Our office recently received several questions regarding the proposed Explanation of Benefits (“EOB”), as well as the current Department of Insurance Rules concerning electronic billing in Workers’ Compensation claims. Amy Bilton, a co-author of this blog post, serves on the Illinois Workers’ Compensation Medical Fee Advisory Board, and was part of the task force that helped create the proposed EOB rules.
The questions relate to the status of Commission Rules mandating medical providers electronically file their medical bills to insurance carriers for payment consideration.
Section 8.2a of the Workers’ Compensation Act required the Department of Insurance (DOI) to file rules that required employers and insurers to accept electronic medical claims. The DOI Rules require that every insurer/carrier accept electronic billing submitted by providers, and has been in place for several years.
The recommended WC Rules were preliminarily vetted through the Joint Committee on Administrative Rules (JCAR) for initial comment, then went to the Commission which voted to send it to JCAR for their final review, publication, public comment, and eventually (in the absence of argument or pushback) adoption.
Assuming the recommended rules are adopted in close to their present form, the biggest change we anticipate is that with a denied claim, a denial letter to the provider will no longer suffice. A formal EOB will need to be sent. This means desk-level claims adjusting will change and either denied bills will need to be sent to bill review for the denial EOB, or the adjuster will need to be trained in how to send a proper denial EOB.
With regard to payment, the DOI electronic billing rules require that insurance companies accept electronic bills, reply to electronic bills with a Health Care Claim Acknowledgement, and send an ERA (Electronic Claims Advice – which is an EOB or EOR) within 30 days of receipt of the bill and before five days after the expected date of receipt of payment of the date the bills was rejected. The Rule itself (2908.60(f)) is titled “Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT)” but there are no rules that actually require EFT payment – this seems to be an oversight in the Rules.