Or. Admin. Code § 436-009-0035 - Interim Medical Benefits
(1)
General.
(a) Interim medical benefits under
ORS 656.247 only apply to initial
claims when the patient has a health benefit plan, i.e., the patient's private
health insurance. For the purpose of this rule the Oregon Health Plan is not a
health benefit plan.
(b) Interim
medical benefits are not due on claims:
(A)
When the patient is enrolled in an MCO prior to claim acceptance or denial
under ORS 656.245(4)(b)(B);
or
(B) When the insurer denies the
claim within 14 days of the employer's notice of the claim.
(c) Interim medical benefits cover
services provided from the date of employer's notice or knowledge of the claim
to the date the insurer accepts or denies the claim. Interim medical benefits
do not include treatments excluded under OAR
436-009-0010(12).
(d) When billing for interim
medical benefits, the medical provider must bill the workers' compensation
insurer according to these rules, and the health benefit plan according to the
plan's requirements. The provider may submit a pre-authorization request to the
health benefit plan prior to claim acceptance or denial.
(e) If the medical provider knows that the
patient filed a work-related claim, the medical provider may not collect any
health benefit plan co-pay, co-insurance, or deductible from the patient during
the interim period.
(2)
Claim Acceptance. If the insurer accepts the claim:
(a) The insurer must pay medical providers
for services according to these rules; and
(b) The provider, after receiving payment
from the insurer, must reimburse the worker and the health benefit plan for any
medical expenses, co-pays, co-insurance, or deductibles, paid by the worker or
the health benefit plan.
(3) Claim Denial. If the insurer denies the
claim:
(a) The insurer must notify the
medical provider as provided in OAR
436-060-0140 that an initial
claim has been denied; and
(b) The
medical provider must bill the health benefit plan, unless the medical provider
has previously billed the health benefit plan. The provider must forward a copy
of the workers' compensation denial letter to the health benefit
plan.
Notes
Stat. Auth.: ORS 656.245, 656.704, 656.726(4)
Stats. Implemented: ORS 656.247
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