§2907.APPENDIX B. Sample Table

a)         Data File Format

The sample table in subsection (b) provides a list of the required data elements for illustrative purposes only.  Do not submit your data in this format.  All files must be submitted electronically as specified in Section 2907.40.  A template is available for use on the Department's website at http://insurance.illinois.gov/.

 

b)         Sample Table

 

NAIC #	FEIN	Company Name	Company Contact Name	Company Contact Phone Number	Contact email	Claims Opened	Medical Claims	Contested Claims
FIELD: 1	FIELD: 2	FIELD: 3	FIELD: 4a	FIELD: 4b	FIELD: 5	FIELD: 6	FIELD: 7	FIELD: 8

 

Client-Attorney	Breakdown of lost time by claim			Adjuster Person-Hours	Claims Paid Time Frame	Medical Payment Time Frame
FIELD 9	FIELD: 10a	FIELD: 10b	FIELD: 10c	FIELD: 11	FIELD: 12	FIELD: 13a	FIELD: 13b

 

Internal Defense Council		External Defense Council		Bill Review Expenses		Fee Schedule Expenses	Managed Care Expenses
FIELD: 14a	FIELD 14b	FIELD: 15a	FIELD: 15b	FIELD: 16a	FIELD: 16b	FIELD: 17	FIELD: 18

 

Internal Medical Nurse Management		External Medical Nurse Management		Medical Exam Expenses	Internal Utilization Review Expenses	External Utilization Review Expenses
FIELD: 19a	FIELD: 19b	FIELD: 20a	FIELD: 20b	FIELD: 21	FIELD: 22	FIELD: 23