Section 127.404. Prospective, concurrent and retrospective review

(a) UR of treatment may be prospective, concurrent or retrospective, and may be requested by any party eligible to request UR under § 127.401(c) (relating to purpose/review of medical treatment).

(b) If an insurer or employer seeks retrospective review of treatment, the request for UR shall be filed within 30 days of the receipt of the bill and medical report for the treatment at issue. Failure to comply with the 30-day time period shall result in a waiver of retrospective review. If the insurer is contesting liability for the underlying claim, the 30 days in which to request retrospective UR is tolled pending an acceptance or determination of liability.

(c) If an employe files a request for UR of treatment, the Bureau will confirm whether the insurer is liable for the underlying alleged work injury. The Bureau will process the UR request only when workers’ compensation liability for the underlying injury has been accepted or determined.

(d) If an employe files a request for UR of prospective treatment which satisfies the requirements of subsection (c), the Bureau will determine whether the insurer is denying payment for the treatment.

(1) The Bureau will send a copy of the employe’s request for UR to the insurer, together with a written notice asking the insurer whether it will accept payment for the treatment or is denying payment for the treatment. The insurer shall respond in writing to the Bureau’s written notice within 7 days of receipt of the notice.

(2) If the insurer responds that it is willing to accept payment for the treatment, the Bureau will not process the employe’s request for UR. After the treatment at issue has been provided, the insurer may not request, and the Bureau will not process, a retrospective UR on the same treatment. The insurer shall pay for the treatment as if there had been an uncontested UR determination finding the treatment to be reasonable or necessary.

(3) If the insurer is denying payment for the treatment, the insurer shall state the reasons for the denial in its written response. If no reasons are stated for the denial, or if the insurer’s written response to the Bureau notice is untimely, the insurer shall pay for the cost of the UR and pay for treatment found to be reasonable or necessary by an uncontested UR determination.

(4) If the insurer responds in writing to the Bureau’s notice by denying a causal relationship between the work-related injury and the treatment, the Bureau will not process the employe’s UR request until the underlying liability is either accepted by the insurer or determined by a Workers’ Compensation judge.

The provisions of this § 127.404 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203489) to (20390).

Notation

Notes of Decisions

Error on Request Form

The fact that the employer erroneously checked the ‘‘medical only’’ box on its review request would not void its otherwise permissible utilization review request. Carter v. Workers’ Compensation Appeal Board (Hertz Corp.), 790 A.2d 1105, 1108 (Pa. Cmwlth. 2002).

Interpretation

The phrase ‘‘in which to request’’ in subsection (b) is synonymous with ‘‘filing an application’’ as used in section 306(f.1)(5) of the Workers’ Compensation Act (77 P. S. § 531(5)). Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 686 (Pa. Cmwlth. 2002).

Jurisdiction

Because liability had not been established to commence the running of the 30-day period for filing a utilization review request, the workers’ compensation judge was without jurisdiction to determine the reasonableness and necessity of the claimant’s medical expenses. That determination was therefore vacated. Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 687 (Pa. Cmwlth. 2002).

Request During Pendency of Claim

An employer is not precluded from filing a request for retrospective utilization review during the pendency of the claimant’s claim petition. Carter v. Workers’ Compensation Appeal Board (Hertz Corp.), 790 A.2d 1105, 1108 (Pa. Cmwlth. 2002).

Termination Petition

The tolling of the 30-day period for challenging medical bills does not apply to termination petitions. Ryndycz v. W.C.A.B. (White Engineering), 936 A.2d 146, 151 (Pa. Cmwlth. 2007).

Time

Because a determination of liability was pending, the employer had not waived its right to challenge the reasonableness or necessity of claimant’s medical bills by its failure to request retrospective utilization review. Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 686 (Pa. Cmwlth. 2002).