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Bureau of Workers' Compensation

Procedures for Completing an Application for Fee Review

Commonly Asked Questions


The resulting medical cost containment measures capped medical fees at 113 percent of the Medicare reimbursement applicable as of December 31, 1994, for comparable services rendered. These rates are adjusted annually by the percentage change in the statewide average weekly wage. Other fee schedule adjustments may also be made to recognize Medicare code changes and geographic provisions.
If no Medicare payment mechanism exists for a particular treatment, accommodation, product or service, the amount of the payment made to a health care provider is either 80 percent of the usual and customary charge in the geographic area where rendered, or the actual charge, whichever is lower.
The information in this pamphlet will help health care providers to complete that application.

Q. How do I know whether to file for amount, timeliness, or both?

  • If you have been paid correctly, but your payment was received late, check the TIMELINESS box.
  • If your bill was not paid in accordance with the workers' compensation medical fee schedule, check the AMOUNT box.
  • If your payment is late and you disagree with the payment, check the BOTH box.
  • If you were not paid at all, you may file for timeliness, amount, or both.

Q. How do I know whether I received a timely payment?

  • If you have not received payment from the correct party within 33 days of the date you properly billed the insurer, payment may be untimely. (30 days + 3 days' mail time = 33 days).

Q. What must I include with my completed application for fee review?

  • It is your responsibility to provide a copy of any and all documentation you sent to the insurer for the treatment you are requesting to be reviewed.
  • The completed LIBC-9, Medical Report Form that was forwarded to the insurer or self-insured employer.
  • Copies or reprints of all original bills pertaining to date of service. CMS billing forms should have signature of provider/representative.
  • Office notes, etc., supporting documentation of services rendered.
  • Properly coded bills on UB-04 or CMS forms.
  • If submitting a UB-04, provide a copy of the itemized bill or statement as submitted to insurer, including associated charges to the respective revenue codes for your facility.
  • Explanation of Review (EOR) or denial, which must coincide with CMS date of service, if available.

Q. How do I get copies of the forms I need?

Q. What can I do to avoid having my application rejected and returned to me?

Complete the LIBC-507 application form in its entirety, including:
  • Provider's name, address and name of contact person
  • Patient's name, etc.
  • Employer and insurer's name, etc.
  • Dates of service requested to be reviewed
  • Date bills originally sent to proper party
  • Proof of service on page two of application form
  • Signature and date
  • The proper party must be billed as stated in §127.203(a) (relating to Medical Bills) prior to filing a fee review.
  • A new application with an updated proof of service is required each time you submit a fee review.

Q. Where can I find the Bureau Code?

Q. When should I NOT file an Application for Fee Review?

  • Do not file if services were not provided by a health care provider.
  • Do not file if you have not billed the proper party.
  • Do not file if the patient's workers' compensation claim is not a Pennsylvania claim, but is a claim which is pending with another state or under a federal workers' compensation program.

Q. What are the time limitations for filing an Application for Fee Review?

  • Do not file until at least 33 days have passed since you first sent the bill to the self-insured employer/insurer.
  • The application must be filed within 30 days following notification of a disputed treatment or 90 days from the provider's original date of billing, whichever is later.

Q. How are applications resolved by the Bureau of Workers' Compensation?

  • When a provider has filed all required documentation and is entitled to a decision on the merits, the bureau will render an administrative decision and will forward it to all parties.

Q. What are my appeal rights?

  • If you disagree with the administrative decision rendered by the bureau, you are entitled to appeal within 30 days of the decision by requesting a hearing before an Office of Adjudication hearing officer. Further appeals may be made to Commonwealth Court.

Q. What if I wish to withdraw my application?

  • If you receive payment after filing a fee review and are satisfied with the payment, you may withdraw your application by faxing a request at 717-783-6366, ATTN: Fee Review Section.

Q. What if I have additional questions?

  • If you have any questions regarding the fee review filing procedures, please contact the Fee Review Section at 717-772-1900.
§306(f.1)(5) of the Workers' Compensation Act. Your application will be returned and your request for review may not be considered until all requested documentation is provided per §127.252(b) and §127.253 of the Rules and Regulations.
The LIBC-507 is a machine-read, two-sided form and must be submitted on a bureau-approved format. Do not staple, date-stamp, or otherwise deface, the document. Originals only will be accepted. The form may not be photocopied or reproduced in any way.
Under 34 Pa. Code 127.251, each provider must file a separate application for fee review.
PA Department of Labor & Industry
Bureau of Workers' Compensation
Health Care Services Review Division
Medical Fee Review Unit
1171 South Cameron Street, Room 310
Harrisburg, PA 17104-2501
LIBC-600 REV 7-11
(Web revision 8-19)