Billing when the patient has 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.