§ 127.254. Downcoding disputes.
(a) When changes in procedure codes are the basis for a fee dispute, the Bureau will give the provider and the insurer the opportunity to produce copies of written communications concerning the changes in procedure codes.
(b) If an insurer has not complied with § 127.207 (relating to downcoding by insurers) the Bureau will resolve downcoding disputes in favor of the provider.
Notes of Decisions Notice
The hearing officer did not err in resolving the fee review dispute in favor of the provider, where the insurer notified the provider that it was not paying because of the unproven nature of the treatment and shifted to the coding issue only after the review was underway and where insurer fails to strictly comply with notice requirements. Philadelphia v. Medical Fee Review Hearing Office, 737 A.2d 356 (Pa. Cmwlth. 1999).
Cross References This section cited in 34 Pa. Code § 127.207 (relating to downcoding by insurers).
No part of the information on this site may be reproduced for profit or sold for profit.
This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
