How is my claim processed?

The process

We begin evaluating a claim as soon as it is received. We will notify you and your employer in writing when the claim has been accepted or denied. A claims adjuster may contact you by telephone or in writing to ask questions or discuss your claim. Remember to have your claim number with you when you complete any forms, see a medical provider, or call SAIF.

A certified SAIF claims adjuster will be assigned to assist you with your claim and may contact you. Be sure to ask your adjuster questions if you don't understand something or have questions about a form or letter you receive.

Timeline: Generally, you will know if your claim has been accepted or denied within 60 days of the date you told your supervisor of the claim (unless it happened before January 1, 2002).

And please remember, the status of your claim may change as you progress through your recovery.

Questions: If you have a question or need help with your claim, please call us at 800.285.8525.

Deferred

While your claim is being evaluated (before it is accepted or denied) it is placed in "deferred status." During this time:

• Information, such as medical reports and statements, is gathered.
• You may be asked to see an independent medical examiner for another medical opinion.
• We will work with your attending physician or authorized nurse practitioner to help you return to your regular job, or a temporary job approved by your doctor, as soon as possible.

While your claim is deferred, you will receive wage replacement benefits if a qualified attending physician or authorized nurse practitioner states that you cannot work and are unable to work for more than three calendar days. (These benefits will not be paid if the claim is denied within 14 days of the day the injury was reported to your employer.)

Medical expenses
Medical providers cannot bill you for medical expenses while the claim is in a deferred status. If SAIF accepts the claim, we will pay your medical providers for medically reasonable and necessary care related to your accepted conditions.

By law, if you have filed a workers' comp claim and are receiving medical care in Oregon, the medical provider may not ask you for payment during the time the claim is being evaluated (or if your treatment is related to an accepted condition).

You should also know that during the time the claim is being evaluated (deferred), SAIF will not make payment for any medication the doctor may prescribe or for any other expenses such as transportation costs for visits to the doctor's office. You definitely should keep receipts for these expenses - they and related medical bills will be reviewed for payment by SAIF if your claim is accepted. If we send you for an examination during this "deferred" period, we will reimburse the expenses incurred to attend the appointment(s).

Helpful contacts
For more help with your claim, don't hesitate to contact us at 800.285.8525.
Department of Consumer and Business Services Injured Workers' Hotline, 800.452.0288.
State Ombudsman for Injured Workers, 800.927.1271.

Accepted

If your claim is accepted, you will receive a letter that lists your accepted medical condition(s) and states whether your claim is disabling or nondisabling. Your claim then will be transferred to an adjuster who specializes in managing claims.

For disabling claims (if you missed time from work and/or have a permanent disability), your new adjuster will contact you within three days and your claim will be enrolled in an MCO (managed care organization).

If you have a nondisabling claim (if you received medical treatment only), your medical treatment relating to the accepted condition will be paid.

Your responsibilities
It is your responsibility to do all you can to recover and to follow your attending physician's or authorized nurse practitioner's advice. Cooperate fully with those who are helping you to return to work. Keep your medical appointments, follow your attending physician's or authorized nurse practitioner's treatment plan, and avoid any activities that will slow or stop recovery.

Keep your employer informed about your condition and pass on any information about your ability to work that you receive from your attending physician or authorized nurse practitioner after each medical visit. When you are released for work, contact your employer immediately. Be sure to obtain a written copy of the work release to give to your employer.

Your SAIF claims adjuster is here to help. Keep us up to date on your recovery progress.

Helpful contacts
For more help with your claim, don't hesitate to contact us at 800.285.8525.
Department of Consumer and Business Services Injured Workers' Hotline, 800.452.0288.
State Ombudsman for Injured Workers, 800.927.1271.

Denied

According to Oregon workers' compensation law, it is up to you to prove that an injury occurred as a result of your work or that an illness was due to job-related factors.

If your claim is denied, you will receive a call from your adjuster explaining why the denial was issued. A letter explaining the decision will follow. All benefits will stop, and you will have 60 days to file a written appeal with the Workers' Compensation Board.

Appealing a denial
If you disagree with the denial decision, you may appeal it. If your date of injury is after January 1, 2002 and while the claim is on appeal, some medical benefits may be paid for medical treatment that occurs between the date you reported the injury and the date of the denial (if you had health insurance). Your adjuster can help provide you more information on these "interim medical" benefits. 

Some claim denials are resolved through a disputed claim settlement (DCS).  If a claim is settled, it means the denial is final and you will not receive any future benefits for the denied condition.

Medical expenses
If a claim is denied, you or your private health insurer will be responsible for payment of all medical bills. Your medical provider may bill your health insurance company for medical treatment. If we are aware of your health insurer, we will notify them of your claim denial.

If you appeal the denial, you do not have to pay for medical services while the appeal is in process and/or the denial is final. 

Fraud
A worker who knowingly files a workers' compensation claim for an injury that was not a result of the person's work, or who attempts to collect benefits for one job while failing to report earnings at another, may be committing fraud and could be prosecuted.

Helpful contacts
For more help with your claim, don't hesitate to contact us at 800.285.8525.
Department of Consumer and Business Services Injured Workers' Hotline, 800.452.0288
State Ombudsman for Injured Workers, 800.927.1271.

Closed

Your claim is ready to be closed when you have reached maximum medical improvement from your injury, or it also may be closed if you have not sought medical treatment for more than 30 days. If this happens, you will receive a letter stating that your claim qualifies for closure. Your adjuster also will call you to discuss the closure process and answer any questions.

If you have a permanent disability due to your injury, your permanent disability will be rated according to a schedule determined by law.

After we receive your closing information, we will send you a notice of closure within 14 days. If you disagree with the decision to close your claim, you will have 60 days to appeal the closure decision. Information about how to appeal is included in the notice of closure.

If the accepted condition worsens at a later time, you may be able to reopen your claim.

Helpful contacts
For more help with your claim, don't hesitate to contact us at 800.285.8525.
Department of Consumer and Business Services Injured Workers' Hotline, 800.452.0288
State Ombudsman for Injured Workers, 800.927.1271.