Postmark Medical Records Within 30 Days

An employer can seek review of medical treatment to determine if it is reasonable and necessary under Section 306(f.1)(6) of the Workers Compensation Act. The regulations under which the utilization process is to occur can be found at 34 Pa. Code Section 127.401-479. The Utilization Review Organization (URO) must request in writing the medical records from the treating doctor, who in turn must mail the records to the URO within 30 days.  The treatment will be considered unreasonable and unnecessary if the provider does not mail the records to the URO within the thirty days.

The facts of this case are as follows.  The employer filed a Utilization Review Request (URR) which was assigned to a URO.  The URO in turn sent a letter to the provider for his records on August 3 2005, instructing him to submit his records to the URO by September 2 2005. The provider mailed his records to the URO on September 2 2005, but the URO did not receive the records until September 14 2005. The URO issued a determination that the care was not reasonable or necessary because the URO did not receive the records by September 2 2005.

The commonwealth Court ruled that it is the date the records are mailed and not the date that they are received that governs. In this case, because the provider mailed the records within the 30 days required by the URO, he complied with the regulation 34 Pa Code Section 127.464.

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