Subchapter C. MEDICAL TREATMENT REVIEW
UR—GENERAL REQUIREMENTS
Sec.
127.401. Purpose/review of medical treatment
127.402. Treatment subject to review.
127.403. Assignment of cases to UROs by the Bureau.
127.404. Prospective, concurrent and retrospective review.
127.405. UR of medical treatment in medical only cases.
127.406. Scope of review of UROs.
127.407. Extent of review of medical records.
UR—INITIAL REQUEST
127.451. Initial requests for UR—who may file.
127.452. Initial requests for UR—filing and service.
127.453. Initial requests for UR—assignment by the Bureau.
127.454. Initial requests for UR—reassignment.
127.455. Initial requests for UR—conflicts of interest.
127.456. Initial requests for UR—withdrawal.
127.457. Time for requesting medical records.
127.458. Obtaining authorization to release medical records.
127.459. Obtaining medical records—provider under review.
127.460. Obtaining medical records—other treating providers.
127.461. Obtaining medical records—independent medical exams.
127.462. Obtaining medical records—duration of treatment.
127.463. Obtaining medical records—reimbursement of costs to provider.
127.464. Effect of failure of provider under review to supply records.
127.465. Initial requests for UR—deadline for URO determination.
127.466. Assignment of UR request to reviewer by URO.
127.467. Duties of reviewers—generally.
127.468. Duties of reviewers—conflict of interest.
127.469. Duties of reviewers—consultation with provider under review.
127.470. Duties of reviewers—issues reviewed.
127.471. Duties of reviewers—finality of decisions.
127.472. Duties of reviewers—content of records.
127.473. Duties of reviewers—signature and verification.
127.474. Duties of reviewers—forwarding report and records to URO.
127.475. Duties of UROs—review of report.
127.476. Duties of UROs—form and service of determinations.
127.477. Payment for initial requests for UR.
127.478. Record retention requirements for UROs.
127.479. Determination against insurer—payment of medical bills.
127.501—127.515. [Reserved].
UR—PETITION FOR REVIEW
127.551. Petition for Review by Bureau of UR determination.
127.552. Petition for Review by Bureau—time for filing.
127.553. Petition for Review by Bureau—notice of assignment and service by Bureau.
127.554. Petition for Review by Bureau—no answer allowed.
127.555. Petition for Review by Bureau—transmission of URO records to Workers’ Compensation judge.
127.556. Petition for Review by Bureau—de novo hearing.
PEER REVIEW
127.601. Peer review—availability.
127.602. Peer review—procedure upon motion of party.
127.603. Peer review—interlocutory ruling.
127.604. Peer review—forwarding of request to Bureau.
127.605. Peer review—assignment by the Bureau.
127.606. Peer review—reassignment.
127.607. Peer review—conflicts of interest.
127.608. Peer review—withdrawal.
127.609. Obtaining medical records.
127.610. Obtaining medical records—independent medical exams.
127.611. Obtaining medical records—duration of treatment.
127.612. Effect of failure of provider under review to supply records.
127.613. Assignment of peer review request to reviewer by PRO.
127.614. Duties of reviewers—generally.
127.615. Duties of reviewers—conflict of interest.
127.616. Duties of reviewers—consultation with provider under review.
127.617. Duties of reviewers—issues reviewed.
127.618. Duties of reviewers—finality of decisions.
127.619. Duties of reviewers—content of reports.
127.620. Duties of reviewers—signature and verification.
127.621. Duties of reviewers—forwarding report and records to PRO.
127.622. Duties of PRO—review of report.
127.623. Peer review—deadline for PRO determination.
127.624. PRO reports—filing with judge and service.
127.625. Record retention requirements for PROs.
127.626. PRO reports—evidence.
127.627. PRO reports—payment.
AUTHORIZATION OF UROs AND PROs
127.651. Application.
127.652. Contents of an application to be authorized as a URO or PRO.
127.653. Decision on application.
127.654. Authorization periods.
127.655. Reauthorization.
127.656. General qualifications.
127.657. Local business office.
127.658. Accessibility.
127.659. Confidentiality.
127.660. Availability of reviewers.
127.661. Qualifications of reviewers.
127.662. Contracts with reviewers.
127.663. UR system.
127.664. Quality assurance system.
127.665. Case communication system.
127.666. Annual reports.
127.667. Compensation policy.
127.668. Suspension of assignments.
127.669. Revocation of authorizations.
127.670. Hearings.
Cross References This subchapter cited in 34 Pa. Code § 127.208 (relating to time for payment of medical bills); 34 Pa. Code § 127.210 (relating to interest on untimely payments); 34 Pa. Code § 127.211 (relating to balance billing prohibited); 34 Pa. Code § 127.252 (relating to application for fee review—filing and service); 34 Pa. Code § 127.255 (relating to premature applications for fee review); and 34 Pa. Code § 127.755 (relating to required notice of employe rights and duties).
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).
§ 127.402. Treatment subject to review.
Treatment for work-related injuries rendered on and after August 31, 1993, may be subject to review.
§ 127.403. Assignment of cases to UROs by the Bureau.
The Bureau will randomly assign requests for UR to authorized UROs. An insurer’s obligation to pay medical bills within 30 days of receipt shall be tolled only when a proper request for UR has been filed with the Bureau in accordance with this subchapter.
§ 127.404. Prospective, concurrent and retrospective review.
(a) UR of treatment may be prospective, concurrent or retrospective, and may be requested by any party eligible to request UR under § 127.401(c) (relating to purpose/review of medical treatment).
(b) If an insurer or employer seeks retrospective review of treatment, the request for UR shall be filed within 30 days of the receipt of the bill and medical report for the treatment at issue. Failure to comply with the 30-day time period shall result in a waiver of retrospective review. If the insurer is contesting liability for the underlying claim, the 30 days in which to request retrospective UR is tolled pending an acceptance or determination of liability.
(c) If an employe files a request for UR of treatment, the Bureau will confirm whether the insurer is liable for the underlying alleged work injury. The Bureau will process the UR request only when workers’ compensation liability for the underlying injury has been accepted or determined.
(d) If an employe files a request for UR of prospective treatment which satisfies the requirements of subsection (c), the Bureau will determine whether the insurer is denying payment for the treatment.
(1) The Bureau will send a copy of the employe’s request for UR to the insurer, together with a written notice asking the insurer whether it will accept payment for the treatment or is denying payment for the treatment. The insurer shall respond in writing to the Bureau’s written notice within 7 days of receipt of the notice.
(2) If the insurer responds that it is willing to accept payment for the treatment, the Bureau will not process the employe’s request for UR. After the treatment at issue has been provided, the insurer may not request, and the Bureau will not process, a retrospective UR on the same treatment. The insurer shall pay for the treatment as if there had been an uncontested UR determination finding the treatment to be reasonable or necessary.
(3) If the insurer is denying payment for the treatment, the insurer shall state the reasons for the denial in its written response. If no reasons are stated for the denial, or if the insurer’s written response to the Bureau notice is untimely, the insurer shall pay for the cost of the UR and pay for treatment found to be reasonable or necessary by an uncontested UR determination.
(4) If the insurer responds in writing to the Bureau’s notice by denying a causal relationship between the work-related injury and the treatment, the Bureau will not process the employe’s UR request until the underlying liability is either accepted by the insurer or determined by a Workers’ Compensation judge.
Source The provisions of this § 127.404 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203489) to (20390).
Notes of Decisions Error on Request Form
The fact that the employer erroneously checked the ‘‘medical only’’ box on its review request would not void its otherwise permissible utilization review request. Carter v. Workers’ Compensation Appeal Board (Hertz Corp.), 790 A.2d 1105, 1108 (Pa. Cmwlth. 2002).
Interpretation
The phrase ‘‘in which to request’’ in subsection (b) is synonymous with ‘‘filing an application’’ as used in section 306(f.1)(5) of the Workers’ Compensation Act (77 P. S. § 531(5)). Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 686 (Pa. Cmwlth. 2002).
Jurisdiction
Because liability had not been established to commence the running of the 30-day period for filing a utilization review request, the workers’ compensation judge was without jurisdiction to determine the reasonableness and necessity of the claimant’s medical expenses. That determination was therefore vacated. Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 687 (Pa. Cmwlth. 2002).
Request During Pendency of Claim
An employer is not precluded from filing a request for retrospective utilization review during the pendency of the claimant’s claim petition. Carter v. Workers’ Compensation Appeal Board (Hertz Corp.), 790 A.2d 1105, 1108 (Pa. Cmwlth. 2002).
Termination Petition
The tolling of the 30-day period for challenging medical bills does not apply to termination petitions. Ryndycz v. W.C.A.B. (White Engineering), 936 A.2d 146, 151 (Pa. Cmwlth. 2007).
Time
Because a determination of liability was pending, the employer had not waived its right to challenge the reasonableness or necessity of claimant’s medical bills by its failure to request retrospective utilization review. Chik-Fil-A v. Workers’ Compensation Appeal Board (Mollick), 792 A.2d 678, 686 (Pa. Cmwlth. 2002).
§ 127.405. UR of medical treatment in medical only cases.
(a) In medical only cases, when an insurer is paying for an injured worker’s medical treatment but has not either filed documents with the Bureau admitting liability for a work-related injury nor has there been a determination to the effect, the insurer may still seek review of the reasonableness or necessity of the treatment by filing a request for UR.
(b) If the insurer files a request for UR in a medical only case, the insurer is responsible for paying for the costs of the UR.
(c) If the insurer files a request for UR in a medical only case, then the insurer shall be liable to pay for treatment found to be reasonable or necessary by an uncontested UR determination.
Source The provisions of this § 127.405 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203490).
Notes of Decisions UR Decision Not Moot
Decision arising from employer’s utilization review request which was filed prior to claimant’s claim petition was not rendered moot because a WCJ never has original jurisdiction over issues concerning reasonableness and necessity; the purpose of the regulation is to encourage payment of medical bills in cases that are, at least initially, medical only. Krouse v. W.C.A.B. (Barrier Enters. Inc.), 837 A.2d 671, 674—675 (Pa. Cmwlth. 2003).
§ 127.406. Scope of review of UROs.
(a) UROs shall decide only the reasonableness or necessity of the treatment under review.
(b) UROs may not decide any of the following issues:
(1) The causal relationship between the treatment under review and the employe’s work-related injury.
(2) Whether the employe is still disabled.
(3) Whether ‘‘maximum medical improvement’’ has been obtained.
(4) Whether the provider performed the treatment under review as a result of an unlawful self-referral.
(5) The reasonableness of the fees charged by the provider.
(6) The appropriateness of the diagnostic or procedural codes used by the provider for billing purposes.
(7) Other issues which do not directly relate to the reasonableness or necessity of the treatment under review.
Notes of Decisions Causal Relationship
The Workers’ Compensation Appeal Board did not abuse its discretion by denying the claimant’s request to remand the matter to the Workers’ Compensation Judge to receive the ‘‘after discovered’’ utilization review organization (URO) determination, because the scope of review of a URO is strictly limited to reviewing the reasonableness and necessity of medical treatment, the URO’s decision that the physical therapy provided to the claimant was reasonable and necessary does not establish that the treatment was causally related to the claimant’s work-related injury or that the claimant remains disabled by his work-related injury. Corcoran v. Workers’ Compensation Appeal Board, 725 A.2d 868 (Pa. Cmwlth. 1999).
General Comment
Clearly, this regulation recognizes a distinction between an issue concerning causation as opposed to reasonableness and necessity of treatment. An action concerning causation cannot be raised before a URO; therefore, it must be raised in a petition that is intended to be heard directly by a WCJ. Likewise, an action concerning the reasonableness and necessity of treatment is to be raised in a request for UR that will be submitted to a URO. Bloom v. Workmen’s Compensation Appeal Board, 677 A.2d 1314 (Pa. Cmwlth. 1996); appeal denied 684 A.2d 558 (Pa. 1996).
§ 127.407. Extent of review of medical records.
(a) In order to determine the reasonableness or necessity of the treatment under review, UROs shall obtain for review all available records of all treatment rendered by all providers to the employe for the work-related injury. However, the UR determination shall be limited to the treatment that is subject to review by the request.
(b) UROs may not obtain or review medical records of treatment which are not related to the work injury.
UR—INITIAL REQUEST
§ 127.451. Requests for UR—who may file.
Requests for UR may be filed by an employe, employer or insurer. Health care providers may not file requests for UR.
Source The provisions of this § 127.451 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222313).
§ 127.452. Requests for UR—filing and service.
(a) A party seeking UR of treatment rendered under the act shall file the original and 8 copies of a form prescribed by the Bureau as a request for UR. All information required by the form shall be provided. If available, the filing party shall attach authorizations to release medical records of the providers listed on the request.
(b) The request for UR shall be served on all parties and their counsel, if known, and the proof of service on the form shall be executed. If the proof of service is not executed, the request for UR will be returned by the Bureau.
(c) Requests for UR shall be sent to the Bureau at the address listed on the form.
(d) The request for UR shall identify the provider under review. Except as specified in subsection (e), the provider under review shall be the provider who rendered the treatment or service which is the subject of the UR request.
(e) When the treatment or service requested to be reviewed is anesthesia, incident to surgical procedures, diagnostic tests, prescriptions or durable medical equipment, the request for UR shall identify the provider who made the referral, ordered or prescribed the treatment or service as the provider under review.
Source The provisions of this § 127.452 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222313).
Notes of Decisions Service
The insurer cannot claim that the fee review should be dismissed as premature because it properly sought a request for a utilization review, where the hearing officer found that the health care provider presented uncontradicted testimony that it had never received notification that the bills would be subjected to a utilization review and that it was not provided with a utilization review report. Royal Insurance v. Department of Labor and Industry, Bureau of Workers’ Compensation, The Spine Center, 728 A.2d 401 (Pa. Cmwlth. 1999).
§ 127.453. Requests for UR—assignment by the Bureau.
(a) The Bureau will randomly assign a properly filed request for UR to an authorized URO.
(b) The Bureau will send a notice of assignment of the request for UR to the URO; the employe; the employer or insurer; the health care provider under review; and the attorneys for the parties, if known.
Source The provisions of this § 127.453 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).
§ 127.454. Requests for UR—reassignment.
(a) If a URO is unable, for any reason, to perform a request for UR assigned to it by the Bureau, the URO shall, within 5 days of receipt of the assignment, return the request for UR to the Bureau for reassignment.
(b) A URO may not directly reassign a request for UR to another URO.
(c) A URO shall return a request for UR assigned to it by the Bureau if the URO has a conflict of interest with the request, as set out in § 127.455 (relating to requests for UR—conflicts of interest).
Source The provisions of this § 127.454 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).
§ 127.455. Requests for UR—conflicts of interest.
(a) A URO shall be deemed to have a conflict of interest and shall return a request for UR to the Bureau for reassignment if one or more of the following exist:
(1) The URO has a previous involvement with the patient or with the provider under review, regarding the same underlying claim.
(2) The URO has performed precertification functions in the same matter.
(3) The URO has provided case management services in the same matter.
(4) The URO has provided vocational rehabilitation services in the same matter.
(5) The URO is owned by or has a contractual arrangement with any party subject to the review.
(b) A URO shall inform the reviewer assigned to perform UR of the reviewer’s obligation to notify the URO of any potential or realized conflicts arising under § 127.468 (relating to duties of reviewers—conflict of interest).
Source The provisions of this § 127.455 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).
Cross References This section cited in 34 Pa. Code § 127.454 (relating to initial requests for UR—reassignment).
§ 127.456. Requests for UR—withdrawal.
(a) A party who wishes to withdraw a request for UR shall notify the Bureau of the withdrawal in writing. The withdrawal notice may not be sent directly to the URO.
(b) The Bureau will promptly notify the URO of the withdrawal.
(c) The insurer or employer shall pay the costs incurred by the URO prior to the withdrawal.
(d) A withdrawal of a request for UR shall be with prejudice.
Source The provisions of this § 127.456 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).
§ 127.457. Time for requesting medical records.
A URO shall request records from the treating providers listed on the request for UR within 5 days from receipt of the Bureau’s notice of assignment.
Source The provisions of this § 127.457 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (222314).
§ 127.458. Obtaining authorization to release medical records.
If a request for UR does not have the necessary authorizations to release records attached to it, the URO may contact the providers or insurer to obtain the necessary authorizations.
§ 127.459. Obtaining medical records—provider under review.
(a) A URO shall request records from the provider under review in writing. The written request for records shall be by certified mail, return receipt requested. In addition, the URO may request the records from the provider under review by telephone.
(b) The medical records of the provider under review may not be requested from, or supplied by, any source other than the provider under review.
(c) The provider under review, or his agent, shall sign a verification that, to the best of his knowledge, the medical records provided constitute the true and complete medical chart as it relates to the employe’s work-injury.
§ 127.460. Obtaining medical records—other treating providers.
(a) A URO shall request records from other treating providers in writing. In addition, the URO may request records from other treating providers by telephone.
(b) A provider, or his agent, who supplies medical records to a URO pursuant to this section shall sign a verification that, to the best of his knowledge, the medical records constitute the true and complete medical chart as it relates to the employe’s work injury.
(c) If a URO is not able to obtain records directly from the other treating providers, it may obtain these records from the insurer, the employer or the employe.
(d) If an insurer, employer or employe supplies medical records to a URO under subsection (c), it shall sign a verification that, to the best of its knowledge, the records supplied are the complete set of records as received from the provider that relate to the work-injury and that the records have not been altered in any manner.
§ 127.461. Obtaining medical records—independent medical exams.
UROs may not request, and the parties may not supply, reports of independent medical examinations performed at the request of an insurer, employer, employe or attorney. Only the records of actual treating health care providers shall be requested by, or supplied to, a URO.
§ 127.462. Obtaining medical records—duration of treatment.
UROs shall attempt to obtain records from all providers for the entire course of treatment rendered to the employe for the work-related injury which is the subject of the UR request, regardless of the period of treatment under review.
§ 127.463. Obtaining medical records—reimbursement of costs of provider.
(a) The URO shall, within 30 days of receiving medical records, reimburse the provider for record copying costs at the rate specified by Medicare and for actual postage costs. The Bureau will publish the Medicare rate in the Pennsylvania Bulletin as a notice when the rate changes.
(b) Reproduction of radiologic films shall be reimbursed at the usual and customary charge. The cost of reproducing such films shall be itemized separately when the URO bills for performing the UR.
§ 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.
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).
§ 127.465. Requests for UR—deadline for URO determination.
(a) A request for UR shall be deemed complete upon receipt of the medical records or 35 days from the date of the notice of assignment, whichever is earlier.
(b) A URO shall complete its review, and render its determination, within 30 days of a completed request for UR.
Source The provisions of this § 127.465 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203494).
§ 127.466. Assignment of UR request to reviewer by URO.
Upon receipt of the medical records, the URO shall forward the records, the request for UR, the notice of assignment and a Bureau-prescribed instruction sheet to a reviewer licensed by the Commonwealth in the same profession and having the same specialty as the provider under review.
Source The provisions of this § 127.466 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203494) to (203495).
§ 127.467. Duties of reviewers—generally.
Reviewers shall apply generally accepted treatment protocols as appropriate to the individual case before them.
§ 127.468. Duties of reviewers—conflict of interest.
A reviewer shall return a review to the URO for assignment to another reviewer if one or more of the following exist:
(1) The reviewer has a previous involvement with the patient, or with the provider under review, regarding the same matter.
(2) The reviewer has performed precertification functions in the same matter.
(3) The reviewer has provided case management services in the same matter.
(4) The reviewer has provided vocational rehabilitation services in the same matter.
(5) The reviewer has a contractual relationship with any party in the matter.
Cross References This section cited in 34 Pa. Code § 127.455 (relating to requests for UR—conflicts of interest).
§ 127.469. Duties of reviewers—consultation with provider under review.
The URO shall give the provider under review written notice of the opportunity to discuss treatment decisions with the reviewer. The reviewer shall initiate discussion with the provider under review when such a discussion will assist the reviewer in reaching a determination. If the provider under review declines to discuss treatment decisions with the reviewer, a determination shall be made in the absence of such a discussion.
§ 127.470. Duties of reviewers—issues reviewed.
(a) Reviewers shall decide only the issue of whether the treatment under review is reasonable or necessary for the medical condition of the employe.
(b) Reviewers shall assume the existence of a causal relationship between the treatment under review and the employe’s work-related injury. Reviewers may not consider or decide issues such as whether the employe is still disabled, whether maximum medical improvement has been obtained, quality of care or the reasonableness of fees.
Notes of Decisions Assumption by Reviewer
The reviewing physicians properly assumed a causal relationship between the treatment and the back injury that was the only recognized injury. There was no requirement to make an assumption with respect to the non-back injuries; therefore, the conclusions that the treatment for the non-back injuries was neither reasonable nor necessary were properly accepted as competent and credible, satisfying the employer’s burden. Reinhardt v. Workers’ Compensation Appeal Board, (Mt. Carmel Nursing Center) 789 A.2d 871 (Pa. Cmwlth. 2002).
Causal Relationship
The Workers’ Compensation Appeal Board did not abuse its discretion by denying the claimant’s request to remand the matter to the workers’ compensation judge to receive the ‘‘after discovered’’ utilization review organization (URO) determination, because the scope of review of a URO is strictly limited to reviewing the reasonableness and necessity of medical treatment, the URO’s decision that the physical therapy provided to the claimant was reasonable and necessary does not establish that the treatment was causally related to the claimant’s work-related injury or that the claimant remains disabled by his work-related injury. Corcoran v. Workers’ Compensation Appeal Board, (Capital City Times Leader) 725 A.2d 868 (Pa. Cmwlth. 1999).
Quality of Care
Physician who performed utilization review did not violate statute prohibiting reviewers form considering or deciding ‘‘quality of care’’ issues by finding that medication prescribed by provider for workers’ compensation claimant was unreasonable and unnecessary when he stated preference for safer medications; it was entirely appropriate for reviewer, in determining the reasonableness and necessity of a prescribed medication, to consider risk to the patient. Sweigart v. Workers’ Compensation Appeal Board (Burnham Corp.), 920 A.2d 962, 965 (Pa. Cmwlth. 2007)
§ 127.471. Duties of reviewers—finality of decisions.
(a) Reviewers shall make a definite determination as to whether the treatment under review is reasonable or necessary. Reviewers may not render advisory opinions as to whether additional tests are needed. In determining whether the treatment under review is reasonable or necessary, reviewers may consider whether other courses of treatment exist. However, reviewers may not determine that the treatment under review is unreasonable or unnecessary solely on the basis that other courses of treatment exist.
(b) If the reviewer is unable to determine whether the treatment under review is reasonable or necessary, the reviewer shall resolve the issue in favor of the provider under review.
Notes of Decisions Basis of Utilization Reviewer’s Testimony
Utilization reviewer’s testimony that Claimant may have needed some other type of care did not violate the regulation disallowing determinations based solely on the fact that other courses of treatment existed; the reviewer also opined that the treatment rendered was unreasonable and unnecessary because it was of little value due to the time elapsed since the original injury. Howrie v. Workers’ Compensation Appeal Board (CMC Equip. Rental), 879 A.2d 820, 821 (Pa. Cmwlth. 2005).
Lack of Complete Medical History
The lack of a complete medical history does not, in itself, preclude the UR reviewer from assessing the reasonableness and necessity of treatment. As with any other evidence, the weight and credibility of the UR report are issues to be decided by the fact-finder. Solomon v. Workers’ Compensation Appeal Board (City of Philadelphia), 821 A.2d 215 (Pa. Cmwlth. 2003).
§ 127.472. Duties of reviewers—content of reports.
The written reports of reviewers shall contain, at a minimum, the following elements: a listing of the records reviewed; documentation of any actual or attempted contacts with the provider under review; findings and conclusions; and a detailed explanation of the reasons for the conclusions reached by the reviewer, citing generally accepted treatment protocols and medical literature as appropriate.
Notes of Decision Burden of Proof
Report filed by physician who performed utilization review did not comply with regulation requiring report to contain detailed explanation of reasons for conclusion that treatment by provider was not reasonable or necessary; burden of proof was on reviewer to provide details explaining his conclusion and statement that provider failed to convince him that treatment was reasonable and necessary failed to meet the reviewer’s burden of proof. Sweigart v. W.C.A.B. (Burnham Corp.), 920 A.2d 962, 965—966 (Pa. Cmwlth. 2007)
§ 127.473. Duties of reviewers—signature and verification.
(a) Reviewers shall sign their reports. Signature stamps may not be used.
(b) Reviewers shall sign a verification pursuant to 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the reviewer personally reviewed the records and that the report reflects the medical opinions of the reviewer.
§ 127.474. Duties of reviewers—forwarding report and records to URO.
Reviewers shall forward their reports and all records reviewed to the URO upon completion of the report.
§ 127.475. Duties of UROs—review of report.
(a) UROs shall check the reviewer’s report to ensure that the reviewer has complied with formal requirements (such as signature and verification).
(b) UROs shall ensure that all records have been returned by the reviewer.
(c) A URO may not contact a reviewer and attempt to persuade the reviewer to change the medical opinions expressed in a report.
§ 127.476. Duties of UROs—form and service of determinations.
(a) Each determination rendered by a URO on the merits shall include a form prescribed by the Bureau as a medical treatment review determination face sheet and the reviewer’s report. The face sheet shall be signed by an authorized representative of the URO.
(b) When a determination is rendered against the provider under review on the basis that no records were supplied by the provider, the determination shall consist only of the face sheet. However, in these cases, the face sheet shall clearly indicate that the basis for the decision is the failure of the provider under review to supply records to the URO.
(c) The URO’s determination, consisting of both the face sheet and the reviewer’s report, shall be served on the employe, the insurer or employer, the provider under review, the attorneys for the parties, if known, and the Bureau.
(d) The URO shall also serve a copy of a petition for review of a UR determination on all parties and their attorneys, if known.
(e) Service shall be made by certified mail, return receipt requested and shall be made on the same date as is entered on the appropriate line of the face sheet.
Source The provisions of this § 127.476 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203497).
§ 127.477. Payment for request for UR.
The insurer or the employer shall pay the reasonable and customary charge of the URO for the UR determination, regardless of who the requesting party is. Payment shall be made within 30 days of the date the UR determination was received. The URO shall send its itemized bill to the insurer responsible for payment and a copy of the itemized bill to the Bureau.
Source The provisions of this § 127.477 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203497) to (203498).
§ 127.478. Record retention requirements for UROs.
(a) UROs shall retain records relating to URs for 1 year from the date that a determination was rendered. These records shall include, but are not limited to, the notice of assignment, all correspondence, all certified mail return receipts and documents, all medical records reviewed, the face sheet and the reviewer’s report.
(b) The URO’s files will be subject to inspection and audit by the Bureau without notice.
Cross References This section cited in 34 Pa. Code § 127.625 (relating to record retention requirements for PROs).
§ 127.479. Determination against insurer—payment of medical bills.
If the UR determination finds that the treatment reviewed was reasonable or necessary, the insurer shall pay the bills submitted for the treatment in accordance with § 127.208 (relating to time for payment of medical bills).
Source The provisions of this § 127.479 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203498).
§ § 127.501—127.515. [Reserved].
Source The provisions of these § § 127.501—127.515 reserved January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial pages (203498) to (203500) and (235597) to (235598).
UR—PETITION FOR REVIEW
§ 127.551. Petition for review by Bureau of UR determination.
If the provider under review, the employe, the employer or the insurer disagrees with the determination rendered by the URO, a request for review by the Bureau may be filed on a form prescribed by the Bureau as a petition for review of a UR determination.
Source The provisions of this § 127.551 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (235598).
Notes of Decisions Procedure
Parties who fail to file a petition for reconsideration from an initial UR determination are not able to challenge the effect of such determination before a Workers’ Compensation Judge. Florence Mining Co. v. Workmen’s Compensation Appeal Board (McGinnis), 691 A.2d 984 (Pa. Cmwlth. 1997).
§ 127.552. Petition for review by Bureau—time for filing.
The original and eight copies of the petition for review shall be filed with the Bureau within 30 days of receipt of the URO’s determination.
Source The provisions of this § 127.552 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (233598).
§ 127.553. Petition for review by Bureau—notice of assignment andservice by Bureau.
(a) The Bureau will assign the petition for review to a workers’ compensation judge. The Bureau will serve the notice of assignment and the petition for review upon the URO, the employe, the employer or insurer, the health care provider under review, and the attorneys for the parties, if known.
(b) When a petition for review is filed in a case already in litigation before a workers’ compensation judge, the Bureau will assign the petition for review to the workers’ compensation judge who is hearing the case-in-chief.
(c) Before assigning a petition for review, the Bureau will review the petition to ensure that a UR has been filed and a determination has been rendered.
Source The provisions of this § 127.553 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (235598).
§ 127.554. Petition for Review by Bureau—no answer allowed.
No answer to the petition for review may be filed.
§ 127.555. Petition for review by Bureau—transmission of URO records to workers’ compensation judge.
(a) Upon the workers’ compensation judge’s own motion, or motion of any party to the proceeding, the workers’ compensation judge may order the URO to forward all medical records obtained for its review to the workers’ compensation judge. The URO shall forward all records within 10 days of the date of the workers’ compensation judge’s order.
(b) When a petition for review has been filed, the Bureau will forward the URO report to the workers’ compensation judge assigned to the case.
(c) An authorized agent of the URO shall sign a verification stating that, to the best of his knowledge, the complete set of unaltered records obtained by the URO is being transmitted to the workers’ compensation judge.
(d) When records are provided under subsection (a), the URO shall transmit its itemized bill for record copying costs to the manager of the Medical Treatment Review Section, together with a copy of the workers’ compensation judge’s order directing the URO to provide the records. The URO shall be reimbursed by the Bureau for its record copying costs at the rate specified by Medicare, and for actual postage costs. Reproduction of radiologic films shall be reimbursed at a reasonable cost.
Source The provisions of this § 127.555 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203503).
§ 127.556. Petition for Review by Bureau—de novo hearing.
The hearing before the workers’ compensation judge shall be a de novo proceeding. The URO report shall be part of the record before the workers’ compensation judge and the workers’ compensation judge shall consider the report as evidence. The workers’ compensation judge will not be bound by the URO report.
Source The provisions of this § 127.556 amended January 16, 1998, effective January 17, 1998, 28 Pa.B. 329. Immediately preceding text appears at serial page (203503).
PEER REVIEW
§ 127.601. Peer review—availability.
(a) A Workers’ Compensation judge may obtain an opinion from an authorized PRO concerning the necessity or frequency of treatment rendered under the act when one of the following exist:
(1) A petition for review of a UR determination has been filed.
(2) It is necessary or appropriate in other litigation proceedings before the Worker’s Compensation judge. Peer review shall be deemed not to be necessary or appropriate if there is a pending UR of the same treatment.
(b) Nothing in subsection (a) requires a Workers’ Compensation judge to grant a party’s motion for peer review.
§ 127.602. Peer review—procedure upon motion of party.
(a) A party may not make a motion for peer review if the same course of treatment has been submitted for UR.
(b) After making a motion for peer review, neither party may file a request for UR while the motion is pending. If the motion is not specifically ruled on within 10 days, then it shall be deemed denied.
(c) If the Workers’ Compensation judge has not ruled on the motion within 10 days, or if the motion is denied, the parties shall be free to file requests for UR.
(d) If the motion is granted, the Workers’ Compensation judge will proceed in accordance with § 127.604 (relating to peer review—forwarding a request to the Bureau).
§ 127.603. Peer review—interlocutory ruling.
The ruling on a motion for peer review shall be deemed interlocutory.
§ 127.604. Peer review—forwarding of request to Bureau.
(a) If the Workers’ Compensation judge decides that peer review is necessary or appropriate, the Judge will forward a request for peer review to the Bureau on a form prescribed by the Bureau. The Workers’ Compensation judge will notify counsel, or the parties, if unrepresented, by serving a copy of the request for peer review upon them.
(b) In cases other than petitions for review of a UR determination, the Worker’s Compensation judge will attach subpoenas to the request for peer review which the assigned PRO shall use to obtain medical records.
Cross References This section cited in 34 Pa. Code § 127.602 (relating to peer review—procedure upon motion of party).
§ 127.605. Peer review—assignment by the Bureau.
(a) The Bureau will randomly assign a properly filed request for peer review to an authorized PRO.
(b) The Bureau will send a notice of assignment of the request for peer review to the PRO, the Workers’ Compensation judge, counsel for the parties, or the parties, if unrepresented, and the health care provider under review.
§ 127.606. Peer review—reassignment.
(a) If a PRO is unable, for any reason, to perform a peer review assigned to it by the Bureau, the PRO shall, within 5 days of receipt of the assignment, return the request for peer review to the Bureau for reassignment.
(b) A PRO may not, under any circumstances, reassign a request for peer review to another PRO.
(c) A PRO shall return requests for peer review assigned to it by the Bureau if the PRO has a conflict of interest in the request assigned to it.
§ 127.607. Peer review—conflicts of interest.
(a) A PRO shall return a request for peer review to the Bureau for reassignment if the following apply:
(1) The PRO has a previous involvement with the patient or provider under review in the same matter.
(2) The PRO has performed precertification functions in the same matter.
(3) The PRO has provided case management services in the same matter.
(4) The PRO has provided vocational rehabilitation services in the same matter.
(5) The PRO is owned by or has a contractual relationship with any party subject to the review.
(b) A PRO shall inform the reviewer assigned to perform peer review of the reviewer’s obligation to notify the PRO of any potential or realized conflicts arising under § 127.615 (relating to duties of reviewers—conflict of interest)
§ 127.608. Peer review—withdrawal.
(a) A request for peer review shall be withdrawn only at the direction of the Workers’ Compensation judge. The Workers’ Compensation judge will notify the Bureau of the withdrawal in writing.
(b) The Bureau will promptly notify the PRO of the withdrawal. The Bureau will pay the costs incurred by the PRO prior to the withdrawal out of the Workmen’s Compensation Administration Fund.
(c) If a previously withdrawn peer review request is resubmitted to the Bureau, the Bureau will assign the matter to the PRO which handled it prior to the withdrawal.
§ 127.609. Obtaining medical records.
(a) In cases where peer review has been requested on a petition for review of a UR determination, the Workers’ Compensation judge may order the URO to forward all the records received and reviewed for the purposes of the UR to the PRO assigned to perform the peer review by the Bureau.
(b) In other cases, the PRO shall have 10 days from the date of the notice of assignment to subpoena records from treating providers.
§ 127.610. Obtaining medical records—independent medical exams.
PROs may not subpoena, request or be supplied with records of independent medical examinations performed at the request of an insurer, employer, employe or attorney. Only the records of actual treating health care providers may be subpoenaed by or supplied to a PRO.
§ 127.611. Obtaining medical records—duration of treatment.
PROs shall attempt to obtain records from all providers for the entire course of treatment rendered to the employe for the work-related injury which is the subject of the peer review request, regardless of the period of treatment under review.
§ 127.612. Effect of failure of provider under review to supply records.
(a) If the provider under review fails to mail records to the PRO within 30 days of the date of service of the subpoena for the records, the PRO shall report the provider’s noncompliance with the subpoena to the Workers’ Compensation judge.
(b) If the provider fails to supply records, the PRO may not assign the matter to a reviewer, and may not make a determination concerning the necessity or frequency of treatment.
§ 127.613. Assignment of peer review request to reviewer by PRO.
Upon receipt of the medical records, the PRO shall forward the records, the request for peer review and the notice of assignment to a reviewer licensed by the Commonwealth in the same profession and Board-certified in the speciality or sub-specialty as the provider under review. Board-certification shall be by an accredited specialty board.
§ 127.614. Duties of reviewers—generally.
Reviewers shall apply generally accepted treatment protocols, as appropriate, to the individual case before them.
§ 127.615. Duties of reviewers—conflict of interest.
A reviewer shall return a review to the PRO for assignment to another reviewer if one or more of the following exist:
(1) The reviewer has a previous involvement with the patient or provider under review regarding the same matter.
(2) The reviewer has performed precertification functions in the same matter.
(3) The reviewer has provided case management services in the same matter.
(4) The reviewer has provided vocational rehabilitation services in the same matter.
(5) The reviewer has a contractual relationship with any party in the matter.
Cross References This section cited in 34 Pa. Code § 127.607 (relating to peer review—conflicts of interest).
§ 127.616. Duties of reviewers—consultation with provider under review.
The PRO shall give the provider under review written notice of the opportunity to discuss treatment decisions with the reviewer. The reviewer shall initiate discussions with the provider under review when such a discussion will assist the reviewer in reaching a determination. If the provider under review declines to discuss treatment decisions with the reviewer, a determination shall be made in the absence of such a discussion.
§ 127.617. Duties of reviewers—issues reviewed.
(a) Reviewers shall decide only issues concerning the necessity and frequency of the treatment under review.
(b) Reviewers shall assume the existence of a causal relationship between the treatment under review and the employe’s work-related injury. The reviewer may not consider or decide issues such as whether the employe is still disabled, whether maximum medical improvement has been obtained, quality of care or the reasonableness of fees.
§ 127.618. Duties of reviewers—finality of decisions.
(a) Reviewers shall make a definite determination as to the necessity and frequency of the treatment under review. Reviewers may not render advisory opinions as to whether additional tests are needed. In determining whether the treatment under review is necessary, reviewers may consider whether other coursers of treatment exist. However, reviewers may not render advisory opinions as to whether other courses of treatment are preferable.
(b) If the reviewer is unable to determine whether the treatment under review is necessary or of appropriate frequency, then the reviewer shall resolve the issue in favor of the provider under review.
§ 127.619. Duties of reviewers—content of reports.
The written reports of reviewers shall contain, at a minimum, the following elements: a listing of the records reviewed; documentation of any actual or attempted contacts with the provider under review; findings and conclusions; and a detailed explanation of the reasons for the conclusions reached by the reviewer, citing generally accepted treatment protocols and medical literature as appropriate.
§ 127.620. Duties of reviewers—signature and verification.
(a) Reviewers shall sign their reports. Signature stamps may not be used.
(b) Reviewers shall sign a verification under 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) that the reviewer personally reviewed the records and that the report reflects the medical opinions of the reviewer.
§ 127.621. Duties of reviewers—forwarding report and records to PRO.
Reviewers shall forward their reports and all records reviewed to the PRO upon completion of the report.
§ 127.622. Duties of PRO—review of report.
(a) PROs shall check the reviewer’s report to ensure that formal requirements, such as signature and verification, have been complied with by the reviewer.
(b) PROs shall ensure that all records have been returned by the reviewer.
(c) A PRO may not contact a reviewer and attempt to persuade the reviewer to change the medical opinions expressed in a report.
§ 127.623. Peer review—deadline for PRO determination.
A PRO shall complete its review and render its determination within 30 days of receipt of the medical records.
§ 127.624. PRO reports—filing with judge and service.
The PRO shall file its report directly with the Workers’ Compensation judge and mail copies to all the parties listed on the notice of assignment by certified mail, return receipt requested.
§ 127.625. Record retention requirements for PROs.
PROs shall comply with all the record retention requirements specified in § 127.478 (relating to record retention requirements). Their files shall be subject to inspection and audit by the Bureau without notice.
§ 127.626. PRO reports—evidence.
The PRO report shall be a part of the record of the pending case. The Workers’ Compensation judge will consider it as evidence but will not be bound by it.
§ 127.627. PRO reports—payment.
The PRO shall submit its itemized bill to the Workers’ Compensation judge for approval. The judge will forward the bill to the Bureau with an order for payment. Payment will be made from the Workmen’s Compensation Administration Fund.
AUTHORIZATION OF UROs AND PROs
§ 127.651. Application.
(a) Any organization seeking to be authorized as a URO or a PRO shall file an application on a form prescribed by the Bureau.
(b) Questions on the application shall be answered thoroughly and completely with the most recent information available. A rider may be attached if more space is necessary.
(c) The application shall be signed by a representative of the applicant and attested to as set forth on the application.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.652. Contents of an application to be authorized as a URO or PRO.
(a) An application to be authorized as a URO or PRO shall include the following:
(1) Ownership information, including the following:
(i) A disclosure of whether the applicant is owned or controlled, directly or indirectly, by a self-insured employer, a third-party administrator, a workers’ compensation insurer or a provider.
(ii) A list of the owners of the proposed URO or PRO with a 5% or greater ownership interest; and a disclosure of whether any such owner is a director or officer of a self-insured employer, a third-party administrator, a workers’ compensation carrier or is a provider.
(iii) A chart of the relationship between the proposed URO or PRO, its parent and other subsidiaries of the parent corporation, if the proposed URO or PRO is a subsidiary or affiliate of another corporation.
(iv) A list of directors and officers of the proposed URO or PRO; and a disclosure of whether any such director or officer is a director or officer of a self-insured employer, a third-party administrator, a workers’ compensation carrier or is a provider.
(2) An organization chart listing reporting relationships and the positions supporting the operations of the URO or PRO, particularly in the areas of UR, quality assurance and case communication systems. An addendum to the chart shall describe how increased utilization of the URO or PRO services will affect staffing.
(3) A complete list of participating providers performing reviews for the URO or PRO:
(i) Identifying whether the provider is an employe or affiliate of or has entered into a contract or agreement with the URO or PRO.
(ii) Identifying the geographic area where the provider practices the provider’s speciality.
(iii) Explaining how the contractual arrangements with providers ensure that the URO or PRO will be able to meet the requirements of the act and of this subchapter for UROs and PROs.
(iv) Establishing that it employs, is affiliated with, or has contracts with a sufficient number and specialty distribution of providers to perform reviews as required by the act and this subchapter.
(v) Including curriculum vitae of each reviewer.
(4) A copy of generic form contracts or letters of agreement used by the applicant to contract with participating providers.
(5) A description of the applicant’s case communication system.
(6) A description of the applicant’s utilization or peer review system which demonstrates how the applicant meets the standards of this subchapter.
(7) A description of the applicant’s quality assurance system.
(8) A description of the applicant’s fee structure.
(b) Subsequent to filing its application, the URO or PRO shall advise the Bureau of any changes to the information provided under subsection (a).
(c) The obligation of a URO or PRO to advise the Bureau of any changes to the criteria in subsection (a) shall continue subsequent to approval of its application for authorization by the Bureau.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.653. Decision on application.
(a) Approval of an applicant URO or PRO will be at the discretion of the Bureau.
(b) The Bureau, in rendering a decision on an application, will consider whether the applicant is capable of rendering impartial reviews and is capable of performing the responsibilities set forth in the act and this subchapter.
(c) The Bureau, in rendering a decision on an application, will consider whether an applicant is owned or controlled by another applicant, or whether more than one applicant is owned or controlled by the same person or entity. The Bureau will not approve more than one application for authorization as a URO or PRO in cases of common ownership or control.
(d) An applicant shall have the right to appeal a decision denying authorization as a URO or PRO within 30 days of the receipt of the decision. Untimely appeals will be dismissed without further action by the Bureau. A hearing will be conducted on the appeal as specified in § 127.670 (relating to hearings).
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.654. Authorization periods.
The Bureau will issue authorization notices to approved UROs and PROs valid for 2 years from the date of issue, unless otherwise suspended or revoked for failure of the URO or PRO to comply with the act and this subchapter.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.655. Reauthorization.
(a) A URO or PRO shall apply for reauthorization no later than 120 days prior to the expiration date of its authorization.
(b) An application for reauthorization shall include information the Bureau may require to demonstrate that the URO or PRO has been operating in accordance with the act and this subchapter, and is able to continue to operate in accordance with the act and this subchapter.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.656. General qualifications.
A URO or PRO shall be capable of performing the responsibilities set forth in the act and this subchapter.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.657. Local business office.
A URO or PRO shall have a business office located within this Commonwealth which is staffed and open at a minimum from 9 a.m.—5 p.m. Monday through Friday, except for legal holidays.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.658. Accessibility.
A URO or PRO shall provide a toll-free telephone number and have adequate staff and telephone lines to handle inquiries from 9 a.m.—5 p.m. Monday through Friday, except for legal holidays. A URO or PRO shall also establish a mechanism to receive and record telephone calls during nonbusiness hours.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.659. Confidentiality.
(a) A URO or PRO shall have in effect policies and procedures to ensure, both that all applicable State and Federal laws to protect the confidentiality of individual medical records are followed, and that the organization does not improperly disclose or release confidential medical information.
(b) A URO or PRO shall have mechanisms in place that allow a provider to verify that an individual requesting information on behalf of the review organization is a legitimate representative of the organization.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.660. Availability of reviewers.
(a) A URO or PRO shall have available to it, by contractual arrangement or otherwise, the services of a sufficient number and specialty distribution of qualified physicians and other practitioner reviewers to ensure the organization can perform reviews as required by the act and this subchapter.
(b) A URO or PRO shall report changes in its list of reviewers to the Bureau within 30 days of the change.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.661. Qualifications of reviewers.
(a) Each reviewer utilized by a URO or PRO shall have an active practice.
(b) To qualify as an active practice the reviewer shall spend at least 20 hours a week treating patients in a clinical practice.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.662. Contracts with reviewers.
Contracts between a URO or PRO and reviewers shall contain, at a minimum, the following:
(1) A provision requiring the reviewer to cooperate with the UR, quality assurance and case communication systems established by the URO and PRO.
(2) A provision requiring the reviewer to abide by the confidentiality requirements of the URO or PRO.
(3) A provision specifying the contract termination rights and termination notice requirements for both the URO or PRO and the reviewer.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.663. UR system.
(a) UROs or PROs shall have a UR system which shall consist of documented criteria, standards and guidelines for the conduct of reviews undertaken under the act and this subchapter.
(b) The UR system shall ensure that the reviews undertaken under the act and this subchapter are impartial reviews.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.664. Quality assurance system.
A URO or PRO shall have a quality assurance system which shall consist of documented procedures to ensure that the URO/PRO and its reviewers comply with all the requirements specified in this subchapter.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.665. Case communication system.
A URO or PRO shall have a case communication system which shall ensure that all communications activities required by this chapter during a UR or peer review are performed by the URO or PRO.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.666. Annual reports.
A URO or PRO shall file an annul report with the Bureau on a form prescribed by the Bureau.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.667. Compensation policy.
(a) A URO or PRO shall charge a reasonable fee for its services on a flat fee or hourly basis. A URO or PRO may not charge for its services on a percentage or contingent fee basis.
(b) The Bureau will publish in the Pennsylvania Bulletin, on an annual basis, the range of fees charged by each URO and PRO for services performed under the act and this chapter during the preceding year.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.668. Suspension of assignments.
If the Bureau obtains information suggesting that a URO or PRO is not acting in accordance with the requirements of the act or this chapter, the Bureau may temporarily suspend the assignment of new reviews to the URO or PRO pending the outcome of an investigation. The suspension period may not exceed 60 days. The URO or PRO shall have the right to confer with the Chief of Medical Cost Containment Division.
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.669. Revocation of authorizations.
(a) Upon investigation and following a conference with the Chief of the Medical Cost Containment Division, if the Bureau determines that a URO or PRO has violated the requirements of the act or this chapter, it may revoke the authorization of the URO or PRO to perform review functions under the act. Revocation of a URO or PRO’s authority to perform reviews will be in writing and will advise the URO or PRO of its appeal rights.
(b) A URO or PRO whose authorization to perform reviews under the act has been revoked by the Bureau shall have the right to appeal the revocation within 30 days of the receipt of the Bureau’s initial determination in accordance with the hearing process set forth in § 127.670 (relating to hearings).
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment).
§ 127.670. Hearings.
(a) The Director of the Bureau will assign appeals to decisions regarding a URO and PRO’s authority to review medical treatment to a hearing officer who will schedule a de novo hearing on the appeal from the initial decision. The URO/PRO will receive reasonable notice of the hearing date, time and place.
(b) The hearing will be conducted in a manner to provide the URO/PRO and the Bureau the opportunity to be heard. The hearing officer will not be bound by strict rules of evidence. All relevant evidence of reasonably probative value may be received into evidence. Reasonable examination and cross-examination of witnesses will be permitted.
(c) Testimony will be recorded and a full record kept of the proceeding. The Bureau and the URO/PRO will be provided the opportunity to submit briefs addressing issues raised.
(d) The hearing officer will issue a written adjudication within 90 days following the close of the record. The decision will include all relevant findings and conclusions, and state the rationale for the decision. The decision will be served upon the URO/PRO, the Bureau and counsel of record. The decision will include a notification to the URO/PRO and the Bureau of further appeal rights to the Commonwealth Court.
(e) The URO/PRO or the Bureau, aggrieved by a hearing officer’s adjudication, may file a further appeal to Commonwealth Court.
Notes of Decisions De Novo Hearing Required
Whether utilization review organization’s authorization to perform utilization reviews should be revoked was to be decided in a de novo hearing pursuant to regulations. Hearing officer’s deference to prior decision by Bureau of Workers’ Compensation to revoke URO’s authorization was clearly an appellate standard of review and inappropriate in this case. Chiro-Med v. Bureau of Workers’ Compensation, 879 A.2d 373, 381 (Pa. Cmwlth. 2005); appeal after remand 908 A.2d 980 (Pa. Cmwlth. 2006).
Utilization Review Mandatory
Workers’ Compensation Judge lacks subject matter jurisdiction to determine the reasonableness and necessity of medical treatment if the matter has not first gone to utilization review. County of Allegheny (John J. Kane Ctr.—Ross) v. Workers’ Compensation Appeal Board (Geisler), 875 A.2d 1222, 1228 (Pa. Cmwlth. 2005).
Cross References This section cited in 34 Pa. Code § 127.401 (relating to purpose/review of medical treatment); 34 Pa. Code § 127.653 (relating to decision on application); and 34 Pa. Code § 127.669 (relating to revocation of authorizations).
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