Once the claim is accepted, the insurer must issue payment within 45 days of receiving your bills and chart notes. If the insurer fails to pay timely, you may charge a reasonable monthly service fee for the period that the payment was delayed, but only if you charge such a fee to the general public.
Tip: When the insurer does not issue a notice of acceptance or denial within 60 days of employer notice, then the workers’ compensation claim is considered denied (de facto denial). The patient may appeal the de facto denial with the Oregon Workers’ Compensation Board.
If you do not receive payment within 45 days or you disagree with the payment amount, first contact the insurer to try to resolve the issue. If you are unable to resolve the issue with the insurer you can file a dispute with the Workers’ Compensation Division (WCD), but you must do so within 90 days of the mailing date on the explanation of benefits (EOB).
An employer may not pay you directly unless the employer is self-insured. Therefore, you must always bill the workers’ compensation insurer and not the employer.
Unless you have an MCO contract or a fee discount agreement, you should get paid either the amount you billed or the amount of the Oregon workers’ compensation fee schedule, whichever is less.
Insurers do not have to pay providers for the following:
- Treating conditions that are not accepted by the insurer
- Completing forms 827 and 4909
- Providing chart notes with the original bill
- Supplying progress notes that document the services billed
- Completing a work release form or completion of a PCE form, when no tests are performed
- A missed appointment ‘no show’
- Dietary supplements
Note: There are excluded treatments that insurers do not have to pay for. See OAR 436-009-0010(12).
If an insurer reduces a fee stating that the service is included in another service billed (bundling), you may want to verify that the CPT® or the Division 009 rules allow that specific bundling.
Note: WCD has not adopted the National Correct Coding Initiative (NCCI) edits, and the insurer should not apply any NCCI edits.
Some insurers may ask you to file an appeal to answer your payment question or resolve your dispute; however, you are not required to file an appeal with the insurer. If you are unable to informally resolve your payment issue with the insurer, you may file a dispute with WCD.
However, you must request dispute resolution with WCD within 90 days of the mailing date of the most recent explanation of benefits or a similar notification.
Tip: Even if you are working with the insurer to resolve your issue during the 90 days, do not let the 90-day time frame pass before requesting dispute resolution with WCD.
To file a dispute, use a copy of Form 2842, “Request for Dispute Resolution of Medical Issues and Medical Fees”. To identify specific services in dispute, you may use Worksheet 2842a, “Medical Fee Dispute Resolution Request and Worksheet,” in addition to Form 2842.
Alternatively, if you have an EOB, you can file a dispute by doing all of the following:
- Signing and dating the EOB
- Attaching copies of chart notes, original bills, or additional supporting documentation
- Providing a cover letter outlining the steps you have taken to try to resolve the dispute and describing the specific issue in dispute