Section 127.205. Calculation of amount of payment due to providers

Bills submitted by providers for payment shall state the provider’s actual charges for the treatment rendered. A provider’s statement of actual charges will not be construed to be an unlawful request or requirement for payment in excess of the medical fee caps. The insurer to whom the bill is submitted shall calculate the proper amount of payment for the treatment rendered.

Notation

Notes of Decisions

Calculation

The Workers’ Compensation Judge erred in awarding medical expenses in the amount of $40,000 without reducing them to the applicable fee caps even though this regulation did not become effective until November 11, 1995, after the health care provider had submitted his bills, where the court was remanding the case so that the provider could submit his bills on the required forms; because this regulation is procedural, as it does not alter any substantive rights, the court instructed the employer and its insurance carrier to calculate the proper amount of payment for the treatment rendered. AT&T v. Workers’ Compensation Appeal Board (Dinapoli), 728 A.2d 381 (Pa. Cmwlth. 1999); appeal denied 829 A.2d 311 (Pa. 2003).

Retroactive Application

The Workers’ Compensation Appeal Board erred in relying upon this regulation in determining that the insurer must calculate the amounts payable under the medical fee caps for the treatment at issue, where this regulation did not become effective until November 11, 1995, after the treatment which ended in December 1994. Acme Markets, Inc. v. Workers’ Compensation Appeal Board, 725 A.2d 863 (Pa. Cmwlth. 1999); appeal denied 743 A.2d 923 (Pa. 1999).