Auto Accident, PIP & Medical Billing State Guides
Oregon Auto Accident, PIP & Medical Billing Laws
Oregon operates an At-Fault automobile insurance system with mandatory Personal Injury Protection (PIP) under ORS 742.518 et seq. Every auto policy must provide at least $15,000 in PIP medical benefits covering treatment within two years of injury. Provider reimbursement is statutorily capped at the Oregon Workers' Compensation Medical Fee Schedule pursuant to ORS 742.525.
Plain-language overview
Add-On PIP (Mandatory PIP with Statutory Fee Schedule under ORS 742.525)
Oregon combines traditional tort liability with mandatory first-party PIP benefits. Regardless of fault, drivers, passengers, and struck pedestrians are entitled to up to $15,000 in medical benefits from the applicable auto insurer. Healthcare providers treating accident victims must adhere to statutory fee caps tied to the state workers' compensation fee schedule, and PIP disputes are subject to statutory arbitration or court litigation under ORS 742.522.
PIP and MedPay coverage
Mandatory Medical Limit
$15,000 statutory minimum per person for reasonable and necessary medical, dental, surgical, hospital, and ambulance expenses incurred within 2 years of the crash (ORS 742.524(1)(a))
Disability And Services
70% of lost wages up to $3,000 per month for up to 52 weeks, and essential replacement services up to $30 per day for 52 weeks
Balance Billing Prohibition
Under ORS 742.525, providers may not charge or collect from the patient any fee exceeding the allowable fee schedule rates
Assignment Of Benefits
Healthcare providers routinely accept patient assignments of PIP benefits to bill the insurer directly
Medical fee schedule and reimbursement rules
Name
Oregon Automobile PIP Medical Fee Schedule (ORS 742.525 & OAR 836-054)
Rules
Reimbursement is capped at the rates established under the Oregon Workers' Compensation Medical Fee Schedule (ORS 656.248 and OAR 436-009). If a service is not covered by the workers' compensation schedule, reimbursement is determined based on the 75th percentile of usual and customary charges.
Cpt Basis
HCPCS/CPT codes benchmarked to Oregon Workers' Compensation Division fee rules
Appeals and dispute resolution
Sixty Day Prompt Payment
Under ORS 742.524(1), PIP benefits must be paid within 60 days after the insurer receives proof of claim. If benefits are denied, the insurer must issue a written notice of denial specifying reasons within 60 days.
Statutory Arbitration
Under ORS 742.522, disputes between the insurer and the insured or provider may be submitted to binding arbitration if both parties agree in writing. Arbitration procedures follow standard dispute protocols.
Circuit Court Litigation
If arbitration is not agreed upon, actions are filed in Oregon Circuit Court. Under ORS 742.061, if settlement is not made within six months of proof of loss and the plaintiff recovers more than tendered, the court awards reasonable attorney fees.
Claim and dispute deadlines
Deadlines can depend on the trigger event and may be affected by agency relief notices. Confirm the live rule before filing.
| Event | Timeframe |
|---|---|
| Accident Notice | Notice to insurer as soon as practicable following injury |
| Treatment Window | Covered medical expenses incurred within 2 years of accident (ORS 742.524) |
| Carrier 60-Day Review | 60 calendar days from receipt of billing to pay or issue written denial |
| Six-Month Attorney Fee Trigger | 6 months from proof of loss to tender payment before attorney fee exposure (ORS 742.061) |
| Statute of Limitations | 2 years for tort bodily injury claims (ORS 12.110); 6 years for contract actions (ORS 12.080) |
Documentation checklist
- Completed Oregon Application for Personal Injury Protection Benefits
- Executed Assignment of Benefits (AOB) and HIPAA release authorization
- Itemized CMS-1500 or UB-04 billing form with CPT/HCPCS codes and ICD-10 diagnostic codes
- Clinical chart notes, therapy flowsheets, operative reports, and diagnostic imaging findings
- Explanation of Benefits (EOB) or written Notice of Denial from the PIP insurer
Responsible agencies
- Oregon Department of Consumer and Business Services (DCBS) - Division of Financial RegulationRegulation of Auto Insurers, Policy Forms & Consumer Inquiries
Primary legal and regulatory sources
- Oregon Revised Statutes Chapter 742 (Insurance Policies - Personal Injury Protection)Oregon State Legislature · 2024
- Oregon Revised Statutes Section 742.525 (Limitation on Medical Charges)Oregon State Legislature · 2024
This operational reference is educational, is not legal advice, and does not create an attorney-client relationship.
Common questions
- What rules govern auto accident, pip & medical billing state guides in Oregon?
- Oregon operates an At-Fault automobile insurance system with mandatory Personal Injury Protection (PIP) under ORS 742.518 et seq. Every auto policy must provide at least $15,000 in PIP medical benefits covering treatment within two years of injury. Provider reimbursement is statutorily capped at the Oregon Workers' Compensation Medical Fee Schedule pursuant to ORS 742.525.
- What dispute deadlines should providers track in Oregon?
- Accident Notice: Notice to insurer as soon as practicable following injury; Treatment Window: Covered medical expenses incurred within 2 years of accident (ORS 742.524); Carrier 60-Day Review: 60 calendar days from receipt of billing to pay or issue written denial. Verify the trigger date, current agency notices, and any extension before acting.
- Which agencies administer these rules in Oregon?
- The guide identifies Oregon Department of Consumer and Business Services (DCBS) - Division of Financial Regulation. The correct agency depends on the plan and claim jurisdiction.