Section 9110.100  Explanations of Benefits

a)         In Section 8.2(d) of the Act, the term "explanation of benefits explaining the basis for the denial and describing any additional necessary data elements" means an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) that contains all the relevant data elements denoting the reason for payment, adjustment or denial, including the following:

1)         The appropriate Group Claim Adjustment Reason Codes, Claim Adjustment Reason Codes (CARC), and associated Remittance Advice Remark Codes (RARC), as specified in the following Accredited Standards Committee X12 (ASC X12) Standards, available for a fee from Accredited Standards Committee X12 at 8300 Greensboro Drive, Suite 800, McLean VA 22102 (703/970-4480; Fax 703/970-4488), store.x12.org:

A)        ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835) (ASC X12N/005010X221) (April 2006);

B)        Type 3 Errata to Health Care Claim Payment/Advice (835) (ASC X12/005010X221A1) (June 2010); and

C)        Code Value Usage in Health Care Claim Payments and Subsequent Claims, ASC X12N Technical Report Type 2 (TR2) (January 2015); and

2)         National Council for Prescription Drug Programs reject codes from the External Code List (ECL), available from the National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260 (https://www.ncpdp.org/home) (July 2012).

b)         All incorporations by reference in subsection (a) are as of the date specified and include no later amendments or editions.

c)         A paper explanation of benefits or SPR must also prominently contain all information necessary to match the explanation of benefits with the associated Medical Bill. A list of any relevant data elements listed in subsection (a) that are required for the paper explanation of benefits or SPR is available at no cost via a link on the Commission's website at www.iwcc.il.gov.

d)         No party shall reject a standard paper or electronic transaction on the basis that it contains data elements not needed or used by the party or its agent or that the paper or electronic transaction includes data elements that exceed those required for a complete bill.

e)         Employers or payers and health care providers may exchange data for medical bills and explanations of benefits in a nonprescribed format by mutual agreement. All data elements required pursuant to this Section shall be present in a mutually agreed upon format.

(Source:  Added at 44 Ill. Reg. 2583, effective January 24, 2020)