justicedao/ipfs_state_laws huggingface dataset:
436-150-0005 Definitions As used in OAR 436-150-0001 through 436-150-0040, unless the context requires otherwise: (1) “Compensation,” for the purposes of this program, means temporary and permanent disability due injured workers pursuant to ORS chapter 656, and out-of-pocket expenses for injured workers in accordance with OAR 436-009-0025, such as prescription and mileage reimbursements. Compensation does not include amounts payable to providers, or benefits payable pursuant to claim settlements or claim disposition agreements. (2) “Default” means an insurer has failed to make payments of compensation due injured workers pursuant to ORS chapter 656 for which there is no dispute over the right of the worker to receive such compensation or the amount therein. (3) “Director” means the director of the Department of Consumer and Business Services or the director’s delegate for the matter. (4) “Hearings Division” means the Hearings Division of the Workers’ Compensation Board. (5) “Insurer” means an insurer authorized under ORS chapter 731 to transact workers’ compensation insurance in this state. (6) “Oregon Insurance Guaranty Association” or “OIGA” means the association created by ORS 734.550. (7) “Paying Agency” means the insurer, or the insurer’s authorized representative, responsible for paying compensation due under ORS chapter 656. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0006 Administration of Rules Any orders issued by the division in carrying out the director’s authority to enforce ORS Chapter 656 and these rules are considered orders of the director. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 6-2021, minor correction filed 04/07/2021, effective 04/07/2021 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0008 Administrative Review (1) Any party as defined by ORS 656.005, and including the Oregon Insurance Guaranty Association, aggrieved by a proposed order or proposed assessment of civil penalty of the director or division issued pursuant to ORS 656.745 may request a hearing by the Hearings Division of the Workers’ Compensation Board in accordance with ORS 656.740. (a) The request for hearing must be sent in writing to the Administrator of the Workers’ Compensation Division. No hearing shall be granted unless the request specifies the grounds upon which the person requesting the hearing contests the proposed order or assessment. (b) The request for hearing must be filed with the Administrator of the Workers’ Compensation Division by the aggrieved person within 60 days after the mailing date of the proposed order or assessment. No hearing will be granted unless the request is mailed or delivered to the administrator within 60 days after the mailing date of the proposed order or assessment. (2) Under ORS 656.704(2), any party that disagrees with an action or order of the director under these rules, other than as described in section (1) of this rule, may request a hearing by filing a request for hearing as provided in OAR 436-001-0019 within 30 days of the mailing date of the order or notice of action. OAR 436-001 applies to the hearing. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445, 656.704 & 656.740 History: WCD 25-2024, minor correction filed 06/18/2024, effective 06/18/2024 WCD 7-2021, minor correction filed 04/07/2021, effective 04/07/2021 WCD 7-2005, f. 10-20-05, cert. ef. 1-2-06 WCD 12-2003, f. 12-4-03, cert. ef. 1-1-04 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0010 Criteria for Eligibility (1) In order for the director to authorize expenditures from the Workers’ Benefit Fund Claims Program there must be: (a) Verification from an authority from the insurer’s state of domicile that the insurer responsible for payment of compensation is in default, such as a notice of voluntary or involuntary rehabilitation, conservatorship, or other information indicating the insurer cannot or will not make payments of compensation; and (b) An order of the director authorizing disbursements to injured workers from the Workers’ Benefit Fund Claims Program. The order shall specify the qualifying claims, duration of payment obligation, and maximum expenditure limitation. The maximum expenditure limitation may not exceed the amount of securities on deposit for the insurer pursuant to ORS 731.628. (2) When expenditures are authorized pursuant to section (1) of this rule, the paying agency shall provide the director with sufficient information, as specified in OAR 436-150-0030(2), to enable the director to advance funds to eligible injured workers. (3) To be eligible for payment under the program: (a) Compensation must be due and payable pursuant to ORS chapter 656; and (b) There must be a record of an insurance policy on file with the director by the insurer covering the employer on the date of injury. (4) Payments to eligible injured workers in accordance with these rules shall be applied toward the insurer's payment obligations under ORS chapter 656 and will be deducted from compensation due, pursuant to ORS 734.570. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0020 Limitation of Program (1) Payment of compensation shall be limited to the amount of securities on deposit for the insurer pursuant to ORS 731.628 and only to the extent the monies are available in the Workers’ Benefit Fund. (2) Payments for individual claims shall be limited to compensation that becomes due and payable during the period of default. (3) Notwithstanding any other provision of these rules, the director may, in the director’s discretion, authorize additional benefits for specific claims in cases of extreme hardship. (4) In the event of insufficient funds in the Workers’ Benefit Fund, the director shall have final authority to determine an equitable distribution, which will proportionately distribute the available funds among the claims having qualified for reimbursement under the Program. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 8-2021, minor correction filed 04/07/2021, effective 04/07/2021 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0030 Payment of Benefits (1) Payment of compensation may be made by the director after receipt of documentation that compensation is due and payable. (2) Documentation to support payment from the Workers’ Benefit Fund Claims Program shall be submitted by the paying agent to include, but not be limited to: (a) Insurer name, address, and policy number; (b) Injured worker name, address, insurer claim number, Workers’ Compensation Division claim number, and date of injury; (c) Employer name and address; (d) Amount, duration, and purpose of compensation due; (e) Amounts payable for support pursuant to ORS 656.234, along with supporting documentation; and (f) Any other information deemed necessary by the director. Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-150-0040 Accounting and Repayment of Payment of Benefits (1) The director shall establish an account of record to monitor all expenditures and transactions relating to the Workers’ Benefit Fund Claims Program and these rules. The accounting shall provide a detailed record of payments to each injured worker and the respective insurer responsible for the claim to include, but not be limited to, information as specified in OAR 436-150-0030(2). (2) When the obligation to make payment of compensation is assumed by the Oregon Insurance Guaranty Association (OIGA) due to the insolvency of an insurer, the OIGA shall reimburse the Workers’ Benefit Fund for all moneys advanced to injured workers for covered claims, as specified by OAR 734.510(4) and these rules. The OIGA shall reimburse the director within 60 days of receipt of sufficient information necessary to support the covered claims. All moneys received from the OIGA by the director shall be placed into the Workers’ Benefit Fund. (3) If an insurer defaults in its payments to injured workers, but later resumes its obligation to make payments, the insurer shall reimburse the director for any moneys paid to the injured worker. Such payment shall be in such amounts and at such intervals as prescribed by an order of the director. Failure of the insurer to comply with the order of the director may result in civil penalty pursuant to ORS 656.745. (4) Any dispute over an amount owing the director in accordance with these rules shall be resolved pursuant to OAR 436-150-0008(2). Statutory/Other Authority: ORS 656.445 & 656.726(4) Statutes/Other Implemented: ORS 656.445 History: WCD 9-2021, minor correction filed 04/07/2021, effective 04/07/2021 WCD 12-2001, f. 12-7-01, cert. ef. 1-1-02
436-160-0001 Authority, Applicability, Purpose, and Administration of these Rules (1) These rules are promulgated under the director's authority contained in ORS 656.726(4). (2) These rules apply to workers’ compensation related transactions filed with the director by electronic data interchange (EDI) on or after Oct. 1, 2014. (3) The purpose of these rules is to require workers’ compensation medical bill data reporting by electronic data interchange. (4) Orders issued by the division in carrying out the director's authority to enforce ORS chapter 656 are considered orders of the director. (5) The director may waive procedural rules as justice requires, unless otherwise obligated by statute. Statutory/Other Authority: ORS 656.264 & 656.726(4) Statutes/Other Implemented: ORS Ch. 84 & 656.264 History: WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11 WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03
436-160-0004 Adoption of Standards (1)(a) The director adopts, by reference, IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb 1, 2014. (b) The director adopts, by reference, the ASC X12 Implementation Acknowledgment for Health Care Insurance (999), dated February 2011. (2) The form, format, and delivery of data elements reported and definitions will conform to the standards adopted under section (1), unless otherwise provided in these rules. (3) Copies of the guides in section (1) are available for review during regular business hours at the Workers’ Compensation Division, Operations Section, 350 Winter Street NE, Salem OR 97301, 503-947-7717. (a) IAIABC members may view a copy of the Release 2.0 guide, or non-members may purchase a copy at the IAIABC website: http://www.iaiabc.org. (b) The ASC X12 999 guide is available for purchase at the X12 online store: http://store.x12.org/store/healthcare-5010-consolidated-guides. Statutory/Other Authority: ORS 656.264 Statutes/Other Implemented: ORS 656.264 History: WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11 WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10 WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09 WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08 WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03
436-160-0040 Recognized Received Date An electronic record is received when: (1) The record enters the division’s designated information processing system; (2) All the required data elements and electronic records are in the form and format specified in these rules in the proper sequence; and (3) The record can be fully processed by the division's information processing system. Statutory/Other Authority: ORS 656.264 & 656.726(4) Statutes/Other Implemented: ORS 84.043 & 656.264 History: Reverted to WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09 WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03
436-160-0060 Testing Procedures and Requirements Testing and transition to production: (1) Before testing can begin, or the division can accept medical billing data, the trading partner must submit a completed Medical Billing Data EDI Trading Partner Profile (Form 4015) to the division’s EDI Coordinator. Form 4015 is available on the division’s website: http://wcd.oregon.gov/insurer/edi/Pages/medical-bill-data.aspx. (2) For test purposes each transmission must conform to the standards specified in OAR 436-160-0004. (3) Test files will be evaluated in terms of whether the data sent was received in the correct standardized format and fully processed by the division's information processing system. (4) The EDI Coordinator will determine the number of required transactions per test submission based on the anticipated volume of production transactions. (5) To be approved to send production transmissions, the sender must: (a) Accomplish secure file transfer protocol (SFTP) uploads and downloads; (b) Demonstrate the ability to send transmissions to the division that are in the correct format and can be processed through the division's information processing system; (c) Resolve any consistently recurring errors, and demonstrate the ability to correct and resubmit corrections to errors identified by the division; (d) Send transmissions to the division that do not result in a 999 acknowledgment indicating a rejection; (e) Send transmissions to the division without transaction level technical errors; (f) Demonstrate the ability to receive and process acknowledgement transactions; and (g) Achieve an acceptance rate of at least 90 percent. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 84.013 & 656.264 History: Reverted to WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11 WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09 WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08 WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03
436-160-0405 Insurers’ Reporting Responsibilities (1) Insurers with an average of at least 100 accepted disabling claims per year, based on the average accepted disabling claim volume for the previous three calendar years, are required to electronically submit detailed medical bill payment data to the Department of Consumer and Business Services under OAR 436-160-0415. (2) The director will notify an insurer when the insurer has reached a three-year average accepted disabling claim count of at least 100. The insurer is required to report medical bill payment data beginning with the date specified in the notice and must continue to report in subsequent years. (3) If the insurer’s claim count drops below an average of 50 accepted disabling claims, based on the average accepted disabling claim volume for the previous three calendar years, insurers may apply to the director for an exemption from the reporting requirement. (4) The list of insurers required to report medical bill data is published in Bulletin 359. (5) Insurers that do not meet the requirement to submit medical data under (1) of this rule may voluntarily submit medical billing data. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.264 History: Reverted to WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11
436-160-0410 Electronic Medical Bill Data Transmission and Format Requirements (1) The transmission data and format requirements are included in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0 (Feb 1, 2014), and Appendices A and B of these rules. Oregon-specific information can be found on the division’s Electronic Data EDI webpage: http://wed.oregon.gov/insurer/edi/Pages/medical-bill-data.aspx. (2) Data elements are listed in Appendices A and B: (a) Appendix A shows all medical bill data elements accepted by EDI in Oregon, and whether the data element is “Fatal Technical” (F), “Mandatory” (M), “Mandatory Conditional” (MC), “If Applicable/Available with Item Reject if Invalid” (AR), or “If Applicable/Available with Item Accept if Invalid” (AA) for each transaction type. (b) Appendix B lists mandatory conditional data elements that are mandatory under specific conditions. (3) Unless otherwise provided in these rules, the data elements must have the meaning provided in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb. 1, 2014, Section 2; Health Care Claim (837). (4) Transactions will be rejected if “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements are omitted, or include invalid values. (5) Transactions will be rejected if “If Applicable/Available with Item Reject if Invalid” data elements include invalid values. (6) Invalid “If Applicable/Available with Item Accept if Invalid” data elements will be ignored if they are included in a transaction. [ED. NOTE: Appendices are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here to view rule.] Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.264 History: WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 1-2014, f. 2-14-14, cert. ef. 7-1-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11 WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10 WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09 WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08 WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08
436-160-0415 Oregon ASC X12 837 Medical Bill Data Reporting Requirements (1) Event reporting requirements: (a) Medical bills, including interpreter bills under OAR 436-009, must be reported within 60 days of the date paid. (b) Denied medical bills for accepted claims must be reported within 60 days of date of denial. Denied bills are defined as any bills in which there is a non-zero charge and a zero payment. (c) Transactions must be received and accepted by the division within 60 days of either the date paid or the date denied to be considered timely reported. If a transaction is initially rejected it must be corrected, resubmitted, and accepted within the original 60 day time period to be considered timely reported. (d) Cancellations must be reported as soon as the payer knows that a medical bill was sent in error. (e) Corrections/Replacements must be reported within 60 days of changes to any of the “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements in Appendices A and B. (f) Bills received by the insurer before Oct. 1, 2014, may be reported to the Division using the IAIABC reporting standard version 1.1. (2) Data reporting requirements are described in Appendices A and B. (3) Technical requirements are described on the division’s Electronic Data EDI webpage for specifications on the Secure File Transfer Protocol (SFTP) requirements. (4) Data Quality: The director will conduct electronic edits for blank or invalid data. Affected insurers are responsible for pre-screening the data they submit to check that all the required information is reported and is formatted correctly. OAR 436-160-0420 describes the acceptance or rejection protocol for all reported medical bills. The insurer is responsible for timely correcting and resubmitting all rejected transactions for which law or rule require filing, reporting, or notice to the director. (5) An insurer must request and receive authorization from the director to stop submitting a previously rejected transaction when the division determines the transaction is uncorrectable. (6) The director will periodically review reported bill data to monitor insurer performance. If the director finds repeated or egregious violations of the reporting requirements of these rules the director may issue civil penalties under OAR 436-160-0445 and ORS 656.745. (a) Medical bills must be reported timely. “Timely” means that an insurer reports medical bills as required by OAR 436-160-0415(1). (b) Medical bills must be reported accurately. “Accurately” means that the reported medical bill data accepted by the division conforms to the reporting requirements of the Appendices A and B. (c) The insurer may be subject to penalties for any reported medical bills that have not been accepted by the division or designated as uncorrectable under OAR 436-160-0415(5) within 180 days of the date of bill payment or denial. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.264 History: WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11
436-160-0420 Medical Bill Acknowledgement (1)(a) The sender is expected to retrieve both TA1 and 999 interchange and functional acknowledgements (as defined by ASC X12) for each medical bill file submitted, unless technical errors in the file prevent 999 processing. In addition, the sender is expected to retrieve the 824 detailed acknowledgement, as defined by IAIABC Release 2.0 (Feb.1, 2014) for each medical bill file submitted, if at least one transaction has successfully passed the 999 edits. (b) The detailed acknowledgement will indicate either an item accepted (IA) or an item rejected (IR) acknowledgement for each individual transaction. (2) A TA1, 999 or 824 acknowledgement will be available for all transactions the division is unable to process, including but not limited to: (a) An omitted mandatory data element; (b) An improperly populated data element field, e.g., numeric data element field is populated with alpha or alphanumeric data, or is not a valid value according to the standards adopted in 436-160-0004; (c) Transactions or electronic records within the transaction that require matching, and cannot be matched to the division's database, e.g., cancellation of an original bill that does not match the Unique Bill ID; (d) Illogical data in mandatory or required conditional field, e.g., payment date is after reporting date; (e) Duplicate transmission or duplicate transaction within the transmission; (f) Invalid bill submission reason code; or (g) Illogical event sequence relationship between transactions, e.g., cancellation transaction submitted before an original bill is accepted. (3) A transaction accepted acknowledgement will be available for all transactions that are in a format capable of being processed by the division's information processing system and that are not rejected under section (2) of this rule. (4) An insurer’s obligation to report medical bill data for the purposes of this rule is not satisfied unless the division acknowledges acceptance of the transaction. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.264 History: WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14 WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14 WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14 WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11 WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10 WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08