§ 1797. Customary charges for treatment.
(a) General rule.--A person or institution providing treatment, accommodations, products or services
to an injured person for an injury covered by liability or uninsured and underinsured
benefits or first party medical benefits, including extraordinary medical benefits,
for a motor vehicle described in Subchapter B (relating to motor vehicle liability
insurance first party benefits) shall not require, request or accept payment for the
treatment, accommodations, products or services in excess of 110% of the prevailing
charge at the 75th percentile; 110% of the applicable fee schedule, the recommended
fee or the inflation index charge; or 110% of the diagnostic-related groups (DRG)
payment; whichever pertains to the specialty service involved, determined to be applicable
in this Commonwealth under the Medicare program for comparable services at the time
the services were rendered, or the provider's usual and customary charge, whichever
is less. The General Assembly finds that the reimbursement allowances applicable in
the Commonwealth under the Medicare program are an appropriate basis to calculate
payment for treatments, accommodations, products or services for injuries covered
by liability or uninsured and underinsured benefits or first party medical benefits
insurance. Future changes or additions to Medicare allowances are applicable under
this section. If the commissioner determines that an allowance under the Medicare
program is not reasonable, he may adopt a different allowance by regulation, which
allowance shall be applied against the percentage limitation in this subsection. If
a prevailing charge, fee schedule, recommended fee, inflation index charge or DRG
payment has not been calculated under the Medicare program for a particular treatment,
accommodation, product or service, the amount of the payment may not exceed 80% of
the provider's usual and customary charge. If acute care is provided in an acute care
facility to a patient with an immediately life-threatening or urgent injury by a Level
I or Level II trauma center accredited by the Pennsylvania Trauma Systems Foundation
under the act of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical Services
Act, or to a major burn injury patient by a burn facility which meets all the service
standards of the American Burn Association, the amount of payment may not exceed the
usual and customary charge. Providers subject to this section may not bill the insured
directly but must bill the insurer for a determination of the amount payable. The
provider shall not bill or otherwise attempt to collect from the insured the difference
between the provider's full charge and the amount paid by the insurer.
(b) Peer review plan for challenges to reasonableness and necessity of treatment.--
(1) Peer review plan.--Insurers shall contract jointly or separately with any peer review organization established
for the purpose of evaluating treatment, health care services, products or accommodations
provided to any injured person. Such evaluation shall be for the purpose of confirming
that such treatment, products, services or accommodations conform to the professional
standards of performance and are medically necessary. An insurer's challenge must
be made to a PRO within 90 days of the insurer's receipt of the provider's bill for
treatment or services or may be made at any time for continuing treatment or services.
(2) PRO reconsideration.--An insurer, provider or insured may request a reconsideration by the PRO of the PRO's
initial determination. Such a request for reconsideration must be made within 30 days
of the PRO's initial determination. If reconsideration is requested for the services
of a physician or other licensed health care professional, then the reviewing individual
must be, or the reviewing panel must include, an individual in the same specialty
as the individual subject to review.
(3) Pending determinations by PRO.--If the insurer challenges within 30 days of receipt of a bill for medical treatment
or rehabilitative services, the insurer need not pay the provider subject to the challenge
until a determination has been made by the PRO. The insured may not be billed for
any treatment, accommodations, products or services during the peer review process.
(4) Appeal to court.--A provider of medical treatment or rehabilitative services or merchandise or an insured
may challenge before a court an insurer's refusal to pay for past or future medical
treatment or rehabilitative services or merchandise, the reasonableness or necessity
of which the insurer has not challenged before a PRO. Conduct considered to be wanton
shall be subject to a payment of treble damages to the injured party.
(5) PRO determination in favor of provider or insured.--If a PRO determines that medical treatment or rehabilitative services or merchandise
were medically necessary, the insurer must pay to the provider the outstanding amount
plus interest at 12% per year on any amount withheld by the insurer pending PRO review.
(6) Court determination in favor of provider or insured.--If, pursuant to paragraph (4), a court determines that medical treatment or rehabilitative
services or merchandise were medically necessary, the insurer must pay to the provider
the outstanding amount plus interest at 12%, as well as the costs of the challenge
and all attorney fees.
(7) Determination in favor of insurer.--If it is determined by a PRO or court that a provider has provided unnecessary medical
treatment or rehabilitative services or merchandise or that future provision of such
treatment, services or merchandise will be unnecessary, or both, the provider may
not collect payment for the medically unnecessary treatment, services or merchandise.
If the provider has collected such payment, it must return the amount paid plus interest
at 12% per year within 30 days. In no case does the failure of the provider to return
the payment obligate the insured to assume responsibility for payment for the treatment,
services or merchandise.
(c) Review authorized.--By December 1, 1991, the Legislative Budget and Finance Committee shall commence a
review of the impact of this section. Such review may be conducted biennially.
(Feb. 12, 1984, P.L.53, No.12, eff. Oct. 1, 1984; Feb. 7, 1990, P.L.11, No.6, eff.
Apr. 15, 1990)
References in Text. The act of July 3, 1985 (P.L.164, No.45), known as the Emergency Medical Services
Act, referred to in subsec. (a), was repealed by the act of August 18, 2009 (P.L.308,
No.37). The subject matter is now contained in Chapter 81 of Title 35 (Health and
Safety).
Cross References. Section 1797 is referred to in section 1712 of this title.
Notes of Decisions
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
· cites it 19× “As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Schappell v. Motorists Mut. Ins., 934 A.2d 1184 (Pa. 2007).
· cites it 10× “In doing so, it dismissed Appellant's argument that 75 Pa.C.S. § 1797 provides the right of action for the interest accrued under section 1716.”
Freedom Med. Supply, Inc. v. State Farm Fire & Cas. Co., 131 A.3d 977 (Pa. 2016).
· cites it 4× “” 75 Pa.C.S. § 1797(a). The MVFRL does not define the phrase “usual and customary charge,” but the Pennsylvania Department of Insurance (“Department”) has promulgated regulations defining it as “[t]he charge most often made” by similarly-situated providers, 31 Pa.”
Nationwide Mut. Ins. v. Foster, 599 A.2d 267 (Pa. Commw. Ct. 1991).
· cites it 17× “In support of this contention Nationwide alleges that 75 Pa.C.S. § 1797 does not expressly or impliedly distinguish between persons injured under No-fault Act policies and those injured under MVFRL policies issued subsequent to the repeal of the No-fault Act on October 1, 1984.”
Levine v. Travelers Prop. Cas. Ins., 69 A.3d 671 (Pa. Super. Ct. 2013).
· cites it 11× “reach of contract claim where attorney’s fees were neither 1) authorized by statute, 2) authorized by contract or agreement among the parties, nor 3) authorized by some other recognized exception, an error of law and/or abuse of discretion? Whether an error of law was committed…”
Barnum v. State Farm Mut. Auto. Ins., 635 A.2d 155 (Pa. Super. Ct. 1993).
· cites it 10× “3 This statutory provision was a part of the same amendatory legislation which produced 75 Pa.C.S. § 1797. 4 It provides as follows: *495 In an action arising under an insurance policy, if the court finds that the insurer has acted in bad faith toward the insured, the court may…”
Harcourt v. Gen. Accident Ins., 615 A.2d 71 (Pa. Super. Ct. 1992).
· cites it 13× “Harcourt’s treatment pursuant to 75 Pa.C.S. § 1797. [Omni-Med] reviewed the matter and determined that the chiropractic care rendered by Dr.”
Olsofsky v. Progressive Ins., 52 Pa. D. & C.4th 449 (2001).
· cites it 16× “§8371 and wanton misconduct under 75 Pa.C.S. §1797. Progressive contends that it cannot be held liable for punitive damages under 42 Pa.”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
· cites it 9× “Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
Pennsylvania Med. Soc'y v. Foster, 608 A.2d 633 (Pa. Commw. Ct. 1992).
· cites it 8× “I respectfully dissent on the basis that I believe the prohibitions against direct patient billing and balance billing set forth in 75 Pa.C.S. § 1797(a) are not rationally related to *551 Act 6's purpose of effectively reducing the cost of automobile insurance.”
Schappell v. Motorists Mut. Ins., 868 A.2d 1 (Pa. Super. Ct. 2004).
· cites it 10× “75 Pa.C.S. § 1797(a). ¶ 7 The final sentence of this section is of particular note.”
— 75 Pa. Cons. Stat. § 1797(6) — 2 cases
— 75 Pa. Cons. Stat. § 1797(7) — 2 cases
— 75 Pa. Cons. Stat. § 1797(a) — 30 cases
Freedom Med. Supply, Inc. v. State Farm Fire & Cas. Co., 131 A.3d 977 (Pa. 2016).
“” 75 Pa.C.S. § 1797(a). The MVFRL does not define the phrase “usual and customary charge,” but the Pennsylvania Department of Insurance (“Department”) has promulgated regulations defining it as “[t]he charge most often made” by similarly-situated providers, 31 Pa.”
Pennsylvania Med. Soc'y v. Foster, 608 A.2d 633 (Pa. Commw. Ct. 1992).
“I respectfully dissent on the basis that I believe the prohibitions against direct patient billing and balance billing set forth in 75 Pa.C.S. § 1797(a) are not rationally related to *551 Act 6's purpose of effectively reducing the cost of automobile insurance.”
Nationwide Mut. Ins. v. Foster, 599 A.2d 267 (Pa. Commw. Ct. 1991).
“In support of this contention Nationwide alleges that 75 Pa.C.S. § 1797 does not expressly or impliedly distinguish between persons injured under No-fault Act policies and those injured under MVFRL policies issued subsequent to the repeal of the No-fault Act on October 1, 1984.”
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
— 75 Pa. Cons. Stat. § 1797(b) — 22 cases
Levine v. Travelers Prop. Cas. Ins., 69 A.3d 671 (Pa. Super. Ct. 2013).
“reach of contract claim where attorney’s fees were neither 1) authorized by statute, 2) authorized by contract or agreement among the parties, nor 3) authorized by some other recognized exception, an error of law and/or abuse of discretion? Whether an error of law was committed…”
Barnum v. State Farm Mut. Auto. Ins., 635 A.2d 155 (Pa. Super. Ct. 1993).
“3 This statutory provision was a part of the same amendatory legislation which produced 75 Pa.C.S. § 1797. 4 It provides as follows: *495 In an action arising under an insurance policy, if the court finds that the insurer has acted in bad faith toward the insured, the court may…”
Olsofsky v. Progressive Ins., 52 Pa. D. & C.4th 449 (2001).
“§8371 and wanton misconduct under 75 Pa.C.S. §1797. Progressive contends that it cannot be held liable for punitive damages under 42 Pa.”
— 75 Pa. Cons. Stat. § 1797(b)(1) — 18 cases
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
“Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
Levine v. Travelers Prop. Cas. Ins., 69 A.3d 671 (Pa. Super. Ct. 2013).
“reach of contract claim where attorney’s fees were neither 1) authorized by statute, 2) authorized by contract or agreement among the parties, nor 3) authorized by some other recognized exception, an error of law and/or abuse of discretion? Whether an error of law was committed…”
— 75 Pa. Cons. Stat. § 1797(b)(2) — 6 cases
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Harcourt v. Gen. Accident Ins., 615 A.2d 71 (Pa. Super. Ct. 1992).
“Harcourt’s treatment pursuant to 75 Pa.C.S. § 1797. [Omni-Med] reviewed the matter and determined that the chiropractic care rendered by Dr.”
— 75 Pa. Cons. Stat. § 1797(b)(3) — 2 cases
Harcourt v. Gen. Accident Ins., 615 A.2d 71 (Pa. Super. Ct. 1992).
“Harcourt’s treatment pursuant to 75 Pa.C.S. § 1797. [Omni-Med] reviewed the matter and determined that the chiropractic care rendered by Dr.”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
“Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
— 75 Pa. Cons. Stat. § 1797(b)(4) — 25 cases
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Schappell v. Motorists Mut. Ins., 934 A.2d 1184 (Pa. 2007).
“In doing so, it dismissed Appellant's argument that 75 Pa.C.S. § 1797 provides the right of action for the interest accrued under section 1716.”
Levine v. Travelers Prop. Cas. Ins., 69 A.3d 671 (Pa. Super. Ct. 2013).
“reach of contract claim where attorney’s fees were neither 1) authorized by statute, 2) authorized by contract or agreement among the parties, nor 3) authorized by some other recognized exception, an error of law and/or abuse of discretion? Whether an error of law was committed…”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
“Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
— 75 Pa. Cons. Stat. § 1797(b)(5) — 5 cases
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Harcourt v. Gen. Accident Ins., 615 A.2d 71 (Pa. Super. Ct. 1992).
“Harcourt’s treatment pursuant to 75 Pa.C.S. § 1797. [Omni-Med] reviewed the matter and determined that the chiropractic care rendered by Dr.”
Barnum v. State Farm Mut. Auto. Ins., 635 A.2d 155 (Pa. Super. Ct. 1993).
“3 This statutory provision was a part of the same amendatory legislation which produced 75 Pa.C.S. § 1797. 4 It provides as follows: *495 In an action arising under an insurance policy, if the court finds that the insurer has acted in bad faith toward the insured, the court may…”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
“Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
— 75 Pa. Cons. Stat. § 1797(b)(6) — 10 cases
Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins., 64 A.3d 1058 (Pa. 2013).
“As the Majority notes, the statute at issue in this case, Section 1797 of the Motor Vehicle Financial Responsibility Law (MVRL), 75 Pa.C.S. § 1797, pertains to treatment provided to an injured person for an injury covered by first party medical benefits, and requires the…”
Levine v. Travelers Prop. Cas. Ins., 69 A.3d 671 (Pa. Super. Ct. 2013).
“reach of contract claim where attorney’s fees were neither 1) authorized by statute, 2) authorized by contract or agreement among the parties, nor 3) authorized by some other recognized exception, an error of law and/or abuse of discretion? Whether an error of law was committed…”
Williams v. State Farm Mut. Auto. Ins., 763 F. Supp. 121 (E.D. Pa. 1991).
“Act 6, Section 18, amended 75 Pa.Cons.Stat.Ann. § 1797 to provide statutory approval for the use of Peer Review Organizations (“PRO”) to evaluate claims.”
— 75 Pa. Cons. Stat. § 1797(b)(7) — 4 cases
Harcourt v. Gen. Accident Ins., 615 A.2d 71 (Pa. Super. Ct. 1992).
“Harcourt’s treatment pursuant to 75 Pa.C.S. § 1797. [Omni-Med] reviewed the matter and determined that the chiropractic care rendered by Dr.”
— 75 Pa. Cons. Stat. § 1797(b)(l) — 3 cases
Olsofsky v. Progressive Ins., 52 Pa. D. & C.4th 449 (2001).
“§8371 and wanton misconduct under 75 Pa.C.S. §1797. Progressive contends that it cannot be held liable for punitive damages under 42 Pa.”
Annotations are extracted automatically from the opinions in the
Syfert caselaw corpus and ranked by authority, recency, and
treatment. Dots show Syfertize treatment of the citing case itself.