Claims – Medical Legal Information

Labor & Industries Cases (Workers Compensation)

If you’ve been injured on the job, the physicians and staff at ROI are committed to returning you quickly and safely back to work. The office has the utmost understanding in navigating the Washington State Labor and Industries system. Our team will work closely with adjustors, nurse case managers and employers to limit multiple unnecessary referrals to other providers. Please read the following to understand your benefits and responsibilities if you have suffered an on the job injury.

Making an appointment at ROI for a work injury:
In order to schedule an appointment please have ready the following information to the receptionist:
Your Claim Number
Your Claim Manager’s Name and Number
Date of Injury
The accepted condition/body part of your work injury

If you do not have the above please see below on how to file a claim. Please be aware that staff at ROI will verify that your claim is open and active, if we cannot verify coverage, you will not be able to be seen by the treating provider. Please note our physicians do not typically file initial Labor and Industry claims since we are considered a specialty office.

How to File and Labor and Industry Claim:
If you are injured at work, you and the doctor who treats you will fill out an accident report form. Your claim is filed when your doctor sends this report to L&I for processing. (NOTE: If your employer is self-insured, you will file your claim directly through them. Contact your personnel department for help.)

Once your claim is accepted:
L&I or your self-insured employer can approve your claim if your doctor certifies that you were injured at a specific time and place at work, or have an occupational disease. Benefits cover medical bills. They also may include wage replacement, return-to-work help and disability or pensions for the severely injured. You will be given a Claim Number and be assigned to a claim manager.

Time-Loss Benefits:
If the physician deems your conditions requires you to be off of work or on modified duty, they will complete an Activity Prescription Form (APF) and send to Labor and Industries. This should be sufficient for your employer and allow you to collect time-loss benefits.

Attending Physician:
The Attending Physician is the physician who is direct control of your medical care. Typically the attending physician is the one who filed your medical claim. Only your attending physician can authorize time-loss, get treatment authorized and have access to your medical records regarding your claim. If you have a consult with an ROI physician and you and the provider agrees to switch your attending physician over to ROI, you will need to fill out a change of physician form. Our office has the form at the reception area.

Claim Closing:
Typically your claim will close when you and the ROI physician have agreed that you are safely able to return to the position you occupied when you were injured. Sometimes this may require an outside functional capacities evaluation, which our office will coordinate for you.

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Frequently Asked Questions about Worker’s Comp claims:

If I am injured at work and am covered under Worker’s Comp or Disability, who decides when I am able to go back to work?

The doctor and the physician’s assistant will be the ones to assess your disability and the progress you make in working through your injury or condition. Therefore, when the doctor or the physician’s assistant deems that the treatments have achieved all that is possible and you are physically able to return to work, they will issue that letter to those required.

If an ROI doctor releases me to go back to work with some physical restrictions, what happens if my employer refuses to accept those limitations?

You will collect partial payments, if you are eligible.

What happens if I cannot return to my job?

You will have to consult with your Worker’s Comp or Disability representative for that information.

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Motor Vehicle Accident (MVA) Information

The physicians and staff at ROI are greatly experienced in treating injuries as a result of motor vehicle accidents. However, understanding your insurance benefits can be complicated. If you have been involved in an MVA and need treatment please read the following to help understand your benefits and responsibilities.

What you will need to schedule an appointment to be covered under PIP:
Insurance Policy Number
Claim Number
Claim Adjuster Name and Number
Address Where to send medical Bills

If you do not have the above please see below on how to file a claim. Please be aware that staff at ROI will verify that your claim is open and active, if we cannot verify coverage, you will not be able to be seen by the treating provider.

See our Auto Accident Questionnaire.

Opening a PIP claim:
If you were a driver involved in an automobile accident and are injured you need to contact your insurance company and open a claim. If you were a passenger, file the claim with the insurance company which covers the car in which you were an occupant. The insurance company will take down some information about the accident and then provide you with a claim number. Shortly thereafter the claim will be assigned to a “PIP adjuster” who will handle your file. You will also be given an address or fax number for medical providers to send bills to. Please have this information available when you call to schedule an appointment.

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Frequently Asked Questions about Auto Accidents:

What is Personal Injury Protection (PIP)

PIP is insurance coverage for medical and other expenses, such as wage loss and funeral expenses, which result from an auto accident, no matter who is at fault. The law does not require you to have PIP coverage, but your insurance company must offer it to you.

One common misconception about PIP benefits is that the person who caused the accident should pay for your medical expenses. Ultimately, that person, if they have liability coverage of their own, will pay for the medical expenses, but they will not pay for these expenses as they accumulate. One exception to the above rule is if you are injured in an accident and you are a pedestrian or cyclist. Another is if you are the passenger of a vehicle and the owner of the vehicle has an automobile insurance policy that has PIP benefits.

What do PIP benefits cover?

PIP benefits cover reasonable and necessary medical treatment related to injuries suffered in an automobile accident. PIP benefits will pay for ambulance bills, hospital bills, chiropractic bills, surgeon bills, diagnostic studies (x-rays, MRI’s, CT scans, etc.), massage therapy, physical therapy, acupuncture, etc.

Who does PIP cover?

PIP covers the person who is named on the policy, household residents related by blood, marriage or adoption, and step- or foster children. It also covers non-family passengers and pedestrians involved in the accident.

What if I’m a passenger in someone else’s car?

If you are the passenger in someone else’s vehicle and are injured in an automobile accident, you need to look at the owner of the vehicle’s insurance policy. If the owner of that vehicle has PIP coverage you will most likely have PIP benefits available to you as a passenger of the vehicle. Again, similar to the pedestrian/cyclist example, if you have your own PIP coverage as well, you will have two layers of PIP coverage to pay for medical expenses.

What if my PIP benefits have been exhausted?

The amount of PIP for each accident varies and often times these benefits can run out before you have completed treatment for your injuries. At the time of exhaustion, your automobile insurance will send you a letter stating this fact. If you come to our office after your pip is exhausted to treat injuries sustained in an MVA, please bring this letter so we can submit with your primary health insurance. If you are currently treating with you and your benefits run out we will begin to bill your primary health insurance. At that time you will be subject to your primary health insurance benefit conditions. Please note that we will not accept any third party liens.

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 Claims

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