| (A) A health care insurer must file a request for medical
dispute resolution with the workers' compensation insurance carrier
or the insurance carrier's utilization review agent not later than
the 120th day after a workers' compensation insurance carrier reduces
or denies the requested reimbursement amount due to lack of medical
necessity.
(B) A medical dispute based on the workers' compensation
insurance carrier's denial of a health care insurer's reimbursement
request due to lack of medical necessity is subject to dispute resolution
pursuant to §133.308 of this title (relating to MDR of Medical
Necessity Disputes).
(C) A subclaimant shall follow the independent review
process allowed for a non-network health care provider seeking retrospective
review of a service under that section, with any modifications specified
by this subsection.
(D) A request for reconsideration is not required prior
to a request for independent review, notwithstanding the requirements
for requesting independent review under §133.308 of this title.
(E) A request for independent review may be filed,
notwithstanding the timeliness requirements for filing a request for
independent review under §133.308 of this title.
(F) Notwithstanding the provisions of §133.308
of this title, regarding independent review organization requests
for additional information, if a health care provider is requested
to submit records, the health care insurer shall reimburse the health
care provider copy expenses for the requested records.
(3) Reduction, Denial or Failure to Respond.
(A) A health care insurer must file a request for medical
dispute resolution with the Division not later than:
(i) the 120th day after a workers' compensation insurance
carrier fails to respond to a health care insurer's reimbursement
request or reduces or denies the requested reimbursement amount for
reasons other than lack of medical necessity; or
(ii) 60 days after the date the requestor receives
the final decision, inclusive of all appeals, on compensability or
extent of injury issues raised in accordance with this subsection.
(B) A medical dispute based on the workers' compensation
insurance carrier's failure to respond to a health care insurer's
reimbursement request or the result of a reduction or denial of the
requested reimbursement amount for reasons other than those listed
in paragraph (1) or (2) of this subsection is subject to medical dispute
resolution pursuant to §133.307 of this title, notwithstanding
the definition of medical fee dispute in §133.305 of this title
(relating to MDR--General), and the health care insurer must follow
the medical fee dispute resolution process allowed for a health care
provider under that section, with any modifications specified by this
subsection.
(C) Notwithstanding the requirements of §133.307(c)(2)
of this title, a health care insurer shall only be required to include
with a request for medical fee dispute resolution, a copy of the health
care insurer reimbursement request as originally submitted to the
workers' compensation insurance carrier, a copy of the EOB relevant
to the fee dispute received from the workers' compensation insurance
carrier, and sufficient information to substantiate the claim.
(D) A request for reconsideration is not required prior
to a request for medical fee dispute resolution, notwithstanding the
requirements for requesting medical fee dispute resolution under §133.307
of this title.
(E) A request for medical fee dispute resolution may
be filed, notwithstanding the timeliness requirements for filing a
request for medical fee dispute resolution under §133.307 of
this title.
(i) Multiple Entities Seeking Reimbursement for Same
Services. If there are multiple entities seeking reimbursement for
the same services and dates of services for the same health care insurer
for the same injured employee, the following apply:
(1) When the workers' compensation insurance carrier
obtains a release from the health care insurer indicating that those
specific services have been paid in full, no other entity may collect
for those specific services.
(2) If a dispute remains over the fees to be paid for
those specific services, the first in time to file a dispute with
the Division is the only subclaimant that has a right to dispute resolution,
and reimbursement, for that injured employee's claim and those specific
services rendered unless that subclaimant abandons the dispute resolution
process prior to a final adjudication of the issues.
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