What dispute deadlines should providers track in Pennsylvania?

First Party Benefit Claim Submission: Within 30 calendar days from service date; Carrier 30-Day Pay or Challenge Window: 30 days from receipt of proof of claim (75 Pa.C.S. § 1716); PRO Referral by Carrier: Within 30 days of receiving medical bill. Verify the trigger date, current agency notices, and any extension before acting.

Which agencies administer these rules in Pennsylvania?

The guide identifies Pennsylvania Insurance Department. The correct agency depends on the plan and claim jurisdiction.

Auto Accident, PIP & Medical Billing State Guides

Pennsylvania Auto Accident, PIP & Medical Billing Laws

Pennsylvania operates a Choice No-Fault system under the Motor Vehicle Financial Responsibility Law (MVFRL, 75 Pa.C.S. § 1701 et seq.). Every motor vehicle liability policy must carry mandatory First Party Benefits (FPB) medical coverage. Provider reimbursement is statutorily governed by Act 6 caps at 110% of Medicare Part B allowable fees.

Accountability & Review

Reviewed by Millennova Legal Operational Integrity Team, Senior Audit and Arbitration Analysts

Last Reviewed

2026-03-01

Plain-language overview

Choice No-Fault (Full Tort vs. Limited Tort under 75 Pa.C.S. § 1705)

PIP and MedPay coverage

Mandatory F P B

$5,000 statutory minimum medical benefit under 75 Pa.C.S. § 1711 (optional higher limits up to $100,000+)

Assignment Of Benefits

Permitted under Pennsylvania common law unless expressly barred by policy terms

Prompt Payment

Payment must be remitted within 30 days after receipt of reasonable proof of the fact and amount of loss realized (75 Pa.C.S. § 1716)

Medical fee schedule and reimbursement rules

Name

Pennsylvania Act 6 Medical Fee Schedule (75 Pa.C.S. § 1797)

Rules

Reimbursement is capped at 110% of the Medicare Part B payment allowance, or if unlisted, 80% of the provider's usual and customary charge.

Cpt Basis

CMS Medicare Part B physician fee schedule for the applicable Medicare carrier locality

Preauthorization and utilization review

Requirement

Pre-certification is not required by statute for acute emergency services; however, ongoing therapy or diagnostic imaging may be subject to carrier peer review.

Deadlines

Providers must bill within reasonable operational windows on CMS-1500 forms.

Penalty For Non Compliance

Direct billing to insured patient is strictly prohibited for balance above Act 6 statutory caps (75 Pa.C.S. § 1797(a)).

Appeals and dispute resolution

Peer Review Organization

Insurers may challenge the medical necessity of treatment by submitting records to an approved Peer Review Organization (PRO) under 75 Pa.C.S. § 1797(b).

Pro Reconsideration

If the PRO determines care was not medically necessary, the provider or insured may request reconsideration within 30 days.

Dispute Forum

Court of Common Pleas civil litigation if insurer refuses payment without valid PRO determination, triggering statutory 12% annual interest and attorney fees under § 1797(b)(6).

Claim and dispute deadlines

Deadlines can depend on the trigger event and may be affected by agency relief notices. Confirm the live rule before filing.

Event	Timeframe
First Party Benefit Claim Submission	Within 30 calendar days from service date
Carrier 30-Day Pay or Challenge Window	30 days from receipt of proof of claim (75 Pa.C.S. § 1716)
PRO Referral by Carrier	Within 30 days of receiving medical bill
PRO Reconsideration Request	Within 30 days of PRO determination
Statute of Limitations	4 years from denial or last payment (42 Pa.C.S. § 5525)

Documentation checklist

Signed Patient Assignment of First Party Benefits
Itemized HCFA/CMS-1500 statement with CPT/HCPCS codes and ICD-10 diagnostic coding
Complete initial intake examination, range-of-motion assessments, and daily progress notes
Diagnostic imaging reports (MRI, X-ray) establishing motor-vehicle-related pathology
Proof of certified mail transmission of demand for unpaid Act 6 allowances

Responsible agencies

Pennsylvania Insurance DepartmentStatewide Insurance Regulation & Carrier Oversight

Primary legal and regulatory sources

Pennsylvania Consolidated Statutes Title 75, Chapter 17 (MVFRL)Pennsylvania General Assembly · 2024

This operational reference is educational, is not legal advice, and does not create an attorney-client relationship.

Common questions

What rules govern auto accident, pip & medical billing state guides in Pennsylvania?: Pennsylvania operates a Choice No-Fault system under the Motor Vehicle Financial Responsibility Law (MVFRL, 75 Pa.C.S. § 1701 et seq.). Every motor vehicle liability policy must carry mandatory First Party Benefits (FPB) medical coverage. Provider reimbursement is statutorily governed by Act 6 caps at 110% of Medicare Part B allowable fees.
What dispute deadlines should providers track in Pennsylvania?: First Party Benefit Claim Submission: Within 30 calendar days from service date; Carrier 30-Day Pay or Challenge Window: 30 days from receipt of proof of claim (75 Pa.C.S. § 1716); PRO Referral by Carrier: Within 30 days of receiving medical bill. Verify the trigger date, current agency notices, and any extension before acting.
Which agencies administer these rules in Pennsylvania?: The guide identifies Pennsylvania Insurance Department. The correct agency depends on the plan and claim jurisdiction.