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    Benefits & Certifications Unit   
503-947-7585   

How do my medical bills get paid?

If your claim is accepted

If your claim is denied

If your claim is deferred

Payment for independent medical examination (IME)

Payment for worker requested medical examination

Prescriptions

How workers’ compensation insurance interacts with your health insurance


The workers’ compensation insurance company (the insurer) will pay for medical treatment and prescriptions for your injury or occupational disease. However, the insurer will not pay any medical bills until your claim is accepted or denied. The insurer has 60 days to accept or deny your claim.


If your claim is accepted
The insurer will pay for injury-related medical treatment and prescription drugs. Transportation, meals, and lodging necessary to visit medical offices will be reimbursed within limits set by Oregon Administrative Rules. Your doctor will bill the insurer directly. Some insurers now pay pharmacies directly for drugs. Be sure to keep receipts for all out-of-pocket expenses. Send a written request for reimbursement with proof of expenses to the insurer within two years of incurring the expenses.

If your claim is denied
The insurer will not pay your medical bills (including bills for services prior to the denial), with the following exceptions:

1.

If you are required by the insurer to receive treatment from a managed care organization (MCO), the insurer will pay your medical bills during the time before your claim is denied.

2.

If you have personal health insurance, the insurer may pay charges not covered by your health insurer for necessary medical care unless your claim is denied within 14 days. These costs may be recovered from future claims.


If your claim is denied based on an independent medical examination (IME), and your own doctor doesn’t agree with the IME report, you may request a hearing on the denial and request a medical examination by a doctor selected by the Workers’ Compensation Division. This is called a worker-requested medical examination.

Before your claim is accepted or denied
No one should pay for medical expenses while waiting for the decision on the claim. If the insurer accepts your claim, the insurer will pay for medical care related to the claim. If the claim is denied, you or your private health insurance carrier will be responsible for medical expenses. However, as of January 1, 2002, a claim that is denied and is on appeal will be processed by the health insurance company, provided you have coverage. However, if there is a balance remaining, the health care provider can bill the workers’ compensation carrier, who will pay up to the fee schedule for certain types of medical services prescribed to reduce pain, diagnose the condition or prevent disability. If the claim denial is ultimately upheld, the amount paid to the health care provider can be held as an overpayment and deducted from future workers’ compensation benefits with the same insurer.

By law, if you are receiving medical care in Oregon, the doctor may not seek payment from you for the medical treatment related to the claim during the time the claim is being evaluated or if the claim is accepted. It is also important to know that during the time the claim is being evaluated (deferred), the insurer will not make payment for any medication the doctor may prescribe or for any other expenses such as transportation costs for visits to the doctor’s office. You should keep receipts for these expenses as they will be paid by the insurer, in addition to related medical bills, if your claim is accepted. If the insurer sends you for an evaluation during this “deferred” period, the insurer will reimburse expenses to attend the appointments.

Payment for independent medical examination (IME)
The insurer pays all costs of an independent medical examination. If you need advance payment of your costs to attend the examination, be sure to request the advance as soon as possible.
You may have a family member or friend accompany you during the examination, if you have the signed observer form and give it to the doctor. However, doctor approval is required for an observer in psychological exams. The insurer will not pay any expenses for the family member or friend.


Payment for worker requested medical examination
The insurer pays all costs for a worker requested medical examination.


Prescriptions
The insurer will reimburse you for prescription costs for those prescriptions directly related to your injury or occupational disease (referred to as accepted condition(s)). Insurers are required to reimburse you within 30 days of receipt of your written request for reimbursement.

The insurer will notify you at the time of your claim acceptance that actual and reasonable costs for prescriptions paid by you will be reimbursed upon request. The insurer may require reasonable documentation to support your request. If the insurer cannot determine if the prescription costs are related to your accepted injury or disease, the insurer will inform you what information is needed before the request for reimbursement can be processed.


How workers’ compensation insurance interacts with your health insurance
If you have personal health insurance, the workers’ compensation insurer may pay charges not covered by your health insurance for necessary medical care unless your claim is denied within 14 days. These costs may be recovered from future claims with this insurer.

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If you have questions about this webpage, please contact Benefits & Certifications Unit, 503-947-7585.