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 C - MEDICAL TREATMENT REVIEW › UR-INITIAL REQUEST › Section 127.469 - Duties of reviewers-consultation with provider under review

Current through Register Vol. 54, No. 28, July 13, 2024
The URO shall give the provider under review written
						notice of the opportunity to discuss treatment decisions with the reviewer. The
						reviewer shall initiate discussion with the provider under review when such a
						discussion will assist the reviewer in reaching a determination. If the
						provider under review declines to discuss treatment decisions with the
						reviewer, a determination shall be made in the absence of such a
						discussion.
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 127.470 - Duties of reviewers-issues reviewed

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall decide only the issue of
					 whether the treatment under review is reasonable or necessary for the medical
					 condition of the employe.
(b)
					 Reviewers shall assume the existence of a causal relationship between the
					 treatment under review and the employe's work-related injury. Reviewers may not
					 consider or decide issues such as whether the employe is still disabled,
					 whether maximum medical improvement has been obtained, quality of care or the
					 reasonableness of fees.
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 127.471 - Duties of reviewers-finality of decisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall make a definite
					 determination as to whether the treatment under review is reasonable or
					 necessary. Reviewers may not render advisory opinions as to whether additional
					 tests are needed. In determining whether the treatment under review is
					 reasonable or necessary, reviewers may consider whether other courses of
					 treatment exist. However, reviewers may not determine that the treatment under
					 review is unreasonable or unnecessary solely on the basis that other courses of
					 treatment exist.
(b) If the
					 reviewer is unable to determine whether the treatment under review is
					 reasonable or necessary, the reviewer shall resolve the issue in favor of 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 127.472 - Duties of reviewers-content of records

Current through Register Vol. 54, No. 28, July 13, 2024
The written reports of reviewers shall contain, at a
						minimum, the following elements: a listing of the records reviewed;
						documentation of any actual or attempted contacts with the provider under
						review; findings and conclusions; and a detailed explanation of the reasons for
						the conclusions reached by the reviewer, citing generally accepted treatment
						protocols and medical literature as appropriate.
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 127.473 - Duties of reviewers-signature and verification

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall sign their reports.
					 Signature stamps may not be used.
(b) Reviewers shall sign a verification
					 pursuant to
					 18 Pa.C.S. §
												4904
					 (relating to unsworn falsification to authorities) that the reviewer personally
					 reviewed the records and that the report reflects the medical opinions of the
					 reviewer.
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 127.474 - Duties of reviewers-forwarding report and records to URO

Current through Register Vol. 54, No. 28, July 13, 2024
Reviewers shall forward their reports and all records
						reviewed to the URO upon completion of the report.
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 127.475 - Duties of UROs-review of report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) UROs shall check the reviewer's report to
					 ensure that the reviewer has complied with formal requirements (such as
					 signature and verification).
(b)
					 UROs shall ensure that all records have been returned by the
					 reviewer.
(c) A URO may not contact
					 a reviewer and attempt to persuade the reviewer to change the medical opinions
					 expressed in a report.
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 127.476 - Duties of UROs-form and service of determinations

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each determination rendered by a URO on
					 the merits shall include a form prescribed by the Bureau as a medical treatment
					 review determination face sheet and the reviewer's report. The face sheet shall
					 be signed by an authorized representative of the URO.
(b) When a determination is rendered against
					 the provider under review on the basis that no records were supplied by the
					 provider, the determination shall consist only of the face sheet. However, in
					 these cases, the face sheet shall clearly indicate that the basis for the
					 decision is the failure of the provider under review to supply records to the
					 URO.
(c) The URO's determination,
					 consisting of both the face sheet and the reviewer's report, shall be served on
					 the employe, the insurer or employer, the provider under review, the attorneys
					 for the parties, if known, and the Bureau.
(d) The URO shall also serve a copy of a
					 petition for review of a UR determination on all parties and their attorneys,
					 if known.
(e) Service shall be made
					 by certified mail, return receipt requested and shall be made on the same date
					 as is entered on the appropriate line of the face sheet.
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 127.477 - Payment for initial requests for UR

Current through Register Vol. 54, No. 28, July 13, 2024
The insurer or the employer shall pay the reasonable and
						customary charge of the URO for the UR determination, regardless of who the
						requesting party is. Payment shall be made within 30 days of the date the UR
						determination was received. The URO shall send its itemized bill to the insurer
						responsible for payment and a copy of the itemized bill to the
						Bureau.
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 127.478 - Record retention requirements for UROs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) UROs shall retain records relating to URs
					 for 1 year from the date that a determination was rendered. These records shall
					 include, but are not limited to, the notice of assignment, all correspondence,
					 all certified mail return receipts and documents, all medical records reviewed,
					 the face sheet and the reviewer's report.
(b) The URO's files will be subject to
					 inspection and audit by the Bureau without notice.
This section cited in 34 Pa. Code §
													127.625 (relating to record
						  retention requirements for PROs).
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 127.479 - Determination against insurer-payment of medical bills

Current through Register Vol. 54, No. 28, July 13, 2024
If the UR determination finds that the treatment reviewed
						was reasonable or necessary, the insurer shall pay the bills submitted for the
						treatment in accordance with §
											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 C - MEDICAL TREATMENT REVIEW › UR-PETITION FOR REVIEW › Section 127.551 - Petition for Review by Bureau of UR determination

Current through Register Vol. 54, No. 28, July 13, 2024
If the provider under review, the employe, the employer
						or the insurer disagrees with the determination rendered by the URO, a request
						for review by the Bureau may be filed on a form prescribed by the Bureau as a
						petition for review of a 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-PETITION FOR REVIEW › Section 127.552 - Petition for Review by Bureau-time for filing

Current through Register Vol. 54, No. 28, July 13, 2024
The original and eight copies of the petition for review
						shall be filed with the Bureau within 30 days of receipt of the URO's
						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-PETITION FOR REVIEW › Section 127.553 - Petition for Review by Bureau-notice of assignment and service by Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Bureau will
					 assign the petition for review to a workers' compensation judge. The Bureau
					 will serve the notice of assignment and the petition for review upon the URO,
					 the employe, the employer or insurer, the health care provider under review,
					 and the attorneys for the parties, if known.
(b) When a petition for review is filed in a
					 case already in litigation before a workers' compensation judge, the Bureau
					 will assign the petition for review to the workers' compensation judge who is
					 hearing the case-in-chief.
(c)
					 Before assigning a petition for review, the Bureau will review the petition to
					 ensure that a UR has been filed and a determination has been
					 rendered.
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-PETITION FOR REVIEW › Section 127.554 - Petition for Review by Bureau-no answer allowed

Current through Register Vol. 54, No. 28, July 13, 2024
No answer to the petition for review may be
						filed.
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-PETITION FOR REVIEW › Section 127.555 - Petition for Review by Bureau-transmission of URO records to Workers' Compensation judge

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Upon the
					 workers' compensation judge's own motion, or motion of any party to the
					 proceeding, the workers' compensation judge may order the URO to forward all
					 medical records obtained for its review to the workers' compensation judge. The
					 URO shall forward all records within 10 days of the date of the workers'
					 compensation judge's order.
(b)
					 When a petition for review has been filed, the Bureau will forward the URO
					 report to the workers' compensation judge assigned to the case.
(c) An authorized agent of the URO shall sign
					 a verification stating that, to the best of his knowledge, the complete set of
					 unaltered records obtained by the URO is being transmitted to the workers'
					 compensation judge.
(d) When
					 records are provided under subsection (a), the URO shall transmit its itemized
					 bill for record copying costs to the manager of the Medical Treatment Review
					 Section, together with a copy of the workers' compensation judge's order
					 directing the URO to provide the records. The URO shall be reimbursed by the
					 Bureau for its record copying costs at the rate specified by Medicare, and for
					 actual postage costs. Reproduction of radiologic films shall be reimbursed at a
					 reasonable cost.
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-PETITION FOR REVIEW › Section 127.556 - Petition for Review by Bureau-de novo hearing

Current through Register Vol. 54, No. 28, July 13, 2024
The hearing before the workers' compensation judge shall
						be a de novo proceeding. The URO report shall be part of the record before the
						workers' compensation judge and the workers' compensation judge shall consider
						the report as evidence. The workers' compensation judge will not be bound by
						the URO report.
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 › PEER REVIEW › Section 127.601 - Peer review-availability

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 A Workers' Compensation judge may obtain an opinion from an authorized PRO
					 concerning the necessity or frequency of treatment rendered under the act when
					 one of the following exist:
(1) A petition for
					 review of a UR determination has been filed.
(2) It is necessary or appropriate in other
					 litigation proceedings before the Worker's Compensation judge. Peer review
					 shall be deemed not to be necessary or appropriate if there is a pending UR of
					 the same treatment.
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 › PEER REVIEW › Section 127.602 - Peer review-procedure upon motion of party

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A party may not make a motion for peer
					 review if the same course of treatment has been submitted for UR.
(b) After making a motion for peer review,
					 neither party may file a request for UR while the motion is pending. If the
					 motion is not specifically ruled on within 10 days, then it shall be deemed
					 denied.
(c) If the Workers'
					 Compensation judge has not ruled on the motion within 10 days, or if the motion
					 is denied, the parties shall be free to file requests for UR.
(d) If the motion is granted, the Workers'
					 Compensation judge will proceed in accordance with §
											127.604 (relating to peer
					 review-forwarding a request to the Bureau).
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 › PEER REVIEW › Section 127.603 - Peer review-interlocutory ruling

Current through Register Vol. 54, No. 28, July 13, 2024
The ruling on a motion for peer review shall be deemed
						interlocutory.
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 › PEER REVIEW › Section 127.604 - Peer review-forwarding of request to Bureau

Current through Register Vol. 54, No. 28, July 13, 2024
(a) If the Workers' Compensation judge
					 decides that peer review is necessary or appropriate, the Judge will forward a
					 request for peer review to the Bureau on a form prescribed by the Bureau. The
					 Workers' Compensation judge will notify counsel, or the parties, if
					 unrepresented, by serving a copy of the request for peer review upon
					 them.
(b) In cases other than
					 petitions for review of a UR determination, the Worker's Compensation judge
					 will attach subpoenas to the request for peer review which the assigned PRO
					 shall use to obtain medical records.
This section cited in 34 Pa. Code §
													127.602 (relating to peer
						  review-procedure upon motion of
						  party).
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 › PEER REVIEW › Section 127.605 - Peer review-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 peer review to an authorized PRO.
(b) The Bureau will send a notice of
					 assignment of the request for peer review to the PRO, the Workers' Compensation
					 judge, counsel for the parties, or the parties, if unrepresented, and the
					 health care 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 › PEER REVIEW › Section 127.606 - Peer review-reassignment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 If a PRO is unable, for any reason, to perform a peer review assigned to it by
					 the Bureau, the PRO shall, within 5 days of receipt of the assignment, return
					 the request for peer review to the Bureau for reassignment.
(b) A PRO may not, under any circumstances,
					 reassign a request for peer review to another PRO.
(c) A PRO shall return requests for peer
					 review assigned to it by the Bureau if the PRO has a conflict of interest in
					 the request assigned to it.
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 › PEER REVIEW › Section 127.607 - Peer review-conflicts of interest

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A PRO shall return a request for peer
					 review to the Bureau for reassignment if the following apply:
(1) The PRO has a previous involvement with
					 the patient or provider under review in the same matter.
(2) The PRO has performed precertification
					 functions in the same matter.
(3)
					 The PRO has provided case management services in the same matter.
(4) The PRO has provided vocational
					 rehabilitation services in the same matter.
(5) The PRO is owned by or has a contractual
					 relationship 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 › PEER REVIEW › Section 127.608 - Peer review-withdrawal

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 A request for peer review shall be withdrawn only at the direction of the
					 Workers' Compensation judge. The Workers' Compensation judge will notify the
					 Bureau of the withdrawal in writing.
(b) The Bureau will promptly notify the PRO
					 of the withdrawal. The Bureau will pay the costs incurred by the PRO prior to
					 the withdrawal out of the Workmen's Compensation Administration Fund.
(c) If a previously withdrawn peer review
					 request is resubmitted to the Bureau, the Bureau will assign the matter to the
					 PRO which handled it prior to the withdrawal.
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 › PEER REVIEW › Section 127.609 - Obtaining medical records

Current through Register Vol. 54, No. 28, July 13, 2024
(a) In
					 cases where peer review has been requested on a petition for review of a UR
					 determination, the Workers' Compensation judge may order the URO to forward all
					 the records received and reviewed for the purposes of the UR to the PRO
					 assigned to perform the peer review by the Bureau.
(b) In other cases, the PRO shall have 10
					 days from the date of the notice of assignment to subpoena records from
					 treating providers.
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 › PEER REVIEW › Section 127.610 - Obtaining medical records-independent medical exams

Current through Register Vol. 54, No. 28, July 13, 2024
PROs may not subpoena, request or be supplied with
						records of independent medical examinations performed at the request of an
						insurer, employer, employe or attorney. Only the records of actual treating
						health care providers may be subpoenaed by or supplied to a
						PRO.
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 › PEER REVIEW › Section 127.611 - Obtaining medical records-duration of treatment

Current through Register Vol. 54, No. 28, July 13, 2024
PROs 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 peer review 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 › PEER REVIEW › Section 127.612 - 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 PRO within 30 days of the date of
					 service of the subpoena for the records, the PRO shall report the provider's
					 noncompliance with the subpoena to the Workers' Compensation judge.
(b) If the provider fails to supply records,
					 the PRO may not assign the matter to a reviewer, and may not make a
					 determination concerning the necessity or frequency of treatment.
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 › PEER REVIEW › Section 127.613 - Assignment of peer review request to reviewer by PRO

Current through Register Vol. 54, No. 28, July 13, 2024
Upon receipt of the medical records, the PRO shall
						forward the records, the request for peer review and the notice of assignment
						to a reviewer licensed by the Commonwealth in the same profession and
						Board-certified in the speciality or sub-specialty as the provider under
						review. Board-certification shall be by an accredited specialty
						board.
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 › PEER REVIEW › Section 127.614 - 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 › PEER REVIEW › Section 127.615 - Duties of reviewers-conflict of interest

Current through Register Vol. 54, No. 28, July 13, 2024
A reviewer shall return a review to the PRO for
						assignment to another reviewer if one or more of the following exist:
(1) The reviewer has a previous involvement
					 with the patient or 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 §
													127.607 (relating to peer
						  review-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 › PEER REVIEW › Section 127.616 - Duties of reviewers-consultation with provider under review

Current through Register Vol. 54, No. 28, July 13, 2024
The PRO shall give the provider under review written
						notice of the opportunity to discuss treatment decisions with the reviewer. The
						reviewer shall initiate discussions with the provider under review when such a
						discussion will assist the reviewer in reaching a determination. If the
						provider under review declines to discuss treatment decisions with the
						reviewer, a determination shall be made in the absence of such a
						discussion.
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 › PEER REVIEW › Section 127.617 - Duties of reviewers-issues reviewed

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall decide only issues
					 concerning the necessity and frequency of the treatment under review.
(b) Reviewers shall assume the existence of a
					 causal relationship between the treatment under review and the employe's
					 work-related injury. The reviewer may not consider or decide issues such as
					 whether the employe is still disabled, whether maximum medical improvement has
					 been obtained, quality of care or the reasonableness of fees.
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 › PEER REVIEW › Section 127.618 - Duties of reviewers-finality of decisions

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall make a definite
					 determination as to the necessity and frequency of the treatment under review.
					 Reviewers may not render advisory opinions as to whether additional tests are
					 needed. In determining whether the treatment under review is necessary,
					 reviewers may consider whether other coursers of treatment exist. However,
					 reviewers may not render advisory opinions as to whether other courses of
					 treatment are preferable.
(b) If
					 the reviewer is unable to determine whether the treatment under review is
					 necessary or of appropriate frequency, then the reviewer shall resolve the
					 issue in favor of 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 › PEER REVIEW › Section 127.619 - Duties of reviewers-content of reports

Current through Register Vol. 54, No. 28, July 13, 2024
The written reports of reviewers shall contain, at a
						minimum, the following elements: a listing of the records reviewed;
						documentation of any actual or attempted contacts with the provider under
						review; findings and conclusions; and a detailed explanation of the reasons for
						the conclusions reached by the reviewer, citing generally accepted treatment
						protocols and medical literature as appropriate.
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 › PEER REVIEW › Section 127.620 - Duties of reviewers-signature and verification

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Reviewers shall sign their reports.
					 Signature stamps may not be used.
(b) Reviewers shall sign a verification under
					 18 Pa.C.S. §
												4904
					 (relating to unsworn falsification to authorities) that the reviewer personally
					 reviewed the records and that the report reflects the medical opinions of the
					 reviewer.
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 › PEER REVIEW › Section 127.621 - Duties of reviewers-forwarding report and records to PRO

Current through Register Vol. 54, No. 28, July 13, 2024
Reviewers shall forward their reports and all records
						reviewed to the PRO upon completion of the report.
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 › PEER REVIEW › Section 127.622 - Duties of PRO-review of report

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 PROs shall check the reviewer's report to ensure that formal requirements, such
					 as signature and verification, have been complied with by the
					 reviewer.
(b) PROs shall ensure
					 that all records have been returned by the reviewer.
(c) A PRO may not contact a reviewer and
					 attempt to persuade the reviewer to change the medical opinions expressed in a
					 report.
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 › PEER REVIEW › Section 127.623 - Peer review-deadline for PRO determination

Current through Register Vol. 54, No. 28, July 13, 2024
A PRO shall complete its review and render its
						determination within 30 days of receipt of the medical
						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 › PEER REVIEW › Section 127.624 - PRO reports-filing with judge and service

Current through Register Vol. 54, No. 28, July 13, 2024
The PRO shall file its report directly with the Workers'
						Compensation judge and mail copies to all the parties listed on the notice of
						assignment by certified mail, return receipt requested.
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 › PEER REVIEW › Section 127.625 - Record retention requirements for PROs

Current through Register Vol. 54, No. 28, July 13, 2024
PROs shall comply with all the record retention
						requirements specified in §
											127.478 (relating to record
						retention requirements). Their files shall be subject to inspection and audit
						by the Bureau without notice.
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 › PEER REVIEW › Section 127.626 - PRO reports-evidence

Current through Register Vol. 54, No. 28, July 13, 2024
The PRO report shall be a part of the record of the
						pending case. The Workers' Compensation judge will consider it as evidence but
						will not be bound by it.
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 › PEER REVIEW › Section 127.627 - PRO reports-payment

Current through Register Vol. 54, No. 28, July 13, 2024
The PRO shall submit its itemized bill to the Workers'
						Compensation judge for approval. The judge will forward the bill to the Bureau
						with an order for payment. Payment will be made from the Workmen's Compensation
						Administration Fund.
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 › AUTHORIZATION OF UROs AND PROs › Section 127.651 - Application

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Any
					 organization seeking to be authorized as a URO or a PRO shall file an
					 application on a form prescribed by the Bureau.
(b) Questions on the application shall be
					 answered thoroughly and completely with the most recent information available.
					 A rider may be attached if more space is necessary.
(c) The application shall be signed by a
					 representative of the applicant and attested to as set forth on the
					 application.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.652 - Contents of an application to be authorized as a URO or PRO

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An application to be authorized as a URO
					 or PRO shall include the following:
(1)
					 Ownership information, including the following:
(i) A disclosure of whether the applicant is
					 owned or controlled, directly or indirectly, by a self-insured employer, a
					 third-party administrator, a workers' compensation insurer or a
					 provider.
(ii) A list of the owners
					 of the proposed URO or PRO with a 5% or greater ownership interest; and a
					 disclosure of whether any such owner is a director or officer of a self-insured
					 employer, a third-party administrator, a workers' compensation carrier or is a
					 provider.
(iii) A chart of the
					 relationship between the proposed URO or PRO, its parent and other subsidiaries
					 of the parent corporation, if the proposed URO or PRO is a subsidiary or
					 affiliate of another corporation.
(iv) A list of directors and officers of the
					 proposed URO or PRO; and a disclosure of whether any such director or officer
					 is a director or officer of a self-insured employer, a third-party
					 administrator, a workers' compensation carrier or is a provider.
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 › AUTHORIZATION OF UROs AND PROs › Section 127.653 - Decision on application

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Approval of an applicant URO or PRO will be at the discretion of the
					 Bureau.
(b) The Bureau, in
					 rendering a decision on an application, will consider whether the applicant is
					 capable of rendering impartial reviews and is capable of performing the
					 responsibilities set forth in the act and this subchapter.
(c) The Bureau, in rendering a decision on an
					 application, will consider whether an applicant is owned or controlled by
					 another applicant, or whether more than one applicant is owned or controlled by
					 the same person or entity. The Bureau will not approve more than one
					 application for authorization as a URO or PRO in cases of common ownership or
					 control.
(d) An applicant shall
					 have the right to appeal a decision denying authorization as a URO or PRO
					 within 30 days of the receipt of the decision. Untimely appeals will be
					 dismissed without further action by the Bureau. A hearing will be conducted on
					 the appeal as specified in §
											127.670 (relating to
					 hearings).
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.654 - Authorization periods

Current through Register Vol. 54, No. 28, July 13, 2024
The Bureau will issue authorization notices to approved
						UROs and PROs valid for 2 years from the date of issue, unless otherwise
						suspended or revoked for failure of the URO or PRO to comply with the act and
						this subchapter.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.655 - Reauthorization

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO or PRO
					 shall apply for reauthorization no later than 120 days prior to the expiration
					 date of its authorization.
(b) An
					 application for reauthorization shall include information the Bureau may
					 require to demonstrate that the URO or PRO has been operating in accordance
					 with the act and this subchapter, and is able to continue to operate in
					 accordance with the act and this subchapter.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.656 - General qualifications

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall be capable of performing the
						responsibilities set forth in the act and this subchapter.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.657 - Local business office

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall have a business office located within
						this Commonwealth which is staffed and open at a minimum from 9 a.m.-5 p.m.
						Monday through Friday, except for legal holidays.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.658 - Accessibility

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall provide a toll-free telephone number
						and have adequate staff and telephone lines to handle inquiries from 9 a.m.-5
						p.m. Monday through Friday, except for legal holidays. A URO or PRO shall also
						establish a mechanism to receive and record telephone calls during nonbusiness
						hours.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.659 - Confidentiality

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO or PRO
					 shall have in effect policies and procedures to ensure, both that all
					 applicable State and Federal laws to protect the confidentiality of individual
					 medical records are followed, and that the organization does not improperly
					 disclose or release confidential medical information.
(b) A URO or PRO shall have mechanisms in
					 place that allow a provider to verify that an individual requesting information
					 on behalf of the review organization is a legitimate representative of the
					 organization.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.660 - Availability of reviewers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO
					 or PRO shall have available to it, by contractual arrangement or otherwise, the
					 services of a sufficient number and specialty distribution of qualified
					 physicians and other practitioner reviewers to ensure the organization can
					 perform reviews as required by the act and this subchapter.
(b) A URO or PRO shall report changes in its
					 list of reviewers to the Bureau within 30 days of the change.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.661 - Qualifications of reviewers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each
					 reviewer utilized by a URO or PRO shall have an active practice.
(b) To qualify as an active practice the
					 reviewer shall spend at least 20 hours a week treating patients in a clinical
					 practice.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.662 - Contracts with reviewers

Current through Register Vol. 54, No. 28, July 13, 2024
Contracts between a URO or PRO and reviewers shall
						contain, at a minimum, the following:
(1) A provision requiring the reviewer to
					 cooperate with the UR, quality assurance and case communication systems
					 established by the URO and PRO.
(2)
					 A provision requiring the reviewer to abide by the confidentiality requirements
					 of the URO or PRO.
(3) A provision
					 specifying the contract termination rights and termination notice requirements
					 for both the URO or PRO and the reviewer.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.663 - UR system

Current through Register Vol. 54, No. 28, July 13, 2024
(a) UROs or PROs
					 shall have a UR system which shall consist of documented criteria, standards
					 and guidelines for the conduct of reviews undertaken under the act and this
					 subchapter.
(b) The UR system shall
					 ensure that the reviews undertaken under the act and this subchapter are
					 impartial reviews.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.664 - Quality assurance system

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall have a quality assurance system which
						shall consist of documented procedures to ensure that the URO/PRO and its
						reviewers comply with all the requirements specified in this
						subchapter.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.665 - Case communication system

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall have a case communication system which
						shall ensure that all communications activities required by this chapter during
						a UR or peer review are performed by the URO or PRO.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.666 - Annual reports

Current through Register Vol. 54, No. 28, July 13, 2024
A URO or PRO shall file an annul report with the Bureau
						on a form prescribed by the Bureau.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).
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 › AUTHORIZATION OF UROs AND PROs › Section 127.667 - Compensation policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A URO or PRO
					 shall charge a reasonable fee for its services on a flat fee or hourly basis. A
					 URO or PRO may not charge for its services on a percentage or contingent fee
					 basis.
(b) The Bureau will publish
					 in the
Pennsylvania Bulletin
, on an annual basis, the range of
					 fees charged by each URO and PRO for services performed under the act and this
					 chapter during the preceding year.
This section cited in 34 Pa. Code §
													127.401 (relating to
						  purpose/review of medical
						  treatment).