reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.161 - Medical fee updates on and after January 1, 1995-prescription drugs and pharmaceuticals

Current through Register Vol. 54, No. 28, July 13, 2024
Payments for prescription drugs and professional
						pharmaceutical services shall continue to be limited to 110% of the average
						wholesale price on and after January 1, 1995.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › MEDICAL FEE UPDATES › Section 127.162 - Medical fee updates on and after January 1, 1995-new allowances adopted by Commissioner

Current through Register Vol. 54, No. 28, July 13, 2024
On and after January 1, 1995, if the Commissioner adopts
						new allowances for services provided under the act, those new allowances will
						be frozen immediately, and thereafter updated annually by the percentage change
						in the Statewide average weekly wage.
This section cited in 34 Pa. Code §
													127.101 (relating to medical fee
						  caps-Medicare).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.201 - Medical bills-standard forms

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Requests for payment of medical bills shall be made either on the HCFA Form
					 1500 or the UB92 Form (HCFA Form 1450), or any successor forms, required by
					 HCFA for submission of Medicare claims. If HCFA accepts a form for submission
					 of Medicare claims by a certain provider, that form shall be acceptable for
					 billing under the act.
(b)
					 Cost-based providers shall submit a detailed bill including the service codes
					 consistent with the service codes submitted to the Bureau on the detailed
					 charge master in accordance with §
											127.155(b)
					 (relating to medical fee updates on and after January 1, 1995-outpatient acute
					 care providers, specialty hospitals and other cost-reimbursed providers), or
					 consistent with new service codes added under §
											127.155(d) and
					 (e).
This section cited in §
													127.202 (relating to medical
						  bills-use of alternative forms).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.202 - Medical bills-use of alternative forms

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Until a provider submits bills on one of
					 the forms specified in §
											127.201 (relating to medical
					 bills-standard forms) insurers are not required to pay for the treatment
					 billed.
(b) Insurers may not
					 require providers to use any form of medical bill other than the forms required
					 by § 127.201.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.203 - Medical bills-submission of medical reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers who treat injured employees are
					 required to submit periodic medical reports to the employer, commencing 10 days
					 after treatment begins and at least once a month thereafter as long as
					 treatment continues. If the employer is covered by an insurer, the provider
					 shall submit the report to the insurer.
(b) Medical reports are not required to be
					 submitted in months during which treatment has not been rendered.
(c) The medical reports required by
					 subsection (a) shall be submitted on a form prescribed by the Bureau for that
					 purpose. The form shall require the provider to supply, when pertinent,
					 information on the claimant's history, the diagnosis, a description of the
					 treatment and services rendered, the physical findings and the prognosis,
					 including whether or not there has been recovery enabling the claimant to
					 return to pre-injury work without limitations. Providers shall supply only the
					 information applicable to the treatment or services rendered.
(d) If a provider does not submit the
					 required medical reports on the prescribed form, the insurer is not obligated
					 to pay for the treatment covered by the report until the required report is
					 received by the insurer.
This section cited in 34 Pa. Code §
													127.130 (relating to special
						  reports).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.204 - Fragmenting or unbundling of charges by providers

Current through Register Vol. 54, No. 28, July 13, 2024
A provider may not fragment or unbundle charges except as
						consistent with Medicare.
This section cited in 34 Pa. Code §
													127.109 (relating to supplies and
						  services not covered by fee
						  schedule).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.205 - Calculation of amount of payment due to providers

Current through Register Vol. 54, No. 28, July 13, 2024
Bills submitted by providers for payment shall state the
						provider's actual charges for the treatment rendered. A provider's statement of
						actual charges will not be construed to be an unlawful request or requirement
						for payment in excess of the medical fee caps. The insurer to whom the bill is
						submitted shall calculate the proper amount of payment for the treatment
						rendered.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.206 - Payment of medical bills-request for additional documentation

Current through Register Vol. 54, No. 28, July 13, 2024
Insurers may request additional documentation to support
						medical bills submitted for payment by providers, as long as the additional
						documentation is relevant to the treatment for which payment is
						sought.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.207 - Downcoding by insurers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Changes
					 to a provider's codes by an insurer may be made if the following conditions are
					 met:
(1) The provider has been notified in
					 writing of the proposed changes and the reasons in support of the
					 changes.
(2) The provider has been
					 given an opportunity to discuss the proposed changes and support the original
					 coding decisions.
(3) The insurer
					 has sufficient information to make the changes.
(4) The changes are consistent with Medicare
					 guidelines, the act and this subchapter.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.208 - Time for payment of medical bills

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Payments for treatment rendered under the
					 act shall be made within 30 days of receipt of the bill and report submitted by
					 the provider.
(b) For purposes of
					 computing the timeliness of payments, the insurer shall be deemed to have
					 received a bill and report 3 days after mailing by the provider. Payments shall
					 be deemed timely made if mailed on or before the 30th day following receipt of
					 the bill and report.
(c) If an
					 insurer requests additional information or records from a provider, the request
					 may not lengthen the 30-day period in which payment shall be made to the
					 provider.
(d) If an insurer
					 proposes to change a provider's codes, the time required to give the provider
					 the opportunity to discuss the proposed changes may not lengthen the 30-day
					 period in which payment shall be made to the provider.
(e) The 30-day period in which payment shall
					 be made to the provider may be tolled only if review of the reasonableness or
					 necessity of the treatment is requested during the 30-day period under the UR
					 provisions of Subchapter C (relating to medical treatment review). The
					 insurer's right to suspend payment shall continue throughout the UR process.
					 The insurer's right to suspend payment shall further continue beyond the UR
					 process to a proceeding before a workers' compensation judge, unless there is a
					 UR determination made that the treatment is reasonable and necessary.
(f) The nonpayment to providers within 30
					 days shall only apply to that particular treatment or portion thereof in
					 dispute. If a portion of the treatment is not in dispute, payment shall be made
					 within 30 days.
(g) If a URO
					 determines that medical treatment is reasonable or necessary, the insurer shall
					 pay for the treatment. Filing a petition for review before a workers'
					 compensation judge, does not further suspend the obligation to pay for the
					 treatment once there has been a determination that the treatment is reasonable
					 or necessary. If it is finally determined that the treatment was not reasonable
					 or necessary, and the insurer paid for the treatment in accordance with this
					 chapter, the insurer may seek reimbursement from the Supersedeas Fund under
					 section 443(a) of the act (77 P. S. §
												999(a)).
This section cited in 34 Pa. Code §
													127.255 (relating to premature
						  applications for fee review); and 34 Pa. Code §
													127.479 (relating to determination
						  against insurer-payment of medical
						  bills).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.209 - Explanation of benefits paid

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Insurers shall supply a written explanation of benefits (EOB) to the provider,
					 describing the calculation of payment of medical bills submitted by the
					 provider. If payment is based on changes to a provider's codes, the EOB shall
					 state the reasons for changing the original codes. If payment of a bill is
					 denied entirely, insurers shall provide a written explanation for the
					 denial.
(b) All EOBs shall contain
					 the following notice: "Health care providers are prohibited from billing for,
					 or otherwise attempting to recover from the employe, the difference between the
					 provider's charge and the amount paid on this bill."
This section cited in 34 Pa. Code §
													127.207 (relating to downcoding by
						  insurers); 34 Pa. Code §
													127.255 (relating to premature
						  applications for fee review); 34 Pa. Code §
													127.302 (relating to resolution of
						  self-referral disputes by Bureau).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.210 - Interest on untimely payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 If an insurer fails to pay the entire bill within 30 days of receipt of the
					 required bills and medical reports, interest shall accrue on the due and unpaid
					 balance at 10% per annum under section 406.1(a) of the act (77 P. S. §
												717.1).
(b) If an insurer fails to pay any portion of
					 a bill, interest shall accrue at 10% per annum on the unpaid balance.
(c) Interest shall accrue on unpaid medical
					 bills even if an insurer initially denies liability for the bills if liability
					 is later admitted or determined.
(d) Interest shall accrue on unpaid medical
					 bills even if an insurer has filed a request for UR under Subchapter C
					 (relating to medical treatment review) if a later determination is made that
					 the insurer was liable for paying the bills.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › BILLING TRANSACTIONS › Section 127.211 - Balance billing prohibited

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 A provider may not hold an employe liable for costs related to care or services
					 rendered in connection with a compensable injury under the act. A provider may
					 not bill for, or otherwise attempt to recover from the employe, the difference
					 between the provider's charge and the amount paid by an insurer.
(b) A provider may not bill for, or otherwise
					 attempt to recover from the employe, charges for treatment or services
					 determined to be unreasonable or unnecessary in accordance with the act or
					 Subchapter C (relating to medical treatment review).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.251 - Medical fee disputes-review by the Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
A provider who has submitted the required bills and
						reports to an insurer and who disputes the amount or timeliness of the payment
						made by an insurer, shall have standing to seek review of the fee dispute by
						the Bureau.
This section cited in 34 Pa. Code §
													127.302 (relating to resolution of
						  self-referral disputes by Bureau).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.252 - Application for fee review-filing and service

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers seeking review of fee disputes
					 shall file the original and one copy of a form prescribed by the Bureau as an
					 application for fee review. The application shall be filed no more than 30 days
					 following notification of a disputed treatment or 90 days following the
					 original billing date of the treatment which is the subject of the fee dispute,
					 whichever is later. The form shall be accompanied by documentation required by
					 §
											127.253 (relating to application
					 for fee review-documents required generally).
(b) Providers shall serve a copy for the
					 application for fee review, and the attached documents, upon the insurer. Proof
					 of service shall accompany the application for fee review and shall indicate
					 the person served, the date of service and the form of service.
(c) Providers shall send the application for
					 fee review and all related attachments to the address for the Bureau listed on
					 the application form.
(d) The time
					 for filing an application for fee review will be tolled if the insurer has the
					 right to suspend payment to the provider due to a dispute regarding the
					 reasonableness and necessity of the treatment under Subchapter C (relating to
					 medical treatment review).
This section cited in 34 Pa. Code §
													127.207 (relating to downcoding by
						  insurers).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.253 - Application for fee review-documents required generally

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Providers reimbursed under the Medicare
					 Part B Program shall submit the following documents with their application for
					 fee review:
(1) The applicable Medicare
					 billing form.
(2) The required
					 medical report form, together with office notes and documentation supporting
					 the procedures performed or services rendered.
(3) The explanation of benefits, if
					 available.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.254 - Downcoding disputes

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When
					 changes in procedure codes are the basis for a fee dispute, the Bureau will
					 give the provider and the insurer the opportunity to produce copies of written
					 communications concerning the changes in procedure codes.
(b) If an insurer has not complied with
					 §
											127.207 (relating to downcoding by
					 insurers) the Bureau will resolve downcoding disputes in favor of the
					 provider.
This section cited in 34 Pa. Code §
													127.207 (relating to downcoding by
						  insurers).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.255 - Premature applications for fee review

Current through Register Vol. 54, No. 28, July 13, 2024
The Bureau will return applications for fee review
						prematurely filed by providers when one of the following exists:
(1) The insurer denies liability for the
					 alleged work injury.
(2) The
					 insurer has filed a request for utilization review of the treatment under
					 Subchapter C (relating to medical treatment review).
(3) The 30-day period allowed for payment has
					 not yet elapsed, as computed under §
											127.208 (relating to time for
					 payment of medical bills).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.256 - Administrative decision on an application for fee review

Current through Register Vol. 54, No. 28, July 13, 2024
When a provider has filed all the documentation required
						and is entitled to a decision on the merits of the application for fee review,
						the Bureau will render an administrative decision within 30 days of receipt of
						all required documentation from the provider. The Bureau will, prior to
						rendering the administrative decision, investigate the matter and contact the
						insurer to obtain its response to the application for fee
						review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.257 - Contesting an administrative decision on a fee review

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A provider or insurer shall have the
					 right to contest an adverse administrative decision on an application for fee
					 review.
(b) The party contesting
					 the administrative decision shall file an original and seven copies of a
					 written request for a hearing with the Bureau within 30 days of the date of the
					 administrative decision on the fee review. The hearing request shall be mailed
					 to the Bureau at the address listed on the administrative decision.
(c) A copy of the request for a hearing shall
					 be served upon the prevailing party in the fee dispute. A proof of service,
					 indicating the person served, the date of service and the form of service,
					 shall be provided to the Bureau at the time the request for hearing is
					 filed.
(d) An untimely request for
					 a hearing may be dismissed without further action by the Bureau.
(e) Filing of a request for a hearing shall
					 act as a supersedeas of the administrative decision on the fee
					 review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.258 - Bureau as intervenor

Current through Register Vol. 54, No. 28, July 13, 2024
The Bureau may, as an intervenor in the fee review
						matter, defend the Bureau's initial administrative decision on the fee
						review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.259 - Fee review hearing

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Bureau
					 will assign the request for a hearing to a hearing officer who will schedule a
					 de novo proceeding. All parties will receive reasonable notice of the hearing
					 date, time and place.
(b) The
					 hearing will be conducted in a manner to provide all parties the opportunity to
					 be heard. The hearing officer will not be bound by strict rules of evidence.
					 All relevant evidence of reasonably probative value may be received into
					 evidence. Reasonable examination and cross-examination of witnesses will be
					 permitted.
(c) The parties may be
					 represented by legal counsel, but legal representation at the hearing is not
					 required.
(d) Testimony will be
					 recorded and a full record kept of the proceeding.
(e) All parties will be provided the
					 opportunity to submit briefs addressing issues raised.
(f) The insurer shall have the burden of
					 proving by a preponderance of the evidence that it properly reimbursed the
					 provider.
This section cited in 34 Pa. Code §
													127.302 (relating to resolution of
						  self-referral disputes by Bureau).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.260 - Fee review adjudications

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 hearing officer will issue a written decision and order within 90 days
					 following the close of the record. The decision will include all relevant
					 findings and conclusions, and state the rationale for the fee review
					 adjudication.
(b) The fee review
					 adjudication will include a notification to all parties of appeal rights to
					 Commonwealth Court.
(c) The fee
					 review adjudication will be served upon all parties, intervenors and counsel of
					 record.
This section cited in 34 Pa. Code §
													127.261 (relating to further
						  appeal rights); 34 Pa. Code §
													127.302 (relating to resolution of
						  self-referral disputes by Bureau).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › REVIEW OF MEDICAL FEE DISPUTES › Section 127.261 - Further appeal rights

Current through Register Vol. 54, No. 28, July 13, 2024
Any party aggrieved by a fee review adjudication rendered
						pursuant to §
											127.260 (relating to fee review
						adjudications) may file an appeal to Commonwealth Court within 30 days from
						mailing of the decision.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › SELF-REFERRALS › Section 127.301 - Referral standards

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Under
					 section 306(f.1)(3)(iii) of the act (77 P. S. §
												531(3)(iii)), a provider may
					 not refer a person for certain treatment and services if the provider has a
					 financial interest with the person or in the entity that receives the referral.
					 A provider may not enter into an arrangement or scheme, such as a
					 cross-referral arrangement, which the provider knows, or should know, has a
					 principal purpose of assuring referrals by the provider to a particular entity
					 which, if the provider directly made referrals to the entity, would be in
					 violation of the act.
(b) No claim
					 for payment may be presented by a person, provider or entity for a service
					 furnished under a referral prohibited under subsection (a).
(c) Referrals permitted under all present and
					 future Safe Harbor regulations promulgated under the Medicare and Medicaid
					 Patient and Program Protection Act at
					 42 U.S.C.A. §
												1320a-7b(1) and (2),
					 published at 42 CFR
					 1001.952 (relating to exceptions), and all
					 present and future exceptions to the Stark amendments to the Medicare Act at
					 42 U.S.C.A. §
												1395nn, and all present and future
					 regulations promulgated thereunder are not prohibited referrals involving
					 financial interest. An insurer may not deny payment to a health care provider
					 involved in such transaction or referral.
(d) For purposes of section 306(f.1)(3)(iii)
					 of the act, a CCO will be considered a single health care provider.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter B - MEDICAL FEES AND FEE REVIEW › SELF-REFERRALS › Section 127.302 - Resolution of self-referral disputes by Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If an insurer determines that a bill has
					 been submitted for treatment rendered in violation of the referral standards,
					 the insurer is not liable to pay the bill. Within 30 days of receipt of the
					 provider's bill and medical report, the insurer shall supply a written
					 explanation of benefits, under §
											127.209 (relating to explanation
					 of benefits paid), stating the basis for believing that the self-referral
					 provision has been violated.
(b) A
					 provider who has been denied payment of a bill under subsection (a) may file an
					 application for fee review with the Bureau under §
											127.251 (relating to medical fee
					 disputes-review by the Bureau) An application for fee review filed under this
					 subsection will be assigned to a hearing officer for a hearing and adjudication
					 in accordance with the procedures set forth in §§
											127.259 and
					 127.260 (relating to fee review
					 hearing; and fee review adjudications).
(c) The insurer shall have the burden of
					 proving by a preponderance of the evidence that a violation of the
					 self-referral provisions has occurred.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.401 - Purpose/review of medical treatment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Section 306(f.1)(6) of the act (77 P. S. §
												531(6)) provides a UR
					 process, intended as an impartial review of the reasonableness or necessity of
					 medical treatment rendered to, or proposed for, work-related injuries and
					 illnesses.
(b) UR of medical
					 treatment shall be conducted only by those organizations authorized as UROs by
					 the Secretary, under the process in §§
											127.651-127.670 (relating to authorization
					 of UROs and PROs).
(c) UR may be
					 requested by or on behalf of the employer, insurer or employe.
(d) A party, including a health care
					 provider, aggrieved by the UR determination, may file a petition for review of
					 UR, to be heard and decided by a workers' compensation judge.
This section cited in 34 Pa. Code §
													127.404 (relating to prospective,
						  concurrent and retrospective
						  review).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.402 - Treatment subject to review

Current through Register Vol. 54, No. 28, July 13, 2024
Treatment for work-related injuries rendered on and after
						August 31, 1993, may be subject to review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.403 - Assignment of cases to UROs by the Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
The Bureau will randomly assign requests for UR to
						authorized UROs. An insurer's obligation to pay medical bills within 30 days of
						receipt shall be tolled only when a proper request for UR has been filed with
						the Bureau in accordance with this subchapter.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.405 - UR of medical treatment in medical only cases

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In medical only cases, when an insurer is
					 paying for an injured worker's medical treatment but has not either filed
					 documents with the Bureau admitting liability for a work-related injury nor has
					 there been a determination to the effect, the insurer may still seek review of
					 the reasonableness or necessity of the treatment by filing a request for
					 UR.
(b) If the insurer files a
					 request for UR in a medical only case, the insurer is responsible for paying
					 for the costs of the UR.
(c) If the
					 insurer files a request for UR in a medical only case, then the insurer shall
					 be liable to pay for treatment found to be reasonable or necessary by an
					 uncontested UR determination.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.406 - Scope of review of UROs

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 UROs shall decide only the reasonableness or necessity of the treatment under
					 review.
(b) UROs may not decide any
					 of the following issues:
(1) The causal
					 relationship between the treatment under review and the employe's work-related
					 injury.
(2) Whether the employe is
					 still disabled.
(3) Whether
					 "maximum medical improvement" has been obtained.
(4) Whether the provider performed the
					 treatment under review as a result of an unlawful self-referral.
(5) The reasonableness of the fees charged by
					 the provider.
(6) The
					 appropriateness of the diagnostic or procedural codes used by the provider for
					 billing purposes.
(7) Other issues
					 which do not directly relate to the reasonableness or necessity of the
					 treatment under review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-GENERAL REQUIREMENTS › Section 127.407 - Extent of review of medical records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In order to determine the reasonableness
					 or necessity of the treatment under review, UROs shall obtain for review all
					 available records of all treatment rendered by all providers to the employe for
					 the work-related injury. However, the UR determination shall be limited to the
					 treatment that is subject to review by the request.
(b) UROs may not obtain or review medical
					 records of treatment which are not related to the work injury.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.451 - Initial requests for UR-who may file

Current through Register Vol. 54, No. 28, July 13, 2024
Requests for UR may be filed by an employe, employer or
						insurer. Health care providers may not file requests for UR.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.452 - Initial requests for UR-filing and service

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A party seeking UR of treatment rendered
					 under the act shall file the original and 8 copies of a form prescribed by the
					 Bureau as a request for UR. All information required by the form shall be
					 provided. If available, the filing party shall attach authorizations to release
					 medical records of the providers listed on the request.
(b) The request for UR shall be served on all
					 parties and their counsel, if known, and the proof of service on the form shall
					 be executed. If the proof of service is not executed, the request for UR will
					 be returned by the Bureau.
(c)
					 Requests for UR shall be sent to the Bureau at the address listed on the
					 form.
(d) The request for UR shall
					 identify the provider under review. Except as specified in subsection (e), the
					 provider under review shall be the provider who rendered the treatment or
					 service which is the subject of the UR request.
(e) When the treatment or service requested
					 to be reviewed is anesthesia, incident to surgical procedures, diagnostic
					 tests, prescriptions or durable medical equipment, the request for UR shall
					 identify the provider who made the referral, ordered or prescribed the
					 treatment or service as the provider under review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.453 - Initial requests for UR-assignment by the Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Bureau will randomly assign a
					 properly filed request for UR to an authorized URO.
(b) The Bureau will send a notice of
					 assignment of the request for UR to the URO; the employe; the employer or
					 insurer; the health care provider under review; and the attorneys for the
					 parties, if known.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.454 - Initial requests for UR-reassignment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If a URO is unable, for any reason, to
					 perform a request for UR assigned to it by the Bureau, the URO shall, within 5
					 days of receipt of the assignment, return the request for UR to the Bureau for
					 reassignment.
(b) A URO may not
					 directly reassign a request for UR to another URO.
(c) A URO shall return a request for UR
					 assigned to it by the Bureau if the URO has a conflict of interest with the
					 request, as set out in §
											127.455 (relating to requests for
					 UR-conflicts of interest).
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.455 - Initial requests for UR-conflicts of interest

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO shall be deemed to have a conflict
					 of interest and shall return a request for UR to the Bureau for reassignment if
					 one or more of the following exist:
(1) The
					 URO has a previous involvement with the patient or with the provider under
					 review, regarding the same underlying claim.
(2) The URO has performed precertification
					 functions in the same matter.
(3)
					 The URO has provided case management services in the same matter.
(4) The URO has provided vocational
					 rehabilitation services in the same matter.
(5) The URO is owned by or has a contractual
					 arrangement with any party subject to the review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.456 - Initial requests for UR-withdrawal

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A party who wishes to withdraw a request
					 for UR shall notify the Bureau of the withdrawal in writing. The withdrawal
					 notice may not be sent directly to the URO.
(b) The Bureau will promptly notify the URO
					 of the withdrawal.
(c) The insurer
					 or employer shall pay the costs incurred by the URO prior to the
					 withdrawal.
(d) A withdrawal of a
					 request for UR shall be with prejudice.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.457 - Time for requesting medical records

Current through Register Vol. 54, No. 28, July 13, 2024
A URO shall request records from the treating providers
						listed on the request for UR within 5 days from receipt of the Bureau's notice
						of assignment.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.458 - Obtaining authorization to release medical records

Current through Register Vol. 54, No. 28, July 13, 2024
If a request for UR does not have the necessary
						authorizations to release records attached to it, the URO may contact the
						providers or insurer to obtain the necessary authorizations.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.459 - Obtaining medical records-provider under review

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO shall request records from the
					 provider under review in writing. The written request for records shall be by
					 certified mail, return receipt requested. In addition, the URO may request the
					 records from the provider under review by telephone.
(b) The medical records of the provider under
					 review may not be requested from, or supplied by, any source other than the
					 provider under review.
(c) The
					 provider under review, or his agent, shall sign a verification that, to the
					 best of his knowledge, the medical records provided constitute the true and
					 complete medical chart as it relates to the employe's work-injury.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.460 - Obtaining medical records-other treating providers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO shall request records from other
					 treating providers in writing. In addition, the URO may request records from
					 other treating providers by telephone.
(b) A provider, or his agent, who supplies
					 medical records to a URO pursuant to this section shall sign a verification
					 that, to the best of his knowledge, the medical records constitute the true and
					 complete medical chart as it relates to the employe's work injury.
(c) If a URO is not able to obtain records
					 directly from the other treating providers, it may obtain these records from
					 the insurer, the employer or the employe.
(d) If an insurer, employer or employe
					 supplies medical records to a URO under subsection (c), it shall sign a
					 verification that, to the best of its knowledge, the records supplied are the
					 complete set of records as received from the provider that relate to the
					 work-injury and that the records have not been altered in any manner.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.461 - Obtaining medical records-independent medical exams

Current through Register Vol. 54, No. 28, July 13, 2024
UROs may not request, and the parties may not supply,
						reports of independent medical examinations performed at the request of an
						insurer, employer, employe or attorney. Only the records of actual treating
						health care providers shall be requested by, or supplied to, a
						URO.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.462 - Obtaining medical records-duration of treatment

Current through Register Vol. 54, No. 28, July 13, 2024
UROs shall attempt to obtain records from all providers
						for the entire course of treatment rendered to the employe for the work-related
						injury which is the subject of the UR request, regardless of the period of
						treatment under review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.463 - Obtaining medical records-reimbursement of costs to provider

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The URO shall,
					 within 30 days of receiving medical records, reimburse the provider for record
					 copying costs at the rate specified by Medicare and for actual postage costs.
					 The Bureau will publish the Medicare rate in the
Pennsylvania
					 Bulletin
as a notice when the rate changes.
(b) Reproduction of radiologic films shall be
					 reimbursed at the usual and customary charge. The cost of reproducing such
					 films shall be itemized separately when the URO bills for performing the
					 UR.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.464 - Effect of failure of provider under review to supply records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the provider
					 under review fails to mail records to the URO within 30 days of the date of
					 request of the records, the URO shall render a determination that the treatment
					 under review was not reasonable or necessary, if the conditions set forth in
					 subsection (b) have been met.
(b)
					 Before rendering the determination against the provider, a URO shall do the
					 following:
(1) Determine whether the records
					 were mailed in a timely manner.
(2)
					 Indicate on the determination that the records were requested but not
					 provided.
(3) Adequately document
					 the attempt to obtain records from the provider under review, including a copy
					 of the certified mail return receipt from the request for
					 records.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.465 - Initial requests for UR-deadline for URO determination

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A request for UR shall be deemed complete
					 upon receipt of the medical records or 35 days from the date of the notice of
					 assignment, whichever is earlier.
(b) A URO shall complete its review, and
					 render its determination, within 30 days of a completed request for
					 UR.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.466 - Assignment of UR request to reviewer by URO

Current through Register Vol. 54, No. 28, July 13, 2024
Upon receipt of the medical records, the URO shall
						forward the records, the request for UR, the notice of assignment and a
						Bureau-prescribed instruction sheet to a reviewer licensed by the Commonwealth
						in the same profession and having the same specialty as the provider under
						review.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.467 - Duties of reviewers-generally

Current through Register Vol. 54, No. 28, July 13, 2024
Reviewers shall apply generally accepted treatment
						protocols as appropriate to the individual case before them.
Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 127 - WORKERS' COMPENSATION MEDICAL COST CONTAINMENT › Subchapter C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.468 - Duties of reviewers-conflict of interest

Current through Register Vol. 54, No. 28, July 13, 2024
A reviewer shall return a review to the URO for
						assignment to another reviewer if one or more of the following exist:
(1) The reviewer has a previous involvement
					 with the patient, or with the provider under review, regarding the same
					 matter.
(2) The reviewer has
					 performed precertification functions in the same matter.
(3) The reviewer has provided case management
					 services in the same matter.
(4)
					 The reviewer has provided vocational rehabilitation services in the same
					 matter.
(5) The reviewer has a
					 contractual relationship with any party in the matter.
This section cited in 34 Pa. Code §
													127.455 (relating to requests for
						  UR-conflicts of interest).