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 127.404 - Prospective, concurrent and retrospective review

Current through Register Vol. 54, No. 28, July 13, 2024
(a) UR of treatment may be prospective,
					 concurrent or retrospective, and may be requested by any party eligible to
					 request UR under §
											127.401(c)
					 (relating to purpose/review of medical treatment).
(b) If an insurer or employer seeks
					 retrospective review of treatment, the request for UR shall be filed within 30
					 days of the receipt of the bill and medical report for the treatment at issue.
					 Failure to comply with the 30-day time period shall result in a waiver of
					 retrospective review. If the insurer is contesting liability for the underlying
					 claim, the 30 days in which to request retrospective UR is tolled pending an
					 acceptance or determination of liability.
(c) If an employe files a request for UR of
					 treatment, the Bureau will confirm whether the insurer is liable for the
					 underlying alleged work injury. The Bureau will process the UR request only
					 when workers' compensation liability for the underlying injury has been
					 accepted or determined.
(d) If an
					 employe files a request for UR of prospective treatment which satisfies the
					 requirements of subsection (c), the Bureau will determine whether the insurer
					 is denying payment for the treatment.
(1) The
					 Bureau will send a copy of the employe's request for UR to the insurer,
					 together with a written notice asking the insurer whether it will accept
					 payment for the treatment or is denying payment for the treatment. The insurer
					 shall respond in writing to the Bureau's written notice within 7 days of
					 receipt of the notice.
(2) If the
					 insurer responds that it is willing to accept payment for the treatment, the
					 Bureau will not process the employe's request for UR. After the treatment at
					 issue has been provided, the insurer may not request, and the Bureau will not
					 process, a retrospective UR on the same treatment. The insurer shall pay for
					 the treatment as if there had been an uncontested UR determination finding the
					 treatment to be reasonable or necessary.
(3) If the insurer is denying payment for the
					 treatment, the insurer shall state the reasons for the denial in its written
					 response. If no reasons are stated for the denial, or if the insurer's written
					 response to the Bureau notice is untimely, the insurer shall pay for the cost
					 of the UR and pay for treatment found to be reasonable or necessary by an
					 uncontested UR determination.
(4)
					 If the insurer responds in writing to the Bureau's notice by denying a causal
					 relationship between the work-related injury and the treatment, the Bureau will
					 not process the employe's UR request until the underlying liability is either
					 accepted by the insurer or determined by a Workers' Compensation
					 judge.