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Medical disputes

For billing or medical fee disputes, parties must request administrative review by the director within 90 days of the explanation of benefits (EOB) mailing date; or for workers, within 90 days of the knowledge of the dispute..

For billing disputes (such as the insurer's reduction of a medical bill or failure to pay within 45 days), use Form 2842 with attachment 2842a.

Medical treatment disputes may be initiated by any party using Form 2842. The insurer can request WCD administrative review to contend treatment is excessive, inappropriate or unnecessary, or in violation of a medical services rules. The health care provider can request administrative review by WCD if the insurer does not approve palliative care, curative care, elective surgery, etc.

Mediation and alternative dispute resolution processes are also available to resolve disputes between parties.

For claims enrolled in a managed care organization (MCO), billing or treatment disputes must go to the MCO for dispute resolution before the worker may request administrative review of the matter by the Workers' Compensation Division. Requests for review through the MCO dispute resolution process must be made to the MCO within 30 days of the mailing date of the initial MCO decision. Requests for review of the final decision of the MCO must be made to the Workers' Compensation Division's Medical Section Resolution Team within 60 days of the mailing date of the MCO decision.

Medical Resolution Team
Workers' Compensation Division
350 Winter St NE
PO Box 14480
Salem, OR 97309-0405
Fax: 503-947-7629

For more information on requests for administrative review by WCD for medical issues, refer to Bulletin 293.

If the insurer denies the compensability of the condition, it will issue a denial, which the worker can appeal to the Workers' Compensation Board.

Workers' Compensation Board
2601 25th St. SE, Suite 150
Salem, OR 97302-1282


Questions? Contact us at 503-947-7606 or e-mail wcd.medicalquestions@state.or.us.