Current through Register Vol. 48, No. 12, March 22, 2024
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 [File Link Not Available]) (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.