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What your claim status means

Your claim will be placed in "deferred," "accepted," "denied," or "closed" status, depending on where it is in the process.

If you're ever unsure about what your claim status means, contact your adjuster.

Deferred (or "new")

We place your claim in "deferred" status while it's being evaluated after we receive it. 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 medical provider to help you return to your regular job, or a temporary modified job approved by your provider, as soon as possible.

Benefits

While your claim is deferred, you may be eligible for:

  • Lost wage ("time-loss") payments if your qualified attending physician says 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.

            Learn more about time-loss payments.

  • Limited coverage for prescription drugs. See What bills should you pay? for information on medical expenses while your claim is being evaluated.

Accepted (or "open" or "active")

These claims fall into two categories: nondisabling and disabling.

  • Nondisabling claims have no expected time lost from work and/or no anticipated physical impairment to you.
  • Disabling claims have expected time lost from work and/or some anticipated physical impairment to you.

Your acceptance letter will include the initial accepted condition. It's possible for additional conditions to be addressed over the duration of the claim if the condition changes. Your claim will be transferred to another adjuster if it's accepted because our adjusters have expertise in different types of claims or different stages of a claim.

Let your doctor know what your accepted condition is and discuss a treatment plan. SAIF will only cover medical costs for the accepted condition(s).

Your expenses for medical equipment, medication, or travel may be reimbursed after your claim has been accepted. Be sure to fill out the reimbursement form and send it to your adjuster. 

Treatment through an MCO 


A managed care organization (MCO) is a network of care providers who treat injured workers. The network ensures that workers receive timely, convenient, appropriate, and effective care. There are multiple types of doctors and specialists in the network.

If your claim is accepted and you aren't already with an MCO, your adjuster may assign one to you. Our goal is to keep you with your provider as long as you are getting the treatment you need, but a change may be necessary.

Read more about MCOs in Choosing a doctor

Denied

Denial 

If your claim is denied, you will receive a phone call and a certified denial letter with information on how to appeal the decision and how to contact the Ombudsman for Injured Workers if you want help with your appeal. (The ombudsman is a free, independent advocate for injured workers in Oregon.) All benefits will stop. 

Appealing a denial 

You have 60 days from the date the denial is issued to file a written appeal with the Workers' Compensation Board if you disagree with the denial. You can get an attorney (of your choosing) to help with your appeal, and you will not be responsible for most attorney fees. 

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

Learn more about the appeal process.

Medical expenses 

If your claim is denied, you or your private health insurer will be responsible for payment of all medical bills. Your doctor may bill your health insurance company for medical treatment. If we are aware of who your health insurer is, 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 until the denial is final. However, if the denial does become final you or your private health insurer will be responsible for paying all medical bills.

Closed (or "inactive")

See Claim closure for a description of this status.

From saif.com

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