I need medical treatment, where
should I go and what is covered?
Immediate medical treatment
to your regular health care provider, an urgent-care clinic, or a hospital
emergency room, depending on the extent of your injury. Tell the health
or intake person that you were injured on the job. Remember that no medical
bills will be paid by the insurer until you file a workers compensation
with your employer and your claim is accepted. If your claim is denied,
you or your private health insurer will be responisible for the bills.
doctor as your "attending physician"
Unless the insurer has enrolled you in a managed care organization (discussed below), you may be treated by any
who qualifies as an attending physician under
Oregon law. Your health
is supposed to tell you if there are any limits to the services he or
she can provide.
is in charge of your medical treatment. Only your doctor can authorize
time off work, reduced work hours or duties, or release you to go back
You may change your attending physician two times. Additional
changes require approval from the insurer or the Workers Compensation
Division. If you do change health
fill out Form 827 at your new
office. Check the box Notice of change of attending physician.
The health care provider will send the notice to the insurer. If you are
treated by a health
on an emergency or on-call basis, or if your attending
refers you to a specialist but remains primarily responsible for your
care, these do not count as changes. If you are enrolled in a managed
care organization (MCO), your rights may differ. Contact the MCO
if you have questions.
covered by managed care organization (MCO) contracts
If your employer is covered by an insurer who has a contract with a managed
care organization (MCO), the insurer may enroll you in the MCO at any
time after your injury and you may be required to pick an MCO doctor with
whom to treat. The insurer must provide you with a written notice of enrollment
that must be complete, contain all required enrollment information, and
includes either a written list of the MCO's eligible attending physicians
or a Web address for you to access the list. Until you are enrolled, you
may treat with any health care provider who qualifies as an attending
physician. After enrollment, if you have a family doctor who qualifies
as a primary care physician or authorized nurse practitioner and meets
certain requirements, he or she may continue to treat you if he or she
agrees to the MCO's rules, terms, and conditions. Contact the MCO if you
Employer or insurer
representative attending medical examinations
It is up to you whether to allow an employer or an insurer representative
to attend your medical examination. It requires your written consent. You have the
right to refuse such attendance. Your benefits cannot be reduced or stopped if you refuse
to allow a representative to attend.
medical examinations (IME)
The insurer may require you to attend medical examinations with doctors
it chooses. Workers compensation benefits may be stopped if you
fail to attend these examinations. However, they can only require you
to attend 3 IME's in each open period of a claim. Invasive procedures cannot be performed without your consent and your benefits
cannot be reduced or stopped if you decline invasive procedures. If you
need advance payment of your costs to attend the examination, be sure
to request the advance as soon as possible. The insurer pays all costs
for the medical examination. 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 health
approval is required for an observer in psychological exams. The insurer
will not pay any expenses for the family member or friend. If you disagree
with the number of exams the insurer has required you to attend, you can
request the Workers' Compensation Division to review. Call 503-947-7606.
requested medical examinations
If your claim has been denied by the insurer based on an independent medical
examination (IME), and your attending physician disagrees with the IME
results, you may be eligible to request a medical examination by a physician
chosen by the Workers Compensation Division. In order to be eligible
for this exam, you must appeal your denied claim in writing within 60
days of the denial. After you have requested an appeal on the denial,
you may send a written request for an exam to WCD, addressed to the Resolution
Team. A copy of your request should be sent simultaneously to the insurer
or self-insured employer. The request must include:
Your name, address, and your claim number;
A list of physicians, including names and addresses, who have previously provided medical
treatment to you on this claim or who have previously provided medical services to
you related to the claimed condition(s);
The date you requested a hearing and a copy of the hearing request;
A copy of the insurers denial letter; and
Document(s) that demonstrate that the attending physician did not
agree with the Independent Medical Examination report(s).
Send all documents to:
Workers' Compensation Division
Attn: Medical Resolution Team
350 Winter St. N.E.Rm. 27
PO Box 14480
Salem, OR 97309
treatment is covered, whats not?
If your claim is accepted, the insurer will
pay for all injury-related medical treatment and prescription
drugs. This does not necessarily include elective surgery (surgery
that is not an emergency). If you disagree with the insurer,
contact the medical
resolution team at 503-947-7606.
This is surgery that is not an emergency. Your physician
is required to notify the insurer before performing elective surgery,
and the insurer may require a second opinion. (MCO procedures may differ.)
If your physician and the insurer dont agree about the need for
surgery, the insurer may ask the Workers Compensation Division to
review the need for surgery and determine if the insurer is required to
pay for it. If
you disagree with the insurer, contact the medical
resolution team at 503-947-7606.
You must keep all of your medical appointments. You
must attend the independent medical examination if one is scheduled. Read
all the letters and notices about your claim pay attention to instructions
about medical appointments. Failure to attend medical appointments may
result in the loss of your benefits.
The term medically stationary means that your condition or
injury is not expected to get better with further treatment or the passage of time. When
your doctor determines that you are medically stationary, the insurer will close your claim.
The insurer will, however, continue to pay for prescriptions and some other medical services.
medical care after becoming medically stationary
After you are medically stationary, the insurer is responsible for future
medical services with some limitations. The insurer is responsible to cover the costs of
compensible medical services such as prescription drugs, diagnostic care, life-preserving
care, and some other services related to your accepted conditions. Some medical costs are
not covered after you are medically stationary. Check with the insurer to find out what services
are covered. Palliative care, a medical service that makes you feel better but doesnt
heal your condition, is covered if you are working and need the care to continue working
or while you attend vocational training. This care is covered only if approved by the insurer
or the Workers Compensation Division. Curative care may also be covered because of
your accepted conditions.
If your condition
gets worse aggravation rights
If your accepted condition gets worse after you become medically stationary,
you may file a claim for aggravation to have your claim reopened. You must fill
out Form 827 at your doctors office and check
the box on the form that says Report of aggravation of original injury. Your
doctor will send this form to the insurer along with medical reports.
Your right to reopen a claim, or your aggravation rights, end five years after
your claim is closed (for a disabling claim) or five years after your date of injury (for
a nondisabling claim.)
If your condition
gets worse after your aggravation rights end
If after five years you cannot work because your condition
worsens, and you need hospitalization, surgery, or other curative
medical treatment to allow you to return to work, you must contact the
insurer. The insurer may reopen your claim and pay you temporary disability
compensation during your recovery, as authorized by your doctor.
and palliative care
care is medical treatment to stabilize temporary symptoms
after youve become medically stationary.
is treatment to relieve pain but does not improve or cure your
condition or injury.
If the claim is accepted the insurer will pay for injury-related prescription
drugs. Some insurers now pay pharmacies directly for drugs. Keep receipts of all out-of-pocket
expenses. Send a written request for reimbursement with proof of expenses to the insurer
within two years of incurring the expense.
If you have questions about this webpage, please contact
Medical outreach, 503-947-7606.