B Sample Table

Section 2907.APPENDIX 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 Department's website at http://insurance.illinois.gov/. 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