Section 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

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