ORS 656.247
Payment for medical services prior to claim acceptance or denial

  • review of disputed services
  • duty of health benefit plan to pay for certain medical services in denied claim

(1)

Except for medical services provided to workers subject to ORS 656.245 (Medical services to be provided) (4)(b)(B), payment for medical services provided to a subject worker in response to an initial claim for a work-related injury or occupational disease from the date of the employer’s notice or knowledge of the claim until the date the claim is accepted or denied shall be payable in accordance with subsection (4) of this section.

(2)

Notwithstanding subsection (1) of this section, no payment shall be due from the insurer or self-insured employer if the insurer or self-insured employer denies the claim within 14 days of the date of the employer’s notice or knowledge of the claim.

(3)

Intentionally left blank —Ed.

(a)

Disputes about whether the medical services provided to treat the claimed work-related injury or occupational disease under subsection (1) of this section are excessive, inappropriate or ineffectual or are consistent with the criteria in subsection (1) of this section shall be resolved by the Director of the Department of Consumer and Business Services. The director may order a medical review by a physician or panel of physicians pursuant to ORS 656.327 (Review of medical treatment of worker) (3) to aid in the review of such services. If a party is dissatisfied with the order of the director, the dissatisfied party may request review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim) within 60 days of the date of the director’s order. The order of the director may be modified only if it is not supported by substantial evidence in the record or if it reflects an error of law.

(b)

Disputes about the amount of the fee or nonpayment of bills for medical treatment and services pursuant to this section shall be resolved pursuant to ORS 656.248 (Medical service fee schedules).

(c)

Except as provided in subsection (2) of this section, when a claim is settled pursuant to ORS 656.289 (Orders of Administrative Law Judge) (4), all medical services payable under subsection (1) of this section that are provided on or before the date of denial shall be paid in accordance with subsection (4) of this section. The insurer or self-insured employer shall notify each affected service provider of the results of the settlement.

(4)

Intentionally left blank —Ed.

(a)

If the claim in which medical services are provided under subsection (1) of this section has not been accepted or denied and a health benefit plan provides benefits to the worker, the health benefit plan shall expedite preauthorizations and guarantee payment of expenses for medical services provided prior to acceptance or denial of the claim according to the terms, conditions and benefits of the plan.

(b)

If the claim for which medical services are provided under subsection (1) of this section is accepted, after the claim has been accepted the insurer or self-insured employer shall pay for the medical services provided for accepted conditions, including reimbursements for medical expenses, copayments and deductibles paid by the injured worker or the health benefit plan. Payments made under this subsection are subject to the fee schedules, limitations and conditions of this chapter.

(c)

If the claim for which medical services are provided under subsection (1) of this section is denied and a health benefit plan provides benefits to the worker, after the claim is denied the health benefit plan shall pay for medical services provided according to the terms, conditions and benefits of the plan.

(d)

As used in this subsection, “health benefit plan” has the meaning given that term in ORS 743B.005 (Definitions) and also means self-insured benefit plans and health benefit plans offered by the Oregon Educators Benefit Board and the Public Employees’ Benefit Board. [2001 c.865 §14; 2005 c.26 §5; 2011 c.99 §3; 2014 c.94 §1]

Source: Section 656.247 — Payment for medical services prior to claim acceptance or denial; review of disputed services; duty of health benefit plan to pay for certain medical services in denied claim, https://www.­oregonlegislature.­gov/bills_laws/ors/ors656.­html.

Notes of Decisions

Worker entitled to payment for medical expenses incurred before denial of claim only if worker has health insurance. Blacknall v. Manpower, Inc., 238 Or App 638, 243 P3d 794 (2010)

656.001
Short title 656.003
Application of definitions to construction of chapter 656.005
Definitions 656.006
Effect on employers’ liability law 656.008
Extension of laws relating to workers’ compensation to federal lands and projects within state 656.010
Treatment by spiritual means 656.012
Findings and policy 656.017
Employer required to pay compensation and perform other duties 656.018
Effect of providing coverage 656.019
Civil negligence action for claim denied on basis of failure to meet major contributing cause standard 656.020
Damage actions by workers against noncomplying employers 656.021
Coverage exception for laborers under contracts with construction and landscape contractor licensees 656.023
Who are subject employers 656.025
Individuals engaged in commuter ridesharing not subject workers 656.027
Who are subject workers 656.029
Obligation of person awarding contract to provide coverage for workers under contract 656.031
Coverage for municipal volunteer personnel 656.033
Coverage for participants in work experience or school directed professional training programs 656.035
Status of workers in separate occupations of employer 656.037
Exemption from coverage for persons engaged in certain real estate activities 656.039
Election of coverage for workers not subject to law 656.041
City or county may elect to provide coverage for adults in custody 656.043
Governmental agency paying wages responsible for providing coverage 656.044
State Accident Insurance Fund Corporation may insure liability under Longshoremen’s and Harbor Workers’ Compensation Act 656.046
Coverage of persons in college work experience and professional education programs 656.052
Prohibition against employment without coverage 656.054
Claim of injured worker of noncomplying employer 656.056
Subject employers must post notice of manner of compliance 656.070
Definitions for ORS 656.027, 656.070 and 656.075 656.075
Exemption from coverage for newspaper carriers 656.126
Coverage while temporarily in or out of state 656.128
Sole proprietors, limited liability company members, partners, independent contractors may elect coverage by insurer 656.132
Coverage of minors 656.135
Coverage of deaf school work experience trainees 656.138
Coverage of apprentices, trainees participating in related instruction classes 656.140
Coverage of persons operating equipment for hire 656.154
Injury due to negligence or wrong of a person not in the same employ as injured worker 656.156
Intentional injuries 656.160
Effect of incarceration on receipt of compensation 656.170
Validity of provisions of certain collective bargaining agreements 656.172
Applicability of and criteria for establishing program under ORS 656.170 656.174
Rules 656.202
Compensation payable to subject worker in accordance with law in effect at time of injury 656.204
Death 656.206
Permanent total disability 656.208
Death during permanent total disability 656.209
Offsetting permanent total disability benefits against Social Security benefits 656.210
Temporary total disability 656.211
“Average weekly wage” defined 656.212
Temporary partial disability 656.214
Permanent partial disability 656.216
Permanent partial disability 656.218
Continuance of permanent partial disability payments to survivors 656.222
Compensation for additional accident 656.225
Compensability of certain preexisting conditions 656.226
Cohabitants and children entitled to compensation 656.228
Payments directly to beneficiary or custodian 656.230
Lump sum award payments 656.232
Payments to aliens residing outside of United States 656.234
Compensation not assignable nor to pass by operation of law 656.236
Compromise and release of claim matters except for medical benefits 656.240
Deduction of benefits from sick leave payments paid to employees 656.245
Medical services to be provided 656.247
Payment for medical services prior to claim acceptance or denial 656.248
Medical service fee schedules 656.250
Limitation on compensability of physical therapist services 656.252
Medical report regulation 656.254
Medical report forms 656.256
Considerations for rules regarding certain rural hospitals 656.258
Vocational assistance service payments 656.260
Certification procedure for managed health care provider 656.262
Processing of claims and payment of compensation 656.263
To whom notices sent under ORS 656.262, 656.265, 656.268 to 656.289, 656.295 to 656.325 and 656.382 to 656.388 656.264
Compensable injury, denied claim and other reports 656.265
Notice of accident from worker 656.266
Burden of proving compensability and nature and extent of disability 656.267
Claims for new and omitted medical conditions 656.268
Claim closure 656.273
Aggravation for worsened conditions 656.277
Request for reclassification of nondisabling claim 656.278
Board has continuing authority to alter earlier action on claim 656.283
Hearing rights and procedure 656.285
Protection of witnesses at hearings 656.287
Use of vocational reports in determining loss of earning capacity at hearing 656.289
Orders of Administrative Law Judge 656.291
Expedited Claim Service 656.295
Board review of Administrative Law Judge orders 656.298
Judicial review of board orders 656.304
When acceptance of compensation precludes hearing 656.307
Determination of issues regarding responsibility for compensation payment 656.308
Responsibility for payment of claims 656.310
Presumption concerning notice of injury and self-inflicted injuries 656.313
Stay of compensation pending request for hearing or review 656.319
Time within which hearing must be requested 656.325
Required medical examination 656.327
Review of medical treatment of worker 656.328
List of authorized providers and standards of professional conduct for providers of independent medical examinations 656.331
Contact, medical examination of worker represented by attorney prohibited without written notice 656.340
Vocational assistance procedure 656.360
Confidentiality of worker medical and vocational claim records 656.362
Liability for disclosure of worker medical and vocational claim records 656.382
Penalties and attorney fees payable by insurer or employer in processing claim 656.383
Attorney fees in cases prior to decision or after request for hearing 656.385
Attorney fees in cases regarding certain medical service or vocational rehabilitation matters 656.386
Recovery of attorney fees, expenses and costs in appeal on denied claim 656.388
Approval of attorney fees required 656.390
Frivolous appeals, hearing requests or motions 656.403
Obligations of self-insured employer 656.407
Qualifications of insured employers 656.419
Workers’ compensation insurance contracts 656.423
Cancellation of coverage by employer 656.427
Termination of workers’ compensation insurance contract or surety bond liability by insurer 656.430
Certification of self-insured employer 656.434
Certification effective until canceled or revoked 656.440
Notice of certificate revocation 656.441
Advancement of funds from Workers’ Benefit Fund for compensation due workers insured by certain decertified self-insured employer groups 656.443
Procedure upon default by employer or self-insured employer group 656.445
Advancement of funds from Workers’ Benefit Fund for compensation due workers insured by insurer in default 656.447
Sanctions against insurer for failure to comply with contracts, orders or rules 656.455
Self-insured employers to process claims and make records available at authorized locations 656.502
“Fiscal year” defined 656.504
Rates, charges, fees and reports by employers insured by State Accident Insurance Fund Corporation 656.505
Estimate of payroll when employer fails to file payroll report 656.506
Assessments for programs 656.508
Authority to fix premium rates for employers 656.526
Distribution of dividends from surplus in Industrial Accident Fund 656.536
Premium charges for coverage of reforestation cooperative workers based on prevailing wage 656.552
Deposit of cash, bond or letter of credit to secure payment of employer’s premiums 656.554
Injunction against employer failing to comply with deposit requirements 656.556
Liability of person letting a contract for amounts due from contractor 656.560
Default in payment of premiums, fees, assessments or deposit 656.562
Moneys due Industrial Accident Fund as preferred claims 656.564
Lien for amounts due from employer on real property, improvements and equipment on or with which labor is performed by workers of employer 656.566
Lien on property of employer for amounts due 656.576
“Paying agency” defined 656.578
Workers’ election whether to sue third person or noncomplying employer for damages 656.580
Payment of compensation notwithstanding cause of action for damages 656.583
Paying agency may compel election and prompt action 656.587
Paying agency must join in any compromise 656.591
Election not to bring action operates as assignment of cause of action 656.593
Procedure when worker or beneficiary elects to bring action 656.595
Precedence of cause of action 656.596
Damage recovery as offset against compensation 656.602
Disbursement procedures 656.605
Workers’ Benefit Fund 656.612
Assessments for department activities 656.614
Self-Insured Employer Adjustment Reserve 656.622
Reemployment Assistance Program 656.625
Reopened Claims Program 656.628
Workers with Disabilities Program 656.630
Oregon Institute of Occupational Health Sciences funding 656.632
Industrial Accident Fund 656.634
Trust fund status of Industrial Accident Fund 656.635
Reserve accounts in Industrial Accident Fund 656.636
Reserves in Industrial Accident Fund for awards for permanent disability or death 656.640
Creation of reserves 656.642
Emergency Fund 656.644
Petty cash funds 656.702
Disclosure of records of corporation, department and insurers 656.704
Actions and orders regarding matters concerning claim and matters other than matters concerning claim 656.708
Hearings Division 656.709
Ombudsman for injured workers 656.712
Workers’ Compensation Board 656.714
Removal of board member 656.716
Board members not to engage in political or business activity that interferes with duties as board member 656.718
Chairperson 656.720
Prosecution and defense of actions by Attorney General and district attorneys 656.722
Authority to employ subordinates 656.724
Administrative Law Judges 656.725
Duties and status of Administrative Law Judges 656.726
Duties and powers to carry out workers’ compensation and occupational safety laws 656.727
Rules for administration of benefit offset 656.730
Assigned risk plan 656.732
Power to compel obedience to subpoenas and punish for misconduct 656.735
Civil penalty for noncomplying employers 656.740
Review of proposed order declaring noncomplying employer or nonsubjectivity determination 656.745
Civil penalty for inducing failure to report claims 656.751
State Accident Insurance Fund Corporation created 656.752
State Accident Insurance Fund Corporation 656.753
State Accident Insurance Fund Corporation exempt from certain financial administration laws 656.754
Manager 656.758
Inspection of books, records and payrolls 656.772
Annual audit of State Accident Insurance Fund Corporation by Secretary of State 656.774
Annual report by State Accident Insurance Fund Corporation to Secretary of State 656.776
Notice to Secretary of State regarding action on audit report 656.780
Certification and training of claims examiners 656.790
Workers’ Compensation Management-Labor Advisory Committee 656.794
Advisory committee on medical care 656.795
Informational materials for nurse practitioners 656.797
Certification by nurse practitioner of review of required materials 656.798
Duty of insurer, self-insured employer and self-insured employer group to provide information to director 656.799
Informational materials for other health care professionals 656.802
Occupational disease 656.804
Occupational disease as an injury under Workers’ Compensation Law 656.807
Time for filing of claims for occupational disease 656.850
License 656.855
Licensing system for worker leasing companies 656.990
Penalties
Green check means up to date. Up to date

Current through early 2024

§ 656.247’s source at oregon​.gov