§2907.APPENDIX A. Data Element Definitions

 

 

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 "[phone]"
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