OAR 836-053-0105: Coordination of Payment for Interim Medical Services

(1) As used in this section: (a) “Expedited preauthorization” means a determination by an insurer prior to provision of interim medical services that the insurer will provide reimbursement for the services. (b) “Health benefit plan” does not include the Oregon Health Plan. (c) “Interim medical benefits” are those benefits described in OAR 436-009-0035. (d) “Interim medical services” means those services provided prior to claim acceptance or denial in accordance with ORS 656.247. (e) “Worker” has the meaning given in ORS 656.005. (2) A health benefit plan carrier that receives a request for expedited preauthorization under ORS 656.247(4) shall submit the expedited preauthorization to the medical provider who is proposing the treatment. The preauthorization shall be based on the terms, conditions and benefits of the health benefit plan. (3) A carrier need only preauthorize medical services for which the health benefit plan requires a preauthorization and may exclude from the preauthorization any treatment otherwise provided by the carrier if that treatment is excluded under OAR 436-009-0010(12). A carrier must provide an expedited preauthorization not later than the third day after the date on which the request for expedited preauthorization is submitted to the carrier. (4) If the workers’ compensation insurer denies a claim and the insurer notifies the medical provider that the initial claim has been denied, the provider must forward a copy of the workers’ compensation denial letter to the health benefit plan. Upon receipt of the denial letter, the health benefit plan carrier shall pay the provider in accordance with the expedited preauthorization issued to the provider at the time the interim medical services were provided. The carrier shall pay the claim in accordance with any other applicable requirements for payment of claims under the Insurance Code. (5) For purposes of complying with ORS 743.911 and OAR 836-080-0080, payment for medical services under ORS 656.247 shall be considered a particular circumstance requiring special treatment that requires special handling and the claim will not be considered a clean claim until after the workers compensation insurer makes the determination to accept or deny the claim.