TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE
PART 2051 PREFERRED PROVIDER PROGRAMS
SECTION 2051.285 WORKERS' COMPENSATION PREFERRED PROVIDER PROGRAM PAYOR AGREEMENTS


 

Section 2051.285  Workers' Compensation Preferred Provider Program Payor Agreements

 

Any payor agreements between WC PPP administrators and payors shall contain, at a minimum:

 

a)         Terms requiring and specifying all incentives to be provided to the insured to utilize services of a provider that has entered into an agreement with the administrator;

 

b)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements, the payor shall ensure that the beneficiary so referred shall incur no greater liability than had the beneficiary received services from a preferred provider, except as provided under Section 8.1a(c)(2) and Section 8.2(e) of the Workers' Compensation Act;

 

c)         Terms stating that, whenever an administrator or a preferred provider finds it medically necessary to refer a beneficiary to a non-preferred provider because the preferred provider program does not contain a provider who can provide the approved treatment, and if the beneficiary has complied with any reasonable pre-authorization requirements consistent with Section 8.1a of the Workers' Compensation Act, the WC PPP shall ensure that the covered employee will be provided the covered services by a non-preferred provider in accordance with the fees established by the Workers' Compensation Fee Schedule (see 50 Ill. Adm. Code 9110.90 and the WCC website at https://iwcc.ingenix.com/ iwcc.asp).

 

(Source:  Amended at 43 Ill. Reg. 11356, effective September 24, 2019)