justicedao/ipfs_state_laws huggingface dataset:
436-009-0060 Oregon Specific Codes (1) Multidisciplinary Services. (a) Services provided by multidisciplinary programs not otherwise described by CPT® codes must be billed under Oregon specific codes. (b) Bills using the multidisciplinary codes must include copies of the treatment record that specifies: (A) The type of service rendered, (B) The medical provider who provided the service, (C) Whether treatment was individualized or provided in a group session, and (D) The amount of time treatment was rendered for each service billed. (2) Table of all Oregon Specific Codes (For OSC fees, see Appendix B .) [See attached table.] (3) CARF / JCAHO Accredited Programs. (a) Treatment in a chronic pain management program, physical rehabilitation program, work hardening program, or a substance abuse program will not be paid unless the program is accredited for that purpose by the Commission on Accreditation of Rehabilitation Facilities (CARF) or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (b) Organizations that have applied for CARF accreditation, but have not yet received accreditation, may receive payment for multidisciplinary programs upon providing evidence to the insurer that an application for accreditation has been filed with and acknowledged by CARF. The organizations may provide multidisciplinary services under this section for a period of up to six months from the date CARF provided notice to the organization that the accreditation process has been initiated, or until such time as CARF accreditation has been received or denied, whichever occurs first. (c) Notwithstanding OAR 436-009-0010(4)(a), program fees for services within a multidisciplinary program may be used based upon written pre-authorization from the insurer. Programs must identify the extent, frequency, and duration of services to be provided. (d) All job site visits and ergonomic consultations must be preauthorized by the insurer. [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 656.248 History: WCD 1-2025, amend filed 03/10/2025, effective 04/01/2025 WCD 1-2024, amend filed 03/05/2024, effective 04/01/2024 WCD 1-2023, amend filed 03/09/2023, effective 04/01/2023 WCD 2-2022, amend filed 03/02/2022, effective 04/01/2022 WCD 4-2020, amend filed 03/04/2020, effective 04/01/2020 WCD 12-2019, amend filed 12/18/2019, effective 01/01/2020 WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 1-2017, f. 3-6-17, cert. ef. 4-1-17 WCD 1-2016, f. 3-7-16, cert. ef. 4-1-16 WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13 WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11 WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10 WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09 WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06 WCD 3-2004, f. 3-5-04, cert. ef. 4-1-04 WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-04 WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03 WCD 3-2002, f. 2-25-02, cert. ef. 4-1-02 WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01 WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99
436-009-0090 Pharmaceutical (1) General. (a) Unless otherwise provided by an MCO contract, prescription medications do not require prior approval even after the patient is medically stationary. (b) When a provider prescribes a brand-name drug, pharmacies must dispense the generic drug (if available), according to ORS 689.515. However, a patient may insist on receiving the brand-name drug and either pay the total cost of the brand-name drug out of pocket or pay the difference between the cost of the brand-name drug and generic to the pharmacy. (c) Unless otherwise provided by MCO contract, the patient may select the pharmacy. (2) Pharmaceutical Billing and Payment. (a) Pharmaceutical billings must contain the National Drug Code (NDC) to identify the drug or biological billed. This includes compounded drugs, which must be billed by ingredient, listing each ingredient’s NDC. Ingredients without an NDC are not reimbursable. (b) All bills from pharmacies must include the prescribing provider’s NPI or license number. (c) Unless otherwise provided by contract, insurers must pay medical providers for prescription medication, including injectable drugs, at the medical provider’s usual fee, or the maximum allowable fee, whichever is less. However, drugs provided by a hospital (inpatient or outpatient) must be billed and paid according to OAR 436-009-0020. (d) Unless directly purchased by the worker (see OAR 436-009-0025(5)), the maximum allowable fee for pharmaceuticals is calculated according to the following table: [See attached table.] (e) Insurers must use a nationally published prescription pricing guide for calculating payments to the provider, e.g., RED BOOK or Medi-Span. (3) Dispensing by Medical Service Providers. (a) Except in an emergency, prescription drugs for oral consumption dispensed by a physician’s or authorized nurse practitioner’s office are compensable only for the initial supply to treat the patient, up to a maximum of 10 days. (b) For dispensed over-the-counter medications, the insurer must pay the retail-based fee. [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 656.248, ORS 656.252 & ORS 656.254 History: WCD 1-2023, amend filed 03/09/2023, effective 04/01/2023 WCD 1-2016, f. 3-7-16, cert. ef. 4-1-16 WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12 WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11 WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09 WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09 WCD 3-2008(Temp), f. & cert. ef. 7-7-08 thru 1-2-09 WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08 WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06 WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05 WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04 WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03 WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02 WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01 WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99
436-009-0998 Sanctions and Civil Penalties (1) The director may impose sanctions upon a medical provider or insurer for violation of these rules in accordance with OAR 436-010-0340. (2) If an insurer applies a contract or fee discount agreement to a provider’s bill that is incorrect, the insurer must pay the provider’s bill at the provider’s usual fee or according to the fee schedule, whichever is less, and the insurer may be subject to a civil penalty. (3) Although insurers may contract with provider networks for certain services, the insurer is responsible for their own actions as well as the actions of others acting on the insurer’s behalf. If an insurer or someone acting on the insurer’s behalf violates any provision of these rules, the director may impose a civil penalty against the insurer. (4) If the director finds a pattern and practice, or an egregious violation of applying incorrect discounts to providers’ fees under these rules, by an insurer or someone acting on the insurer’s behalf, the director may issue a civil penalty up to the amount allowed under ORS Chapter 656. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245, 656.254 & 656.745 History: WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 Renumbered from 436-009-0199, WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11 Renumbered from 436-009-0100 by WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10 WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09 WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00 WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99 WCD 5-1998, f. 4-3-98, cert. ef. 7-1-98 WCD 20-1996, f. 10-2-96, cert. ef. 1-1-97 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96
436-010-0001 Purpose and Applicability of These Rules (1) Purpose . The purpose of these rules is to establish uniform standards for administering the delivery of and payment for medical services to workers within the workers’ compensation system. (2) Applicability of Rules . (a) These rules apply on or after the effective date to carry out the provisions of ORS 656.245, 656.247, 656.248, 656.250, 656.252, 656.254, 656.256, 656.260, 656.268, 656.313, 656.325, 656.327, 656.331, 656.704, and 656.794, and govern all providers of medical services licensed or authorized to provide a product or service under ORS chapter 656. (b) The director may waive procedural rules as justice requires, unless otherwise obligated by statute. (c) Any orders issued by the division in carrying out the director’s authority to enforce Oregon Revised Statute (ORS) chapter 656 and Oregon Administrative Rule (OAR) chapter 436, are considered orders of the director of the Department of Consumer and Business Services. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245, 656.248, 656.250, 656.252, 656.254, 656.256, 656.260, 656.268, 656.273, 656.313, 656.325, 656.327, 656.331, 656.704 & 656.794 History: WCD 2-2021, amend filed 03/03/2021, effective 04/01/2021 WCD 2-2019, amend filed 03/11/2019, effective 04/01/2019 WCD 2-2017(Temp), f. 4-10-17, cert. ef. 4-11-17 thru 10-7-17 WCD 1-2016, f. 3-7-16, cert. ef. 4-1-16 WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02 WCD 11-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96 WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92 WCD 30-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 12-1990(Temp), f. 6-20-90, cert. ef. 7-1-90 WCD 2-1985, f. 4-29-85, ef. 6-3-85, Renumbered from 436-069-0003 WCD 1-1984, f. & ef. 1-16-84 WCD 5-1982, f. 2-23-82, ef. 3-1-82 WCD 2-1980, f. 1-28-80, ef. 2-1-80 WCD 7-1978, f. & ef. 6-5-78 WCB 4-1976, f. 10-20-76, ef. 11-1-76 WCB 1-1972, f. & ef. 1-14-72
436-010-0200 Medical Advisory Committee The Medical Advisory Committee members are appointed by the director of the Department of Consumer and Business Services. The committee must include one insurer representative, one employer representative, one worker representative, one managed care organization representative, and a diverse group of health care providers representative of those providing medical care to injured or ill workers. The director may appoint other persons as may be determined necessary to carry out the purpose of the committee. Health care providers must comprise a majority of the committee at all times. When appointing members, the director should select health care providers who will consider the perspective of specialty care, primary care, and ancillary care providers and consider the ability of members to represent the interests of the community at large. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.794 History: WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15 WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02 WCD 3-2000, f. 4-3-00, cert. ef. 4-21-00 WCD 11-1998, f. 12-16-98, cert. ef. 1-1-1999 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0095 WCD 13-1994, f. 12-20-94, cert. ef. 2-1-95 WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92 WCD 30-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 12-1990(Temp), f. 6-20-90, cert. ef. 7-1-90 WCD 1-1988, f. 1-20-88, cert. ef. 2-1-88
436-010-0225 Choosing a Person to Provide Interpreter Services (1) A worker may choose a person to communicate with a medical provider when the worker and the medical provider speak different languages, including sign language. The worker may choose a family member, a friend, an employee of the medical provider, or someone who provides interpreter services as a profession. However, for signed language interpretation services, the worker may only choose an interpreter who is a medical sign language interpreter licensed under ORS 676.765. A representative of the worker’s employer may not provide interpreter services. The medical provider may disapprove of the worker’s choice at any time the medical provider feels the interpreter services are not improving communication with the worker, or feels the interpretation is not complete or accurate. (2) When a worker asks an insurer to arrange for interpreter services, the insurer must: (a) For interpretation services, other than signed language interpretation services, use a certified or qualified health care interpreter listed on the Oregon Health Care Interpreter Registry of the Oregon Health Authority, available at: http://www.oregon.gov/OHA/OEI/Pages/HCI-Program.aspx. The interpreter’s certification or qualification must be in effect on the date the interpreter services are provided. If no certified or qualified health care interpreter is available, the insurer may schedule an interpreter of its choice subject to the limits in section (1) of this rule. (b) For signed language interpretation services, use a sign language interpreter licensed under ORS 676.750 to 676.789. (3) Prior to offering interpreter services by a health care interpreter employed by the medical provider, the medical provider must inform the worker of the worker’s right to choose an interpreter. (4) For the purpose of this rule, interpreter services means the act of orally translating between a medical provider and a worker who speak different languages, including sign language. It includes reasonable time spent waiting at the location for the medical provider to examine or treat the worker as well as reasonable time spent on necessary paperwork for the provider’s office. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245 History: WCD 1-2025, amend filed 03/10/2025, effective 04/01/2025 WCD 4-2023, amend filed 11/22/2023, effective 01/01/2024 WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10
436-010-0241 Form 827, Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims (1) First Visit . (a) When the patient has filed an initial claim or wants to file an initial claim, the patient and the first medical service provider must complete and sign Form 827. The provider must send the form to the insurer no later than 72 hours after the patient’s first visit. Saturdays, Sundays, and legal holidays are not counted in the 72-hour period. Legal holidays are those listed in ORS 187.010 and 187.020. (b) Form 3283 ("A Guide for Workers Recently Hurt on the Job") is included with Form 827. All medical service providers must give a copy of Form 3283 and Form 827 to the patient. (2) New or Omitted Medical Condition . A patient may use Form 827 to request that the insurer formally accept a new or omitted medical condition. If the patient uses the form to request acceptance of a new or omitted medical condition during a medical visit, the medical service provider may write the claimed condition or the appropriate International Classification of Diseases (ICD) diagnosis code for the patient in the space provided on the form. After the patient signs the form, the provider must send it to the insurer within five days. (3) Change of Attending Physician . When the patient changes attending physician or authorized nurse practitioner, the patient and the new medical service provider must complete and sign Form 827. The provider must send Form 827 to the insurer within five days after becoming a patient’s attending physician or authorized nurse practitioner. The new attending physician or authorized nurse practitioner is responsible for requesting all available medical records from the previous attending physician, authorized nurse practitioner, or insurer. Anyone failing to forward the requested information to the new attending physician or authorized nurse practitioner within 14 days of receiving the request may be subject to sanctions under OAR 436-010-0340. (4) Aggravation . After the patient has been declared medically stationary, and an exam reveals an aggravation of the patient’s accepted condition, the patient may file a claim for aggravation. The patient or the patient’s representative and the attending physician must complete and sign Form 827. The physician, on the patient’s behalf, must submit Form 827 to the insurer within five days of the exam. Within 14 days of the exam, the attending physician must send a written report to the insurer that includes objective findings that document: (a) Whether the patient has suffered a worsened condition attributable to the compensable injury under the criteria in ORS 656.273; and (b) Whether the patient is unable to work as a result of the compensable worsening. [Forms referenced are available from the agency.] Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245, ORS 656.252, ORS 656.254 & ORS 656.273 History: WCD 2-2022, amend filed 03/02/2022, effective 04/01/2022 WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15
436-010-0300 Requesting Exclusion of Medical Treatment from Compensability If a worker or insurer believes that any medical treatment is unscientific, unproven as to its effectiveness, outmoded, or experimental, either party may initiate a request for exclusion of the medical treatment from compensability under ORS 656.245(3). The request must include documentation on why the medical treatment should be excluded from compensability for workers’ compensation claims. The director will request advice from the licensing boards of practitioners that might be affected and the Medical Advisory Committee. The director will issue an order and may adopt a rule declaring the treatment to be noncompensable. The decision of the director is appealable under ORS 656.704. Request for administrative review of an individual worker’s treatment under ORS 656.327 does not initiate review under this process. Excluded treatments are listed in OAR 436-009-0010. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245 History: WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15 WCD 8-2005, f. 12-6-05, cert. ef. 1-1-06 WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02 WCD 11-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0045 WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92 WCD 30-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 1-1990, f. 1-5-90, cert. ef. 2-1-90 WCD 1-1988, f. 1-20-88, cert. ef. 2-1-88
436-010-0330 Medical Arbiters and Physician Reviewers (1) The director will establish and maintain a list of arbiters. The director will appoint a medical arbiter or a panel of medical arbiters from this list under ORS 656.268. (2) The director will establish and maintain a list of physician reviewers. The director will appoint an appropriate physician or a panel of physicians from this list to review medical treatment or medical services disputes under ORS 656.245 and 656.327. (3) When a worker is required to attend an examination under this rule, the director will provide notice of the examination to the worker and all affected parties. The notice will inform all parties of the time, date, location, and purpose of the examination. Examinations will be at a place reasonably convenient to the worker, if possible. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.268, 656.325 & 656.327 History: WCD 1-2016, f. 3-7-16, cert. ef. 4-1-16 WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13 WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12 WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10 WCD 2-2008, f. 6-13-08, cert. ef. 6-30-08 WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02 WCD 11-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0047 WCD 13-1994, f. 12-20-94, cert. ef. 2-1-95 WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92 WCD 30-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 12-1990(Temp), f. 6-20-90, cert. ef. 7-1-90
436-010-0335 Monitoring and Auditing Medical Providers (1) The director may monitor and conduct periodic audits of medical providers to ensure compliance with ORS chapter 656 and chapter 436 of the administrative rules. (2) All records maintained or required to be maintained must be disclosed upon request of the director. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.245, 656.254 & 656.745 History: Renumbered from 436-010-0260 by WCD 5-2015, f. 8-20-15, cert. ef. 10-1-15 WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02 WCD 11-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0101 WCD 30-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 12-1990(Temp), f. 6-20-90, cert. ef. 7-1-90
436-015-0001 Purpose and Applicability of These Rules (1) Purpose . The purpose of these rules is to establish and provide policies, procedures, and requirements to administer, evaluate, and enforce statutes relating to the delivery of medical services by managed care organizations (MCOs) to workers within the workers’ compensation system. (2) Applicability of Rules . (a) These rules apply on and after the effective date and govern all MCOs and insurers contracting with an MCO. (b) The director may waive procedural rules as justice requires, unless otherwise obligated by statute. (c) Any orders issued by the division in carrying out the director’s authority to enforce Oregon Revised Statute (ORS) chapter 656 and Oregon Administrative Rule (OAR) chapter 436, are considered orders of the director of the Department of Consumer and Business Services. (3) Timeliness of Documents . Timeliness of any document required by these rules to be filed with or submitted to the division is determined as follows: (a) If a document is mailed, it will be considered filed on the date it is postmarked. (b) If a document is faxed or emailed, it must be received by the division by 11:59 p.m. Pacific Time to be considered filed on that date. (c) If a document is delivered, it must be delivered during regular business hours to be considered filed on that date. (d) The date and time of receipt for electronic filings is determined under ORS 84.043. (e) Time periods allowed for a filing or submission to the division are calculated in calendar days. The first day is not included. The last day is included unless it is a Saturday, Sunday, or legal holiday. In that case, the period runs until the end of the next day that is not a Saturday, Sunday, or legal holiday. Legal holidays are those listed in ORS 187.010 and 187.020. Statutory/Other Authority: ORS 656.260 & 656.726(4) Statutes/Other Implemented: ORS 656.260 History: WCD 2-2021, amend filed 03/03/2021, effective 04/01/2021 WCD 2-2019, amend filed 03/11/2019, effective 04/01/2019 WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02 WCD 12-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 14-1994, f. 12-20-94, cert. ef. 2-1-95 WCD 33-1990, f. 12-12-90, cert. ef. 12-26-90 WCD 11-1990(Temp), f. 6-19-90, cert. ef. 7-1-90
436-015-0007 Entities Allowed to Manage Care (1) Only an MCO may provide managed care services as described in ORS 656.260(4)(d) and (21)(a), except as allowed under OAR 436-015-0009. (2) An insurer or someone acting on behalf of an insurer may not manage the care of workers by limiting the choice of medical providers, or by requiring medical providers to abide by specific treatment standards, treatment guidelines, or treatment protocols. Statutory/Other Authority: ORS 656.726(4) & ORS 656.260 Statutes/Other Implemented: ORS 656.260 History: WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12 WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09