Health Care Services Review FAQs
Q. What exactly is a utilization review (UR) request?
A. A UR request is made by either the insurer, the employer or the injured worker to determine if the medical treatment being given by a particular medical provider is actually reasonable and necessary.
Q. How does the UR process work?
A. When a UR is filed, it is assigned to a utilization review organization (URO) who requests the medical records from the medical provider under review for the treatment requested and the dates requested. The URO sends those records to a reviewer who matches the license and specialty of the provider under review. The reviewer looks at the medical records and a statement from the injured worker (if sent) and makes a determination, based on accepted medical standards and their experience, as to whether the treatment in question is reasonable and necessary for the work-related injury. The decision is rendered approximately 65 days after the initial UR request is filed.
Q. What are my rights as an injured worker under the UR process?
A. You have the right to issue a statement to the URO describing your feelings regarding the medical treatment. A "Notice to Injured Worker" will be mailed to you when the assignment of the UR is made to a particular URO. Follow the directions on the notice. The letter is always mailed to the URO, and the mailing address will be on that notice.
You also have the right to petition the final determination, if you disagree with anything in the determination. You will receive a copy of the determination in the mail with a petition form attached for your use, if needed.
Q. What do the UR determinations mean to me as an injured worker?
A. Always seek the advice of your own attorney to decipher the determinations. Generally speaking, a YES determination means that the review indicates that the treatment in question for the timeframe in question is reasonable and necessary for your work-related injury. A NO determination means that a determination was made that the treatment is not reasonable and necessary for your work-related injury. A PART YES/PART NO determination means that some of the treatment is reasonable and some is not
OR some might be reasonable for a certain time period, but then not for another time period … read the final determination carefully!
Q. A UR request was filed for only one of my providers. How do I get the other bills paid?
A. The UR request is only for the treatment of the provider named on the form. If another provider you currently see is not listed on the form, they are not under review. Bills are "on hold" until the determination is made. If the provider is not under review, the bills cannot be held.
Q. Will my treatment be paid for in the future? I don't want to be "stuck" with bills.
A. Payment for treatment depends on the final determination and, again, you should talk to your own attorney when you receive the determination. An injured worker cannot be stuck with bills because the Worker's Compensation Act prohibits a provider from billing an injured worker for treatment for a work-related injury.
Q. Can I still get my medications while the review is in process?
A. That depends on your pharmacy. During a utilization review, the bills are "tolled," meaning they are "on hold," until the final determination is made.
Q. Why should the injured worker have to pay for the UR? How much does a UR cost?
A. The injured worker does
not pay for the UR. Payment to the URO is the responsibility of the insurer. The range of fees charged by UROs is published annually in the Pennsylvania Bulletin..
Q. If the injured worker loses or misplaces either the URO determination or their copy of the employee statement, can they get a copy?
A. Because determinations are rendered by the UROs, the injured worker must call the URO to request copies of either the determination or the statement.
Q. Who can assist me with general questions on the UR filing process via WCAIS?
A. A UR request may only be filed via the Workers' Compensation Automation and Integration System. Please reference the Customer Service feature within WCAIS for filing instructions and simulations.
Q. If health care providers are not paid correctly or timely for services they rendered to an injured worker, what is their recourse?
A. The provider may file a fee review, per Section 127.251 of the Workers' Compensation Act and regulations.
Q. Are there time constraints for filing a fee review?
A. Yes, a provider may file an application for fee review within 90 days from the original billing date of treatment, or 30 days from a notification of disputed treatment, whichever is later per Section 127.252(a).
Q. Why must I submit a new fee review application with each submission?
A. Online applications for fee review that are returned with a fourteen day file preservation date may be edited and resubmitted within fourteen days of the date of return. These applications become "new" fee review applications because when any changes are made to the fee review application, the proof of service must be updated.
Q. What is the LIBC-9?
A. The Medical Report Form, LIBC-9, is a form prescribed by the bureau. Section 127.203(a) of the regulations states: Providers who treat injured employees are required to submit periodic medical reports to the employer, commencing 10 days after treatment begins and at least once a month thereafter as long as treatment continues. If the employer is covered by an insurer, the provider shall submit the report to the insurer.
Also note: Section 127.203(d) states: If a provider does not submit the required medical reports on the prescribed form, the insurer is not obligated to pay for the treatment covered by the report until the required report is received by the insurer.
Q. Where can I obtain Application for Fee Review, LIBC-507, and Medical Report, LIBC-9, forms?
A. Select the hyperlink for the LIBC-9 form to be directed to an interactive online form that you may complete, print or otherwise circulate. The Application for Fee Review, LIBC-507 may be completed on the Workers’ Compensation Automation and Integration System (WCAIS). Please reference the Customer Service feature within WCAIS for filing instructions and simulations.
Q. Did I bill the proper party?
A. You must first determine if the employer has workers' compensation coverage. Contact the employer and ask for the name of their insurance carrier. You may want to call the insurance carrier to verify the information the employer gave you is correct. Sometimes insurance carriers or self-insured employers will use third party administrators (TPA) and you may be directed to send the bill to the TPA. Be careful to make sure you are sending the bills to a valid party under the Act like an insurance carrier, a TPA, a self-insured employer, or a group self-insured trust. Parties such as repricers or health management organizations are not considered valid parties under the Act, so always make sure to include a valid party in your bill submissions. If you are having a hard time determining who the employer uses for workers’ compensation coverage, you may try using the carrier search engine provided by the Bureau as a part of your investigation. Fee reviews filed for services that were not billed to the correct and valid party, or were billed to the correct party but at the wrong address, will be returned as prematurely filed.
Q. If a provider does not agree with the decision they have received from the bureau, should they call the staff to discuss the decision?
A. No, the Fee Review Section cannot discuss any decision that it has issued. Providers may, however, appeal decisions as outlined therein.
Q. I have received a positive fee review decision, but have not received my reimbursement. What can I do?
A. Thirty days after the decision, if you still have not received payment, access the Decision tab for the fee review within WCAIS and click on the link at the bottom of the page to file a notification that payment was not received from Insurer/TPA.
Q. When should a provider expect reimbursement from an insurer?
A. Payments for treatments rendered under the act shall be made within 30 days of receipt of the bill and report (LIBC-9) submitted by the provider [§127.208(a)]
Q. Do Pennsylvania providers require pre-approval from the bureau on a claim?
A. There is no pre-authorization process in the Workers' Compensation Act. A provider may seek a prospective utilization review on a treatment.
Q. What if the employer refuses to give me their workers' compensation insurance information?
A. Access WCAIS and in the Search Questions Repository of the Customer Service feature, you may click on the hyperlink for Submit a Ticket and ask for help from Bureau staff.
Q. What if I still cannot determine the name of the employer's workers' compensation insurance carrier?
A. Send an email to the bureau at
RA-LI-BWC-HCSRD@pa.gov explaining what you have done to determine insurance coverage, and the bureau will try to assist you.
Q. Can I balance-bill the patient?
A. No. Section 306(f.1)(7) of the Workers' Compensation Act, 77 P.S. §531(7), states: A provider shall not hold an employe liable for costs related to care or service rendered in connection with a compensable injury under this act. A provider shall not bill or otherwise attempt to recover from the employe the difference between the provider's charge and the amount paid by the employer or the insurer.
Q. Will I be granted interest on untimely payments?
A. If an insurer fails to pay the entire bill or any portion of a bill within 30 days of receipt of the required bills and medical reports, interest shall accrue on the due and unpaid balance at 10 percent per annum, under Section 406.1(a) of the act, 77 P.S. §717.1(a). Interest shall accrue on unpaid medical bills if an insurer initially denies liability, if liability is later admitted or determined.
Q. The fee schedule on the bureau's website contains a "0" in the fee schedule amount column for the CPT code I am billing. Does this mean that the service is not reimbursable?
A. No. Payment is to be made pursuant to Section 127.102 of the workers' compensation medical cost containment regulations.
Q. Do the same rules apply to "site of service?"
A. Site of service only applies when:
- A provider bills with place of service 20, 21, 22, 23 or 24 –and-
- There is an amount listed in the site of service column.
If no amount is listed in the site of service column, reimbursement will be at the fee schedule amount.
Q. May I bill with a temporary code?
A. Temporary codes are not a part of the Pennsylvania Worker's Compensation Fee Schedule. For services associated with temporary codes, the most appropriate non-temporary CPT or HCPCS code describing the service may be billed. In some circumstances, the selected code may be a miscellaneous code.
Q. Is a copy of the workers' compensation medical fee schedule available?
A. A courtesy copy of the
fee schedule is available on the department's website.