Illinois Administrative Code › Title 50 - INSURANCE › Part 2908 - WORKERS' COMPENSATION ELECTRONIC AND STANDARDIZED PAPER BILLING › Section 2908.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"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).