Payment for medical services prior to claim acceptance or denial
- • review of disputed services
- • duty of health benefit plan to pay for certain medical services in denied claim
(1) Except for medical services provided to workers subject to ORS 656.245 (Medical services to be provided) (4)(b)(B), payment for medical services provided to a subject worker in response to an initial claim for a work-related injury or occupational disease from the date of the employer’s notice or knowledge of the claim until the date the claim is accepted or denied shall be payable in accordance with subsection (4) of this section.
(2) Notwithstanding subsection (1) of this section, no payment shall be due from the insurer or self-insured employer if the insurer or self-insured employer denies the claim within 14 days of the date of the employer’s notice or knowledge of the claim.
(3)(a) Disputes about whether the medical services provided to treat the claimed work-related injury or occupational disease under subsection (1) of this section are excessive, inappropriate or ineffectual or are consistent with the criteria in subsection (1) of this section shall be resolved by the Director of the Department of Consumer and Business Services. The director may order a medical review by a physician or panel of physicians pursuant to ORS 656.327 (Review of medical treatment of worker) (3) to aid in the review of such services. If a party is dissatisfied with the order of the director, the dissatisfied party may request review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim) within 60 days of the date of the director’s order. The order of the director may be modified only if it is not supported by substantial evidence in the record or if it reflects an error of law.
(b) Disputes about the amount of the fee or nonpayment of bills for medical treatment and services pursuant to this section shall be resolved pursuant to ORS 656.248 (Medical service fee schedules).
(c) Except as provided in subsection (2) of this section, when a claim is settled pursuant to ORS 656.289 (Orders of Administrative Law Judge) (4), all medical services payable under subsection (1) of this section that are provided on or before the date of denial shall be paid in accordance with subsection (4) of this section. The insurer or self-insured employer shall notify each affected service provider of the results of the settlement.
(4)(a) If the claim in which medical services are provided under subsection (1) of this section has not been accepted or denied and a health benefit plan provides benefits to the worker, the health benefit plan shall expedite preauthorizations and guarantee payment of expenses for medical services provided prior to acceptance or denial of the claim according to the terms, conditions and benefits of the plan.
(b) If the claim for which medical services are provided under subsection (1) of this section is accepted, after the claim has been accepted the insurer or self-insured employer shall pay for the medical services provided for accepted conditions, including reimbursements for medical expenses, copayments and deductibles paid by the injured worker or the health benefit plan. Payments made under this subsection are subject to the fee schedules, limitations and conditions of this chapter.
(c) If the claim for which medical services are provided under subsection (1) of this section is denied and a health benefit plan provides benefits to the worker, after the claim is denied the health benefit plan shall pay for medical services provided according to the terms, conditions and benefits of the plan.
(d) As used in this subsection, “health benefit plan” has the meaning given that term in ORS 743B.005 (Definitions) and also means self-insured benefit plans and health benefit plans offered by the Oregon Educators Benefit Board and the Public Employees’ Benefit Board. [2001 c.865 §14; 2005 c.26 §5; 2011 c.99 §3; 2014 c.94 §1]
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.