Ill. Admin. Code tit. 50, § 2908.30 - Definitions

Current through Register Vol. 46, No. 15, April 8, 2022

"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).

Notes

Ill. Admin. Code tit. 50, § 2908.30
Adopted at 39 Ill. Reg. 10872, effective 7/24/2015.

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