Ill. Admin. Code tit. 50 , 2907 app 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
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 |
Notes
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