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 average cost for a UR in 2010 was $900.

 

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 forms?
A. The UR request form itself is fairly self-explanatory and easy to fill out. All information on the form is required. Each form comes with an instruction sheet that explains what is needed in each section. If you have questions not covered on the instruction sheet, you may call the bureau's Medical Treatment Review Section at 717-772-1914 for assistance. All UR request forms must be mailed. Faxed copies are not accepted.

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(a) 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.

 

Q. Why must I submit a new fee review application with each submission?
A. If your application is returned to you as incomplete, a new Application for Fee Review, LIBC-507, with an updated proof of service to the insurer is required. The insurer, as listed in the insurer block on the LIBC-507, has also been notified that your fee review application was returned to you as incomplete. You must complete a new LIBC-507 showing the new date upon which you served the insurer with another copy of the application and attached documentation, per Section 127.252(b) of the regulations. For assistance in completing this form, visit our LIBC-507 tutorial.

 

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. For assistance in completing this form, visit our LIBC-9 tutorial.

 

Q. Where can I obtain Application for Fee Review, LIBC-507, and Medical Report, LIBC-9, forms?
A. You may contact the Fee Review Section at 717-772-1900 for copies of the LIBC-507 and LIBC-9. You may also download the LIBC-507 and LIBC-9 forms.

 

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 and bureau code of the workers' compensation carrier. Next, you should verify that the provided information is correct. This information can be obtained via the department's website: bureau codes. Only a self-insured employer or an insurer authorized to write workers' compensation insurance policies will have a bureau code.

 

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. Contact the bureau's Health Care Services Review Division via email at RA-LI-BWC-HCSRD@pa.gov 30 days after you have received the decision.

 

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. The Bureau of Workers' Compensation provides a search engine to assist you in determining the insurance carrier for an employer.

 

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:

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. You may; however, the regulations do not recognize the use of temporary codes. Therefore, they will not be found on the fee schedule.

 

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.

Q. As an injured worker, I disagree with the IRE decision. Can I get a list of state-approved IRE physicians?
A. Yes, all current IRE physicians are listed on the department's website.

 

Q. What is the cost of an impairment rating evaluation? A. The cost of the IRE will vary. The bureau does not become involved in the charges for an IRE.