Procedures for Completing an 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. Without evidence of an LIBC-9, the fee review application may be considered incomplete and will effect application’s outcome.

• Copies or reprints of all original bills pertaining to the date(s) of service. In accordance with Commonwealth Court decisions, the date on the bill of the bill form is to be utilized as the bill date for the purposes of fee review. Make sure the date on the copy used for fee review has the same date as the original bill sent to the payer.

• 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.

• The LIBC-9 Medical Report form can be found at LIBC-9 int.pdf
  
  
• Workers’ Compensation has an online system for submission of the electronic version of the LIBC-507 Application for Fee Review at www.wcais.pa.gov
  
  
• The bureau does not provide CMS 1500 or UB-04 bill form templates.

The Workers’ Compensation Automation and Integration System (WCAIS) prevents most technical filing errors through its online filing process.

• Make sure the fee review only contains information for one injured worker and one provider. Make sure to redact information relating to other workers from EOBs submitted with the application.

• The proper party must be billed as stated in §127.203(a) (relating to Medical Bills) prior to filing a fee review.

• Make sure at least 30 days have passed from the date the insurer was billed prior to filing.

• Ensure all required documents are submitted and accurately reflect the original billing submission to the insurer, including the bill date on the bill form and the report date on the LIBC-9.

• 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.

• Do not file if payment for the billed services is subject to the outcome of a pending utilization review.

• Do not file if you are not the provider, professional or an agent acting on their behalf/at their direction. The right to file a fee review may not be assigned.

• 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.

• 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.

• Information on how to exercise your appeal rights is included in the fee review administrative decision correspondence. For questions about a fee review appeal, the Office of Workers’ Compensation Adjudication should be contacted rather than the bureau. Appeal related questions may be submitted via a WCAIS Customer Service Request or directed to directed to WCOAResourceCenter@pa.gov or 844-237-6316.

• Log into WCAIS and select the fee review you want to withdraw. From the summary screen, select Withdraw from the Action drop-down, and then click the Continue button. Upon clicking Confirm, WCAIS will automatically generate notice of the withdrawal to the interested parties.

• If you have any questions regarding the fee review filing procedures, please contact the Fee Review Section at RA-LI-BWC-HCSRD, create a Customer Service request directly in WCAIS, or provide your inquiry details and contact information at 717-772-1900.