OAR 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.