[36 Pa.B. 2913]
[Saturday, June 10, 2006]
[Continued from previous Web Page] * * * * * (Editor's Note: As part of this proposed rulemaking, the Department is proposing to delete the text of §§ 127.153--127.161, which appears in 34 Pa. Code pages 127-28--127-33, serial pages (203472) to (203474), (294663) to (294664) and (261181).)
§§ 127.153--127.161. (Reserved).
BILLING TRANSACTIONS § 127.201. Medical bills[--standard forms] generally.
* * * * * (b) Cost-based providers shall submit a detailed bill including the service [codes] descriptors consistent with the service [descriptors] codes submitted to the Bureau in accordance with § [127.155(b)] 127.117 (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] descriptors added under § [127.155(d) and (e)] 127.117(d)--(i).
(c) Providers shall request payment for medical bills and provide all applicable reports required under § 127.203 (relating to medical bills--submission of medical documentation) within 90 days from the first date of treatment reflected on the bill.
(d) A provider may not seek payment from the insurer or employee if the provider failed to request payment within the time set forth in subsection (c).
(e) A provider may not bill, accept payment for, or attempt to recover from the employee, employer or insurer, charges relating to services that are beyond the scope of the provider's practice or licensure, under the laws of the jurisdiction where the services are performed.
§ 127.202. Medical bills--use of alternative forms.
(a) Until a provider submits bills on one of the forms specified in § 127.201 (relating to medical bills[--standard forms] generally) insurers are not required to pay for the treatment billed.
* * * * * § 127.203. Medical bills--submission of medical [reports] documentation.
(a) Providers who treat injured [employes are required to submit periodic] employees shall periodically submit [medical reports] 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] has insured its workers' compensation liability, the provider shall instead submit the [report] Medical Reports to the insurer. If the employer is self-insured, the provider shall submit the Medical Reports to the employer, or to the employer's agent or administrator if the employer has informed the provider that the agent or administrator is the proper billing recipient for the patient.
(b) [Medical reports are not required to be submitted in] Providers are not required to submit Medical Reports for months during which no 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.] Providers shall submit the Medical Reports required by subsection (a) with the Medical Report Form.
(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.] In submitting the Medical Report Form and Medical Reports, the provider shall provide the following:
(1) Information on the employee's history.
(2) The employee's diagnosis.
(3) A description of the treatment and services rendered to the employee.
(4) The physical findings and prognosis, including whether there has been recovery enabling the employee to return to preinjury work without limitations.
(5) The medical records documenting the billed treatment.
(e) The insurer is not obligated to make payment until 30 days after its receipt of the bill, Medical Reports and the Medical Report Form.
§ 127.204. Fragmenting or unbundling of charges by providers.
A provider may not fragment or unbundle charges except as consistent with the Correct Coding Initiative in effect on the date of service.
§ 127.207. Downcoding by insurers.
(a) [Changes to a provider's codes by an] An insurer may [be made] make changes to a provider's codes if all of the following conditions are met:
(1) The provider has been notified in writing of the proposed code changes and the reasons in support of the changes.
(2) The provider has been given an opportunity to discuss the proposed code changes and support the original coding decisions.
(3) The insurer has sufficient information to make the code changes.
(4) The code changes are consistent with [Medicare guidelines] the Correct Coding Initiative, the act and this subchapter.
(b) For purposes of subsection (a)(1), the provider shall be given 10 days to respond to the notice of the proposed code changes, and the insurer must have written evidence of the date notice was sent to the provider.
(c) Whenever changes to a provider's billing codes are made, the insurer shall inform the provider of the code that it asserts is correct and shall state the reasons why the provider's original codes were changed in the [explanation of benefits] EOR required by § 127.209 (relating to explanation of [benefits] reimbursement paid).
* * * * * § 127.208. Time for payment of medical bills.
(a) Payments for treatment rendered under the act shall be made within 30 days of the insurer's receipt of the bill, Medical Reports, and [report submitted by the provider] Medical Report Form required by § 127.203 (relating to medical bills--submission of medical documentation).
(b) For purposes of computing the timeliness of payments, the insurer shall be deemed to have received [a] the bill, [medical records] Medical Reports and [report] Medical Report Form 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] all of these documents.
(c) If an insurer requests additional information or records from a provider under § 127.206 (relating to payment of medical bills--request for additional documentation), 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 code 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] E (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.
* * * * * (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)).
§ 127.209. Explanation of [benefits] reimbursement paid.
(a) Insurers shall supply a written [explanation of benefits (EOB)] EOR to the provider, [describing the calculation of] in a Department-prescribed format explaining the insurer's decision to pay, downcode or deny payment of medical bills submitted by the provider. Insurers shall supply the EOR within 30 days of the insurer's receipt of the documentation required by § 127.203 (relating to medical bills--submission of medical documentation).
(b) If payment is based on changes to a provider's codes, the [EOB] EOR shall state the reasons for changing the original codes and state the codes that the insurer asserts are correct. If payment of a bill or service is denied entirely, [insurers shall provide a written explanation for the denial] an insurer shall in the EOR, inform the provider whether:
(1) The insurer disclaims liability for the employee's injury.
(2) The insurer asserts that the treatment provided is not related to the employee's work-injury.
(3) The insurer has not received the documentation required by § 127.203.
(4) The insurer asserts that the provider failed to bill within the time permitted by § 127.201 (relating to medical bills--generally).
(5) The insurer requested utilization review of the billed treatment.
(6) The insurer asserts that the billed treatment was rendered in violation of the referral standards of § 127.301 (relating to referral standards).
(c) All [EOBs] EORs shall prominently display the Bureau Code and name of the insurer and contain the following notice: ''Health care providers are prohibited from billing for, or otherwise attempting to recover from the [employe] employee, the difference between the provider's charge and the amount paid on this bill.[''] If you believe that payment has been incorrectly calculated or is untimely, you may file an application for fee review with the Bureau of Workers' Compensation.''
§ 127.209a. Adjusting and administering the payment of medical bills.
A person or entity that engages in calculating reimbursement or paying medical bills under §§ 127.201--127.209, on behalf of a provider, insurer, employer or self-insurer, is engaged in the business of adjusting or servicing injury cases under section 441(c) of the act (77 P. S. § 997(c)).
§ 127.210. Interest on untimely payments.
(a) If an insurer fails to pay the entire bill [within 30 days of receipt of the required bills and medical reports] as required by § 127.208 (relating to time for payment of medical bills), 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).
* * * * * (c) Interest shall accrue on unpaid medical bills from the date by which payment must be made under § 127.208, even if an insurer initially denies liability for the bills [if], when liability is later admitted or determined.
(d) Interest shall accrue on unpaid medical bills from the date by which payment must be made under § 127.208, even if an insurer has filed a request for UR under Subchapter [C] E (relating to medical treatment review) [if a], when it is later [determination is made] determined that the insurer was liable for paying the bills.
§ 127.211. Balance billing prohibited.
(a) [A provider may not hold an employee liable for the] A provider may not bill, accept payment for or attempt to recover from the employee costs related to care or services rendered in connection with a compensable injury under the act. A provider may not bill [for], accept payment for or attempt to recover from the [employe] employee or employer, the difference between the provider's charge and the amount paid by an insurer.
(b) A provider may not bill, accept payment for [,] or attempt to recover from the [employe] employee, insurer or employer, charges for treatment or services determined to be unreasonable or unnecessary in accordance with the act or Subchapter [C] E (relating to medical treatment review).
(c) A provider may not bill, accept payment for or attempt to recover from the employee, charges relating to treatment rendered for a reported work injury until the provider has received an EOR from the insurer denying that the treatment is related to the work injury or denying liability for a work injury.
(d) An insurer that issues an EOR containing an improper or incorrect denial of liability, or that fails to issue an EOR required by the act or this chapter, violates the act and this chapter under section 435 of the act (77 P. S. § 991).
REVIEW OF MEDICAL FEE DISPUTES § 127.251. Medical fee disputes--review by the Bureau.
A provider who has submitted the required bills [and reports], Medical Reports and Medical Report Forms to [an] the appropriate insurer and who disputes the amount or timeliness of the payment made by [an] the insurer, shall have standing to seek review of the fee dispute by the Bureau.
§ 127.252. Application for fee review--filing and service.
(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 for fee review 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[,] or 30 days following the insurer's receipt of the first notification of a disputed treatment, whichever is later. Under this section, the insurer shall be deemed to have received a notification of disputed treatment 3 days after the notification is deposited in the United States Mail. The form [shall] must be accompanied by documentation required by § 127.253 (relating to application for fee review--documents required generally).
(b) Providers shall serve a copy [for] of the application for fee review[,] and the attached documents[,] required by § 127.253 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) The application must include a proof of service which must be completed and signed by the provider as required by § 127.2 (relating to filing and service--computation of time) and indicate the person served, the date of service and the form of service.
(d) The Bureau will return any application which is incomplete or on which the proof of service has not been signed.
(e) Providers shall send the application for fee review and all related attachments to the address for the Bureau listed on the application form, or file the application for fee review electronically as the Bureau may permit.
[(d)] (f) The time for filing an application for fee review will be tolled while [if] the insurer has the right to suspend payment to the provider under § 127.208 (relating to time for payment of medical bills) due to a dispute regarding the reasonableness and necessity of the treatment under Subchapter [C] E (relating to medical treatment review).
(g) Subsections (a)--(f) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32 and 33.34--33.37.
§ 127.253. Application for fee review--documents required generally.
(a) Providers [reimbursed under the Medicare Part B Program] shall submit all of the following documents with their application for fee review:
(1) [The applicable Medicare billing form.] A copy of the first bill submitted to the insurer under § 127.201 (relating to medical bills--generally).
(2) [The] A copy of the required [medical report form] Medical Report Form, together with [office notes] the Medical Reports and documentation supporting the procedures performed or services rendered required under § 127.203 (relating to medical bills--submission of medical documentation).
(3) [The explanation of benefits] A copy of the EOR, if available.
(b) [Providers reimbursed under the Medicare Part A Program and providers reimbursed by Medicare based on HCFA Forms 2552, 2540, 2088 or 1728, or successor forms, shall submit the following documents with the application for fee review:] This section supersedes 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32 and 33.34--33.37.
[(1) The applicable Medicare billing form.
(2) The most recent Medicare interim rate notification.
(3) The most recent Notice of Program Reimbursement.
(4) The most recently audited Medicare cost report.
(5) The required medical report form, together with documentation supporting the procedures performed or services rendered.
(6) The explanation of reimbursement, if available.
(c) For treatment rendered on and after January 1, 1995, the items specified in subsections (b)(2)--(4) shall be submitted if the requirements of § 127.155 (relating to medical fee updates on and after January 1, 1995--outpatient acute care providers, specialty hospitals and other cost-reimbursed providers) have been met.]
§ 127.255. Premature applications for fee review.
(a) The Bureau will return, and will not issue administrative decisions and orders on applications for fee review [prematurely] filed by providers [when one of the following exists] for any of the following reasons:
(1) The insurer [denies] has issued an EOR denying liability for the alleged work injury or denying that the treatment is causally related to the work injury.
(2) The insurer accurately informs the Bureau that it has filed a request for utilization review of the treatment under Subchapter [C] E (relating to medical treatment review).
* * * * * (b) This section supersedes 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32 and 33.34--33.37.
§ 127.256. Administrative decision and order on an application for fee review.
(a) [When] The Bureau will render an administrative decision and order if a provider has filed [all] the application, proof of service and all documentation required by § 127.203 (relating to medical bills--submission of medical documentation) unless the application will be returned under § 127.255 (relating to premature applications for fee review) [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].
(b) [The Bureau will, prior to] Before rendering [the administrative] its decision[, investigate the matter] and order, the Bureau may contact the insurer to obtain its response to the application for fee review. If the Bureau can determine from the application and documentation submitted by the provider that the application was not submitted within the time permitted by § 127.252 (relating to application for fee review--filing and service), it will not contact the insurer and will issue an administrative decision and order denying the application.
(c) The Bureau may correct or amend typographical or mathematical errors in its administrative decision and order within 15 days of rendering its administrative decision and order.
(d) Subsections (a)--(c) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32 and 33.34--33.37.
§ 127.257. Contesting an administrative decision and order on a fee review.
(a) A provider or insurer shall have the right to contest an adverse administrative decision and order on an application for fee review.
(b) The party contesting the administrative decision and order shall file [an original and seven copies of] a written request for a hearing with the Bureau on a Bureau-prescribed form within the later of 30 days of the date of the administrative decision and order on the fee review, or 30 days of the date of any corrected or amended administrative decision and order issued under § 127.256(c) (relating to an administrative decision and order on an application for fee review). The hearing request shall be [mailed to the Bureau at the address listed on the administrative decision] filed with the Bureau, signed by the appellant or its counsel and served on all parties as required by § 127.2 (relating to filing and service--computation of time). A signature stamp may not be used.
(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.] Filing of a request for a hearing shall act as a supersedeas of the administrative decision and order on the fee review.
(d) Subsections (a)--(c) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32, 33.34--33.37, 35.1-35.16 and 35.18--35.41.
§ 127.258. Bureau as intervenor.
(a) The Bureau may[, as an intervenor] intervene as a party in the fee review matter[, defend the Bureau's initial administrative decision on the fee review].
(b) This section supersedes 1 Pa. Code §§ 35.27--35.32.
§ 127.259. Fee review hearing.
(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.] If a request for hearing was timely and properly filed, the hearing officer will schedule one or more hearings. The hearing officer will notify all parties of hearing dates, times and places. If a request for hearing does not appear to have been timely or properly filed, the hearing officer may dismiss the request without further action, or may schedule a hearing to determine whether the request was timely and properly filed.
(b) [The hearing] The hearing officer may require that the parties complete a prehearing filing regarding the underlying fee dispute.
(c) Hearings will be conducted in a manner to provide all parties the opportunity to be heard, and will be governed by applicable provisions of 1 Pa. Code Part II (relating to general rules of administrative practice and procedure) unless this chapter supersedes those rules. 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)] (d) [The parties may be represented by legal counsel, but legal representation at the hearing is not required.] Legal representation at the hearing is governed by 1 Pa. Code Chapter 31, Subchapter C (relating to representation before agency).
[(d)] (e) * * *
(f) All parties will be provided the opportunity to submit briefs addressing issues raised. [The insurer shall have the burden of proving by a preponderance of the evidence that it properly reimbursed the provider.]
(g) Subsections (a)--(f) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32, 33.34--33.37, 35.1--35.24, 35.35, 35.37--35.41 and 35.54.
§ 127.259a. Fee review hearing--burden of proof.
(a) When proper reimbursement is disputed, the insurer shall have the burden of proving by a preponderance of the evidence that it properly reimbursed the provider.
(b) When a party alleges that procedural requirements have not been met or that the provider did not timely file its application for fee review, the party making the allegation shall have the burden of proving by a preponderance of the evidence that the opposing party has failed to meet these requirements.
(c) The hearing officer will dismiss an application for fee review when the application is premature under § 127.255 (relating to premature applications for fee review).
(d) The hearing officer may dismiss a request for hearing when the moving party fails to appear and present evidence at a scheduled hearing.
(e) Subsections (a)--(d) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32, 33.34--33.37, 35.1-35.24, 35.35, 35.37--35.41, 35.54, 35.201--35.202, and 35.205--35.214.
§ 127.260. Fee review adjudications.
(a) The hearing officer will issue a fee review adjudication consisting of a written decision and order [within 90 days] following the close of the record. The decision and order will include all relevant findings and conclusions, and state the rationale for the fee review adjudication.
* * * * * (c) The fee review adjudication will be served upon all parties, intervenors and [counsel of record] their attorneys, if known.
(d) Subsections (a)--(c) supersede 1 Pa. Code §§ 31.5, 31.11, 31.12, 31.13, 31.14, 31.15, 31.26, 33.31, 33.32, 33.34--33.37, 35.1--35.24, 35.35, 35.37--35.41, 35.54, 35.201--35.202 and 35.205--35.214, and 1 Pa. Code Chapter 35, Subchapter H.
§ 127.261. Further appeal rights.
A party aggrieved by a fee review adjudication rendered [pursuant to] under § 127.260 (relating to fee review adjudications) may file an appeal to Commonwealth Court within 30 days [from] of the mailing date of the decision.
SELF-REFERRALS § 127.301. Referral standards.
* * * * * (d) For purposes of section 306(f.1)(3)(iii) of the act, a CCO will be considered a single [health care] provider.
§ 127.302. Resolution of referral disputes by Bureau.
(a) If an insurer determines that a [bill has been submitted for] billed treatment has been rendered in violation of the referral standards, the insurer is not [liable] required to pay the bill. [Within 30 days of receipt of the provider's bill and medical report, the] An insurer shall supply a written [explanation of benefits] EOR under § 127.209 (relating to explanation of reimbursement paid), stating the basis for believing that the [self-referral provision has] referral standards have been violated.
* * * * * (c) The insurer shall have the burden of proving by a preponderance of the evidence that a violation of the [self-referral provisions] referral standards has occurred.
Subchapter D. EMPLOYER LIST OF DESIGNATED PROVIDERS § 127.751. Employer's option to establish a list of designated [health care] providers.
(a) Employers [have the option to] may establish a list of designated [health care] providers under section 306(f.1)(1)(i) of the act (77 P. S. § 531(1)(i)).
(b) If an employer has established a list of providers [which] that meets the requirements of the act and this subchapter, an [employe] employee with a work-related injury or illness shall seek treatment with one of the designated providers from the list. The [employe] employee shall continue to treat with the same provider or another designated provider for 90 days from the date of the first visit for the treatment of the work injury or illness.
(c) The employer may not require treatment with any one specific provider on the list, nor may the employer restrict the [employe] employee from switching from one designated provider to another designated provider.
(d) An [employe] employee may not be required to obtain emergency medical treatment from a listed provider. However, once emergency conditions no longer exist, the injured [employe] employee shall treat with a listed provider for the remainder of the 90-day period.
(e) If an employer's list of designated providers fails to comport with the act and this subchapter, the [employe] employee shall have the right to seek medical treatment from any provider from the time of the initial visit.
(f) If an employer chooses not to establish a list of designated providers, the [employe] employee shall have the right to seek medical treatment from any provider from the time of the initial visit.
(g) If a designated provider prescribes invasive surgery for the [employe] employee, the [employe] employee may seek an additional opinion from any healthcare provider of the [employe's] employee's choice. If the additional opinion differs from the opinion of the designated provider and the additional opinion provides a specific and detailed course of treatment, the [employe] employee shall determine which course of treatment to follow. If the [employe] employee opts to follow the course of treatment outlined by the additional opinion, the treatment shall be performed by one of the [health care] providers on the employer's designated list for 90 days from the date of the first visit to the provider of the additional opinion.
§ 127.752. Contents of list of designated [health care] providers.
(a) If an employer establishes a list of designated [health care] providers, there shall be at least six providers on the list.
* * * * * (b) The employer shall prominently include the names, addresses, telephone numbers and area of medical specialties of each of the designated providers on the list. The employer may not require the employee to report to a single point of contact before receiving treatment from a provider on the list.
(c) The employer shall include on the list only providers who are geographically accessible and whose specialties are appropriate based on the anticipated work-related medical problems of the [employes] employees.
* * * * * (e) If the list references a single point of contact or referral for more than one provider on the list, all providers associated with the point of contact or referral shall be considered a single provider under subsection (a).
(f) The employer may change the designated providers on a list. However, changes to the list may not affect the options available to an [employe] employee who has already commenced the 90-day treatment period.
§ 127.753. Disclosure requirements.
(a) The employer may not include on the list of designated [health care] providers a physician or other [health care] provider who is employed, owned or controlled by the employer or the employer's insurer, unless employment, ownership or control is disclosed on the list.
* * * * * § 127.754. Prominence of list of designated providers.
If an employer chooses to establish a list of providers, the list shall be posted in prominent and readily accessible places at the worksite. These places include places used for treatment and first aid of injured [employes] employees and [employe] employee informational bulletin boards.
§ 127.755. Required notice of [employe] employee rights and duties.
(a) If a list of designated providers is established, the employer shall provide a clearly written notice to an injured [employe] employee of the [employe's] employee's rights and duties under section 306(f.1)(1)(i) of the act (77 P. S. § 531(1)(i)).
(b) The contents of the written notice [shall] must, at a minimum, contain the following conditions:
(1) The [employe] employee has the duty to obtain treatment for work-related injuries and illnesses from one or more of the designated [health care] providers for 90 days from the date of the first visit to a designated provider.
(2) The [employe] employee has the right to have all reasonable medical supplies and treatment related to the injury paid for by the employer as long as treatment is obtained from a designated provider during the 90-day period.
(3) The [employe] employee has the right, during this 90-day period, to switch from one [health care] provider on the list to another provider on the list, and that all the treatment shall be paid for by the employer.
(4) The [employe] employee has the right to seek treatment from a referral provider if the [employe] employee is referred to him by a designated provider, and the employer shall pay for the treatment rendered by the referral provider.
(5) The [employe] employee has the right to seek emergency medical treatment from any provider, but that subsequent nonemergency treatment shall be by a designated provider for the remainder of the 90-day period.
* * * * * (7) The employee has the right to seek treatment from any [health care] provider after the 90-day period has ended, and that treatment shall be paid for by the employer, if it is reasonable and necessary.
(8) The employee has the duty to notify the employer of treatment by a nondesignated provider within 5 days of the first visit to that provider. The employer may not be required to pay for treatment rendered by a nondesignated provider prior to receiving this notification. However, the employer shall pay for these services once notified, unless the treatment is found to be unreasonable by a URO, under Subchapter [C] E (relating to medical treatment review).
(9) The employee has the right to seek an additional opinion from any [health care] provider of the employee's choice when a designated provider prescribes invasive surgery for the employee. If the additional opinion differs from the opinion of the designated provider and the additional opinion provides a specific and detailed course of treatment, the employee shall determine which course of treatment to follow. If the employee opts to follow the course of treatment outlined by the additional opinion, the treatment shall be performed by one of the [health care] providers on the employer's designated list for 90 days from the date of the first visit to the provider of the additional opinion.
* * * * * (d) The employer's duty under subsection (a) shall be evidenced by the employee's written acknowledgment of having been informed of and having understood the notice of the employee's rights and duties. Any failure of the employer to provide [and evidence] the notification relieves the employee from any duties specified in the notice, and the employer remains liable for all treatment rendered to the employee. However, an employee may not refuse to sign an acknowledgment to avoid duties specified in the notice.
(Editor's Note: The following text is new. It has been printed in regular type to enhance readability.)
Subchapter E. MEDICAL TREATMENT REVIEW UR--GENERAL REQUIREMENTS
Sec.
127.801. Review of medical treatment generally. 127.802. Treatment subject to review. 127.803. Assignment of cases to UROs. 127.804. Prospective, concurrent and retrospective review. 127.805. Requests for UR--filing and service. 127.805a. UR of medical treatment prior to acceptance of claim. 127.806. Requests for UR--assignment by the Bureau. 127.807. Requests for UR--reassignment. 127.808. Requests for UR--conflicts of interest. 127.809. Requests for UR--withdrawal. UR--ENTIRE COURSE OF TREATMENT
127.811. UR of entire course of treatment. UR--PRECERTIFICATION
127.821. Precertification. 127.822. Precertification--insurer obligations. 127.823. Precertification--provider-filed requests. 127.824. Precertification--employee-filed requests. 127.825. Assignment of proper requests for precertification. PROSPECTIVE, CONCURRENT AND RETROSPECTIVE UR
127.831. Prospective, concurrent and retrospective UR--insurer requests. 127.832. Concurrent and retrospective UR--payment obligations. 127.833. Continuing effect of UR determinations. REQUESTS FOR UR--RECERTIFICATION AND REDETERMINATION
127.841. Requests for UR--recertfication. 127.842. Requests for UR--redetermination. URO OPERATIONS
127.851. Requesting and providing medical records. 127.852. Scope of review of UROs. 127.853. Extent of review of medical records. 127.854. Obtaining medical records--provider under review. 127.855. Employee personal statement. 127.856. Insurer submission of studies. 127.857. Obtaining medical records--other treating providers. 127.858. Obtaining medical records--independent medical exams. 127.859. Obtaining medical records--duration of treatment. 127.860. Obtaining medical records--reimbursement of costs of provider. 127.861. Provider under review's failure to supply medical records. 127.862. Requests for UR--deadline for URO determination. 127.863. Assignment of UR request to reviewer. 127.864. Duties of reviewers--generally. 127.865. Duties of reviewers--conflict of interest. 127.866. Duties of reviewers--content of reports. 127.867. Duties of reviewers--signature and verification. 127.868. Duties of reviewers--forwarding report and medical records to URO. 127.869. Duties of UROs --review of report. 127.870. Form and service of determinations. 127.871. Determination against insurer--payment of medical bills. UR--PETITION FOR REVIEW
127.901. Petition for review of UR determination. 127.902. Petition for review--time for filing. 127.903. Petition for review--notice of assignment and service. 127.904. Petition for review--no answer allowed. 127.905. Petition for review-- transmission of records 127.906. Petition for review by Bureau--hearing and evidence. PEER REVIEW
127.1001. Peer review--availability. 127.1002. Peer review--procedure upon motion of party. 127.1003. Peer review--interlocutory ruling. 127.1004. Peer review--forwarding request to Bureau. 127.1005. Peer review--assignment by the Bureau. 127.1006. Peer review--reassignment. 127.1007. Peer review--conflicts of interest. 127.1008. Peer review--withdrawal. 127.1009. Obtaining medical records. 127.1010. Obtaining medical records--independent medical exams. 127.1011. Provider under review's failure to supply medical records. 127.1012. Assignment of peer review request to reviewer by PRO. 127.1013. Duties of reviewers--generally. 127.1014. Duties of reviewers--conflict of interest. 127.1015. Duties of reviewers--finality of decisions. 127.1016. Duties of reviewers--content of reports. 127.1017. Duties of reviewers--signature and verification. 127.1018. Duties of reviewers--forwarding report and records to PRO. 127.1019. Duties of PRO--review of report. 127.1020. Peer review--deadline for PRO determination. 127.1021. PRO reports--filing with judge and service. 127.1022. PRO reports--evidence. 127.1023. PRO reports--payment. URO/PRO AUTHORIZATION
127.1051. Authorization of UROs/PROs. 127.1052. UROs/PROs authorized prior to (the effective date of these amendments).
UR--GENERAL REQUIREMENTS § 127.801. Review of medical treatment generally.
(a) Throughout this subchapter the words ''insurer'' and ''employer'' shall be used interchangeably.
(b) UR may be requested by or on behalf of the insurer or employee.
(c) UR may be filed by a provider on behalf of an employee who seeks medical treatment from that provider.
(d) A provider, employee or insurer that seeks or is subject to UR shall be a party to the UR.
(e) UR of medical treatment shall be conducted only by organizations authorized as UROs by the Secretary under § 127.1051 (relating to authorization of UROs/PROs).
(f) The Bureau will return any request for UR which is incomplete or on which the proof of service has not been signed.
(g) A party aggrieved by a UR determination may file a petition for review of UR, to be heard and decided by a workers' compensation judge under §§ 127.901--127.906 (relating to UR--petition for review).
§ 127.802. Treatment subject to review.
Treatment for work-related injuries rendered on and after August 31, 1993, may be subject to review under this subchapter.
§ 127.803. Assignment of cases to UROs.
(a) The Bureau will assign requests for UR to authorized UROs.
(b) The Bureau will not assign and will return requests for UR of treatment that is already under review at the time of filing or which is subject to an effective determination, recertification or redetermination under § 127.833 (relating to continuing effect of UR determinations).
§ 127.804. Prospective, concurrent and retrospective review.
UR of treatment may be prospective, concurrent or retrospective.
§ 127.805. Requests for UR--filing and service.
(a) A party seeking UR of treatment rendered under the act shall file the Bureau-prescribed form.
(b) The request for UR shall be served on all parties and their known counsel.
(c) The filing party shall complete the proof of service on the form.
(d) Requests for UR shall be sent to the Bureau at the address listed on the form or filed electronically as the Bureau may permit.
(e) The Bureau will not accept and will return UR requests when it can determine any of the following:
(1) The UR requests review of treatment addressed by a previous UR determination.
(2) The UR request is not complete.
(3) The UR request was not served on all parties to the request.
(4) The treatment under review was not treatment for purposes of this chapter.
(5) The request does not identify all providers who rendered care to the injured employee for the work injury.
(6) The provider indicated as the provider under review did not provide health care services to the employee or is not a provider under this chapter.
(f) An insurer's obligation to pay medical bills under § 127.208 (relating to time for payment of medical bills) shall be tolled only when a proper request for UR has been filed with and accepted by the Bureau in accordance with this subchapter.
§ 127.805a. UR of medical treatment prior to acceptance of claim.
(a) The insurer shall pay for treatment found to be reasonable or necessary under § 127.208 (relating to time for payment of medical bills).
(b) When an insurer requests UR but has not filed documents with the Bureau admitting liability for a work-related injury, or is not subject to a determination imposing this liability, it may not later disclaim liability for the treatment under review in the request for UR.
§ 127.806. Requests for UR--assignment by the Bureau.
(a) The Bureau will 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 following:
(1) The URO.
(2) The employee.
(3) The insurer.
(4) All of the providers under review.
(5) The attorneys for all of the parties, if known.
§ 127.807. Requests for UR--reassignment.
(a) If a URO is unable to perform a request for UR assigned to it by the Bureau, the URO shall return the request for UR to the Bureau for reassignment within 5 days of its receipt of the Notice of Assignment.
(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 under § 127.808 (relating to requests for UR--conflicts of interest).
(d) A URO shall be deemed to have received a Notice of Assignment on the date that the Bureau transmits the notice to the URO by electronic means or by facsimile.
§ 127.808. Requests for UR--conflicts of interest.
A URO shall have a conflict of interest and return a request for UR to the Bureau for reassignment if any 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, except as permitted by §§ 127.841 and 127.842 (relating to requests for UR--recertification; and requests for UR--redetermination).
(2) The URO has provided case management services in a matter involving the patient whose treatment is under review.
(3) The URO has provided vocational rehabilitation services in a matter involving the patient whose treatment is under review.
(4) The URO is owned by or has a contractual arrangement with a party to the review.
(5) The URO has assigned utilization review or peer review matters to the provider under review in the provider's capacity as a reviewer.
§ 127.809. Requests for UR--withdrawal.
(a) A party may withdraw a request for UR by notifying the Bureau, in writing, that it seeks to withdraw the request for UR. A party may not send the withdrawal notification directly to the URO.
(b) The Bureau will promptly notify the URO of the withdrawal.
(c) The insurer shall pay the costs of the withdrawn UR.
(d) A withdrawal of a request for UR shall be with prejudice.
UR--ENTIRE COURSE OF TREATMENT § 127.811. UR of entire course of treatment.
(a) An insurer may request UR of the entire course of treatment rendered to the employee, regardless of the license or specialty of the providers rendering the treatment. This UR shall be retrospective, concurrent and prospective.
(b) An insurer shall make payment for all related medical bills issued more than 30 days before the date the UR request is filed with the Bureau under § 127.208 (relating to time for payment of medical bills).
(c) In response to requests under this section, the URO shall assign each portion of the review rendered by each provider to a reviewer having the same professional license and specialty as the provider rendering treatment to the employee. An inconsistency between reviewers regarding treatment rendered by differently licensed or specialty providers shall be resolved by the URO through consultation of the involved reviewers.
UR--PRECERTIFICATION § 127.821. Precertification.
An employee or provider may seek precertification of treatment that has not yet been provided. If a request for precertification of the same treatment is filed by both a provider and employee, the Bureau will consolidate the requests as if a single request had been filed.
§ 127.822. Precertification--insurer obligations.
(a) Treatment that has not yet been rendered may be precertified as reasonable and necessary in response to a request for prospective UR. Before requesting precertification, the parties shall complete the following:
(1) The employee or provider seeking precertification of treatment shall submit a Bureau-prescribed form to the insurer. The form must contain a request for precertification of treatment, and the employee or provider shall, on the form, specifically identify the treatment for which precertification is requested.
(2) The insurer shall respond by completing and returning the form to the employee and provider listed on the form within 10 days of the date upon which the form was mailed. The provider or employee may evidence the date of mailing through the use of the United States Postal Service Form 3817 (Proof of Mailing).
(b) If the insurer responds that it is willing to pay for the treatment, the Bureau will not process any request for precertification of the treatment. After the treatment has been provided, the insurer may not request, and the Bureau will not assign, a retrospective UR regarding the same treatment. The insurer shall pay for the treatment as if there had been an uncontested UR determination finding that the treatment was reasonable and necessary.
(c) If the insurer declines to pay for the treatment, the insurer shall indicate the reasons for its denial as set forth on the Department-designated form. If no reasons are indicated on the form, or if the insurer has failed to return the form to the employee or provider within the 10 days under subsection (a)(2), the insurer shall pay for the treatment.
(d) If the insurer denies a causal relationship between the work-related injury and the treatment or denies liability for the work injury on the form, the Bureau will not process a request for precertification. The provider or employee may refile the request when the underlying liability is accepted by the insurer or determined by a workers' compensation judge. If a workers' compensation judge determines that the insurer improperly denied the existence of a causal relationship or liability for the injury, penalties may be assessed under section 435 of the act (77 P. S. § 501). In determining whether the underlying liability has been accepted or determined, the Bureau may utilize information contained in its official records.
(e) If the insurer does not agree to pay for the treatment but does not contest liability or causation, the provider or employee may file a request for precertification with the Bureau.
(f) An insurer's denial of payment for treatment later determined to be reasonable and necessary may result in the imposition of penalties under section 435 of the act.
§ 127.823. Precertification--provider-filed requests.
(a) A provider filing a request for precertification shall detail the treatment plan, procedure or referral that is the subject of the request on or in an attachment to the form.
(b) If the provider seeks precertification of a referral, the provider shall serve a copy of the request on the provider to whom the referral will be made.
(c) The Bureau may return a request that fails to comply with this subchapter.
§ 127.824. Precertification-employee-filed requests.
(a) When an employee seeks precertification of treatment, the employee shall identify the provider who may provide the treatment under review. The assigned URO shall contact the provider identified by the employee. The URO shall contact the provider in writing and request that the provider submit the treatment plan, procedure or referral for the treatment under review within 10 days of the request.
(b) A provider's failure to timely supply information under this section shall result in a determination that the treatment under review is unreasonable and unnecessary.
§ 127.825. Assignment of proper requests for precertification.
If the Bureau determines that the requester is entitled to request precertification, the Bureau will assign the request to a URO in accordance with this chapter. The Bureau's assignment or nonassignment of a UR to a URO under this section is interlocutory and is subject to appeal only after the UR determination is rendered. An appeal shall be permitted under § 127.901 (relating to petition for review of UR determination).
PROSPECTIVE, CONCURRENT AND RETROSPECTIVE UR § 127.831. Prospective, concurrent and retrospective UR--insurer requests.
(a) An insurer may request review of treatment that the employee is currently undergoing or may undergo in the immediate future.
(b) If the Bureau determines that the requester is entitled to request UR, the Bureau will assign the request to a URO in accordance with this chapter. The Bureau's assignment or nonassignment of a UR to a URO under this section is interlocutory and is subject to appeal only after the UR determination is rendered. An appeal shall be permitted under § 127.901 (relating to petition for review of UR determination).
§ 127.832. Concurrent and retrospective UR--payment obligations.
(a) An insurer shall make payment for all related medical bills issued more than 30 days before the date the UR request is filed with the Bureau under § 127.208 (relating to time for payment of medical bills).
(b) If the insurer is contesting liability for the work injury, the 30 days in which to request retrospective UR is tolled pending the insurer's acceptance of liability or a workers' compensation judge's determination of liability.
§ 127.833. Continuing effect of UR determinations.
(a) A determination that prospective treatment is reasonable and necessary remains effective for continuing treatment only to the extent specified in the determination.
(b) An employee or provider who was a party to a determination granting precertification of treatment may request that the treatment be recertified as reasonable and necessary as permitted by § 127.841 (relating to requests for UR--recertification).
(c) A determination that treatment is unreasonable or unnecessary remains effective for all treatment found unreasonable or unnecessary, regardless of the provider who renders the treatment, until the employee demonstrates that a change in the employee's medical condition merits redetermination of the treatment.
(d) An employee or provider may request redetermination of treatment previously determined to be unreasonable or unnecessary under § 127.842 (relating to requests for UR--redetermination) if a change in the employee's medical condition has altered the reasonableness or necessity of treatment.
REQUESTS FOR UR--RECERTIFICATION AND REDETERMINATION § 127.841. Requests for UR-recertfication.
(a) If a request for UR resulted in a determination that treatment was or is reasonable and necessary, the employee or provider may request that the treatment be recertified as reasonable and necessary.
(b) The Bureau will not accept a request for recertification submitted more that 30 days before the expiration of a preceding UR or recertification relating to the same treatment.
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