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Frequently Asked Questions: For Health Care Providers

  • Biling and Payment
  • Interim Medical Benefits
  • Medical Forms
  • Pharmaceutical Clinical Justification Form
  • EDI Medical Bill Reporting
  • Fee Discount Agreement
  • Managed Care Organizations
  • Certification and Authorization

If the insurer denies the claim by the 14th day after the employer knows of the claim, the insurer is not liable for any medical services.

If the insurer denies the claim after the 14th day after the employer knows of the claim, the medical services may be payable under interim medical benefits rules.

Payments for medical services under the interim medical benefits may be made if all of the following apply:

  • The claim was denied after 14 days from the date the employer knew of the claim
  • The worker has a private health insurance plan (the Oregon Health Plan is not considered a private health plan)
  • The medical services provided are for any of the following:
  • diagnostic services
  • medication
  • services required to stabilize and prevent further disability

  • If the above items are true, then you should use the following process:

    Send the bills with a copy of the workers' compensation insurer's denial to the worker's health insurer. Once the explanation of benefit (EOB) is received from the worker's private health plan, you can re-submit your bill to the workers' compensation insurer. Note: Be sure to include the private health insurer's EOB.

    The workers' compensation insurer will pay the amount not paid by the private health insurer up to the amount allowed by the Oregon fee schedule.

    Interim medical benefits do not apply if:
  • The worker is enrolled in a managed care organization before claim acceptance
  • If the insurer denies the claim within 14 days of the employer's notice
  • The date of injury is before Jan. 1, 2002.
  • EDI - Filing Related:

    EDI - Filing Related:

    EDI - Structure-related:

    EDI - Form-related:

    EDI - Pharmacy Reporting: