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    Benefits & Certifications Unit   
503-947-7585   

I need medical treatment, where
should I go and what is covered?

Immediate medical treatment

Your doctor as your "attending physician"

Your provider’s role

Changing attending physicians

Employers covered by managed care organization (MCO) contracts

Employer or insurer representative attending medical examinations

Independent medical examinations (IME)

Worker requested medical examinations

What treatment is covered, what’s not?

Elective surgery

Your responsibilities

Medically stationary

Additional medical care after becoming medically stationary

If your condition gets worse – aggravation rights

Curative and palliative care

Prescriptions



Immediate medical treatment
Go 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 care provider 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 claim (Form 801) 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.


Your doctor as your "attending physician"
Unless the insurer has enrolled you in a managed care organization (discussed below), you may be treated by any
health care provider who qualifies as an attending physician under Oregon law. Your health care provider is supposed to tell you if there are any limits to the services he or she can provide.


Your provider’s role
Your
health care provider 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 to work.


Changing attending physicians
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 care providers, fill out Form 827 at your new attending physician's 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 care provider on an emergency or “on-call” basis, or if your attending physician 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.

Employers 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.


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.

Independent 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 care provider. However, health care provider 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.


Worker requested medical examinations
If your claim has been denied by the insurer based on an insurer 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, address 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 claim identifying information of the injured worker;

 

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 insurer’s denial letter; and

 

Document(s) that demonstrate that the attending physician did not concur with the Insurer Medical Examination report(s).

 

Worker requested medical examination guide

 

Doctors participating in workers’ compensation exams

Send all documents to:
     Workers' Compensation Division
     Attn: Medical Resolution Team
     350 Winter St. N.E.Rm. 27
     PO Box 14480
     Salem, OR 97309


What treatment is covered, what’s 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.


Elective surgery
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 don’t 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.


Your responsibilities
You must keep all of your medical appointments. You must attend the insurer 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.


Medically stationary
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.

Additional 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 doesn’t 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 doctor’s 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.

Curative and palliative care

Curative care is medical treatment to stabilize temporary symptoms after you’ve become medically stationary.

Palliative care is treatment to relieve pain but does not improve or cure your condition or injury.


Prescriptions
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.

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