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7553 - Amendment 4 Executed DocuSign Transmittal Coversheet File Name Purchasing Contact Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E 7553 Gallagher Bassett Third Party Administrator - Amendment Christina Dormady Procurement 901 B Texas St., Denton, TX 76209  (940) 349-7100 OUR CORE VALUES Inclusion  Collaboration  Quality Service  Strategic Focus  Fiscal Responsibility March 3, 2025 Gallagher Bassett Services, Inc. 4121 International Parkway Suite 2030 Carrollton, TX 75007 Re: File # 7553 – Third Party Administrator, Amendment 4 Dear Stephanie, Thank you for being such a valued partner. By signing this Amendment below, COD and Gallagher Bassett Services, Inc. agree that the Contract is hereby deemed amended to the updated Schedule of Charges, as shown in Attachment A. Except as amended by this Amendment, the Contract is not otherwise amended and all other terms and conditions of the Contract remain in full force and effect, as amended hereby. This Amendment may be executed in any number of counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures transmitted electronically shall have the same effect as the delivery of original signatures. The City of Denton reserves the right to re-evaluate pricing as the market conditions change and can ask your firm to provide updated proposed pricing, including, but not limited to, a decrease in pricing, as a result of any such change. We look forward to future business with your firm. Regards, ____________________________ ___________________________ Christina Dormady, Buyer Stephanie Renguso Procurement or Authorized Representative City of Denton Gallagher Bassett Services, Inc. Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E FEE PER CLAIM - LIFE OF PARTNERSHIP Est. ClaimFrequency Per ClaimFee ProjectedService Fee Workers' Compensation WC Medical Only 96 $182 $17,472 WC Indemnity (TX) 42 $1,132 $47,544 Incidents - Workers' Compensation 2 $56 $112 Total Workers' Compensation Fee Per Claim 140 $65,128 ADMINISTRATIVE SERVICES Quantity Rate Fee Administrative Services Administration / Data Management $5,517 RMIS Standard License (2 RMIS Users) $1,250 RMIS Additional Full-Access Users 0 $1,000 $0 RMIS Additional View-Only Users 0 $500 $0 Total Administrative Services $6,767 TOTAL USD $71,895 This is a one-year contract with a 4% increase in per-claim and administrative fees.There is no fee for monthly data feeds to the City's RMIS vendor, Origami. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 1 Attachment A Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E LIFE OF PARTNERSHIP ASSUMED CLAIMS HANDLING FEES SERVICE Est. ClaimFrequency Per ClaimFee ProjectedService Fee Workers' Compensation WC Indemnity (FL, NY, OH, TX) 6 Included Total 6 $0 TOTAL FEES FOR ASSUMED CLAIMS: $0 The per-claim fees quoted for handling Assumed claims is a one-time, Year 1 only cost. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 2 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E GBCARE MEDICAL MANAGEMENT SERVICES SERVICES CHARGES Fee Schedule (Bill Review / UCR) $9.50 Per Bill All Other Savings •System Savings •Clinical Validation/Nurse Review (CV) •Preferred Provider Networks (PPO) •Out Of Network (OON) •Specialty Networks/PhysicalTherapy (PT) 28 % of Savings 28 % of Savings 28 % of Savings 28 % of Savings 28 % of Savings $30,000 per bill cap on fees Electronic Receipt of Medical Bills $2 additional Per Bill Telephonic Case Management $90 Medical Triage one time per file $340 per claim (each 30 days) Utilization Review Program $115 Outpatient Pre-Certification Letter Only Authorization Program - Included at no charge UR Physician Review $270 per Review California UR IMR Processing $125 per IMR Request Medical Case Management and Vocational Rehabilitation - Hourly $115 per hour plus expenses $135 per hour plus expenses - AK, CA, HI, NY $175 per hour plus expenses Complex or CAT cases $225 per hour plus expenses CAT - AK, CA, HI, NY Priority Care 365 $95 per call - Language line charges apply where utilized Other State Services: •California MPN Service •IIIinois PPP Service •New York PPO Service • Texas HCN Service For claims handled in the designated states (otherwise,Not Applicable) No additional fees beyond the normal Cost & Terms No additional fees beyond the normal Cost & Terms No additional fees beyond the normal Cost & Terms Percent of savings: 9.5% of total savings to include bill review, network access & Nurse triage. •West Virginia MHCP Service Medical Cost Projection (MCP) and Clinical Recommendations $150 per hour Pharmacy Benefit Management (PBM) Cost of prescriptions -- no charge for Bill Review or PPO reductions for PBM transactions City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 3 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E SERVICES CHARGES Durable Medical Equipment (DME) Program Cost of medical equipment - no charge for Bill Review or PPO reductions for Prospective DME transactions Dental Review Program Charged on a per review basis Client and GB agree as follows: If a vendor other than the GBCARE Medical Management Services preferred vendor is utilized, an administrative fee may apply in exchange for bona fide administrative services. The administrative services may include, but not be limited to overhead costs for the oversight and management of medical management vendors which includes the development and oversight of quality standards, development and maintenance of EDI interfaces and reports, and ensuring proper mandatory state compliance and reporting. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 4 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E OTHER SERVICES SERVICES CHARGES RMIS Additional Users (RMIS Standard License includes a set number of Full Access Users outlined under Administrative Services, and unlimited use of GB standard scheduled training classes) RMIS View-only User, $500 annually per user RMIS Full Access User, $1,000 annually per user Loss control $150 per hour OSHA Reporting $6,000, OSHA platform to produce compliant OSHA 301 Report, 300 and 300a Logs. If electronic OSHA reporting is required, an additional fee will be charged. Oversight and accuracy of all OSHA data is the responsibility of the employer prior to posting or submitting to OSHA. Subrogation and Recovery 20% of net recovery amount less legal and collectionsexpense based on recovery date Recoveries include subrogation, credits, lien waivers, filetransfer (based on lien to date at time of transfer), andcontribution or coverage handled in a separate action. Applies to all coverage types Gallagher Bassett Investigative Services (GBIS) Special Fraud Investigations - SIU, Outside Field Investigations, Surveillance Investigations, Targeted Field Investigations Prevailing hourly rate plus expenses Targeted Database Searches, Self Service Database Searches Prevailing rate per report Gallagher Bassett Litigation Management Program (GBLMP) Invoice and Matter Management platform for adjusters/counsel If utilized, 2% of net legal invoice (invoice net of disbursements and invoice review savings). Charged as discount off total payment remitted to counsel and will be reflected as an allocated expense on the claim file. 5 client licenses for Legal Analytics platform Attorney-led legal bill review Gallagher Bassett Compliance Services (GBCS) Medicare Set-Aside Services: Allocation, CMS Submission, Medicare Eligibility Inquiry (MEI), SSDI Verification, Medical Cost Projection (MCP) Prevailing rate per each service Rush fees apply for MSA completed within 5 business days MSA Revision fees apply Medicare Secondary Payer Services: BCRC Notification, Conditional Payment Research (CPR), Conditional Payment Negotiations (CPN), Conditional Payment Notice Evaluation, Conditional Payment Dispute, Securing Final Demand for Settlement (SFD), Release / Settlement Agreement Review, Lien Research and Resolution (Advantage Plan, Medicaid, Part D) Prevailing rate per each service Taxes Taxes All applicable taxes will be added to the service fees whererequired City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 5 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E PROGRAM SPECIFIC TERMS AND CONDITIONS 1. Claim Count Reconciliation: •Actual - Claims will be reconciled and billed monthly for the first 18 months and then at the 24th month and thenevery 12 months thereafter. 2. Billing and Payment Terms: Fees will be billed monthly during the service period. 3. Claim Pricing Terms: Life of Partnership: Claims will be handled for the life of the partnership with no additional per claim fees. If the client decides to non- renew all or a portion of the program, all open files will be handled in one of the following two ways: - GB will return the files to the client (contingent upon Carrier approval) at the client's expense. - GB will continue to handle the open files at our prevailing annual rate per year open. Assumed Claims: Life of Partnership: Claims will be handled for the life of the partnership with no additional per claim fees. If the client decides to non- renew all or a portion of the program, all open files will be handled in one of the following two ways: - GB will return the files to the client (contingent upon Carrier approval) at the client's expense. - GB will continue to handle the open files at our prevailing annual rate per year open. Additional Charges: There will be additional charges for ongoing Data Management (RISX-FACS®), RMIS users, Administration, Banking fees and monthly reports for as long as GB handles claims. 4. Account Administration includes the following: •Client Services •Client Accessible Dashboards & Reports via GB’s RMIS & Analytics Platform •4 Claim Strategy Meeting(s) •1 Stewardship Meeting(s) •Detailed Status Reports All Lines of Business @ $50,000 •Settlement Consultation All Lines of Business @ $15,000 •Loss Fund /Banking Services (SIMMS) •Claim Reporting •Data Transfer to Carrier(s) •Data Transfer to Other •Acknowledgement Letter to Injured Employee WC •Acknowledgement Letter to Claimant Liab 5. Claim Charges: Claim and incident fees will be assessed on a per occurrence, per claimant, per line of coveragebasis. 6. This material is the proprietary, confidential property of Gallagher Bassett Services, Inc. It has been provided to you for the sole purpose of considering a quote for claims administration services. It is not to be duplicated or shared in any form with anyone other than the individuals of such prospective client that have a business need to know the information. It must be destroyed or returned to Gallagher Bassett Services, Inc. after its intended use. 7. Gallagher Bassett Services, Inc. will not pay a fee, commission, or rebate to any party for the privilege of presentingour proposal or in order to secure the awarding of any program to Gallagher Bassett Services, Inc. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 6 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E PROGRAM SPECIFIC TERMS AND CONDITIONS 8. Pricing is based on using GBCARE Medical Management Services preferred vendors for Bill Review, PPO, out-of- network, utilization review, telephonic case management, MSA and field case management. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 7 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E GENERAL CONTRACT TERMS AND CONDITIONS 1. Independent Adjusters - If applicable, following any significant loss as a result of a single event (hurricane, tornado, flood, earthquake, etc.), GB reserves the right to retain outside resources (adjusters) when appropriate and those fees will be paid as an Allocated Expense off the file. 2. The pricing quoted in this Cost & Terms is based upon the data and information provided by Client, as well as existing legislative and regulatory requirements. Material inaccuracies or changes to the foregoing may require adjustments to the quoted pricing. 3. Taxes - All applicable taxes will be added to the service fees where required. 4. Allocated Expenses: Shall be your responsibility as applicable and shall include, but not be limited to: •Legal Fees•Legal Bill Review•Medical Examination•Professional Photographs•Travel made at client's request•Costs for witness statements•Court reporter service, translation, and interpretation•Record retrieval and copying services (Including medical and legal) •Accident reconstruction •Experts' rehabilitation costs •Chemist •Fees for service of process •Collection cost payable to third parties on subrogation •Architects, contractors •Engineer •Any other similar cost, fee or expense reasonably chargeable to the investigation, negotiation, settlement or defense of a claim or loss which must have the explicit prior approval of the client•Police, fire, coroner, weather, or other such reports•Property damage appraisals •Vehicle appraisals (vehicle damage assessment) •SIU, surveillance and sub rosa investigation•Official documents and transcripts•Pre- and post-judgment interest paid •Outside Field Investigations •Subrogation at 20% of net recovery •Index Bureau Reporting (All Coverages)•Second Injury Fund Recovery •Data Intelligence Self-Service Reports •Medical Management - Medical Management services may include, but are not limited to: - Preferred provider organization networks - Utilization review services - Automated state fee scheduling - Light duty/return-to-work programs - Medical case management and Vocational rehabilitation network - Prospective injury management services - Hospital bill audit services City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 8 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E DEFINITIONS Incidents An incident is a loss reported electronically through ClaimLine and/or the Web, or set up manually at the branch. GB will review the incident and make a courtesy call (if necessary) to determine if it is a claim or incident. GB will have full discretion in the determination and handling of these incidents and/or their conversion into claim status. Workers' Compensation - Medical Only Claims A work-related Claim that meets all of the following criteria: •Payments for either indemnity or vocational rehabilitation were not required •The Claim has not become contested or in suit•No investigation required to determine compensability or subrogation requirements •No loss notices, captioned reports, client meetings (other than routine meetings where the claim is listed and noted) or settlement consultation approvals were required•Payments on the Claim do not exceed $5,000 •Days open do not exceed 180 days Workers' Compensation - Indemnity Claims A work-related claim that is not a Medical Only Claim. City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 9 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E ACKNOWLEDGEMENT OF COST & TERMS The undersigned parties acknowledge and agree that this Cost & Terms is effective for the service period stated above. Notices to Gallagher Bassett Services, Inc. should be directed to: Gallagher Bassett Services, Inc. 2850 Golf Road Rolling Meadows, Illinois 60008-4050 Attn: Legal Department Email: GB-Contracts@gbtpa.com ACCEPTED AND AGREED TO BY: ACCEPTED AND AGREED TO BY: GALLAGHER BASSETT SERVICES, INC. City of Denton, TX By: _____________________________ By: _____________________________ Print Name: ______________________ Print Name: ______________________ Title: ____________________________ Title: ____________________________ Date: ____________________________ Date: ____________________________ City of Denton, TX 01/06/2025 - 01/06/2026 Cost & Terms 100444.2 20250221171018 Page 10 Docusign Envelope ID: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E Stephanie L. Renguso Corporate Counsel 3/3/2025 Buyer 3/7/2025 Christina Dormady Certificate Of Completion Envelope Id: 36C0169D-FAD7-4695-A0B4-DE9073ED6C4E Status: Completed Subject: ***Purchasing Approval*** 7553 Gallagher Bassett Third Party Administrator - Amendment Source Envelope: Document Pages: 12 Signatures: 4 Envelope Originator: Certificate Pages: 5 Initials: 3 Christina Dormady AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) 901B Texas Street Denton, TX 76209 christina.dormady@cityofdenton.com IP Address: 198.49.140.104 Record Tracking Status: Original 3/3/2025 9:18:41 AM Holder: Christina Dormady christina.dormady@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Christina Dormady christina.dormady@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Completed Using IP Address: 198.49.140.104 Sent: 3/3/2025 9:21:18 AM Viewed: 3/3/2025 9:21:47 AM Signed: 3/3/2025 9:21:58 AM Electronic Record and Signature Disclosure: Not Offered via Docusign Lori Hewell lori.hewell@cityofdenton.com Purchasing Manager City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.104 Sent: 3/3/2025 9:22:00 AM Viewed: 3/3/2025 9:47:09 AM Signed: 3/3/2025 10:10:03 AM Electronic Record and Signature Disclosure: Not Offered via Docusign Marcella Lunn marcella.lunn@cityofdenton.com Senior Deputy City Attorney City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 3/3/2025 10:10:05 AM Viewed: 3/3/2025 5:09:58 PM Signed: 3/3/2025 5:13:47 PM Electronic Record and Signature Disclosure: Not Offered via Docusign Stephanie L. Renguso steph_renguso@gbtpa.com Corporate Counsel Security Level: Email, Account Authentication (None)Signature Adoption: Pre-selected Style Using IP Address: 75.35.40.212 Sent: 3/3/2025 5:13:49 PM Viewed: 3/3/2025 10:31:56 PM Signed: 3/3/2025 10:35:56 PM Electronic Record and Signature Disclosure: Accepted: 3/3/2025 10:31:56 PM ID: 61af3e0e-c9d1-4992-81fb-642bae2614ca Signer Events Signature Timestamp Megan Gilbreath Megan.gilbreath@cityofdenton.com HR Director City of Denton - Human Resources Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.104 Sent: 3/3/2025 10:35:59 PM Resent: 3/4/2025 1:52:30 PM Resent: 3/7/2025 1:03:16 PM Viewed: 3/7/2025 1:03:40 PM Signed: 3/7/2025 1:10:46 PM Electronic Record and Signature Disclosure: Not Offered via Docusign Christina Dormady christina.dormady@cityofdenton.com Buyer City of Denton Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style Using IP Address: 198.49.140.10 Sent: 3/7/2025 1:10:48 PM Viewed: 3/7/2025 1:16:49 PM Signed: 3/7/2025 1:16:53 PM Electronic Record and Signature Disclosure: Not Offered via Docusign In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Cheyenne Defee cheyenne.defee@cityofdenton.com Procurement Administration Supervisor City of Denton Security Level: Email, Account Authentication (None) Sent: 3/7/2025 1:16:56 PM Electronic Record and Signature Disclosure: Not Offered via Docusign Witness Events Signature Timestamp Notary Events Signature Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 3/3/2025 9:21:18 AM Envelope Updated Security Checked 3/3/2025 9:26:00 AM Envelope Updated Security Checked 3/3/2025 9:26:00 AM Certified Delivered Security Checked 3/7/2025 1:16:49 PM Signing Complete Security Checked 3/7/2025 1:16:53 PM Completed Security Checked 3/7/2025 1:16:56 PM Payment Events Status Timestamps Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, City of Denton (we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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