UR—GENERAL REQUIREMENTS
§ 127.401. Purpose/review of medical treatment.
(a) Section 306(f.1)(6) of the act (77 P. S. § 531(6)) provides a UR process, intended as an impartial review of the reasonableness or necessity of medical treatment rendered to, or proposed for, work-related injuries and illnesses.
(b) UR of medical treatment shall be conducted only by those organizations authorized as UROs by the Secretary, under the process in § § 127.651—127.670 (relating to authorization of UROs and PROs).
(c) UR may be requested by or on behalf of the employer, insurer or employe.
(d) A party, including a health care provider, aggrieved by the UR determination, may file a petition for review of UR, to be heard and decided by a workers’ compensation judge.
Source The provisions of this § 127.401 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203488) to (203489).
Notes of Decisions Utilization Review Process
Utilization review process is exclusive way to challenge the reasonableness and necessity of medical bills of a workers’ compensation claimant; neither a Workers’ Compensation Judge nor the Workers’ Compensation Appeal Board has jurisdiction to determine the reasonableness of medical treatment unless and until a report is issued and the Utilization Review Organization issues a determination. County of Allegheny (John J. Kane Ctr.—Ross) v. Workers’ Compensation Appeal Board (Geisler), 875 A.2d 1222, 1226 (Pa. Cmwlth. 2005).
Cross References This section cited in 34 Pa. Code § 127.404 (relating to prospective, concurrent and retrospective review).
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