Section 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 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, whichever is later. The form shall be accompanied by documentation required by § 127.253 (relating to application for fee review—documents required generally).

(b) Providers shall serve a copy for the application for fee review, and the attached documents, 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) Providers shall send the application for fee review and all related attachments to the address for the Bureau listed on the application form.

(d) The time for filing an application for fee review will be tolled if the insurer has the right to suspend payment to the provider due to a dispute regarding the reasonableness and necessity of the treatment under Subchapter C (relating to medical treatment review).

The provisions of this § 127.252 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203481) to (203482).

Notation

Notes of Decisions

Burden

Although insurer bears the burden of proving that it properly reimbursed provider, the provider must first show that it filed a timely application for fee review. The provider has the burden of proving the existence of a dispute as to liability. Thomas Jefferson University Hospital v. Bureau of Workers’ Compensation Medical Fee Review Hearing Office, 794 A.2d 933, 935 (Pa. Cmwlth. 2002).

Time

Where there is a dispute as to liability, but the provider has actual knowledge of a decision regarding liability, the provider must file its application within 30 days of notification of that decision, or 90 days from the original billing date. Thomas Jefferson University Hospital v. Bureau of Workers’ Compensation Medical Fee Review Hearing Office, 794 A.2d 933, 934 (Pa. Cmwlth. 2002).

Time limits for medical provider to file application for review of medical fee disputes with workers’ compensation insurer is 90 days following the original billing date of treatment on the UB92 form, not the date the bill was sent by provider to insurer; hospital’s fee review application was untimely and subject to denial since it was submitted 102 days after the original billing date. Nationwide Mut. Fire Ins. Co. v. Bureau of Workers’ Comp. Fee Review Hearing Office, 981 A.2d 366 (Pa. Cmwlth. 2009).

Time for Review

Where the original Application for Fee Review was denied because of the failure to submit the forms required under § 127.202, the time for submission of a fee review runs from the insurer’s denial of a later Application by the provider which complies with the form requirements. Harburg Medical Sales Co. v. Bureau of Workers’ Compensation, 784 A.2d 866, 870 (Pa. Cmwlth. 2001).

Cross References

This section cited in 34 Pa. Code § 127.207 (relating to downcoding by insurers).