engage the services of or otherwise
interfere - with the employment relationship of any Contractor employee who was in any way
involved in providing services to The City pursuant to the Agreement without the prior written
consent of Contractor. In the event The City breaches this covenant of non-solicitation and non-
employment, Contractor shall be entitled to recover the amount of one (I) times annual salary per
employee from The City as liquidated damages. The parties acknowledge that Contractor's actual
damages in the event of such a breach by The City would be extremely difficult or impracticable
to determine and acknowledge that this liquidated damages amount has been agreed upon as a
reasonable estimate of Contractor's damages and as Contractor's exclusive remedy against The
City in the event of a breach of this Section 3D by The City. The parties further agree that in any
action brought on account of any alleged breach of this covenant, the prevailing party shall be
entitled to recover its reasonable attorney's fees and costs.
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REPRESENTATIONS, WARRANTIES AND COVENANTS OF CONTRACTOR
A. Authoritv. Contractor represents and warrants that (i) it has all necessary corpomte power and
authority to enter into lhis Agreement and to perform its obligalions hereunder, and the execution
and delivery of this Agreement and the consummation of the transactions c011lemplated hereby
have been duly authorized by all necessary corporate actions on its part, (ii) this Agreement
constitutes a legal, valid and binding obligation of Contractor, enForceable against it in
accordance with its terms, and (iii) the execution, delivery and perFormance of this Agreement
will not constitute a violation of any judgment, order or decree or a breach of a material
agreemenl that would materially impair or prevent Contraclor from complying with its
obligations under this Agreement.
B. Performance. Contractor represents and warrants that (i) it has the necessary knowledge,
skills and experience to provide and perform the Managed Care Services in accordance with the
Agreement, and (ii) it will perForm the Managed Care Services in a diligent, professional and
workmanlike manner using an appropriate number of properly trained and qualified individuals
and in accordance with applicable industry standards;
DISCLAIMERS .
A. Coverage and ComDensabilitv. CONTRACTOR IS NEITHER A HEALTH CARE
PROVIDER NOR A CLAIMS ADMINISTRATOR AND CONTRACTOR DOES NOT MAKE
FINAL DETERMINATIONS REGARDING THE COVERAGE OR COMPENSABILITY OF
HEALTH CARE SERVICES RENDERED BY HEALTH CARE PROVIDERS TO INJURED
PERSONS. THE SERVICES PROVIDED BY CONTRACTOR UNDER THIS AGREEMENT
ARE ADVISORY ONLY AND ARE PROVIDED SOLELY TO FACILITATE THE CITY'S
BUSINESS OPERATIONS. THE CITY AND THE CITY'S EMPLOYEES AND/OR AGENTS
HAVE THE OPTION TO ACCEPT OR REJECT ANY ADVICE OFFERED BY
CONTRACTOR HEREUNDER. CONTRACTOR DOES NOT MAKE DETERMINATIONS
RELATING TO THE CITY'S BUSINESS, INCLUDING, BUT NOT LIMITED TO, THOSE
REGARDING THE COVERAGE UR COMPENSABILITY OF HEALTH CARE SERVICES.
THE CITY SHALL RETAIN FULL RESPONSmILITY FOR ALL FINAL
DETERMINATIONS REGARDING THE PAYMENT OF POLICY BENEFITS.
B. Healthcare Authoritv. CONTRACTOR AND ITS AGENTS HAVE NO AUTHORITY TO
CONTROL OR DIRECT THE HEALTH CARE SERVICES PROPOSED FOR OR PROVIDED
TO INJURED PERSONS. THIS AUTHORITY SHALL LIE ONLY WITH THE INJURED
PERSON AND HISIHER TREATING PHYSICIAN IN ANY CASE, AND THOSE
INDIVIDUALS MAY ACCEPT, REJECT OR MODIFY ANY ADVISORY
DETERMINATIONS MADE BY CONTRACTOR OR ITS AGENTS, EXCEPT INSOFAR AS
STATE WORKERS' COMPENSATION LAWS MAY REQUIRE THEM TO FOLLOW THE
DETERMINATIONS OF THE CITY, THE CITY'S AGENTS, A WORKERS'
COMPENSATION JUDGE OR REVIEW PANEL, OR ANOTHER THIRD PARTY.
C. No Interference with Practice of Medicine. Neither Contractor nor The City shall ilttempt to
directly or indirectly, to control, direct or interfere with the practice of medicine by any health
care provider.
CONFIDENTIALITY
A. Definition of Confidential Information. "Confidential Information" shall mean any non-
public data, information and other materials regarding the products, services or business of a
party (and/or, if either party is bound to protect the confidentiality of any third party's
information. of a third party) provided to either party by the other party where such information is
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marked or otherwise communicated as being "proprietary" or "confidential" or the like, or where
such information should, by its nature, be reasonably considered to be confidential and/or
proprietary. Without limiting the foregoing, the parties agree that (i) the CareMC Application,
Documentation, Contractor Content (as defined in the in the CareMC License Agreement) and all
software, source code, source aocumentation, inventions, know-how, and ideas, updates and any
documentation and information relating thereto constitutes Confidential Information of
Contractor, (ii) the The City Data (as defined in the CareMC License Agreement) constitute
Confidential Information of The City, and (iii) this Agreement, the Exhibits and Schedules
attached hereto, and the terms and conditions set forth herein and therein are Confidential
Information of both parties.
B. Disclosure and Use of Confidential Information. The Confidential Information disclosed by
either party (UDisclosin2 Partv") to the other ("Receivin!! Partv") constitutes the confidential and
proprietary information of the Disclosing Party and the Receiving Party agrees to treat such
Confidential Information in the same manner as it treats its own similar proprietary information,
but in no case will the degree of care be less than reasonable care. The Receiving Party shall use
the Confidential Informati9n of the Disclosing Party only in performing 'under this Agreement
and shall retain the Confidential Information in confidence and not disclose it to any third party
(except as authorized under this Agreement) without the Disclosing Party's express written
consent. The Receiving Party shall disclose the Disclosing Party's Confidential Information only
to those employees and contractors of the Receiving Party who have a need to know such
information for the purposes of this Agreement, and such employees and contractors must be
bound by this Agreement or have entered into agreements with the Receiving Party containing
confidentiality provisions covering the Confidential Information with terms and conditions at
least as restrictive as those set forth herein.
C. ExceptiolJ~. Notwithstanding the foregoing, the parties' confidentiality obligations hereunder
shall not apply to information which: (i) is already known to the Receiving Party prior to
disclosure by the Disclosing Party, (ii) becomes publicly available without fault of the Receiving
Party, (Hi) is rightfully obtained by the Receiving Party from a third party without restriction as to
disclosure, (iv) is approved for release by written authorization of the Disclosing Party, (v) is
developed independently by the Recei ving Party without use of or access to the Disclosing
Party's Confidential Information, or (vi) is required to be disclosed by law, rule, regulation, court
of competent jurisdiction or governmental order, provided, however, that the Receiving Party
shall advise the Disclosing Party of the Confidential Information required to be disclosed
promptly upon learning thereof in order to afford the Disclosing Party a reasonable opportunity to
contest, limit or assist the Receiving Party in crafting the disclosure, and then such disclosure
shall be made only to the extent necessary to satisfy such requirements.
D: Use of Data. Nothing shall prohibit Contractor from using aggregate, non-identifying,
statistical data generated through its customers', including The City, use of the CareMC
Application and Online Services for marketing purposes, provided that Contractor shall not use or
disclose any such data or information in a manner that would reveal the identity of, or other
confidential information concerning, The City. Such aggregate, non-identifying statistical data
could include, without limitation, statistics regarding usage of the CareMC Application and
Online Services, the number of case referrals generated through the CareMC Application and
Online Services and the efficiencies gained by Contractor customers through their use of the
CareMC Application and Online Services.
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Attachment H
Workers Comp Insurance
CorVel Corporation
Page 29 City of San Bernardino
Workers' Compensation Utilization Review