Pennsylvania Code › Title 31 - INSURANCE › Part II - Automobile Insurance › Chapter 69 - MOTOR VEHICLE FINANCIAL RESPONSIBILITY LAW › Subchapter A - AUTOMOBILE INSURANCE MEDICAL COST CONTAINMENT › PROVIDER BILLING › Section 69.22 - Billing procedures

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
					 insurer shall apply the Medicare payment limitations of Act 6 to provider
					 services covered by bodily injury liability, uninsured and underinsured
					 motorists, first-party medical and extraordinary medical benefits coverages
					 under an automobile insurance policy.
(b) In an action for damages against a
					 tortfeasor arising out of the maintenance or use of a motor vehicle
					 75 Pa.C.S. §
												1720
					 (relating to subrogation) applies.
(c) If an insured's first-party limits have
					 been exhausted, the insurer shall, within 30 days of the receipt of the
					 provider's bill, provide notice to the provider and the insured that the
					 first-party limits have been exhausted.
(d) Upon receipt of a provider's bill, the
					 insurer shall make a determination of the appropriate Medicare payment and pay
					 up to the first-party benefit limits of the policy. If the determined amount
					 exceeds the benefit limits of the policy, or the determined amount plus
					 previously paid benefits exceed the benefit limits of the policy, the provider
					 may directly bill the insured or a secondary insurance carrier.
(e) If only a portion of the provider's
					 services are paid by the automobile insurance policy, because benefit limits
					 have been exhausted, the provider may bill the insured for the remaining
					 services not paid under the automobile insurance policy. The provider's bill to
					 the insured shall be limited to the remaining services not paid under the
					 automobile insurance policy.
Example
: Assume an insured has $5,000 of
						first-party benefits from the insured's automobile insurance policy and no
						health insurance. Further assume the provider's bill totals $10,000 and the
						Medicare payment for the $10,000 total bill would be $6,000. The actual worth
						of the $5,000 of first-party benefits applied at the appropriate Medicare
						payment is $8,333 worth of services of the $10,000 bill ($5,000 is to $6,000 as
						x is to $10,000; x is $8,333). The provider may bill the insured $1,677, or
						$10,000 less $8,333, for the remaining services not paid under the automobile
						insurance policy.
(f) If another
					 insurance policy exists and a provider bills that insurer for the actual worth
					 of remaining services not paid (such as $1,667 in the Example in subsection
					 (e)) that insurer shall determine the appropriate amount of payment to the
					 provider under the terms of the insured's health or other insurance policy,
					 without regard to the medical cost containment provisions of the act.
(g) When multiple providers seek
					 reimbursement and when their bills for services collectively exceed the policy
					 limits, providers shall be paid by the insurer in the order the insurer
					 receives a provider's bill. If bills are received simultaneously, the bill with
					 the lowest payment amount in accordance with §
											69.43 (relating to insurer payment
					 requirements) shall be paid first.
(h) If no portion of the provider's bill is
					 payable under automobile insurance coverage, the Medicare payment limitations
					 no longer apply. A provider may directly bill the insured or other insurance
					 carrier as it has prior to passage of Act 6.