Illinois Administrative Code › Title 50 - INSURANCE › Part 9110 - MISCELLANEOUS › Section 9110.90 - Illinois Workers' Compensation Commission Medical Fee Schedule

Current through Register Vol. 48, No. 28, July 12, 2024
a) In accordance
			 with Sections 8(a), 8.2 and 16 of the Workers' Compensation Act [
			 820 ILCS
			 305/8(a), 8.2 and 16] (the Act), the
			 Illinois Workers' Compensation Commission Medical Fee Schedule, including
			 payment rates, instructions, guidelines, and payment guides and policies
			 regarding application of the schedule, is adopted as a fee schedule to be used
			 in setting the maximum allowable payment for procedures, treatment, products,
			 services or supplies for hospital inpatient, hospital outpatient, emergency
			 room, ambulatory surgical treatment centers, accredited ambulatory surgical
			 treatment facilities, prescriptions filled and dispensed outside of a licensed
			 pharmacy, dental services and professional services covered under the Act. The
			 fee schedule is published on the Internet at no charge to the user via a link
			 from the Commission's website at www.iwcc.il.gov. The fee schedule may be
			 examined at any of the offices of the Illinois Workers' Compensation
			 Commission.
b) The payment rates
			 for procedures, services or treatments in the fee schedule were established in
			 accordance with Section 8.2 of the Act by determining 90% of the
			 80th percentile of charges utilizing health care
			 provider and hospital charges from August 1, 2002 through August 1, 2004. The
			 charges were adjusted by the Consumer Price Index-U for the period August 1,
			 2004 through September 30, 2005. For procedures, treatments, services or
			 supplies covered under the Act and rendered or to be rendered on or after
			 September 1, 2011, the maximum allowable payment shall be 70% of the fee
			 schedule amounts, which shall be adjusted yearly by the Consumer Price Index-U.
			 The payment rates in the fee schedule are designated by geozip (geographic area
			 in which all zip codes have the same first 3 digits). Starting January 1, 2012,
			 the payment rates in the fee schedule shall be grouped into geographic regions
			 pursuant to Section 8.2 of the Act.
c) The fee schedule applies to any medical
			 procedure, treatment or service covered by the Act and rendered on or after
			 February 1, 2006, regardless of the date of injury.
d) Under the fee schedule, the employer pays
			 the lesser of the rate set forth in the schedule or the provider's actual
			 charge. If an employer or insurance carrier contracts with a provider for the
			 purpose of providing services under the Act, the rate negotiated in the
			 contract shall prevail.
e)
			 Reimbursement Not Covered by Fee Schedule
1)
			 Prior to September 1, 2011, whenever the fee schedule does not set a specific
			 fee for a procedure, treatment or service in the schedule, the amount of
			 reimbursement shall be at 76% of actual charge, except where this Section
			 provides that revenue codes (codes that identify a specific accommodation or
			 ancillary charge on a UB-04/CMS 1450 uniform billing form used by hospitals)
			 are to be deducted from the charge and reimbursed at 65% of charge billed at
			 the provider's normal rates under its standard chargemaster. A standard
			 chargemaster is the provider's list of charges for procedures, services and
			 supplies used to bill payers in a consistent manner. If the provider cannot use
			 the chargemaster to demonstrate the charge is the provider's normal rate, the
			 provider shall provide evidence that the charge is billed at the provider's
			 normal rate.
2) On and after
			 September 1, 2011, whenever the fee schedule does not set a specific fee for a
			 procedure, treatment or service in the schedule, the amount of reimbursement
			 shall be at 53.2 % of actual charge, except where this Section provides that
			 revenue codes (codes that identify a specific accommodation or ancillary charge
			 on a UB-04/CMS 1450 uniform billing form used by hospitals) are to be deducted
			 from the charge and reimbursed at 65% of charge billed at the provider's normal
			 rates under its standard chargemaster. A standard chargemaster is the
			 provider's list of charges for procedures, services and supplies used to bill
			 payers in a consistent manner. If the provider cannot use the chargemaster to
			 demonstrate the charge is the provider's normal rate, the provider shall
			 provide evidence that the charge is billed at the provider's normal
			 rate.