Employee Selects from Network

Starting on June 28, 2011, to satisfy its liabilities under the Workers’ Compensation Act for the provision of medical treatment, an employer may utilize a preferred provider program (PPP) approved by the Illinois Department of Insurance. (820 ILCS 305/8.1a)

Except for the provisions of 820 ILCS 305/8(a)(4), and for injuries occurring on or after 6/28/11, an employee of an employer utilizing a PPP shall only be allowed to select a participating network provider from the network.

An employer shall be responsible for:

  • all first aid and emergency treatment;
  • all medical, surgical, and hospital services provided by the participating network provider initially selected by the employee or by any other participating network provider recommended by the initial participating network provider or any subsequent participating network provider in the chain of referrals from the initial participating network provider; and
  • all medical, surgical, and hospital services provided by the participating network provider subsequently chosen by the employee or by any other participating network provider recommended by the subsequent participating network provider or any subsequent participating network provider in the chain of referrals from the second participating network provider. (820 ILCS 305/8.1a(c))

When the injured employee notifies the employer of the injury or files a claim for workers' compensation with the employer, the employer shall notify the employee of his or her right to be treated by a physician of his or her choice from the PPP established pursuant to this Section, and the method by which the list of participating network providers may be accessed by the employee, except as provided in subsection (a)(4) of Section 8. (820 ILCS 305/8.1a(c)(1))

Consistent with Article XX-1/2 of the Illinois Insurance Code, treatment by a specialist who is not a member of the preferred provider network shall be permitted on a case- by-case basis if the medical provider network does not contain a physician who can provide the approved treatment, and if the employee has complied with any pre-authorization requirements of the preferred provider network. (820 ILCS 305/8.1a(c)(2))

Subsequent to the report of an injury by an employee, the employee may choose in writing at any time to decline the PPP, in which case that would constitute one of the two choices of medical providers to which the employee is entitled under subsection (a)(2) or (a)(3) of 820 ILCS 305/8 (Non-PPP) ; and (C) Prior to the report of an injury by an employee, when an employee chooses non-emergency treatment from a provider not within the PPP, that would constitute the employee's one choice of medical providers to which the employee is entitled under subsection (a)(2) or (a)(3) of 820 ILCS 305/8 (Non-PPP) (§ 820 ILCS 305/8 (4)(B) & (C)

Each administrator shall provide to each beneficiary of any program subject to this Article a document which:

  • sets forth those providers with which agreements or arrangements have been made to provide health care services to such beneficiary, a source for the beneficiary to contact regarding changes in such providers and a clear description of any incentives for the beneficiary to utilize such providers,

  • discloses the extent of coverage as well as any limitations or exclusions of health care services under the program,

  • clearly sets out the circumstances under which reimbursement will be made to a beneficiary unable to utilize the services of a provider with which an arrangement or agreement has been made,

  • a description of the process for addressing a beneficiary complaint under the program, and

  • discloses deductible and coinsurance amounts charged to any person receiving health care services from such a provider. (215 ILCS 5/370m adopted by citing reference at § 820 ILCS 305/8.1a)

Change of Provider

An employer shall be responsible for:

  • all first aid and emergency treatment;
  • all medical, surgical, and hospital services provided by the participating network provider initially selected by the employee or by any other participating network provider recommended by the initial participating network provider or any subsequent participating network provider in the chain of referrals from the initial participating network provider; and
  • all medical, surgical, and hospital services provided by the participating network provider subsequently chosen by the employee or by any other participating network provider recommended by the subsequent participating network provider or any subsequent participating network provider in the chain of referrals from the second participating network provider. (820 ILCS 305/8.1a(c))

Except as provided in 820 ILCS 305/8(a)(4), upon a finding by the Commission that the care being rendered by the employee's second choice of provider within the employer's network is improper or inadequate, the employee may then choose a provider outside of the network at the employer's expense. The Commission shall issue a decision on any petition filed pursuant to this Section within 5 working days. (820 ILCS 305/8.1a(d))

 

Should you need additional information regarding the IL PPP or programs and services offered by Gallagher Bassett, please contact your Account Executive.

 

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The information provided throughout this Web site is provided from a general insurance/risk management perspective and is NOT legal advice. Gallagher Bassett Services, Inc. (GB) does not provide legal advice as it is not qualified to do so. GB recommends that you seek the advice of legal counsel in order to become fully apprised of the legal implications related to the information provided above as such implications are highly dependent on the unique facts and circumstances applicable to an individual situation.