Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 8238 (December 30, 2023).

34 Pa. Code § 127.302. Resolution of self-referral disputes by Bureau.

§ 127.302. Resolution of self-referral disputes by Bureau.

 (a)  If an insurer determines that a bill has been submitted for treatment rendered in violation of the referral standards, the insurer is not liable to pay the bill. Within 30 days of receipt of the provider’s bill and medical report, the insurer shall supply a written explanation of benefits, under §  127.209 (relating to explanation of benefits paid), stating the basis for believing that the self-referral provision has been violated.

 (b)  A provider who has been denied payment of a bill under subsection (a) may file an application for fee review with the Bureau under §  127.251 (relating to medical fee disputes—review by the Bureau) An application for fee review filed under this subsection will be assigned to a hearing officer for a hearing and adjudication in accordance with the procedures set forth in § §  127.259 and 127.260 (relating to fee review hearing; and fee review adjudications).

 (c)  The insurer shall have the burden of proving by a preponderance of the evidence that a violation of the self-referral provisions has occurred.

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