Source: https://www.oregonlaws.org/ors/656.245
Timestamp: 2019-06-20 13:48:45
Document Index: 139476695

Matched Legal Cases: ['§23', '§32', '§31', '§14', '§4', '§24', '§10', '§25', '§25', '§1', '§10', '§12', '§1', '§1', '§3', '§3', '§3', '§2', '§2', '§3', '§1', '§1', '§1']

ORS 656.245 - Medical services to be provided - 2017 Oregon Revised Statutes
2017 ORS Vol. 14 Chapter 656 Section 656.245
2017 ORS 656.245¹
• services by providers not members of managed care organizations
• authorizing temporary disability compensation and making finding of impairment for disability rating purposes by certain providers
• review of disputed claims for medical services
(1)(a) For every compensable injury, the insurer or the self-insured employer shall cause to be provided medical services for conditions caused in material part by the injury for such period as the nature of the injury or the process of the recovery requires, subject to the limitations in ORS 656.225 (Compensability of certain preexisting conditions), including such medical services as may be required after a determination of permanent disability. In addition, for consequential and combined conditions described in ORS 656.005 (Definitions) (7), the insurer or the self-insured employer shall cause to be provided only those medical services directed to medical conditions caused in major part by the injury.
(b) Compensable medical services shall include medical, surgical, hospital, nursing, ambulances and other related services, and drugs, medicine, crutches and prosthetic appliances, braces and supports and where necessary, physical restorative services. A pharmacist or dispensing physician shall dispense generic drugs to the worker in accordance with ORS 689.515 (Regulation of generic drugs). The duty to provide such medical services continues for the life of the worker.
(c) Notwithstanding any other provision of this chapter, medical services after the worker’s condition is medically stationary are not compensable except for the following:
(A) Services provided to a worker who has been determined to be permanently and totally disabled.
(B) Prescription medications.
(C) Services necessary to administer prescription medication or monitor the administration of prescription medication.
(D) Prosthetic devices, braces and supports.
(E) Services necessary to monitor the status, replacement or repair of prosthetic devices, braces and supports.
(F) Services provided pursuant to an accepted claim for aggravation under ORS 656.273 (Aggravation for worsened conditions).
(G) Services provided pursuant to an order issued under ORS 656.278 (Board has continuing authority to alter earlier action on claim).
(H) Services that are necessary to diagnose the worker’s condition.
(I) Life-preserving modalities similar to insulin therapy, dialysis and transfusions.
(J) With the approval of the insurer or self-insured employer, palliative care that the worker’s attending physician referred to in ORS 656.005 (Definitions) (12)(b)(A) prescribes and that is necessary to enable the worker to continue current employment or a vocational training program. If the insurer or self-insured employer does not approve, the attending physician or the worker may request approval from the Director of the Department of Consumer and Business Services for such treatment. The director may order a medical review by a physician or panel of physicians pursuant to ORS 656.327 (Review of medical treatment of worker) (3) to aid in the review of such treatment. The decision of the director is subject to review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim).
(K) With the approval of the director, curative care arising from a generally recognized, nonexperimental advance in medical science since the worker’s claim was closed that is highly likely to improve the worker’s condition and that is otherwise justified by the circumstances of the claim. The decision of the director is subject to review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim).
(L) Curative care provided to a worker to stabilize a temporary and acute waxing and waning of symptoms of the worker’s condition.
(d) When the medically stationary date in a disabling claim is established by the insurer or self-insured employer and is not based on the findings of the attending physician, the insurer or self-insured employer is responsible for reimbursement to affected medical service providers for otherwise compensable services rendered until the insurer or self-insured employer provides written notice to the attending physician of the worker’s medically stationary status.
(e) Except for services provided under a managed care contract, out-of-pocket expense reimbursement to receive care from the attending physician or nurse practitioner authorized to provide compensable medical services under this section shall not exceed the amount required to seek care from an appropriate nurse practitioner or attending physician of the same specialty who is in a medical community geographically closer to the worker’s home. For the purposes of this paragraph, all physicians and nurse practitioners within a metropolitan area are considered to be part of the same medical community.
(2)(a) The worker may choose an attending doctor, physician or nurse practitioner within the State of Oregon. The worker may choose the initial attending physician or nurse practitioner and may subsequently change attending physician or nurse practitioner two times without approval from the director. If the worker thereafter selects another attending physician or nurse practitioner, the insurer or self-insured employer may require the director’s approval of the selection. The decision of the director is subject to review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim). The worker also may choose an attending doctor or physician in another country or in any state or territory or possession of the United States with the prior approval of the insurer or self-insured employer.
(b) A medical service provider who is not a member of a managed care organization is subject to the following provisions:
(A) A medical service provider who is not qualified to be an attending physician may provide compensable medical service to an injured worker for a period of 30 days from the date of the first visit on the initial claim or for 12 visits, whichever first occurs, without the authorization of an attending physician. Thereafter, medical service provided to an injured worker without the written authorization of an attending physician is not compensable.
(B) A medical service provider who is not an attending physician cannot authorize the payment of temporary disability compensation. However, an emergency room physician who is not authorized to serve as an attending physician under ORS 656.005 (Definitions) (12)(c) may authorize temporary disability benefits for a maximum of 14 days. A medical service provider qualified to serve as an attending physician under ORS 656.005 (Definitions) (12)(b)(B) may authorize the payment of temporary disability compensation for a period not to exceed 30 days from the date of the first visit on the initial claim.
(C) Except as otherwise provided in this chapter, only a physician qualified to serve as an attending physician under ORS 656.005 (Definitions) (12)(b)(A) or (B)(i) who is serving as the attending physician at the time of claim closure may make findings regarding the worker’s impairment for the purpose of evaluating the worker’s disability.
(D) Notwithstanding subparagraphs (A) and (B) of this paragraph, a nurse practitioner licensed under ORS 678.375 (Nurse practitioners) to 678.390 (Authority of nurse practitioner and clinical nurse specialist to write prescriptions or dispense drugs):
(i) May provide compensable medical services for 180 days from the date of the first visit on the initial claim;
(ii) May authorize the payment of temporary disability benefits for a period not to exceed 180 days from the date of the first visit on the initial claim; and
(iii) When an injured worker treating with a nurse practitioner authorized to provide compensable services under this section becomes medically stationary within the 180-day period in which the nurse practitioner is authorized to treat the injured worker, shall refer the injured worker to a physician qualified to be an attending physician as defined in ORS 656.005 (Definitions) for the purpose of making findings regarding the worker’s impairment for the purpose of evaluating the worker’s disability. If a worker returns to the nurse practitioner after initial claim closure for evaluation of a possible worsening of the worker’s condition, the nurse practitioner shall refer the worker to an attending physician and the insurer shall compensate the nurse practitioner for the examination performed.
(3) Notwithstanding any other provision of this chapter, the director, by rule, upon the advice of the committee created by ORS 656.794 (Advisory committee on medical care) and upon the advice of the professional licensing boards of practitioners affected by the rule, may exclude from compensability any medical treatment the director finds to be unscientific, unproven, outmoded or experimental. The decision of the director is subject to review under ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim).
(4) Notwithstanding subsection (2)(a) of this section, when a self-insured employer or the insurer of an employer contracts with a managed care organization certified pursuant to ORS 656.260 (Certification procedure for managed health care provider) for medical services required by this chapter to be provided to injured workers:
(a) Those workers who are subject to the contract shall receive medical services in the manner prescribed in the contract. Workers subject to the contract include those who are receiving medical treatment for an accepted compensable injury or occupational disease, regardless of the date of injury or medically stationary status, on or after the effective date of the contract. If the managed care organization determines that the change in provider would be medically detrimental to the worker, the worker shall not become subject to the contract until the worker is found to be medically stationary, the worker changes physicians or nurse practitioners, or the managed care organization determines that the change in provider is no longer medically detrimental, whichever event first occurs. A worker becomes subject to the contract upon the worker’s receipt of actual notice of the worker’s enrollment in the managed care organization, or upon the third day after the notice was sent by regular mail by the insurer or self-insured employer, whichever event first occurs. A worker shall not be subject to a contract after it expires or terminates without renewal. A worker may continue to treat with the attending physician or nurse practitioner authorized to provide compensable medical services under this section under an expired or terminated managed care organization contract if the physician or nurse practitioner agrees to comply with the rules, terms and conditions regarding services performed under any subsequent managed care organization contract to which the worker is subject. A worker shall not be subject to a contract if the worker’s primary residence is more than 100 miles outside the managed care organization’s certified geographical area. Each such contract must comply with the certification standards provided in ORS 656.260 (Certification procedure for managed health care provider). However, a worker may receive immediate emergency medical treatment that is compensable from a medical service provider who is not a member of the managed care organization. Insurers or self-insured employers who contract with a managed care organization for medical services shall give notice to the workers of eligible medical service providers and such other information regarding the contract and manner of receiving medical services as the director may prescribe. Notwithstanding any provision of law or rule to the contrary, a worker of a noncomplying employer is considered to be subject to a contract between the State Accident Insurance Fund Corporation as a processing agent or the assigned claims agent and a managed care organization.
(b)(A) For initial or aggravation claims filed after June 7, 1995, the insurer or self-insured employer may require an injured worker, on a case-by-case basis, immediately to receive medical services from the managed care organization.
(B) If the insurer or self-insured employer gives notice that the worker is required to receive treatment from the managed care organization, the insurer or self-insured employer must guarantee that any reasonable and necessary services so received, that are not otherwise covered by health insurance, will be paid as provided in ORS 656.248 (Medical service fee schedules), even if the claim is denied, until the worker receives actual notice of the denial or until three days after the denial is mailed, whichever event first occurs. The worker may elect to receive care from a primary care physician or nurse practitioner authorized to provide compensable medical services under this section who agrees to the conditions of ORS 656.260 (Certification procedure for managed health care provider) (4)(g). However, guarantee of payment is not required by the insurer or self-insured employer if this election is made.
(C) If the insurer or self-insured employer does not give notice that the worker is required to receive treatment from the managed care organization, the insurer or self-insured employer is under no obligation to pay for services received by the worker unless the claim is later accepted.
(D) If the claim is denied, the worker may receive medical services after the date of denial from sources other than the managed care organization until the denial is reversed. Reasonable and necessary medical services received from sources other than the managed care organization after the date of claim denial must be paid as provided in ORS 656.248 (Medical service fee schedules) by the insurer or self-insured employer if the claim is finally determined to be compensable.
(5)(a) A nurse practitioner licensed under ORS 678.375 (Nurse practitioners) to 678.390 (Authority of nurse practitioner and clinical nurse specialist to write prescriptions or dispense drugs) who is not a member of the managed care organization is authorized to provide the same level of services as a primary care physician as established by ORS 656.260 (Certification procedure for managed health care provider) (4) if the nurse practitioner maintains the worker’s medical records and with whom the worker has a documented history of treatment, if that nurse practitioner agrees to refer the worker to the managed care organization for any specialized treatment, including physical therapy, to be furnished by another provider that the worker may require and if that nurse practitioner agrees to comply with all the rules, terms and conditions regarding services performed by the managed care organization.
(b) A nurse practitioner authorized to provide medical services to a worker enrolled in the managed care organization may provide medical treatment to the worker if the treatment is determined to be medically appropriate according to the service utilization review process of the managed care organization and may authorize temporary disability payments as provided in subsection (2)(b)(D) of this section. However, the managed care organization may authorize the nurse practitioner to provide medical services and authorize temporary disability payments beyond the periods established in subsection (2)(b)(D) of this section.
(6) Subject to the provisions of ORS 656.704 (Actions and orders regarding matters concerning claim and matters other than matters concerning claim), if a claim for medical services is disapproved, the injured worker, insurer or self-insured employer may request administrative review by the director pursuant to ORS 656.260 (Certification procedure for managed health care provider) or 656.327 (Review of medical treatment of worker). [1965 c.285 §23; 1979 c.839 §32; 1981 c.535 §31; 1981 c.854 §14; 1985 c.739 §4; 1987 c.884 §24; 1990 c.2 §10; 1995 c.332 §25; amendments by 1995 c.332 §25a repealed by 1999 c.6 §1; 1999 c.6 §10; 1999 c.582 §12; 1999 c.868 §1; 1999 c.926 §1; 2003 c.811 §§3,4; 2005 c.26 §§3,4; 2007 c.252 §§3,4; 2007 c.270 §§2,3; 2007 c.365 §2a; 2007 c.505 §§3,4; 2009 c.32 §1; 2009 c.36 §1; 2013 c.179 §1]
Medical expenses are not compensable if they are result of pre-existing disability that contributed to award of permanent total disability but not result of compensable injury. Francoeur v. SAIF, 17 Or App 37, 520 P2d 477 (1974), Sup Ct review denied
Right to medical services for compensable injury does not terminate upon finding of no permanent disability. Bowser v. Evans Prod. Co., 270 Or 841, 530 P2d 44 (1974)
Where third party paid medical bills after insurer’s denial of claim, order could properly provide for reimburse­ment by insurer directly to third party. Francoeur v. SAIF, 20 Or App 604, 532 P2d 1148 (1975)
Lack of general acceptance by medical profession does not prevent finding that treat­ment method is reasonable and necessary. McGarry v. SAIF, 24 Or App 883, 547 P2d 654 (1976)
Pay­ment of medical expenses for claim of aggrava­tion does not amount to acceptance of aggrava­tion claim and does not estop employer from contesting claim. Jacobson v. SAIF, 36 Or App 789, 585 P2d 1146 (1978), Sup Ct review denied
Insurer could refuse to pay for medical services rendered by claimant-selected out-of-state physician not approved by insurer. Rivers v. SAIF, 45 Or App 1105, 610 P2d 288 (1980)
Psychotherapy considered necessary by licensed psychologist, to whom claimant had been referred by physician for job counseling, was medical service for which carrier was responsible. Kemery v. SAIF, 51 Or App 813, 627 P2d 34 (1981)
Exploratory surgery performed as result of industrial injury was compensable even though surgery revealed noncompensable condi­tion. Brooks v. D & R Timber, 55 Or App 688, 639 P2d 700 (1982)
Neither worker’s elec­tion to pursue third party recovery nor worker’s receipt of share of proceeds recovered absolved insurance carrier of duty to provide continued medical services. SAIF v. Parker, 61 Or App 47, 656 P2d 335 (1982)
Claimant impliedly can have only one attending physician at given time. Kemp v. Workers’ Comp. Dept., 65 Or App 659, 672 P2d 1343 (1983), modified 67 Or App 270, 677 P2d 725 (1984), Sup Ct review denied
If insurer gives claimant reasonable basis to believe that it has approved claimant’s choice of doctor, claimant need not obtain insurer’s con­sent to medical services that doctor provides for condi­tions that result from compensable injury. Mogliotti v. Reynolds Metals, 67 Or App 142, 676 P2d 919 (1984)
Insurer may not deny worker choice of treat­ments by restricting approval of out-of-state physician to certain categories of service provider. Reynaga v. Northwest Farm Bureau, 300 Or 255, 709 P2d 1071 (1985); Day v. S & S Pizza Co., 77 Or App 711, 714 P2d 275 (1986), Sup Ct review denied
Exposure to substance capable of causing occupa­tional disease is not, by itself, injury absent sub­se­quent develop­ment of occupa­tional disease. Brown v. SAIF, 79 Or App 205, 717 P2d 1289 (1986), Sup Ct review denied
Even after claim closure, employer cannot deny its future responsibility for pay­ment of medical services for pre­vi­ously accepted claim. Evanite Fiber Corp. v. Striplin, 99 Or App 353, 781 P2d 1262 (1989)
Where treat­ment request has pre­vi­ously been denied, claimant renewing request for treat­ment must show that condi­tion has changed and that request is supported by new facts unavailable at time of earlier request. Liberty Northwest Ins. Corp. v. Bird, 99 Or App 560, 783 P2d 33 (1989), Sup Ct review denied
Cost of palliative care is compensable where there is substantial evidence in record that service is reasonable and necessary as result of compensable injury. Elixir Industries v. Lange, 100 Or App 492, 786 P2d 1301 (1990)
Special review standard is allowable where items recommended for palliative care purposes are not usually viewed as medical services. Rager v. EBI Companies, 102 Or App 457, 795 P2d 573 (1990), modified 107 Or App 22, 810 P2d 1315 (1991)
Open status of claim does not prevent employer from denying request for ongoing care. Green Thumb, Inc. v. Basl, 106 Or App 98, 806 P2d 186 (1991)
Employer can deny current need for particular treat­ment and specific unpaid services, but cannot deny responsibility for possible future needs. Green Thumb, Inc. v. Basl, 106 Or App 98, 806 P2d 186 (1991)
Employers have only limited right to veto claimant’s choice of out-of-state physician, and only adequate basis for veto is when out-of-state doctor would be unlikely to comply with reporting require­ments. Safeway Stores, Inc. v. Dupape, 106 Or App 126, 806 P2d 191 (1991), Sup Ct review denied
Claim is subject to statute pro­vi­sions and rules making certain medical treat­ment noncompensable, notwithstanding that pro­vi­sions and rules were adopted after time of injury. Thorpe v. Seige Logging, 115 Or App 335, 838 P2d 628 (1992), Sup Ct review denied
Where claimant fell at home and damaged sutures, claimant suffered no new “injury” or condi­tion different from compensable carpal tunnel syndrome and emergency room treat­ment necessary to resuture wound is compensable. Roseburg Forest Products v. Ferguson, 117 Or App 601, 845 P2d 930 (1993), Sup Ct review denied
Where no new injury has occurred and compensable injury is ma­te­ri­al cause of need for continuing medical treat­ment, major contributing cause standard does not apply. Roseburg Forest Products v. Ferguson, 117 Or App 601, 845 P2d 930 (1993), Sup Ct review denied; Beck v. James River Corp., 124 Or App 484, 863 P2d 526 (1993), Sup Ct review denied; Fred Meyer, Inc. v. Crompton, 150 Or App 531, 946 P2d 1171 (1997)
Use of independent medical examina­tion to impeach attending physician’s assess­ment of claimant’s disability was improper. Koitzsch v. Liberty Northwest Ins. Corp., 125 Or App 666, 866 P2d 514 (1994)
Exclusive ability of attending physician to make findings on medical condi­tion does not require acceptance of physician findings or prevent reliance on nonmedical evidence. Libbett v. Roseburg Forest Products, 130 Or App 50, 880 P2d 935 (1994), Sup Ct review denied
Where permanent total disability claim is based on unscheduled disability, impair­ment finding is not re­quired and testimony of physician other than attending physician is permissible. EBI Companies v. Hunt, 132 Or App 128, 887 P2d 372 (1994)
Physician request for approval of noncompensable type of palliative care does not constitute “claim.” Hathaway v. Health Future Enterprises, 320 Or 383, 884 P2d 549 (1994); Nicholson v. Salem Area Transit, 320 Or 391, 884 P2d 864 (1994)
Director has exclusive power to review appropriateness of ongoing or proposed medical treat­ment. Liberty Northwest Ins. Corp. v. Yon, 137 Or App 413, 904 P2d 645 (1995)
“Other related services” that are compensable are limited to services of same kind or class as those listed. Baar v. Fairview Training Center, 139 Or App 196, 911 P2d 1232 (1996), Sup Ct review denied
Require­ment that director make physician change determina­tion with “advice of one or more physicians” does not prohibit use of generalized medical guide­lines in place of claimant-specific advice. Liberty Northwest Ins. Corp. v. Vasquez, 147 Or App 704, 938 P2d 237 (1997)
Referral for consulta­tion does not place sub­se­quent change to consulting physician outside limita­tion on attending physician changes. Country Mutual Insurance Co. v. Mendoza, 148 Or App 397, 939 P2d 674 (1997)
Where remodeling of claimant’s residence is reasonable and necessary to further claimant’s self-sufficient status, remodeling services are compensable medical services. SAIF v. Glubrecht, 156 Or App 339, 967 P2d 490 (1998)
Provisions for use of managed care organiza­tion or in-lieu services apply to all forms of claims, not just initial or aggrava­tion claims. SAIF v. Reid, 160 Or App 383, 982 P2d 14 (1999); Travelers Indemnity of Illinois v. Curtis, 195 Or App 305, 97 P3d 673 (2004), Sup Ct review denied
Limita­tion on compensability of treat­ment rendered by medical service provider not qualifying as attending physician applies to both accepted and denied claims. SAIF v. Jensen, 183 Or App 439, 52 P3d 1118 (2002)
Where work-related injury is fact of consequence re­gard­ing claimant’s need of medical services, injury may be “ma­te­ri­al” regardless of amount of contribu­tion. Mize v. Comcast Corp-AT&T Broadband, 208 Or App 563, 145 P3d 315 (2006)
Where prescribed type of modified vehicle was uniquely suited to accommodating claimant’s disability resulting from compensable injury, vehicle was medical service. Sedgwick Claims Manage­ment Services v. Jones, 214 Or App 446, 166 P3d 547 (2007)
Where treat­ment is necessitated in ma­te­ri­al part by accepted condi­tion, treat­ment of condi­tion other than accepted condi­tion is compensable. SAIF v. Martinez, 219 Or App 182, 182 P3d 873 (2008); SAIF v. Sprague, 221 Or App 413, 190 P3d 443 (2008), aff’d 346 Or 661, 217 P3d 644 (2009)
Medical services to determine cause or extent of compensable injury are compensable even if condi­tion discovered is not compensable. SAIF v. Martinez, 219 Or App 182, 182 P3d 873 (2008)
Frequency of treat­ment cannot be limited so long as treat­ment is reasonable and necessary. West v. SAIF, 74 Or App 317, 702 P2d 1148 (1985)
Claimant bears burden of proof with regard to re­quired frequency of treat­ment. Freres Lumber Co., Inc. v. Murphy, 101 Or App 92, 789 P2d 674 (1990), Sup Ct review denied
Services rendered by clinical social worker independently and not at direc­tion of doctor or physician as constituting medical services re­quired to be provided claimants, (1981) Vol 42, p 167
27 WLR 81 (1991); 32 WLR 217 (1996)