Ill. Admin. Code tit. 50, § 2907.APPENDIX B – Sample Table | Midpage

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Illinois Administrative Code

Appendix 2907.APPENDIX B

Ill. Admin. Code tit. 50, § 2907.APPENDIX B

Sample Table

AUTHORITY: Implementing and authorized by Section 401 of the Illinois Insurance Code [215 ILCS 5] and Section 29.2(b) of the Workers' Compensation Act [820 ILCS 305].DEPARTMENT OF INSURANCE

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