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 and include supporting documentation such as a copy of the original bill and chart notes. Use attachment 2842a to list specific CPT codes and dates of services in dispute.
Medical treatment disputes may be initiated by any party using Form 2842 within 90 days of when the aggrieved party knew or should have known there was a dispute. The insurer can request administrative review by the director to contend treatment is excessive, inappropriate or unnecessary, or in violation of a medical services rule. The provider can request administrative review by the director 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 by the director. 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 Resolution Team within 60 days of the mailing date of the MCO decision.
Workers' Compensation Division
Medical Resolution Team
350 Winter St NE
PO Box 14480
Salem, OR 97309-0405
For more information on requesting administrative review by the director for medical issues, refer to Bulletin 293.
If the insurer denies the compensability of the condition, it will issue a denial, and 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 firstname.lastname@example.org.