Section 127.255. Premature applications for fee review

The Bureau will return applications for fee review prematurely filed by providers when one of the following exists:

(1) The insurer denies liability for the alleged work injury.

(2) The insurer has filed a request for utilization review of the treatment under Subchapter C (relating to medical treatment review).

(3) The 30-day period allowed for payment has not yet elapsed, as computed under § 127.208 (relating to time for payment of medical bills).

Notation

Notes of Decisions

Premature Fee Review Request

Department of Labor and Industry could not consider medical provider’s fee review application for services provided to workers’ compensation claimant after insurer denied liability for the claim; determination of whether insurer is liable for an injury requires the exercise of legal judgment and requires the Department to evaluate the Notice of Compensation Payable that insurer issued, insurer’s denial, and any other relevant documentation and evidence. Crozer Chester Medical Center v. Dep’t. of Labor & Industry, 955 A.2d 1037, 1042 (Pa. Cmwlth. 2008).

Provider who supplied workers’ compensation claimant with orthopedic mattress, foundation, and frame pursuant to doctor’s order, failed to establish it mailed bill for equipment to insurer on November 18; instead, the hearing officer credited insurer’s evidence that it did not receive bill until December 28, therefore insurer’s utilization review request received by Workers’ Compensation Bureau on January 12 of the following year was timely since it was within 30 days of receipt of bill as required by law and insurer’s obligation to pay had not yet been established, providers’ fee review application was properly denied and dismissed. Harrisburg Medical Sales Co. v. Bureau of Workers’ Compensation (Employers’ Mutual Casualty Co.), 911 A.2d 214 (Pa. Cmwlth. 2006).