§ 127.207. Downcoding by insurers.
(a) Changes to a provider’s codes by an insurer may be made if the following conditions are met:
(1) The provider has been notified in writing of the proposed changes and the reasons in support of the changes.
(2) The provider has been given an opportunity to discuss the proposed changes and support the original coding decisions.
(3) The insurer has sufficient information to make the changes.
(4) The changes are consistent with Medicare guidelines, the act and this subchapter.
(b) For purposes of subsection (a)(1), the provider shall be given 10 days to respond to the notice of the proposed changes, and the insurer must have written evidence of the date notice was sent to the provider.
(c) Whenever changes to a provider’s billing codes are made, the insurer shall state the reasons why the provider’s original codes were changed in the explanation of benefits required by § 127.209 (relating to explanation of benefits paid).
(d) If an insurer changes a provider’s codes without strict compliance with subsections (a)—(c), the Bureau will resolve an application for fee review filed under § 127.252 (relating to application for fee review—filing and service) in favor of the provider under § 127.254 (relating to downcoding disputes).
Notes of Decisions Billing Codes
The insurer’s argument that it can summarily deny any application for medical fee reimbursement as incomplete if the application contains a billing code that the insurer believes should be different than the one used, and when that occurs, it is not required to contact the provider or provide a reason for denial, was disingenuous, where its assertion was contrary to the plain language of this regulation and the only reason it gave for denying payment was that the therapy billed for was unproven. Philadelphia v. Medical Fee Review Hearing Office, 737 A.2d 356 (Pa. Cmwlth. 1999).
Cross References This section cited in 34 Pa. Code § 127.254 (relating to downcoding disputes).
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