FAQ
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Q: What is Oregon Health Systems?
A: OHS is a state-certified managed care organization. We contract with physicians, hospitals, and other health care providers to provide medical services to covered employees with work-related injuries or illnesses. Our providers are carefully selected and trained in the treatment of work-related conditions. OHS, and the health care providers in our network, want to make sure that timely, effective, and convenient medical services are available for our covered workers. OHS will also be working closely with your doctor and insurer to help you return to gainful
as soon as possible after an on-the-job injury or illness.
Q: Is OHS a Workers' Compensation insurance company?
A: No. OHS contracts with insurance companies and self-insured employers to provide managed care services to injured workers. We monitor medical care that is provided to ensure that it is appropriate and necessary, and that it meets our quality standards.
OHS does not make decisions on acceptance or denial of claims, payment of time loss or medical benefits, or any other workers' compensation benefits. Decisions concerning these and all other claims issues remain the responsibility of the claims examiner for the insurer or self-insured employer.
Q: Am I required to see one of the OHS doctors if I am injured on the job and need medical care?
A: In most cases, yes. Once your claim is enrolled by your workers' compensation insurance carrier (which means you have been given written notice of your requirement to treat within the MCO) you will be required to treat with an MCO provider unless one of the circumstances explained below applies. However, if you are enrolled in the MCO prior to your claim being accepted, your workers' compensation insurance company will be required to pay for all reasonable and necessary medical services related to your claim received from an MCO member provider that are not otherwise covered by your group health insurance. This requirement applies even if your claim is denied, until you receive notice of the denial, or until three days after the denial is mailed, whichever occurs first. The situations in which you may receive compensable care from a non-OHS provider after your claim is enrolled follow.
1. You have a private physician or nurse practitioner who qualifies as a primary care physician or authorized nurse practitioner.
Your family physician or authorized nurse practitioner may qualify to treat you under the managed care arrangement, even if he or she is not on the OHS list of contracted providers. To qualify:
Your provider must be a medical doctor (M.D.) or osteopath (D.O.) or authorized nurse practitioner.
Your doctor must be a family practitioner, general practitioner, internal medicine specialist or authorized nurse practitioner.
You must have a history of being treated by that doctor or authorized nurse practitioner, or have the doctor or authorized nurse practitioner as a designated primary care provider under your group health plan.
The doctor or authorized nurse practitioner must agree to abide by all terms and conditions of Oregon Health Systems, and must refer you to an OHS provider for any additional care you may need.
If your authorized nurse practitioner is qualified to provide your care, he or she will be allowed to authorize time loss for 60 days from the date of the first nurse practitioner visit on the initial claim and may provide medical treatment for 90 days from the date of the first nurse practitioner visit on the initial claim.
2. There are fewer than three MCO providers available in a given category in the OHS geographical service area.
You may be allowed to seek treatment from a non-OHS provider if there are fewer than three OHS providers in the following categories:
•Acupuncturist (L.A.C.)
•Optometrist (O.D.)
•Chiropractor (D.C.)
•Dentist (D.M.D. or D.D.S.)
•Naturopath (N.D.)
•Osteopath ((D.O.)
•Physician (M.D.)
•Podiatrist (D.P.M.)
•Physical therapist
•Psychologist
•Authorized nurse practitioner
All out-of-panel treatment will be subject to OHS's utilization and treatment standards.
3. You reside outside OHS's geographical service area.
If you reside outside OHS's geographical service area you may select a non-MCO provider if they practice closer to your residence than an MCO provider of the same category and if they agree to the terms and conditions of the MCO.
If you think you qualify for any of the above exceptions and would like consideration for out-of-panel treatment, please contact Oregon Health Systems.
Should you receive care from a provider who does not meet the above criteria for out-of-panel treatment, your Workers' Compensation insurer will not be required to pay for medical services. In addition, the provider will not be allowed to authorize your time loss from work.
A list of OHS providers in your geographical service area will be provided to you at the time you have a work-related injury or illness that is subject to the MCO agreement. You may also obtain a complete panel list for the entire state by contacting OHS.
Q: What if I live a long distance from OHS's service area?
A: If you live more than one hundred miles from OHS's geographic service area, you will not be subject to the MCO arrangement.
Q: What if I am currently receiving care from a non-MCO provider for a work-related injury or illness at the time I am enrolled into the MCO program?
A: You will be required to treat with an MCO provider, with the exceptions noted above. However, if you have not yet been declared medically stationary, are required to change physicians, and the MCO determines that it would be medically detrimental for you to change physicians, you would not be subject to the MCO requirements until you become medically stationary or choose to change physicians, whichever occurs first.
If you are not yet medically stationary and think that a change of physicians would be medically detrimental to you, you may request review of your situation by the MCO. To request review, please submit your request in writing to the address listed within 30 days of the date of the action. Failure to request review in writing within 30 days precludes further appeal.
Q: What do I do if there is a medical emergency and I'm not able to see an OHS provider?
A: In true emergency cases, OHS, your employer and your insurer believe the first priority is to have the medical emergency taken care of and the worker removed from immediate danger. An emergency is defined as a medical condition that if treatment is not rendered immediately, creates the risk of death, serious disability or serious medical consequences.
If your claim is subject to the MCO, and you are far away from or otherwise unable to receive care from an OHS provider in an emergency, you should seek care from the nearest appropriate medical facility. After you are out of immediate danger, all follow-up care will be provided within the MCO. If emergency care is needed and an appropriate OHS facility is available, care should be sought from the OHS member facility if possible.
If you are in need of emergency care and unsure of where to go, seek medical care from the closest available medical facility. Emergency care should not be used as a substitute for routine, ongoing medical care from an attending physician.
Q: What about medical care I might need for non-work related conditions?
A: OHS has no involvement with medical care that you might seek for illnesses or injuries that are not job-related. You will continue to receive group health benefits, if any, as provided by your employer. Contact your Human Resources or Employee Benefits department for information concerning these benefits.
Q: What do I do if I am injured on the job?
A: Report all injuries to your designated employer representative immediately. He or she will provide you with necessary forms to complete.
Once your claim is enrolled in the MCO, if you require medical care, you may choose to see any physician on the OHS Provider list who is listed as an 'Attending Physician', or an Authorized Nurse Practitioner listed under Non-Attending Physicians. Authorized Nurse Practitioners will be allowed to authorize time loss for 60 days from the date of the first nurse practitioner visit on the initial claim and may provide medical treatment for 90 days from the date of the first nurse practitioner visit on the initial claim. Or, you may treat with a non-OHS provider as explained previously.
If you have trouble scheduling an appointment or need help in accessing care, OHS will be happy to assist you.
In addition, you should always follow all of your company's rules relating to work-related injuries including reporting requirements, modified work schedules, etc.
Q: What can I do if I disagree with an action taken by OHS or its member physicians?
A: OHS wants to make sure you receive timely, effective and convenient medical services for your work-related injury. However, should a dispute arise concerning your care within the MCO, you may request review through OHS Internal Dispute Resolution Process.
Such request must be made in writing within 30 days of the action giving rise to the dispute. You should state the specific issue for which you are requesting review, and include any information you think we should consider in our review. Address your requests to Administrator, Oregon Health Systems, P.O. Box 3810, Tualatin, OR 97062-3810. If you appeal timely, we will review the disputed decision and notify you of our decision within 60 days of your request. Thereafter, if you continue to disagree with our decision, you may appeal to the Director of the Department of Consumer and Business Services for further review.
Please note that failure to request a review in writing to Oregon Health Systems within 30 days of the action giving rise to the dispute means you lose your right of further appeal to the Director of DCBS.