Chiropractic insurance billing in Pennsylvania.

YES – a state-mandated auto medical fee schedule under Act 6 / 75 Pa.C.S. 1797(a). A provider generally may not require, request, or accept payment in excess of 110% of the applicable Medicare reimbursement (the prevailing charge at the 75th percentile, the applicable Medicare fee schedule / recommended fee / inflation-index charge, or the DRG payment, whichever applies) OR the provider’s usual and customary charge, whichever is LESS.

For services with no Medicare-established rate, 31 Pa. Code Ch. 69 sets the allowance. Because there is a fee schedule, providers generally CANNOT balance-bill the patient for the difference above the cap on covered first-party medical care.

(Note the contrast with WC: auto = 110% of CURRENT Medicare; WC = 113% of a frozen mid-1990s Medicare base – do not cross-apply the two caps.)

WHO can file/submit the first-party PIP claim, and HOW.

• Opening the claim: the statutory right to first-party benefits belongs to the injured INSURED (the patient). The insured – or someone acting for them (a family member, the treating practice, or an attorney) – notifies the auto carrier; PA requires no court filing and no formal state ‘application’ to start, only ‘reasonable proof of the fact and the amount of loss’ (75 Pa.C.S. 1716). The carrier opens a claim, assigns a claim number, and typically sends a benefits application/affidavit and wage-loss verification for the insured. An attorney is NOT a legal prerequisite for routine PIP billing.
• Submitting/billing the medical claim: the treating chiropractic or multi-specialty practice CAN and routinely DOES bill the auto insurer DIRECTLY. Workflow – patient gives the office the carrier name, policy number, and PIP claim number at intake; the office submits a CMS-1500 (HCFA-1500) with diagnosis/CPT codes plus supporting records (chart notes, exam findings, treatment plan, causally relating care to the MVA) to the carrier’s first-party/medical-benefits unit identified by the 1713 priority cascade. The provider need not have the patient or attorney ‘file for’ them to get paid – the provider submits its own bills. The carrier pays at the 1797 cap and the provider may not balance-bill.
• Enforcing if reduced/denied (the subtle point): the right to SUE for the insured’s first-party benefits belongs to the INSURED – a provider generally lacks independent standing to sue the auto insurer for unpaid PIP benefits in the insured’s place ABSENT AN ASSIGNMENT OF BENEFITS from the patient (the 1716 overdue-benefits/interest/fee remedy and 42 Pa.C.S. 8371 bad faith run to the insured). BUT 1797 gives the provider its OWN track when the dispute is reasonableness/necessity or amount: peer review (see penalties/appeal). Practical net: YOU submit the CMS-1500 + records and get paid directly; do not promise patients ‘we will sue the carrier for your benefits’ – that is the insured’s right unless assigned.

ORDER-OF-PRIORITY (whose auto policy pays the medical bills FIRST) – 75 Pa.C.S. 1713 (‘Source of benefits’), read with 1714 (ineligible claimants). The cascade, in order:

• NAMED INSURED – the policy on which the injured person is the named insured. Your own policy follows you regardless of whose car you were in or whether you were driver, passenger, or pedestrian.
• INSURED (e.g., resident relative) – the policy covering the insured; ‘insured’ includes a spouse and relatives who RESIDE in the named insured’s household. KEY NUANCE: this turns on who you LIVE WITH (residency/household), not on whose car was involved – a child living at home, injured as a pedestrian or as a passenger in a stranger’s car, looks to a resident parent’s auto policy here.
• OCCUPANT of an insured vehicle – the policy on THAT vehicle; this is where a passenger with no policy of their own and no resident-relative coverage lands.
• NON-OCCUPANT (e.g., pedestrian/cyclist) – the policy on ANY vehicle involved in the accident (a parked, unoccupied vehicle is not ‘involved’ unless parked so as to create unreasonable risk). EQUAL-PRIORITY RULE (1713(b)): when multiple insurers share the same tier, the insurer the claim is asserted against FIRST must process and pay ‘as if wholly responsible,’ then seek pro-rata contribution from the others – so you submit to one carrier and it cannot stall by pointing at another. OVERRIDING EXCEPTION (1714): an OWNER of a currently-registered vehicle who does NOT maintain financial responsibility (an uninsured owner) is generally SHUT OUT of first-party PIP benefits entirely – a critical billing flag: confirm the patient is not an uninsured registered-vehicle owner before assuming PIP is available. LAST RESORT: if no coverage exists at any tier (e.g., uninsured pedestrian with no household policy), an eligible claimant may turn to the PA Financial Responsibility Assigned Claims Plan (PFRACP / Assigned Claims Plan) for limited statutory first-party benefits through an assigned servicing carrier – the payer of last resort, not a routine billing path. Billing tip: confirm the correct priority carrier at intake – a wrong-carrier submission burns the 1716 30-day clock.

An insurer must pay first-party medical benefits within 30 days after receiving ‘reasonable proof’ of the AMOUNT of benefits due (75 Pa.C.S. 1716); benefits not paid within 30 days are ‘overdue.’ The clock starts on the insurer’s RECEIPT of reasonable proof (a clean bill with supporting documentation), NOT on the date of service; if only part of a bill is supported, that supported part still becomes overdue after 30 days even if the rest is disputed.

To contest the reasonableness or medical necessity of treatment, the insurer generally must route the bill to a Peer Review Organization (PRO), and must do so within 90 days of receiving the provider’s bill (and may refer at any time for continuing treatment) (75 Pa.C.S. 1797(b)).

During peer review the INSURED may not be billed for the treatment under review (1797(b)(3)) – an auto-specific protection.

Strong penalty/interest framework.

• Overdue benefits bear 12% per annum interest from the date due (75 Pa.C.S. 1716).
• If an insurer is found to have acted in an UNREASONABLE manner in refusing to pay benefits when due, it owes a reasonable attorney fee based on actual time expended (75 Pa.C.S. 1716; see also 1798).
• Under 75 Pa.C.S. 1797(b), insurer conduct found to be WANTON is subject to TREBLE (3x) damages to the injured party – the heavy stick, a higher bar than merely ‘unreasonable,’ reserved for egregious refusals.
• COURT CHALLENGE FOR REFUSALS WITHOUT PEER REVIEW: where an insurer refuses to pay WITHOUT first invoking the PRO/peer-review process, a provider or insured may challenge that refusal in court; if the treatment is found reasonable and necessary, the insurer must pay the outstanding amount PLUS 12% interest, the costs of the challenge, AND all attorney fees (75 Pa.C.S. 1797(b)). IMPORTANT NUANCE (on-point chiropractic case law): where the insurer DID properly invoke peer review, Section 1797 does NOT independently authorize attorney fees against the insurer – in Turnpaugh Chiropractic Health & Wellness Center, P.C. v. Erie Ins. Exch. (2023 PA Super 99) the Superior Court held an insurer’s proper USE of peer review is not a ‘refusal to pay,’ so a provider does not get 1797(b) attorney fees merely because a PRO was invoked (see also Herd Chiropractic Clinic v. State Farm, 64 A.3d 1058 (Pa. 2013)). In that posture, fees/interest/overdue remedies flow from Section 1716 if the insurer’s conduct was unreasonable. So: peer review done correctly = no 1797 fee-shifting; payment refused WITHOUT a PRO + wanton conduct = exposure to treble damages and full fees. State this distinction plainly rather than over-promising treble damages. Separately, PA’s general bad-faith statute (42 Pa.C.S. 8371) allows interest (prime + 3%), punitive damages, costs, and fees for bad-faith claim handling – a distinct cause of action that can stack in egregious cases.

PA’s posture is comparatively provider-favorable because the dispute is generally about medical NECESSITY (resolved by a Peer Review Organization under 1797(b)), not a private insurer’s discretionary ‘usual & customary’ reduction. Two distinct avenues by basis of reduction:

• reduced on REASONABLENESS/NECESSITY grounds – the peer-review track (1797(b)), then PRO reconsideration, then court review of necessity; if the insurer reduced/denied WITHOUT properly invoking peer review, the provider or insured can pursue payment plus 12% interest, the costs of the challenge, and attorney fees in court.
• reduced on AMOUNT/FEE grounds (a 1797(a) cost-containment calculation dispute) – the fight is the Act-6 math under 31 Pa. Code Ch. 69, and the provider can pursue the correct capped amount with 1716 interest/fee exposure if the refusal was unreasonable. As recognized in Turnpaugh, a provider may still recover under Section 1716 – including 12% interest and attorney fees – where the insurer’s refusal was unreasonable, even though Section 1797 itself did not authorize fees in the peer-review context. Note the standing point: the provider’s own track is 1797 peer review; stepping into the insured’s 1716 benefits suit generally requires a patient assignment of benefits.

YES – a mandatory state WC medical fee schedule set by the Bureau of Workers’ Compensation (34 Pa. Code Ch. 127, Subch. B). Outpatient provider fees are generally capped at 113% of the applicable Medicare reimbursement rate for comparable services (34 Pa.

Code 127.101). Rates were effectively set against the Medicare baseline as of the mid-1990s (Jan. 1, 1995) and are thereafter updated annually by the percentage change in the statewide average weekly wage rather than by current Medicare changes – so the WC base does NOT float with current Medicare.

Services with no Medicare-established mechanism are generally paid at 80% of the usual and customary charge in the area (or the actual charge, whichever is lower). Chiropractic services have their own provision (34 Pa. Code 127.105): spinal manipulation (HCPCS 98940-98943), physical-medicine/therapeutic procedures (97000-series), and office/E-M visits are reimbursed by reference to the Medicare allowance multiplied by 113%.

Balance-billing the injured worker is prohibited (34 Pa. Code 127.211). (Distinct from the auto 110%-of-current-Medicare cap – different program, different multiplier, different base.)

The unique PA WC documentation rule: a bill ALONE does NOT trigger the payment obligation. Bills must be on the standard billing form (CMS-1500 / HCFA-1500 for professional services, or the applicable UB-04/UB-92 for facility) (34 Pa.

Code 127.201) AND be accompanied by the required medical report. PA uses the LIBC-9 (Workers’ Compensation Medical Report Form) for periodic reporting: a report is due commencing 10 days after treatment begins and at least monthly while treatment continues (no report required for months with no treatment), and must contain history, diagnosis, services rendered, physical findings, and prognosis (34 Pa.

Code 127.203). Per 127.203, if the provider does NOT submit the required report on the prescribed form, the insurer is NOT obligated to pay until the report is received – so in PA WC, ‘clean bill + conforming report’ is a SINGLE package and a CMS-1500 alone is not enough.

This ‘no report, no pay’ rule is the single most-missed PA WC submission requirement.

An insurer/employer must pay properly submitted medical bills within 30 days of receipt of BOTH the bill AND the required report (34 Pa. Code 127.208). For timeliness purposes, the insurer is deemed to receive a bill and report 3 days after the provider mails them, and payment is timely if mailed by the 30th day.

Requesting additional records, or proposing to change (down-code) the provider’s codes, does NOT lengthen the 30-day window. The 30-day clock is tolled ONLY when a proper Utilization Review request is filed with the Bureau (34 Pa.

Code 127.403). A retrospective UR request must generally be filed within 30 days of receipt of the bill and medical report to preserve the right to retrospective review (34 Pa. Code 127.404); missing that window waives retrospective necessity review.

Interest accrues on overdue WC medical payments.

Two distinct tracks – do not confuse them.

• UTILIZATION REVIEW (UR) – the EXCLUSIVE way to dispute whether treatment was reasonable or NECESSARY (34 Pa. Code Ch. 127, Subch. C). Filed (LIBC-601) through WCAIS to a Bureau-assigned Utilization Review Organization (URO). Retrospective UR must be filed within 30 days of receipt of the bill + report (else waived, 127.404); the URO must issue its determination within 30 days of a completed request (127.465); the provider under review must mail records to the URO within 30 days, and failure means the treatment is found NOT reasonable/necessary by default (127.464), with a signed verification that the records are the true and complete chart (127.459). A party dissatisfied files a Petition for Review of UR Determination (generally within 30 days), heard by a Workers’ Compensation Judge.
• FEE REVIEW (Application for Fee Review, LIBC-507, 34 Pa. Code 127.251-127.261) – for disputes about the AMOUNT paid (fee-schedule underpayment/down-coding) or TIMELINESS of payment, NOT necessity or liability. A provider files with the Bureau no more than 30 days following notification of a disputed treatment OR 90 days following the original billing date, whichever is later; proof of service on the insurer is required; down-coding has its own procedure (127.254-127.255). Necessity goes to UR; amount/timeliness goes to Fee Review. (Caution: a Fee Review generally cannot be won while underlying liability/necessity is unresolved or a UR is pending.)

Pennsylvania Medical Assistance (Medicaid) coverage of chiropractic is generally limited and is typically delivered through HealthChoices managed-care plans, so benefits, prior-authorization rules, and visit limits often vary by MCO.

Children under 21 may have broader access to medically necessary care through the EPSDT benefit, while adult chiropractic coverage is usually narrower, making eligibility and authorization verification important before billing.

Under Pennsylvania’s Chiropractic Practice Act (Act 188 of 1986), DCs may generally evaluate and adjust or manipulate the spine and other articulations, perform examinations and diagnosis to determine appropriate chiropractic treatment, and expose and interpret X-rays they are trained to use.

With proper certification they may also provide adjunctive procedures such as physiotherapy modalities and offer nutritional counseling, so common billing includes spinal manipulation (CMT), office visit E/M codes, diagnostic imaging, and therapeutic modalities.