Section 127.254. Downcoding disputes

Latest version.

(a) When changes in procedure codes are the basis for a fee dispute, the Bureau will give the provider and the insurer the opportunity to produce copies of written communications concerning the changes in procedure codes.
(b) If an insurer has not complied with § 127.207 (relating to downcoding by insurers) the Bureau will resolve downcoding disputes in favor of the provider.

Notation

Notes of Decisions

Notice

The hearing officer did not err in resolving the fee review dispute in favor of the provider, where the insurer notified the provider that it was not paying because of the unproven nature of the treatment and shifted to the coding issue only after the review was underway and where insurer fails to strictly comply with notice requirements. Philadelphia v. Medical Fee Review Hearing Office, 737 A.2d 356 (Pa. Cmwlth. 1999).

Cross References

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

                    
                        var val = document.getElementById('citecontent').innerHTML;
                        art.dialog.defaults.title = window.location.href;
                        art.dialog.data('cite', val);
                        art.dialog.data('homeDemoPath', '/Scripts/plus/artDialog/');
                        art.dialog.open('/Scripts/plus/artDialog/citeiframe.html');