Section 2908.10  Applicability

 

Every employer and insurer, or the employer's or insurer's payer or payer's agent, and every third party administrator must accept electronic claims for payment of medical services as provided by Section 8.2a of the Act.  Every health care provider or facility rendering treatment pursuant to the Act must submit medical bills for payment on standardized forms either electronically or on paper as provided by Section 8.2a of the Act. 

 

Section 2908.20  Purpose and Scope

 

Subject to Section 8.2a of the Act, the purpose of this Part is to set forth the requirements for electronic billing, processing and payment of medical and facility services, treatments and products and to adopt standardized forms provided to an injured employee.

 

Section 2908.30  Definitions

 

"Act" means the Workers' Compensation Act [820 ILCS 305].

 

"ASC X12 Standards for Electronic Data Interchange" means Accredited Standards Committee X12 (ASC X12) EDI American National Standards, with reports incorporated by reference in this Part published by Washington Publishing Company, 2107 Elliott Ave., Suite 305, Seattle WA 98121.

 

"Business day" means Monday through Friday, excluding days on which a holiday is observed by the State.

 

"CAQH CORE" means the Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange, which is a national standards organization that develops operating rules for the business aspects of HHS mandates for electronic healthcare transactions.

 

"Clearinghouse" means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches, that is an agent of either the payer or the provider and that may perform the following functions:

 

Processes or facilitates the processing of medical billing information, received from a client in a nonstandard format or containing nonstandard data content, into standard data elements or a standard transaction for further processing of a bill related transaction; or

 

Receives a standard transaction from another entity and processes or facilitates the processing of medical billing information into nonstandard format or nonstandard data content for a client entity.

 

"Commission" means the Illinois Workers' Compensation Commission.

 

"CMMS" means the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services (HHS), the federal agency that administers these programs.

 

"Companion Guide" means the IAIABC Workers' Compensation Electronic Billing and Payment Companion Guides, based on IAIABC National Companion Guides (IAIABC Workers' Compensation Electronic Medical Billing Model Rule and IAIABC Worker's Compensation Electronic Billing and Payment National Companion Guide (Version 2.1) published by the International Association of Industrial Accident Boards and Commissions, 5610 Medical Circle, Suite 24, Madison WI 53719 (2014; no later amendments or editions) available at http://www.iaiabc.org/i4a/pages/index.cfm?pageid=3990#Handbooks), a separate document that gives detailed information for Electronic Data Interchange (EDI) medical billing and payment for the workers' compensation industry using national standards and Illinois Workers' Compensation Commission procedures.

 

"Complete electronic medical bill" means a medical bill that meets all of the criteria enumerated in Section 2908.60(b).

 

"Electronic" refers to a communication between computerized data exchange systems that complies with the standards enumerated in this Part.

 

"Health care provider" means a person or entity, appropriately certified or licensed, as required, who provides medical services or products to an injured worker in accordance with the Act.

 

"Health care provider agent" means a person or entity that contracts with a health care provider establishing an agency relationship to process bills for services provided by the health care provider under the terms and conditions of a contract between the agent and health care provider. The contracts may permit the agent to submit bills, request reconsideration, receive reimbursement, and seek medical dispute resolution for the health care provider services billed.

 

"Health Plan Identifier" or "HPID" means an identifier for health plans (as defined in 45 CFR 162.506) that need to be identified in standard transactions.

 

"IAIABC" means the International Association of Industrial Accident Boards and Commissions.

 

"NCPDP" means National Council for Prescription Drug Programs.

 

"National Provider Identification Number" or "NPI" means the unique identifier assigned to a health care provider or health care facility by the HHS Secretary. (See 42 CFR 506.)

 

"Other Entity Identifier" or "OEID" means an identifier for entities that are not health plans, health care providers or "individuals'" (as defined in 45 CFR 162.514), but that need to be identified in standard transactions (including, for example, workers' compensation payers, third party administrators, transaction vendors, clearinghouses and other payers).

 

"Operating Rules" means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.

 

"Payer" means the insurer or authorized self-insured employer legally responsible for paying the workers' compensation medical bills.

 

"Payer agent" includes, but is not limited to, any person or entity that performs medical bill related processes for the payer responsible for the bill. These processes include, but are not limited to, reporting to government agencies, electronic transmission, forwarding or receipt of documents, review of reports, review of bills, adjudication of bills, and their final payment.

 

"Supporting documentation" means those documents necessary for the payer to process a bill.

 

"Technical Report Type 3" (TR3 Implementation Guide) is an ASC X12 published document for national electronic standard formats that specifies data requirements and data transaction sets, incorporated by reference in Section 2908.40(a).

 

Section 2908.40  Formats for Electronic Medical Bill Processing

 

a)         For electronic transactions, the following electronic medical bill processing standards shall be used:

 

1)         Billing:

 

A)        Professional Billing –

 

The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Professional (837), May 2006, ASC X12, 005010X222 (no later amendments or editions); and Type 3 Errata to Health Care Claim: Professional (837), June 2010, ASC X12, 005010X222A1 (no later amendments or editions);

 

B)        Institutional/Hospital Billing –

 

i)          The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Institutional (837), June 2010, ASC X12N/005010X223 (no later amendments or editions);

 

ii)         Type 1 Errata to Health Care Claim: Institutional (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X223A1 (no later amendments or editions); and

 

iii)        Type 3 Errata to Health Care Claim: Institutional (837), June 2010, ASC X12, 005010X223A2 (no later amendments or editions);

 

C)        Dental Billing –

 

i)          The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Dental (837), June 2010, ASC X12N/005010X224 (no later amendments or editions);

 

ii)         Type 1 Errata to Health Care Claim: Dental (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X224A1 (no later amendments or editions); and

 

iii)        Type 3 Errata to Health Care Claim: Dental (837), June 2010, ASC X12, 005010X224A2 (no later amendments or editions);

 

D)        Retail Pharmacy Billing –

 

i)          The Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2007, National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260, July 2012 (no later amendments or editions); and

 

ii)         The Batch Standard Batch Implementation Guide, Version 1, Release 2 (Version 1.2), January 2006, National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260, July 2012 (no later amendments or editions).

 

2)         Acknowledgment:

 

A)        Electronic responses to ASC X12N 837 transactions:

 

i)          The ASC X12 Standards for Electronic Data Interchange TA1 Interchange Acknowledgment contained in the standards adopted under subsection (a)(1);

 

ii)         The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Implementation Acknowledgment for Health Care Insurance (999), June 2007, ASC X12N/005010X231 (no later amendments or editions); and

 

iii)        The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Acknowledgment (277CA), January 2007, ASC X12N/005010X214 (no later amendments or editions);

 

B)        Electronic responses to NCPDP transactions: the response contained in the standards adopted under subsection (a)(1)(D).

 

3)         Electronic Remittance Advice (ERA):

The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835), April 2006, ASC X12N/005010X221 (no later amendments or editions); and Type 3 Errata to Health Care Claim Payment/Advice (835), June 2010, ASC X12/005010X221A1 (no later amendments or editions).

 

4)         ASC X12 Ancillary Formats:

 

A)        The ASC X12N/005010X213 Request for Additional Information (277) is used to request additional attachments that were not originally submitted with the electronic medical bill.

 

B)        Health Claim Status Request and Response

The use of the Health Claim Status Request and Response, 005010X213, shall be by mutual agreement.

 

5)         Documentation submitted with an electronic medical bill in accordance with Section 2908.60(d) (Electronic Documentation): ASC X12N Additional Information to Support a Health Claim or Encounter (275), February 2008, ASC X12/005010X210 (no later amendments or editions).

 

b)         Insurance carriers and health care providers may exchange electronic data in a nonprescribed format by mutual agreement. All data elements required pursuant to this Part shall be present in a mutually agreed upon format.

 

c)         The implementation specifications for the ASC X12N and the ASC X12 Standards for Electronic Data Interchange may be obtained from the ASC X12, 7600 Leesburg Pike, Suite 430, Falls Church VA 22043; Telephone (703) 970-4480 and FAX (703) 970-4488. They are also available through the Internet at http://store.x12.org/. A fee is charged for all implementation specifications.

 

d)         The implementation specifications for the retail pharmacy standards may be obtained from the National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260; Telephone (480) 477-1000 and FAX (480) 767-1042. They are also available through the Internet at http://www.ncpdp.org. A fee is charged for all implementation specifications.

 

e)         Nothing in this Section prohibits payers and health care providers, through mutual agreement, from using a direct data entry methodology for complying with these requirements, provided the methodology complies with the data content requirements of the adopted formats and this Part.

 

Section 2908.50  Billing Code Sets

 

All billing codes and modifier systems used for electronic billing shall be in accordance with 50 Ill. Adm. Code 9110.90 (Illinois Workers' Compensation Commission Medical Fee Schedule). Billing codes and modifier systems identified in this Section are valid codes for the specified workers' compensation transactions, in addition to any code sets defined by the standards adopted in the Workers' Compensation Act [820 ILCS 305] and 50 Ill. Adm. Code 9110.90.

 

a)         "CDT-4 Codes" − codes and nomenclature prescribed by the American Dental Association, as published in CDT 2015: Dental Procedure Codes, September 2014, American Dental Association, 211 East Chicago Ave., Chicago IL 60611-2678, website http://www.ada.org/en/ (no later amendments or editions).

 

b)         "CPT-4 Codes" − the procedural terminology and codes contained in the "Current Procedural Terminology, Fourth Edition", as published by the American Medical Association (AMA) and as adopted in the appropriate fee schedule contained in 50 Ill. Adm. Code 9110.90.

 

c)         "Diagnosis Related Group" or "DRG" − the inpatient classification scheme used by CMMS for hospital inpatient reimbursement. The DRG system classifies patients based on principal diagnosis, surgical procedure, age, presence of co-morbidities and complications, and other pertinent data.  (See 42 CFR 412.)

 

d)         "HCPCS" − CMMS' Healthcare Common Procedure Coding System, a coding system that describes products, supplies, procedures and health professional services and that includes AMA's CPT-4 codes, alphanumeric codes, and related modifiers.

 

e)         "ICD-9-CM Codes" − diagnosis and procedure codes in the International Classification of Diseases, 9^th Revision, Clinical Modification, published by HHS.

 

f)         "ICD-10-CM/PCS Codes" − diagnosis and procedure codes in the International Classification of Diseases, 10^th Edition, Clinical Modification/Procedure Coding System, maintained and published by HHS.

 

g)         "NDC" − National Drug Codes of the United States Food and Drug Administration. (See Section 510 of the Federal Food, Drug, and Cosmetic Act (21 USC 360).)

 

h)         "Revenue Codes" − the 4-digit coding system developed and maintained by the National Uniform Billing Committee (NUBC) for billing inpatient and outpatient hospital services, home health services, and hospice services.  The revenue codes are contained in the Official UB-04 Data Specifications Manual 2016 (Manual 2016), July 2015, National Uniform Billing Committee, website http://www.nubc.org/ (no later amendments or editions).

 

i)          "National Uniform Billing Committee Codes" − code structure and instructions established for use by NUBC, such as occurrence codes, condition codes, or prospective payment indicator codes.  These are known as UB-04 codes and are contained in Manual 2016.

 

Section 2908.60  Electronic Medical Billing, Reimbursement and Documentation

 

a)         Applicability

 

1)         This Section outlines the exclusive process for the initial exchange of electronic medical bill and related payment processing data for professional, institutional/hospital, pharmacy and dental services. This Section does not apply when a hospital, physician, surgeon or other person rendering treatment pursuant to the Act is submitting a standardized form on paper in conformity with 50 Ill. Adm. Code 2017 (Uniform Medical Claim and Billing Forms) as applicable to the service rendered or responding to requests for reconsideration or judicial appeals concerning any matter related to medical compensation or requests for informational copies of medical records.

 

2)         Unless exempted from this process in accordance with subsection (m), payers or their agents shall:

 

A)        Accept electronic medical bills submitted in accordance with the standards set forth in this Part;

 

B)        Transmit acknowledgments and remittance advice in compliance with this Part, in response to electronically submitted medical bills; and

 

C)        Support methods to receive electronic documentation required for the adjudication of a bill, as described in Section 2908.90.

 

3)         Before accepting an electronically submitted medical bill, the payer shall ensure that the medical provider or clearing house:

 

A)        has implemented a software system capable of exchanging medical bill data in accordance with the adopted standards or has contracted with a clearinghouse to exchange its medical bill data;

 

B)        is able to submit medical bills in accordance with Section 2908.40(a)(1) to the payer and has established connectivity between the payer and the health care provider's or clearinghouse's system;

 

C)        can submit required documentation in accordance with this Part; and

 

D)        can receive and process any acceptance or rejection acknowledgment from the payer.

 

b)         Complete Electronic Medical Bill

 

1)         To be considered a complete electronic medical bill, the bill or supporting transmission shall:

 

A)        Be submitted in the correct billing format, with the correct billing code sets as set forth in Section 2908.50;

 

B)        Be transmitted in compliance with the format requirements described in Section 2908.40;

 

C)        Include in legible text the supporting documentation that is minimally necessary under the current version of the federal Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) for the bill that is in the possession of the provider, including, but not limited to, medical reports and records, including, but not limited to, evaluation reports, narrative reports, assessment reports, progress reports/notes, clinical notes, hospital records and diagnostic test results that are expressly required by law or can reasonably be expected by the payer or its agent;

 

D)        Identify the:

 

i)          Injured employee;

 

ii)         Employer;

 

iii)        Insurance carrier, third party administrator, managed care organization or its agent;

 

iv)        Health care provider; and

 

v)         Medical service or product.

 

2)         Any electronically submitted bill determined to be complete but not paid or objected to within 30 days shall be subject to interest pursuant to Section 8.2(d)(3) of the Act.

 

c)         Acknowledgment

 

1)         An Interchange Acknowledgment (TA1), as specified in Section 2908.40(a)(2)(A)(i), notifies the sender of the receipt of, and certain structural defects associated with, an incoming transaction.

 

2)         An Implementation Acknowledgment (ASC X12 999) transaction as specified in Section 2908.40(a)(2)(A)(ii) is an electronic notification to the sender of the file that it has been received and has been:

 

A)        Accepted as a complete and structurally correct file; or

 

B)        Rejected with a valid rejection code.

 

3)         A Health Care Claim Acknowledgment (ASC X12 277CA) transaction as specified in Section 2908.40(a)(2)(A)(iii) is an electronic acknowledgment to the sender of an electronic transaction that the transaction has been received and has been:

 

A)        Accepted as a complete, correct submission; or

 

B)        Rejected with a valid rejection code.

 

4)         A payer shall acknowledge receipt of an electronic medical bill by returning an Implementation Acknowledgment (ASC X12 999) within one business day after receipt of the electronic submission.

 

A)        Notification of a rejected bill is transmitted using the appropriate acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill as described in this subsection (c).

 

B)        A health care provider or its agent shall not submit a duplicate electronic medical bill earlier than 60 business days from the date originally submitted if a payer has acknowledged acceptance of the original complete electronic medical bill. A health care provider or its agent may submit a corrected medical bill electronically to the payer after receiving notification of a rejection. The corrected medical bill is submitted as a new, original bill.

 

5)         A payer shall acknowledge receipt of an electronic medical bill by returning a Health Care Claim Status Response or Acknowledgment (ASC X12 277CA) transaction (detail acknowledgment) within two business days after receipt of the electronic submission.

 

A)        Notification of a rejected bill is transmitted in an ASC X12N 277CA response or acknowledgment when an electronic medical bill does not meet the definition of a complete electronic medical bill or does not meet the edits defined in the applicable implementation guide or guides.

 

B)        A health care provider or its agent shall not submit a duplicate electronic medical bill earlier than 30 business days from the date originally submitted if a payer has acknowledged acceptance of the original complete electronic medical bill. A health care provider or its agent may submit a corrected medical bill electronically to the payer after receiving notification of a rejection. The corrected medical bill is submitted as a new, original bill.

 

6)         Acceptance of a complete medical bill is not an admission of liability by the payer. A payer may subsequently reject an accepted electronic medical bill if the employer or other responsible party named on the medical bill is not legally liable for its payment.

 

A)        The rejection shall be transmitted by means of an 835 transaction.

 

B)        The subsequent rejection of a previously accepted electronic medical bill shall occur no later than 30 days from the date of receipt of the complete electronic medical bill.

 

C)        The transaction to reject the previously accepted complete medical bill shall clearly indicate the reason for rejection is that the payer is not legally liable for its payment.

 

7)         Acceptance of a complete or incomplete medical bill by a payer does not begin the time period by which a payer shall accept or deny liability for any alleged claim related to the medical treatment pursuant to the Act.

 

8)         Transmission of an Implementation Acknowledgment (ASC X12 999) under subsection (c)(2), and acceptance of a complete, structurally correct file, serves as proof of the received date for an electronic medical bill in this subsection (c).

 

d)         Electronic Documentation 

 

1)         Electronic documentation, including, but not limited to, medical reports and records submitted electronically that support an electronic medical bill, may be required by the payer before payment may be remitted to the health care provider.

 

2)         Complete electronic documentation shall be submitted by secure fax, secure encrypted electronic mail, first class U.S. Mail, or in conformity with Section 2908.40(a).

 

3)         The electronic transmittal by fax or electronic mail must be submitted, either by secure fax or by secure encrypted electronic mail or any other secure electronic format, and shall contain the following details prominently on its cover sheet or first page of the transmittal:

 

A)        The name of the injured employee;

 

B)        Identification of the worker's employer if known, the employer's insurance carrier, or the third party administrator or its agent handling the workers' compensation claim;

 

C)        Identification of the health care provider billing for services to the injured worker and, when applicable, its agent;

 

D)        Date or dates of service;

 

E)        The workers' compensation claim number assigned by the payer, if established by the payer; and

 

F)         the unique attachment indicator number.

 

4)         When requested by the payer, a health care provider or its agent shall submit electronic documentation within 14 business days after the request. Electronic documentation may be submitted simultaneously with the electronic medical bill or may be submitted separately within 14 business days after successful submission of the electronic medical bill.

 

5)         If electronic transmittal of documentation proves to be impossible or infeasible, the documentation will be sent via first class mail to the address of record for the payer. Documentation transmitted via first class mail must contain the following details prominently:

 

A)        The name of the injured employee;

 

B)        Identification of the worker's employer to the extent known, the employer's insurance carrier, or the third party administrator or its agent handling the workers' compensation claim;

 

C)        Identification of the health care provider billing for services to the injured worker and, when applicable, its agent;

 

D)        Dates of service; and

 

E)        The workers' compensation claim number assigned by the payer, if established by the payer.

 

6)         When a signed release is required from the injured worker before release of requested records, the request is not complete and actionable until the medical provider or its agent has received a valid, signed release form.

 

e)         Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT)  

 

1)         An Electronic Remittance Advice (ERA) is an explanation of benefits (EOB) or explanation of review (EOR) submitted electronically regarding payment or denial of a medical bill, recoupment request or receipt of a refund.

 

2)         A payer shall provide an ERA in accordance with 50 Ill. Adm. Code 9110.90.

 

3)         The ERA shall contain the appropriate Group Claim Adjustment Reason Codes, Claim Adjustment Reason Codes (CARC) and associated Remittance Advice Remark Codes (RARC) as specified by the ASC X12 Technical Report Type 2 (TR2) Workers' Compensation Code Usage Section for pharmacy charges, the NCPDP Reject Codes, National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260 (http://www.ncpdp.org/standards_info.aspx) (July 2012, no later amendments or editions), denoting the reason for payment, adjustment or denial. Instructions for the use of the ERA and code sets are found in section 7.4 of the IAIABC eBill Companion Guide.

 

4)         In addition to the requirements of Section 8.2(d)(2) of the Act, the ERA shall be sent before 5 days after:

 

A)        the expected date of receipt by the medical provider of payment from the payer; or

 

B)        the date the bill was rejected by the payer.

 

f)         Payers shall accept from health care providers paper medical bills for payment in the formats set forth in 50 Ill. Adm. Code 2017 as applicable to the service rendered.

 

g)         A payer shall not accept or submit a duplicate paper medical bill from a health care provider or its agent earlier than 30 business days from the date originally submitted unless the payer has returned the medical bill as incomplete in accordance with Section 2908.70.  A payer may accept a corrected paper medical bill after the return of an incomplete medical bill. The corrected medical bill is submitted as a new, original bill.

 

h)         Unless the payer or its agent is exempted from the electronic medical billing process in accordance with this Section, it should attempt to establish connectivity through a trading partner agreement with any clearinghouse that requests the exchange of data in accordance with Section 2908.40.

 

i)          No party to the electronic transactions shall charge excessive fees to any other party in the transaction. A payer or clearinghouse that requests another payer or clearinghouse to receive, process or transmit a standard transaction shall not charge fees or costs in excess of the fees or costs for normal telecommunications that the requesting entity incurs when it directly transmits or receives a standard transaction.

 

j)          A payer may accept reasonable fees related to data translation, data mapping and similar data functions when the health care provider is not capable of submitting a standard transaction. In addition, a payer may accept a reasonable fee related to:

 

1)         Transaction management of standard transactions, such as editing, validation, transaction tracking, management reports, portal services and connectivity; and

 

2)         Other value added services, such as electronic file transfers related to medical documentation.

 

k)         A payer or its agent may not reject a standard transaction on the basis that it contains data elements not needed or used by the payer or its agent, or that the electronic transaction includes data elements that exceed those required for a complete bill as enumerated in subsection (b).

 

l)          A payer may offer to a health care provider electing to submit bills electronically, who has not implemented a software system capable of sending standard transactions, an Internet-based direct data entry system if the payer does not charge a transaction fee.  A health care provider using an Internet-based direct data entry system offered by a payer or other entity must use the appropriate data content and data condition requirements of the standard transactions.

 

m)        Exemption

 

1)         The Director of Insurance may grant exemptions to employers and insurance carriers who are unable to accept medical bills electronically.

 

2)         Requests must be submitted in writing to the Director of Insurance.

 

3)         Grounds for exemption will be based on the following factors:

 

A)        Premium volume;

 

B)        Number of policyholders; and

 

C)        Expense to comply would be burdensome.

 

(Source:  Amended at 43 Ill. Reg. 9237, effective August 19, 2019)

 

Section 2908.70  Employer, Insurance Carrier, Managed Care Organization or Agents' Receipt of Medical Bills from Health Care Providers

 

a)         Upon receipt of medical bills submitted in accordance with Sections 2908.30, 2908.40 and 2908.50, a payer shall evaluate each bill's conformance with the criteria for a complete medical bill set forth in Section 8.2(d) of the Act.

 

1)         A payer shall not reject medical bills that are complete, unless the bill is a duplicate bill.

 

2)         Within 21 calendar days after receipt of an incomplete medical bill, a payer or its agent shall either:

 

A)        Complete the bill by adding missing health care provider identification or demographic information already known to the payer; or

 

B)        Reject the incomplete bill in accordance with this subsection (a).

 

b)         The received date of an electronic medical bill is the date all of the contents of a complete electronic medical bill are successfully received by the claims payer. Transmission of an Implementation Acknowledgment (ASC X12 999) under Section 2908.40(a)(2), and acceptance of a complete, structurally correct file, serve as proof of the received date for an electronic medical bill in this subsection (b).

 

c)         The payer may contact the medical provider to obtain the information necessary to make the bill complete.

 

1)         Any request by the payer or its agent for additional documentation to pay a medical bill shall:

 

A)        be made by telephone or electronic transmission unless the information cannot be sent by those media, in which case the sender shall send the information by first class mail or personal delivery;

 

B)        be specific to the bill or the bill's related episode of care;

 

C)        describe with specificity the clinical and other information to be included in the response;

 

D)        be relevant and necessary for the resolution of the bill;

 

E)        be for information that is contained in or is in the process of being incorporated into the injured employee's medical or billing record maintained by the health care provider; and

 

F)         indicate the specific reason for which the insurance carrier is requesting the information.

 

2)         If the payer or its agent obtains the missing information and completes the bill to the point it can be adjudicated for payment, the payer shall document the name and telephone number of the person who supplied the information.

 

3)         Payers shall maintain documentation of any pertinent internal or external communications that are necessary to make the medical bill complete.

 

d)         A payer shall not return a medical bill except as provided in subsection (a). When rejecting or denying an electronic medical bill, the payer shall provide written notification in the form of an explanation of benefits and clearly identify the reasons for the bill's rejection or denial by utilizing the appropriate Reason and Rejection Code identified in the standards incorporated by reference in Section 2908.40.

 

e)         The rejection of an incomplete medical bill in accordance with this Section fulfills the obligation of the payer to provide to the health care provider or its agent information related to the incompleteness of the bill.

 

f)         Payers shall timely reject incomplete bills or request additional information needed to reasonably determine the amount payable.

 

1)         For bills submitted electronically, the rejection of the entire bill or the rejection of specific service lines included in the initial bill shall be sent to the submitter within two business days after receipt.

 

2)         If bills are submitted in a batch transmission, only the specific bills failing edits shall be rejected.

 

3)         If there is a technical defect within the transmission itself that prevents the bills from being accessed or processed, the transmission will be rejected with a TA1 and/or a 999 transaction, as appropriate.

 

g)         If a payer has reason to challenge the coverage or amount of a specific line item on a bill, but has no reasonable basis for objections to the remainder of the bill, the uncontested portion must be paid timely, as defined in subsection (h).

 

h)         Payment of all uncontested portions of a complete medical bill shall be made within 30 days after receipt of the original bill or receipt of additional information requested by the payer allowed under the law. Amounts paid after this 30 day review period will accrue an interest penalty of one percent per month after the due date. The interest payment must be made at the same time as the medical bill payment.

 

i)          A payer shall not reject or deny a medical bill except as provided in this Section. When rejecting or denying a medical bill, the payer shall also communicate the reasons for the medical bill's rejection or denial.

 

(Source:  Amended at 43 Ill. Reg. 9237, effective August 19, 2019)

 

Section 2908.80  Communication Between Health Care Providers and Payers

 

a)         Any communication between the health care provider and the payer related to medical bill processing shall be of sufficient specific detail to allow the responder to easily identify the information required to resolve the issue or question related to the medical bill. Generic statements that simply state a conclusion, including, but not limited to, "payer improperly reduced the bill" or "health care provider did not document" or other similar phrases with no further description of the factual basis for the sender's position, do not satisfy the requirements of this Section.

 

b)         The payer's utilization of the Claim Adjustment Group Codes, Claim Adjustment Reason Codes, and/or the Remittance Advice Remark Codes, or as appropriate, the NCPDP Reject/Payment Codes, specified in Section 2908.60(e)(3), when communicating with the health care provider or its agent or assignee through the use of the 835 transaction, provides a standard mechanism to communicate issues associated with the medical bill.

 

c)         Communication between the health care provider and payer related to medical bill processing shall be made by telephone or secured electronic transmission unless the information cannot be sent by those media, in which case the sender shall send the information by first class mail or personal delivery.

 

Section 2908.90  Medical Documentation Necessary for Billing Adjudication

 

a)         Medical documentation includes all medical reports and records permitted or required in accordance with the Act.

 

b)         Requests for medical reports shall be accompanied by releases from the patient.

 

c)         Any request by the payer for additional documentation to process a medical bill shall conform to the requirements of Section 2908.70(c).

 

d)         It is the obligation of an insurer or employer to furnish its agents with any documentation necessary for the resolution of a medical bill.

 

e)         Payers shall take reasonable steps to ensure that health care providers, health care facilities, third-party biller/assignees, and claims administrators and their agents comply with all applicable federal and State rules related to privacy, confidentiality and security.

 

Section 2908.100  Administrative Fines

 

a)           The Department shall impose an administrative fine if it determines that a payer has failed to comply with the electronic claims acceptance and response process required by this Part or by the Act. The amount of the administrative fine shall be no greater than $1,000 per violation and shall not exceed $10,000 for identical violations during a calendar year. [820 ILCS 305/8.2a(a)(7)]

 

b)         The amount of the fine assessed for each violation by the payer or payer agent shall be as follows:

 

1)         For the first violation of an applicable requirement within a calendar year, $300;

 

2)         For a second, identical violation within the same year, $700; and

 

3)         For each additional, identical violation within the same year, $1,000.

 

c)         For purposes of calculating fines, a payer or payer agent's violation of an applicable requirement of this Part or Section 8.2a of the Act occurs only once per medical bill. A given medical bill includes all duplicates, but a corrected medical bill counts as a new, original bill.

 

d)         Identical violations are violations of the same requirement of this Part or Section 8.2a of the Act that occur in relation to different medical bills. Violations of different requirements are not identical violations even if they occur in relation to the same medical bill. Each nonidentical violation carries its own fine determined under subsection (b). It is possible for a payer or payer agent to commit multiple, nonidentical violations in relation to the same medical bill.

 

e)         If a late payment violation causes a payer or payer agent to accrue an interest penalty provided in this Part or Section 8.2(d)(3) of the Act, a fine will not be assessed for that violation unless one month of interest has accrued.

 

(Source:  Added at 43 Ill. Reg. 9237, effective August 19, 2019)