Section 127.464. Effect of failure of provider under review to supply records

(a) If the provider under review fails to mail records to the URO within 30 days of the date of request of the records, the URO shall render a determination that the treatment under review was not reasonable or necessary, if the conditions set forth in subsection (b) have been met.

(b) Before rendering the determination against the provider, a URO shall do the following:

(1) Determine whether the records were mailed in a timely manner.

(2) Indicate on the determination that the records were requested but not provided.

(3) Adequately document the attempt to obtain records from the provider under review, including a copy of the certified mail return receipt from the request for records.

(c) If the URO renders a determination against the provider under subsection (a), it may not assign the request to a reviewer.

Notation

Notes of Decisions

URO

Because medical provider mailed claimant’s health care records to Utilization Review Organization (URO) within 30 days of the request for such records, it was timely; language of regulation is clear that records must be ‘‘mailed’’ and not ‘‘received’’ within the 30 days of the date health care records are requested. Sueta v. Workers’ Comp. Appeal Bd. (City of Scranton and PMA Group), 943 A.2d 1017, 1021 (Pa. Cmwlth. 2008)

Workers’ Compensation Judge (WCJ) lacked jurisdiction to hear claimant’s appeal of Utilization Review Organization (URO) determination that treatments provided by claimant’s physician were not reasonable or necessary; claimant’s physician failed to provide medical records within 30 days to URO, and in the absence of a peer review report on the substantive merits of medical treatment, there is nothing for a WCJ to review. Stafford v. Workers’ Compensation Appeal Board (Advanced Placement Serv.), 933 A.2d 139, 142—143 (Pa. Cmwlth. 2007)

Claimant sought review of decision of workers’ compensation judge dismissing, for lack of jurisdiction, his petition for review of utilization review organization (URO) determination that medical treatment was not reasonable or necessary based on failure of claimant’s physician to provide medical records; WCJ had jurisdiction to determine the adequacy of URO’s pursuit of requested medical records, URO’s compliance with applicable regulatory procedures requirements, and whether claimant’s medical provider complied with requirements since these issues did not involve a determination as to reasonableness and necessity of medical treatment. Gazzola v. Workers’ Compensation Appeal Board (Ikon Office Solutions), 911 A.2d 662, 664, 665 (Pa. Cmwlth. 2006).