Benefits & Certifications Unit
I need medical treatment, where
should I go and what is covered?
Immediate medical treatment
Go to your
regular health care provider, an urgent-care clinic, or a hospital emergency room, depending
on the extent of your injury. Tell the health
care provider or
intake person that you were injured on the job. Remember that no medical bills will be paid
by the insurer until you file a workers compensation claim (Form
801) with your
employer and your claim is accepted. If your claim is denied, you or your private health
insurer will be responisible for the bills.
Your doctor as
your "attending physician"
Unless the insurer has enrolled you in a managed care organization (discussed below), you may be treated by any health
care provider who
qualifies as an attending physician under Oregon law. Your health
care provider is
supposed to tell you if there are any limits to the services he or she can provide.
care provider is
in charge of your medical treatment. Only your doctor can authorize time off work, reduced
work hours or duties, or release you to go back to work.
You may change your attending physician two times. Additional changes require
approval from the insurer or the Workers Compensation Division. If you do change health
fill out Form 827 at your new
office. Check the box Notice of change of attending physician. The health care
provider will send the notice to the insurer. If you are treated by a health
care provider on
an emergency or on-call basis, or if your attending
you to a specialist but remains primarily responsible for your care, these do not count as
changes. If you are enrolled in a managed
care organization (MCO), your rights may differ. Contact the MCO if you have questions.
covered by managed care organization (MCO) contracts
If your employer is covered by an insurer who has a contract
with a managed care organization (MCO), the insurer may enroll
you in the MCO at any time after your injury and you may be required to pick an MCO doctor
with whom to treat. The insurer must provide you with a written notice
of enrollment that must be complete,
contain all required enrollment information, and includes either a written list of the MCO's
eligible attending physicians or a Web address for you to access the list. Until you are
enrolled, you may treat with any health care provider who qualifies as an attending physician.
After enrollment, if you have a family doctor who qualifies as a primary
care physician or authorized
nurse practitioner and meets certain requirements, he or she may continue to treat you
if he or she agrees to the MCO's rules, terms, and conditions.
Employer or insurer
representative attending medical examinations
It is up to you whether to allow an employer or an insurer representative
to attend your medical examination. It requires your written consent. You have the
right to refuse such attendance. Your benefits cannot be reduced or stopped if you refuse
to allow a representative to attend.
medical examinations (IME)
The insurer may require you to attend medical examinations with doctors it chooses. Workers
compensation benefits may be stopped if you fail to attend these examinations. However, they
can only require you to attend 3 IME's in each open period of a claim. Invasive procedures cannot be performed without your consent and your benefits cannot be reduced
or stopped if you decline invasive procedures. If you need advance payment of your costs
to attend the examination, be sure to request the advance as soon as possible. The insurer
pays all costs for the medical examination. You may have a family member or friend accompany
you during the examination, if you have the signed observer
form and give it to the health
care provider approval
is required for an observer in psychological exams. The insurer will not pay any expenses
for the family member or friend. If you disagree with the number of exams the insurer has
required you to attend, you can request the Workers' Compensation Division to review. Call
requested medical examinations
If your claim has been denied by the insurer based on an insurer medical examination (IME),
and your attending physician disagrees with the IME results, you may be eligible to request
a medical examination by a physician chosen by the Workers Compensation Division. In
order to be eligible for this exam, you must appeal your denied claim in writing within 60
days of the denial. After you have requested an appeal on the denial, you may send a written
request for an exam to WCD, address to the Resolution Team. A copy of your request should
be sent simultaneously to the insurer or self-insured employer. The request must include:
Your name, address, and claim identifying information of the injured worker;
A list of physicians, including names and addresses, who have previously provided medical
treatment to you on this claim or who have previously provided medical services to
you related to the claimed condition(s);
The date you requested a hearing and a copy of the hearing request;
A copy of the insurers denial letter; and
Document(s) that demonstrate that the attending physician did not
concur with the Insurer Medical Examination report(s).
Send all documents to:
Workers' Compensation Division
Attn: Medical Resolution Team
350 Winter St. N.E.Rm. 27
PO Box 14480
Salem, OR 97309
treatment is covered, whats not?
If your claim is accepted, the insurer will
pay for all injury-related medical treatment and prescription
drugs. This does not necessarily include elective surgery (surgery
that is not an emergency). If you disagree with the insurer,
contact the medical
resolution team at 503-947-7606.
This is surgery that is not an emergency.
Your physician is required to notify the insurer before performing
elective surgery, and the insurer may require a second opinion.
(MCO procedures may differ.) If your physician and the insurer
dont agree about the need for surgery, the insurer may
ask the Workers Compensation Division to review the need
for surgery and determine if the insurer is required to pay
for it. If
you disagree with the insurer, contact the medical
resolution team at 503-947-7606.
You must keep all of your medical appointments. You must attend the insurer
medical examination if one is scheduled. Read all the letters and notices about your claim
pay attention to instructions about medical appointments. Failure to attend medical
appointments may result in the loss of your benefits.
The term medically stationary means that your condition or
injury is not expected to get better with further treatment or the passage of time. When
your doctor determines that you are medically stationary, the insurer will close your claim.
The insurer will, however, continue to pay for prescriptions and some other medical services.
medical care after becoming medically stationary
After you are medically stationary, the insurer is responsible for future
medical services with some limitations. The insurer is responsible to cover the costs of
compensible medical services such as prescription drugs, diagnostic care, life-preserving
care, and some other services related to your accepted conditions. Some medical costs are
not covered after you are medically stationary. Check with the insurer to find out what services
are covered. Palliative care, a medical service that makes you feel better but doesnt
heal your condition, is covered if you are working and need the care to continue working
or while you attend vocational training. This care is covered only if approved by the insurer
or the Workers Compensation Division. Curative care may also be covered because of
your accepted conditions.
If your condition
gets worse aggravation rights
If your accepted condition gets worse after you become medically stationary,
you may file a claim for aggravation to have your claim reopened. You must fill
out Form 827 at your doctors office and check
the box on the form that says Report of aggravation of original injury. Your
doctor will send this form to the insurer along with medical reports.
Your right to reopen a claim, or your aggravation rights, end five years after
your claim is closed (for a disabling claim) or five years after your date of injury (for
a nondisabling claim.)
If your condition gets worse after
your aggravation rights end
If after five years you cannot work because your condition worsens, and
you need hospitalization, surgery, or other curative
medical treatment to allow you to return to work, you must contact the insurer. The insurer
may reopen your claim and pay you temporary disability compensation during your recovery,
as authorized by your doctor.
and palliative care
care is medical treatment to stabilize temporary symptoms after youve
become medically stationary.
Palliative care is treatment
to relieve pain but does not improve or cure your condition or injury.
If the claim is accepted the insurer will pay for injury-related prescription
drugs. Some insurers now pay pharmacies directly for drugs. Keep receipts of all out-of-pocket
expenses. Send a written request for reimbursement with proof of expenses to the insurer
within two years of incurring the expense.