49

affect the employee’s right to compensation payable under

paragraphs (b), (c) and (e) of this Section for the disabilities therein

covered.

(e) For accidental injuries in the following schedule, the employee shall

receive compensation for the period of temporary total incapacity for

work resulting from such accidental injury, under subparagraph 1 of

paragraph (b) of this Section, and shall receive in addition thereto

compensation for a further period for the specific loss herein mentioned,

but shall not receive any compensation under any other provisions of this

Act. The following listed amounts apply to either the loss of or the

permanent and complete loss of use of the member specified, such

compensation for the length of time as follows:

1. Thumb-

70 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

76 weeks if the accidental injury occurs on or after February 1, 2006.

2. First, or index finger-

40 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

43 weeks if the accidental injury occurs on or after February 1, 2006.

3. Second, or middle finger-

35 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

38 weeks if the accidental injury occurs on or after February 1, 2006.

4. Third, or ring finger-

25 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

27 weeks if the accidental injury occurs on or after February 1, 2006.

5. Fourth, or little finger-

20 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

22 weeks if the accidental injury occurs on or after February 1, 2006.

6. Great toe-

35 weeks if the accidental injury occurs on or after the effective date

50

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

38 weeks if the accidental injury occurs on or after February 1, 2006.

7. Each toe other than great toe-

12 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

13 weeks if the accidental injury occurs on or after February 1, 2006.

8. The loss of the first or distal phalanx of the thumb or of any finger or

toe shall be considered to be equal to the loss of one-half of such

thumb, finger or toe and the compensation payable shall be one-half of

the amount above specified. The loss of more than one phalanx shall

be considered as the loss of the entire thumb, finger or toe. In no case

shall the amount received for more than one finger exceed the amount

provided in this schedule for the loss of a hand.

9. Hand-

190 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

205 weeks if the accidental injury occurs on or after February 1, 2006.

The loss of 2 or more digits, or one or more phalanges of 2 or more

digits, of a hand may be compensated on the basis of partial loss of

use of a hand, provided, further, that the loss of 4 digits, or the loss of

use of 4 digits, in the same hand shall constitute the complete loss of a

hand.

10. Arm-

235 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

253 weeks if the accidental injury occurs on or after February 1, 2006.

Where an accidental injury results in the amputation of an arm below

the elbow, such injury shall be compensated as a loss of an arm.

Where an accidental injury results in the amputation of an arm above

the elbow, compensation for an additional 15 weeks (if the accidental

injury occurs on or after the effective date of this amendatory Act of

51

compensation for an additional 65 weeks (if the accidental injury

occurs on or after the effective date of this amendatory Act of the 94th

General Assembly but before February 1, 2006) or an additional 70

weeks (if the accidental injury occurs on or after February 1, 2006)

shall be paid.

11. Foot-

155 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

167 weeks if the accidental injury occurs on or after February 1, 2006.

12. Leg-

200 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

215 weeks if the accidental injury occurs on or after February 1, 2006.

Where an accidental injury results in the amputation of a leg below

the knee, such injury shall be compensated as loss of a leg. Where an

accidental injury results in the amputation of a leg above the knee,

compensation for an additional 25 weeks (if the accidental injury

occurs on or after the effective date of this amendatory Act of the

this amendatory Act of the 94

14. Loss of hearing of one ear

50 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

54 weeks if the accidental injury occurs on or after February 1, 2006.

Total and permanent loss of hearing of both ears-

200 weeks if the accidental injury occurs on or after the effective

date of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

215 weeks if the accidental injury occurs on or after February 1, 2006.

15. Testicle-

50 weeks if the accidental injury occurs on or after the effective date

of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

54 weeks if the accidental injury occurs on or after February 1, 2006.

Both testicles-

150 weeks if the accidental injury occurs on or after the effective

date of this amendatory Act of the 94th General Assembly but before

February 1, 2006.

162 weeks if the accidental injury occurs on or after February 1, 2006.

16. For the permanent partial loss of use of a member or sight of an eye,

or hearing of an ear, compensation during that proportion of the

number of weeks in the foregoing schedule provided for the loss of

such member or sight of an eye, or hearing of an ear, which the

partial loss of use thereof bears to the total loss of use of such

member, or sight of eye, or hearing of an ear.

(a) Loss of hearing for compensation purposes shall be confined to

the frequencies of 1,000, 2,000 and 3,000 cycles per second.

Loss of hearing ability for frequency tones above 3,000 cycles

per second are not to be considered as constituting disability for

hearing.

(b) The percent of hearing loss, for purposes of the determination of

compensation claims for occupational deafness, shall be

calculated as the average in decibels for the thresholds of

hearing for the frequencies of 1,000, 2,000 and 3,000 cycles per

second. Pure tone air conduction audiometric instruments,

approved by nationally recognized authorities in this field, shall

be used for measuring hearing loss. If the losses of hearing

average 30 decibels or less in the 3 frequencies, such losses of

hearing shall not then constitute any compensable hearing

disability. If the losses of hearing average 85 decibels or more

53

in the 3 frequencies, then the same shall constitute and be total

or 100% compensable hearing loss.

(c) In measuring hearing impairment, the lowest measured losses in

each of the 3 frequencies shall be added together and divided by

3 to determine the average decibel loss. For every decibel of

loss exceeding 30 decibels an allowance of 1.82% shall be made

up to the maximum of 100% which is reached at 85 decibels.

(d) If a hearing loss is established to have existed on July 1, 1975 by

audiometric testing the employer shall not be liable for the

previous loss so established nor shall he be liable for any loss for

which compensation has been paid or awarded.

(e) No consideration shall be given to the question of whether or not

the ability of an employee to understand speech is improved by

the use of a hearing aid.

(f) No claim for loss of hearing due to industrial noise shall be

brought against an employer or allowed unless the employee has

been exposed for a period of time sufficient to cause permanent

impairment to noise levels in excess of the following:

Sound Level DBA

Slow Response Hours Per Day

90 8

92 6

95 4

97 3

100 2

102 1-1/2

105 1

110 1/2

115 1/4

This subparagraph (f) shall not be applied in cases of hearing

loss resulting from trauma or explosion.

17. In computing the compensation to be paid to any employee who,

before the accident for which he claims compensation, had before

that time sustained an injury resulting in the loss by amputation or

partial loss by amputation of any member, including hand, arm,

thumb or fingers, leg, foot or any toes, such loss or partial loss of any

such member shall be deducted from any award made for the

subsequent injury. For the permanent loss of use or the permanent

partial loss of use of any such member or the partial loss of sight of

an eye, for which compensation has been paid, then such loss shall

be taken into consideration and deducted from any award for the

54

subsequent injury.

18. The specific case of loss of both hands, both arms, or both feet, or

both legs, or both eyes, or of any two thereof, or the permanent and

complete loss of the use thereof, constitutes total and permanent

disability, to be compensated according to the compensation fixed by

paragraph (f) of this Section. These specific cases of total and

permanent disability do not exclude other cases.

Any employee who has previously suffered the loss or permanent

and complete loss of the use of any of such members, and in a

subsequent independent accident loses another or suffers the

permanent and complete loss of the use of any one of such members

the employer for whom the injured employee is working at the time

of the last independent accident is liable to pay compensation only

for the loss or permanent and complete loss of the use of the member

occasioned by the last independent accident.

19. In a case of specific loss and the subsequent death of such injured

employee from other causes than such injury leaving a widow,

widower, or dependents surviving before payment or payment in full

for such injury, then the amount due for such injury is payable to the

widow or widower and, if there be no widow or widower, then to

such dependents, in the proportion which such dependency bears to

total dependency.

Beginning July 1, 1980, and every 6 months thereafter, the Commission

shall examine the Second Injury Fund and when, after deducting all

advances or loans made to such Fund, the amount therein is $500,000

then the amount required to be paid by employers pursuant to paragraph

(f) of Section 7 shall be reduced by one-half. When the Second Injury

Fund reaches the sum of $600,000 then the payments shall cease entirely.

However, when the Second Injury Fund has been reduced to $400,000,

payment of one-half of the amounts required by paragraph (f) of Section

7 shall be resumed, in the manner herein provided, and when the Second

Injury Fund has been reduced to $300,000, payment of the full amounts

required by paragraph (f) of Section 7 shall be resumed, in the manner

herein provided. The Commission shall make the changes in payment

effective by general order, and the changes in payment become

immediately effective for all cases coming before the Commission

thereafter either by settlement agreement or final order, irrespective of the

date of the accidental injury.

On August 1, 1996 and on February 1 and August 1 of each subsequent

year, the Commission shall examine the special fund designated as the

55

“Rate Adjustment Fund” and when, after deducting all advances or loans

made to said fund, the amount therein is $4,000,000, the amount required

to be paid by employers pursuant to paragraph (f) of Section 7 shall be

reduced by one-half. When the Rate Adjustment Fund reaches the sum of

$5,000,000 the payment therein shall cease entirely. However, when said

Rate Adjustment Fund has been reduced to $3,000,000 the amounts

required by paragraph (f) of Section 7 shall be resumed in the manner

herein provided.

(f) In case of complete disability, which renders the employee wholly and

permanently incapable of work, or in the specific case of total and

permanent disability as provided in subparagraph 18 of paragraph (e) of

this Section, compensation shall be payable at the rate provided in

subparagraph 2 of paragraph (b) of this Section for life.

An employee entitled to benefits under paragraph (f) of this Section shall

also be entitled to receive from the Rate Adjustment Fund provided in

paragraph (f) of Section 7 of the supplementary benefits provided in

paragraph (g) of this Section 8.

If any employee who receives an award under this paragraph afterwards

returns to work or is able to do so, and earns or is able to earn as much as

before the accident, payments under such award shall cease. If such

employee returns to work, or is able to do so, and earns or is able to earn

part but not as much as before the accident, such award shall be modified

so as to conform to an award under paragraph (d) of this Section. If such

award is terminated or reduced under the provisions of this paragraph,

such employees have the right at any time within 30 months after the date

of such termination or reduction to file petition with the Commission for

the purpose of determining whether any disability exists as a result of the

original accidental injury and the extent thereof.

Disability as enumerated in subdivision 18, paragraph (e) of this Section

is considered complete disability.

If an employee who had previously incurred loss or the permanent and

complete loss of use of one member, through the loss or the permanent

and complete loss of the use of one hand, one arm, one foot, one leg, or

one eye, incurs permanent and complete disability through the loss or the

permanent and complete loss of the use of another member, he shall

receive, in addition to the compensation payable by the employer and

after such payments have ceased, an amount from the Second Injury Fund

provided for in paragraph (f) of Section 7, which, together with the

compensation payable from the employer in whose employ he was when

the last accidental injury was incurred, will equal the amount payable for

permanent and complete disability as provided in this paragraph of this

56

Section.

The custodian of the Second Injury Fund provided for in paragraph (f) of

Section 7 shall be joined with the employer as a party respondent in the

application for adjustment of claim. The application for adjustment of

claim shall state briefly and in general terms the approximate time and

place and manner of the loss of the first member.

In its award the Commission or the Arbitrator shall specifically find the

amount the injured employee shall be weekly paid, the number of weeks

compensation which shall be paid by the employer, the date upon which

payments begin out of the Second Injury Fund provided for in paragraph

(f) of Section 7 of this Act, the length of time the weekly payments

continue, the date upon which the pension payments commence and the

monthly amount of the payments. The Commission shall 30 days after

the date upon which payments out of the Second Injury Fund have begun

as provided in the award, and every month thereafter, prepare and submit

to the State Comptroller a voucher for payment for all compensation

accrued to that date at the rate fixed by the Commission. The State

Comptroller shall draw a warrant to the injured employee along with a

receipt to be executed by the injured employee and returned to the

Commission. The endorsed warrant and receipt is a full and complete

acquittance to the Commission for the payment out of the Second Injury

Fund. No other appropriation or warrant is necessary for payment out of

the Second Injury Fund. The Second Injury Fund is appropriated for the

purpose of making payments according to the terms of the awards.

As of July 1, 1980 to July 1, 1982, all claims against and obligations of

the Second Injury Fund shall become claims against and obligations of

the Rate Adjustment Fund to the extent there is insufficient money in the

Second Injury Fund to pay such claims and obligations. In that case, all

references to “Second Injury Fund” in this Section shall also include the

Rate Adjustment Fund.

(g) Every award for permanent total disability entered by the Commission on

and after July 1, 1965 under which compensation payments shall become

due and payable after the effective date of this amendatory Act, and every

award for death benefits or permanent total disability entered by the

Commission on and after the effective date of this amendatory Act shall

be subject to annual adjustments as to the amount of the compensation

rate therein provided. Such adjustments shall first be made on July 15,

1977, and all awards made and entered prior to July 1, 1975 and on July

15 of each year thereafter. In all other cases such adjustment shall be

made on July 15 of the second year next following the date of the entry of

the award and shall further be made on July 15 annually thereafter. If

during the intervening period from the date of the entry of the award, or

57

the last periodic adjustment, there shall have been an increase in the

State’s average weekly wage in covered industries under the

Unemployment Insurance Act, the weekly compensation rate shall be

proportionately increased by the same percentage as the percentage of

increase in the State’s average weekly wage in covered industries under

the Unemployment Insurance Act. The increase in the compensation rate

under this paragraph shall in no event bring the total compensation rate to

an amount greater than the prevailing maximum rate at the time that the

annual adjustment is made. Such increase shall be paid in the same

manner as herein provided for payments under the Second Injury Fund to

the injured employee, or his dependents, as the case may be, out of the

Rate Adjustment Fund provided in paragraph (f) of Section 7 of this Act.

Payments shall be made at the same intervals as provided in the award or,

at the option of the Commission, may be made in quarterly payment on

For every accident occurring on or after July 20, 2005 but before the

effective date of this amendatory Act of the 94th General Assembly

(Senate Bill 1283 of the 94th General Assembly), the annual adjustments

to the compensation rate in awards for death benefits or permanent total

disability, as provided in this Act, shall be paid by the employer. The

adjustment shall be made by the employer on July 15 of the second year

next following the date of the entry of the award and shall further be

made on July 15 annually thereafter. If during the intervening period

from the date of the entry of the award, or the last periodic adjustment,

there shall have been an increase in the State's average weekly wage in

covered industries under the Unemployment Insurance Act, the employer

shall increase the weekly compensation rate proportionately by the same

percentage as the percentage of increase in the State's average weekly

wage in covered industries under the Unemployment Insurance Act. The

increase in the compensation rate under this paragraph shall in no event

bring the total compensation rate to an amount greater than the prevailing

58

maximum rate at the time that the annual adjustment is made. In the

event of a decrease in such average weekly wage there shall be no change

in the then existing compensation rate. Such increase shall be paid by the

employer in the same manner and at the same intervals as the payment of

compensation in the award. This paragraph shall not apply to cases

where there is disputed liability and in which a compromise lump sum

settlement between the employer and the injured employee, or his or her

dependents, as the case may be, has been duly approved by the Illinois

Workers' Compensation Commission.

The annual adjustments for every award of death benefits or permanent

total disability involving accidents occurring before July 20, 2005 and

accidents occurring on or after the effective date of this amendatory Act

of the 94th General Assembly (Senate Bill 1283 of the 94th General

Assembly) shall continue to be paid from the Rate Adjustment Fund

pursuant to this paragraph and Section 7(f) of this Act.

(h) In case death occurs from any cause before the total compensation to

which the employee would have been entitled has been paid, then in case

the employee leaves any widow, widower, child, parent (or any

grandchild, grandparent or other lineal heir or any collateral heir

dependent at the time of the accident upon the earnings of the employee

to the extent of 50% or more of total dependency) such compensation

shall be paid to the beneficiaries of the deceased employee and

distributed as provided in paragraph (g) of Section 7.

(h-1) In case an injured employee is under legal disability at the time when

any right or privilege accrues to him or her under this Act, a guardian

may be appointed pursuant to law, and may, on behalf of such person

under legal disability, claim and exercise any such right or privilege with

the same effect as if the employee himself or herself had claimed or

exercised the right or privilege. No limitations of time provided by this

Act run so long as the employee who is under legal disability is without a

conservator or guardian.

(i) In case the injured employee is under 16 years of age at the time of the

accident and is illegally employed, the amount of compensation payable

under paragraphs (b), (c), (d), (e) and (f) of this Section is increased 50%.

However, where an employer has on file an employment certificate

issued pursuant to the Child Labor Law or work permit issued pursuant to

the Federal Fair Labor Standards Act, as amended, or a birth certificate

properly and duly issued, such certificate, permit or birth certificate is

conclusive evidence as to the age of the injured minor employee for the

purposes of this Section.

Nothing herein contained repeals or amends the provisions of the Child

Labor Law relating to the employment of minors under the age of 16

years.

59

(j)

1. In the event the injured employee receives benefits, including

medical, surgical or hospital benefits under any group plan covering

non-occupational disabilities contributed to wholly or partially by the

employer, which benefits should not have been payable if any rights

of recovery existed under this Act, then such amounts so paid to the

employee from any such group plan as shall be consistent with, and

limited to, the provisions of paragraph 2 hereof, shall be credited to

or against any compensation payment for temporary total incapacity

for work or any medical, surgical or hospital benefits made or to be

made under this Act. In such event, the period of time for giving

notice of accidental injury and filing application for adjustment of

claim does not commence to run until the termination of such

payments. This paragraph does not apply to payments made under

any group plan which would have been payable irrespective of an

accidental injury under this Act. Any employer receiving such credit

shall keep such employee safe and harmless from any and all claims

or liabilities that may be made against him by reason of having

received such payments only to the extent of such credit.

Any excess benefits paid to or on behalf of a State employee by the

State Employees’ Retirement System under Article 14 of the Illinois

Pension Code on a death claim or disputed disability claim shall be

credited against any payments made or to be made by the State of

Illinois to or on behalf of such employee under this Act, except for

payments for medical expenses which have already been incurred at

the time of the award. The State of Illinois shall directly reimburse

the State Employees’ Retirement System to the extent of such credit.

2. Nothing contained in this Act shall be construed to give the employer

or the insurance carrier the right to credit for any benefits or

payments received by the employee other than compensation

payments provided by this Act, and where the employee receives

payments other than compensation payments, whether as full or

partial salary, group insurance benefits, bonuses, annuities or any

other payments, the employer or insurance carrier shall receive credit

for each such payment only to the extent of the compensation that

would have been payable during the period covered by such

payment.

3. The extension of time for the filing of an Application for Adjustment

of Claim as provided in paragraph 1 above shall not apply to those

cases where the time for such filing had expired prior to the date on

which payments or benefits enumerated herein have been initiated or

resumed. Provided however that this paragraph 3 shall apply only to

60

cases wherein the payments or benefits herein above enumerated

shall be received after July 1, 1969.

(Source: P.A. 93-721, eff. 1-1-05; 94-277, eff. 7-20-05; 94-695, eff. 11/16/05.)

Section 8.2. Fee schedule.

(a) Except as provided for in subsection (c), for procedures, treatments, or

services covered under this Act and rendered or to be rendered on and

after February 1, 2006, the maximum allowable payment shall be 90% of

the 80th percentile of charges and fees as determined by the Commission

utilizing information provided by employers' and insurers' national

databases, with a minimum of 12,000,000 Illinois line item charges and

fees comprised of health care provider and hospital charges and fees as of

August 1, 2004 but not earlier than August 1, 2002. These charges and

fees are provider billed amounts and shall not include discounted charges.

The 80th percentile is the point on an ordered data set from low to high

such that 80% of the cases are below or equal to that point and at most

20% are above or equal to that point. The Commission shall adjust these

historical charges and fees as of August 1, 2004 by the Consumer Price

Index-U for the period August 1, 2004 through September 30, 2005. The

Commission shall establish fee schedules for procedures, treatments, or

services for hospital inpatient, hospital outpatient, emergency room and

trauma, ambulatory surgical treatment centers, and professional services.

These charges and fees shall be designated by geozip or any smaller

geographic unit. The data shall in no way identify or tend to identify any

patient, employer, or health care provider. As used in this Section,

"geozip" means a three-digit zip code based on data similarities,

geographical similarities, and frequencies. A geozip does not cross state

boundaries. As used in this Section, "three-digit zip code" means a

geographic area in which all zip codes have the same first 3 digits. If a

geozip does not have the necessary number of charges and fees to

calculate a valid percentile for a specific procedure, treatment, or service,

the Commission may combine data from the geozip with up to 4 other

geozips that are demographically and economically similar and exhibit

similarities in data and frequencies until the Commission reaches 9

charges or fees for that specific procedure, treatment, or service. In cases

where the compiled data contains less than 9 charges or fees for a

procedure, treatment, or service, reimbursement shall occur at 76% of

charges and fees as determined by the Commission in a manner

consistent with the provisions of this paragraph. The Commission has the

authority to set the maximum allowable payment to providers of out-ofstate

procedures, treatments, or services covered under this Act in a

manner consistent with this Section. Not later than September 30 in 2006

and each year thereafter, the Commission shall automatically increase or

decrease the maximum allowable payment for a procedure, treatment, or

61

service established and in effect on January 1 of that year by the

percentage change in the Consumer Price Index-U for the 12 month

period ending August 31 of that year. The increase or decrease shall

become effective on January 1 of the following year. As used in this

Section, "Consumer Price Index-U" means the index published by the

Bureau of Labor Statistics of the U.S. Department of Labor, that

measures the average change in prices of all goods and services

purchased by all urban consumers, U.S. city average, all items, 1982-

84=100.

(b) Notwithstanding the provisions of subsection (a), if the Commission finds

that there is a significant limitation on access to quality health care in

either a specific field of health care services or a specific geographic

limitation on access to health care, it may change the Consumer Price

Index-U increase or decrease for that specific field or specific geographic

limitation on access to health care to address that limitation.

(c) The Commission shall establish by rule a process to review those medical

cases or outliers that involve extra-ordinary treatment to determine

whether to make an additional adjustment to the maximum payment

within a fee schedule for a procedure, treatment, or service.

(d) When a patient notifies a provider that the treatment, procedure, or

service being sought is for a work-related illness or injury and furnishes

the provider the name and address of the responsible employer, the

provider shall bill the employer directly. The employer shall make

payment and providers shall submit bills and records in accordance with

the provisions of this Section. All payments to providers for treatment

provided pursuant to this Act shall be made within 60 days of receipt of

the bills as long as the claim contains substantially all the required data

elements necessary to adjudicate the bills. In the case of nonpayment to a

provider within 60 days of receipt of the bill which contained

substantially all of the required data elements necessary to adjudicate the

bill or nonpayment to a provider of a portion of such a bill up to the lesser

of the actual charge or the payment level set by the Commission in the fee

schedule established in this Section, the bill, or portion of the bill, shall

incur interest at a rate of 1% per month payable to the provider.

(e) Except as provided in subsections (e-5), (e-10), and (e-15), a provider

shall not hold an employee liable for costs related to a non-disputed

procedure, treatment, or service rendered in connection with a

compensable injury. The provisions of subsections (e-5), (e-10), (e-15),

and (e-20) shall not apply if an employee provides information to the

provider regarding participation in a group health plan. If the employee

participates in a group health plan, the provider may submit a claim for

services to the group health plan. If the claim for service is covered by the

62

group health plan, the employee's responsibility shall be limited to

applicable deductibles, co-payments, or co-insurance. Except as provided

under subsections (e-5), (e-10), (e-15), and (e-20), a provider shall not

bill or otherwise attempt to recover from the employee the difference

between the provider's charge and the amount paid by the employer or the

insurer on a compensable injury.

(e-5) If an employer notifies a provider that the employer does not consider

the illness or injury to be compensable under this Act, the provider may

seek payment of the provider's actual charges from the employee for any

procedure, treatment, or service rendered. Once an employee informs the

provider that there is an application filed with the Commission to resolve

a dispute over payment of such charges, the provider shall cease any and

all efforts to collect payment for the services that are the subject of the

dispute. Any statute of limitations or statute of repose applicable to the

provider's efforts to collect payment from the employee shall be tolled

from the date that the employee files the application with the Commission

until the date that the provider is permitted to resume collection efforts

under the provisions of this Section.

(e-10) If an employer notifies a provider that the employer will pay only a

portion of a bill for any procedure, treatment, or service rendered in

connection with a compensable illness or disease, the provider may seek

payment from the employee for the remainder of the amount of the bill up

to the lesser of the actual charge, negotiated rate, if applicable, or the

payment level set by the Commission in the fee schedule established in

this Section. Once an employee informs the provider that there is an

application filed with the Commission to resolve a dispute over payment

of such charges, the provider shall cease any and all efforts to collect

payment for the services that are the subject of the dispute. Any statute

of limitations or statute of repose applicable to the provider's efforts to

collect payment from the employee shall be tolled from the date that the

employee files the application with the Commission until the date that the

provider is permitted to resume collection efforts under the provisions of

this Section.

(e-15) When there is a dispute over the compensability of or amount of

payment for a procedure, treatment, or service, and a case is pending or

proceeding before an Arbitrator or the Commission, the provider may

mail the employee reminders that the employee will be responsible for

payment of any procedure, treatment or service rendered by the provider.

The reminders must state that they are not bills, to the extent practicable

include itemized information, and state that the employee need not pay

until such time as the provider is permitted to resume collection efforts

under this Section. The reminders shall not be provided to any credit

rating agency. The reminders may request that the employee furnish the

provider with information about the proceeding under this Act, such as

63

the file number, names of parties, and status of the case. If an employee

fails to respond to such request for information or fails to furnish the

information requested within 90 days of the date of the reminder, the

provider is entitled to resume any and all efforts to collect payment from

the employee for the services rendered to the employee and the employee

shall be responsible for payment of any outstanding bills for a procedure,

treatment, or service rendered by a provider.

(e-20) Upon a final award or judgment by an Arbitrator or the Commission, or

a settlement agreed to by the employer and the employee, a provider may

resume any and all efforts to collect payment from the employee for the

services rendered to the employee and the employee shall be responsible

for payment of any outstanding bills for a procedure, treatment, or service

rendered by a provider as well as the interest awarded under subsection

(d) of this Section. In the case of a procedure, treatment, or service

deemed compensable, the provider shall not require a payment rate,

excluding the interest provisions under subsection (d), greater than the

lesser of the actual charge or the payment level set by the Commission in

the fee schedule established in this Section. Payment for services deemed

not covered or not compensable under this Act is the responsibility of the

employee unless a provider and employee have agreed otherwise in

writing. Services not covered or not compensable under this Act are not

subject to the fee schedule in this Section.

(f) Nothing in this Act shall prohibit an employer or insurer from contracting

with a health care provider or group of health care providers for

reimbursement levels for benefits under this Act different from those

provided in this Section.

(g) On or before January 1, 2010 the Commission shall provide to the

Governor and General Assembly a report regarding the implementation

of the medical fee schedule and the index used for annual adjustment to

that schedule as described in this Section.

(Source: P.A. 94-277, eff. 7-20-05; 94-695, eff. 11/16/05.)

Section 8.3. Workers' Compensation Medical Fee Advisory Board. There is

created a Workers' Compensation Medical Fee Advisory Board consisting of

9 members appointed by the Governor with the advice and consent of the

Senate. Three members of the Advisory Board shall be representative citizens

chosen from the employee class, 3 members shall be representative citizens

chosen from the employing class, and 3 members shall be representative

citizens chosen from the medical provider class. Each member shall serve a

4-year term and shall continue to serve until a successor is appointed. A

vacancy on the Advisory Board shall be filled by the Governor for the

unexpired term.

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Members of the Advisory Board shall receive no compensation for their

services but shall be reimbursed for expenses incurred in the performance of

their duties by the Commission from appropriations made to the Commission

for that purpose.

The Advisory Board shall advise the Commission on establishment of fees for

medical services and accessibility of medical treatment.

(Source: P.A. 94-277, eff. 7-20-05.)

Section 8.7. Utilization review programs.

(a) As used in this Section:

"Utilization review" means the evaluation of proposed or provided health

care services to determine the appropriateness of both the level of health

care services medically necessary and the quality of health care services

provided to a patient, including evaluation of their efficiency, efficacy,

and appropriateness of treatment, hospitalization, or office visits based on

medically accepted standards. The evaluation must be accomplished by

means of a system that identifies the utilization of health care services

based on standards of care or nationally recognized peer review

guidelines as well as nationally recognized evidence based upon

standards as provided in this Act. Utilization techniques may include

prospective review, second opinions, concurrent review, discharge

planning, peer review, independent medical examinations, and

retrospective review (for purposes of this sentence, retrospective review

shall be applicable to services rendered on or after July 20, 2005).

Nothing in this Section applies to prospective review of necessary first

aid or emergency treatment.

(b) No person may conduct a utilization review program for workers'

compensation services in this State unless once every 2 years the person

registers the utilization review program with the Department of Financial

and Professional Regulation and certifies compliance with the Workers'

Compensation Utilization Management standards or Health Utilization

Management Standards of URAC sufficient to achieve URAC

accreditation or submits evidence of accreditation by URAC for its

Workers' Compensation Utilization Management Standards or Health

Utilization Management Standards. Nothing in this Act shall be

construed to require an employer or insurer or its subcontractors to

become URAC accredited.

(c) In addition, the Secretary of Financial and Professional Regulation may

certify alternative utilization review standards of national accreditation

organizations or entities in order for plans to comply with this Section.

Any alternative utilization review standards shall meet or exceed those

standards required under subsection (b).

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(d) This registration shall include submission of all of the following

information regarding utilization review program activities:

(1) The name, address, and telephone number of the utilization review

programs.

(2) The organization and governing structure of the utilization review

programs.

(3) The number of lives for which utilization review is conducted by

each utilization review program.

(4) Hours of operation of each utilization review program.

(5) Description of the grievance process for each utilization review

program.

(6) Number of covered lives for which utilization review was conducted

for the previous calendar year for each utilization review program.

(7) Written policies and procedures for protecting confidential

information according to applicable State and federal laws for each

utilization review program.

(e) A utilization review program shall have written procedures to ensure that

patient-specific information obtained during the process of utilization

review will be:

(1) kept confidential in accordance with applicable State and federal

laws; and

(2) shared only with the employee, the employee's designee, and the

employee's health care provider, and those who are authorized by law

to receive the information. Summary data shall not be considered

confidential if it does not provide information to allow identification

of individual patients or health care providers.

Only a health care professional may make determinations regarding the

medical necessity of health care services during the course of utilization

review.

When making retrospective reviews, utilization review programs shall

base reviews solely on the medical information available to the attending

physician or ordering provider at the time the health care services were

provided.

(f) If the Department of Financial and Professional Regulation finds that a

utilization review program is not in compliance with this Section, the

Department shall issue a corrective action plan and allow a reasonable

amount of time for compliance with the plan. If the utilization review

program does not come into compliance, the Department may issue a

cease and desist order. Before issuing a cease and desist order under this

Section, the Department shall provide the utilization review program with

a written notice of the reasons for the order and allow a reasonable

amount of time to supply additional information demonstrating

compliance with the requirements of this Section and to request a hearing.

The hearing notice shall be sent by certified mail, return receipt

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requested, and the hearing shall be conducted in accordance with the

Illinois Administrative Procedure Act.

(g) A utilization review program subject to a corrective action may continue

to conduct business until a final decision has been issued by the

Department.

(h) The Secretary of Financial and Professional Regulation may by rule

establish a registration fee for each person conducting a utilization review

program.

(i) A utilization review will be considered by the Commission, along with all

other evidence and in the same manner as all other evidence, in the

determination of the reasonableness and necessity of the medical bills or

treatment. Nothing in this Section shall be construed to diminish the

rights of employees to reasonable and necessary medical treatment or

employee choice of health care provider under Section 8(a) or the rights

of employers to medical examinations under Section 12.

(j) When an employer denies payment of or refuses to authorize payment of

first aid, medical, surgical, or hospital services under Section 8(a) of this

Act, if that denial or refusal to authorize complies with a utilization

review program registered under this Section and complies with all other

requirements of this Section, then there shall be a rebuttable presumption

that the employer shall not be responsible for payment of additional

compensation pursuant to Section 19(k) of this Act and if that denial or

refusal to authorize does not comply with a utilization review program

registered under this Section and does not comply with all other

requirements of this Section, then that will be considered by the

Commission, along with all other evidence and in the same manner as all

other evidence, in the determination of whether the employer may be

responsible for the payment of additional compensation pursuant to

Section 19(k) of this Act.