Section 127.208. Time for payment of medical bills

(a) Payments for treatment rendered under the act shall be made within 30 days of receipt of the bill and report submitted by the provider.

(b) For purposes of computing the timeliness of payments, the insurer shall be deemed to have received a bill and report 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.

(c) If an insurer requests additional information or records from a provider, 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 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 (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.

(f) The nonpayment to providers within 30 days shall only apply to that particular treatment or portion thereof in dispute. If a portion of the treatment is not in dispute, payment shall be made within 30 days.

(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)).

The provisions of this § 127.208 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203479) to (203480).

Notation

Notes of Decisions

Payment for Medical Treatment

Once it is determined that an employer is liable for an injury under the Workers’ Compensation Act, the employer is required to pay claimant’s medical bills within 30 days of receipt. Westinghouse Electric v. W.C.A.B. (Weaver), 823 A.2d 209, 218 (Pa.Cmwlth 2003); appeal denied 864 A.2d 531 (Pa. 2004).

Suspension of Payment

The Workers’ Compensation Judge did not err by failing to order the employer to pay the chiropractor’s bills up to the date of his decision, where this regulation permits a suspension of an employer’s obligation to continue paying medical bills during the utilization review process. Musko v. Workers’ Compensation Appeal Board (Calgon Carbon Corp.), 729 A.2d 657 (Pa. Cmwlth. 1999).

Cross References

This section cited in 34 Pa. Code § 127.255 (relating to premature applications for fee review); and 34 Pa. Code § 127.479 (relating to determination against insurer—payment of medical bills).