34 Pa. Code § 127.252
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).
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).
This section cited in 34 Pa. Code § 127.207 (relating to downcoding by insurers).