Ill. Admin. Code tit. 50, pt. 2907, app A
Field # | Data Field | Data Definition | Date Based On: |
1 | Company NAIC # | Character value 5 digits "00000" | |
2 | Company FEIN | Character value 10 digits "00-0000000" | |
3 | Company Name | Character value any length | |
4a | Company Contact Name | Character value any length | |
4b | Company Contact Phone Number | Character value "(000) 000-0000" | |
5 | Company Contact email | Character value any length | |
6 | # of claims opened | A claim received by the insurer during the survey period | Claims opened |
7 | # of reported medical only claims | The number of claims reported in field #6 in which recovery was limited to medical expenses only | Claims opened |
8 | # of contested claims | The number of claims reported in field #6 in which resolution was delayed due to a dispute regarding policy language or in which litigation was involved | Claims opened |
9 | # of claims for which the employee has attorney representation | The number of claims that are opened during the survey period in which the insurer has received notice that the employee has retained legal counsel | All claims |
10a | # of claims with lost time and # of claims for which temporary total disability was paid | a) The number of claims that are opened during the survey period in which the employee incurred time off of less than 3 working days | Claims opened |
10b | b) The number of claims that are opened during the survey period in which the employee incurred time off of between 3 and 14 calendar days | ||
10c | c) The number of claims that are opened during the survey period in which the employee incurred time off of greater than 14 calendar days | ||
11 | # of claim adjusters employed to adjust workers' compensation claims | The total number of person hours allocated to adjust workers' compensation claims received by the company during the survey period | All claims |
12 | # of claims for which temporary total disability was not paid within 14 days from the first full day off, regardless of reason | The number of temporary total disability claims that are opened during the survey period in which temporary total disability benefits were not paid within 14 days from the first full day off, regardless of reason | Claims opened |
13a | # of medical bills paid 60 days or later from date of service | a) The total number of medical bills paid during the survey period when the time between the date of service and the date paid was greater than 60 days | All claims |
13b | The average days paid on those paid after 60 days for the previous calendar year | b) The average number of days for all claim payments identified in field #13a | All claims |
14a | # of claims in which in-house defense counsel participated | a) The total number of claims open at any time during the survey period in which internal counsel was utilized | All claims |
14b | Total amount spent on in-house legal services | b) Total expenses (actual or estimated) applied to all internal defense counsel activities associated with the claims reported in field #14a | All claims |
15a | # of claims in which outside defense counsel participated | a) The total number of claims open at any time during the survey period in which external (i.e., outside) defense counsel was utilized | All claims |
15b | Total amount paid to outside defense counsel | b) Total expenses (actual or estimated) applied to all external defense counsel activities associated with the claims reported in field #15a | All claims |
16a | Total amount billed to employers for bill review | a) The total amount of fees billed to employers in connection with all medical bill review services provided by the insurer during the survey period: 1) Review individual bills and identify charges in excess of the Workers' Compensation Commission Fee Schedule. 2) Review individual bills and identify improperly applied Managed Care discount. 3) Review individual bills and identify medically unnecessary procedures. 4) Review individual bills and identify improperly coded medical procedures. 5) Review individual bills and identify medical providers who provide excessive utilization of their services. 6) Review individual bills and identify medical procedures not covered by the Workers' Compensation Commission Fee Schedule. 7) Review bills and identify duplications. 8) Re-price pharmaceutical services based on a reliable method. 9) Track prescription usage and alerts concerning potential abuse. 10) Review bills not covered under the Fee Schedule and determine if the provider has charged according to reasonable and customary rates. | All claims |
16b | b) The total allocated expenses paid on behalf of employers for services described in field #16a during the survey period. | ||
17 | Total amount billed to employers for fee schedule savings | The total amount of fees billed to employers in connection with all fee schedule discount review services | All claims |
18 | Total amount charged to employers for any and all managed care fees | The total amount of costs allocated for services provided by a Workers' Compensation Preferred Provider Program as defined in 50 Ill. Adm. Code 2051.220 | All claims |
19a | # of claims involving in-house medical nurse case management | a) The total number of claims internal medical nurse management expenses were applied to or associated with during the survey period, regardless of when the claim was opened | All claims |
19b | The total amount spent on in-house medical nurse case management | b) The total amount of all internal nurse management expenses associated with the claims reported in field #19a | All claims |
20a | # of claims involving outside medical nurse case management | a) The total number of claims external medical nurse management expenses were applied to or associated with during the survey period, regardless of when the claim was opened | All claims |
20b | The total amount paid for outside medical nurse case management | b) The total amount of all outside nurse management expenses associated with the claims reported in field #20a | All claims |
21 | Total amount paid for independent medical exams | The total amount paid for all independent medical exams by the insurer during the survey period | All claims |
22 | Total amount spent on in-house Utilization Review for the previous calendar year | The total amount of all internal Utilization Review expenses incurred by the insurer during the survey period | All claims |
23 | Total amount paid for outside Utilization Review for the previous calendar year | The total amount of all external Utilization Review expenses incurred by the insurer during the survey period | All claims |
Ill. Admin. Code tit. 50, pt. 2907, app A