Billing and workers' compensation benefits
Priority Health, like most other health plans, specifically excludes from
coverage any claims which are covered under any Workers' Compensation laws
and/or loss due to work related injury or sickness.
Coverage for a Workers' Compensation injury or sickness starts at the onset
of the disabling condition and lasts until the condition has subsided or the
claimant has accepted a settlement.
Priority Health will assume that a condition is work-related when we
receive information from any source, such as:
- Physician, either verbal (with internal documentation) or written
- Claimant, either verbal (with internal documentation) or written
- Employer
- Other sources
Priority Health will not be responsible for:
- Any work-related injury or sickness
- Care denied by a Workers' Compensation carrier as a result of the
claimant not following appropriate procedures, such as reporting the
incident to the employers
- Claims when the claimant refuses to report or file the claim with the
employer's Workers' Compensation carrier
- Related claims incurred after a Workers' Compensation settlement
- Claims that are in dispute by the Workers' Compensation carrier. Claims
will only be reconsidered under Priority Health when a final resolution has
been reached and only when we receive a copy of the Department of Labor
Opinion/Order stating the claim has been denied.
