Part of our role in the workers’ comp system is making sure you receive payments you are due for providing medical treatment to an injured worker.
Get bills and payments faster with these convenient features.
Payment for compensable medical treatment of an injured worker is made according to the Oregon fee schedule, MCO contract rate, or another negotiated rate, whichever is less.
Payment for services related to workers’ compensation is governed by the Workers’ Compensation Division (WCD) Medical Fee and Payment Rules, Chapter 436, Division 9.
Good to know: billing requirements
Please carefully review this helpful list (from WCD). Not only do we appreciate it, but it’ll help you get paid faster.
- Include your taxpayer ID number (TIN) on every document you submit. We're required to return billings without a TIN for correction and resubmission.
- Include the claim number, if available.
- Bill on the correct form (statement billings may be returned).
- CMS-1500 form
- Effective April 1, 2015, we can accept only the current version of 02-12, according to Oregon administrative rules.
- List the correct rendering in box 31.
- Complete box 32 if different than box 33.
- Payments will only be sent to the address in box 33.
- UB-04 (hospital) form
- Inpatient bills must include a valid admit code in box 14.
- All bills must include an itemization of charges.
- Pharmacy form (NCPDP)
- Billings must include Rx written date, prescriber name and ID, qualifier, and compound indicator.
- CMS-1500 form
- Bill valid procedure codes (CPT, HCPCS, CDT, NDC, etc.).
- Bill valid ICD-10 diagnosis codes.
- Bill correct modifiers.
- Effective April 1, 2015, surgical assistants must bill modifier 81.
- Ambulatory surgical centers must bill modifier SG.
- Multiple surgeries must be billed modifier 51.
- Bilateral surgeries must bill modifier 50.
- Bill correct units.
- Bills for chart note copies must include the number of copies.
- Attach supporting documentation.
- Bill correct date of service, as identified by the supporting documentation.
Send bills to: SAIF, 400 High St. SE, Salem, OR 97312
SAIF has 60 days to decide whether to accept the claim. Usually a payment is not issued until the decision is made.
Medical providers must bill SAIF within:
- 60 days of the date of service. Bills received after one year from the date of service are not payable.
- 60 days after the medical provider has received notice or knowledge of the responsible workers’ comp insurer
- Rebills and reconsiderations should be submitted within one year from the date of service.
SAIF has 45 days from the date that all necessary information is received to pay a bill.
EOB adjustment codes
For complete descriptions about specific payment determinations, please refer to:
- The explanation of benefits-adjustment code list, or
- The cross-reference to national standard adjustment codes (e-billing)
Submitting rebills or reconsiderations
When rebilling, you must indicate that the charges have been previously billed.
When requesting reconsideration, please identify the reason for the reconsideration.
Billing the worker
Providers cannot bill the worker for any medical service or treatment related to the compensable condition or conditions.
However, there are some exceptions, including:
- Treatment for conditions not related to the accepted compensable condition or conditions
- Treatment that has not been prescribed by the attending physician, authorized nurse practitioner, or specialist physician upon referral by the attending physician or authorized nurse practitioner
- Palliative care that is not compensable and/or not preauthorized by the insurer
- Treatment outside the provisions of the governing MCO contract
- Treatment after the worker has been notified that such treatment is considered unscientific, unproven, outmoded, or experimental
If you have any questions about billing or payments, please contact us at 800.285.8525 and ask for the Medical Audit Review Section. We’d be happy to help.