Pennsylvania Claims Dispute & Statutory Guide
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.
Statutory Framework & Jurisdiction
Choice No-Fault (Full Tort vs. Limited Tort under 75 Pa.C.S. § 1705)
PIP / MedPay Coverage & Medical Fee Rules
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)
Official Medical Fee Schedule & Reimbursement Standards
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 & Decision Point 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)).
Administrative Appeals & Dispute Mechanism
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).
Critical Statutory & Dispute Deadlines
| Dispute Phase / Trigger Event | Statutory Timeline / Deadline |
|---|---|
| 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) |
Required Evidentiary Filing 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
Official Primary Sources & Legislative Authorities
Governing Regulatory Authorities
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