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