Reconsideration
If you disagree with a denial of payment or the amount of the payment you receive from us, you may file for reconsideration.
What to know about this process
EOB adjustment codes
First, review the adjustment code used to reduce the charges. An explanation of the codes is found on the back of the analysis. The full list is also available here.Submitting a reconsideration
You may ask for reconsideration of a bill that is denied or not fully paid.Submit by mail a written request explaining the reason you are requesting reconsideration, along with a copy of the original Explanation of Benefits you received, a copy of the CMS or UB-04 form, and a copy of the medical records.
The 90 day rule
To qualify for reconsideration, you must submit a written request to us for additional payment within 90 days of the original analysis. For more, see Oregon Administrative Rule (OAR) 436-009-0010(5).Denial for MCO-related reasons
For denial of payment for MCO-related reasons, contact the MCO directly. In general, if a claim is denied you may bill the worker and/or the health insurance carrier.Late filing exemption
If you find out after the deadline that an injury was work-related and if the billing has been adjusted because of late filing, SAIF can help.Send the bill to us clearly documenting the date you were made aware that the claim was work-related. Please include a copy of the billing ledger that indicates where the bill was originally sent and when. Also enclose the corresponding chart notes for the billing dates of service.
If you have additional questions, call the number listed on the bottom of your analysis to discuss the bill with one of our medical audit specialists.