justicedao/ipfs_state_laws huggingface dataset:
436-001-0400 General Provisions and Requirements for Attorney Fees In addition to the specific provisions in OAR 436-001-0410 through 436-001-0440, the following provisions apply to attorney fees: (1) The attorney must file with the director a signed attorney retainer agreement. (2) In cases in which time devoted is required to be considered in determining the amount of the fee: (a) The attorney should submit a statement of the number of hours spent on the case. (b) The director may request the attorney to submit additional information to support or clarify the statement of hours. (c) If the attorney does not submit a statement of hours or other information requested by the director before an order is issued, the director will presume the attorney spent one to two hours on the case. (3) In cases in which a reasonable fee is to be determined, the director may consider the following factors: (a) The time devoted to the case for legal services. (b) The complexity of the issue(s) involved. (c) The value of the interest involved. (d) The skill of the attorneys. (e) The nature of the proceedings. (f) The benefit secured for the represented party. (g) The risk in a particular case that an attorney’s efforts may go uncompensated and the contingent nature of the practice. (h) The assertion of frivolous issues or defenses. Statutory/Other Authority: ORS 656.385(1) & ORS 656.726(4) Statutes/Other Implemented: ORS 656.262, ORS 656.277, ORS 656.383 & ORS 656.385 History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 4-2018, amend filed 03/15/2018, effective 04/01/2018 Renumbered from 436-001-0265, WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08 WCD 7-2005, f. 10-20-05, cert. ef. 1-2-06 WCD 6-2005, f. 6-9-05, cert. ef. 7-1-05 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 8-1998, f. 8-10-98, cert. ef. 9-15-98 WCD 7-1996, f. & cert. ef. 2-12-96 WCD 6-1995(Temp), f. & cert. ef. 7-14-95
436-001-0410 Attorney Fees Under ORS 656.385(1) (Medical and Vocational Disputes) (1) In cases in which the director or administrative law judge orders a fee to be paid under ORS 656.385(1): (a) The fee must fall within the ranges of the matrix in subsection (d), unless extraordinary circumstances are shown or the parties otherwise agree. (b) Extraordinary circumstances are not established merely by exceeding eight hours or a benefit of $6,000. (c) The matrix in subsection (d) shows the maximum fee and fee ranges as percentages of the maximum fee under ORS 656.385(1), as adjusted annually by the same percentage increase, if any, to the average weekly wage defined in ORS 656.211. Before July 1 of each year the director will publish in Bulletin 356 (available on the division’s website at http://wcd.oregon.gov/Bulletins/bul_356.pdf ) the matrix showing the maximum fee and fee ranges as dollar amounts after the annual adjustment to the statutory maximum fee. Dollar amounts will be rounded to the nearest whole dollar. If the average weekly wage does not change or decreases, the maximum attorney fee under ORS 656.385(1) will not be adjusted for that year. (d) [See attached table.] (2) For purposes of applying the matrix in medical disputes under ORS 656.245, 656.247, 656.260, and 656.327, the following may be considered in determining the value of the results achieved or the benefit to the worker: (a) The fee allowed by the medical fee schedule in OAR 436-009 for the medical service at issue. (b) The overall cost of the medical service at issue. (3) For purposes of applying the matrix in vocational disputes under ORS 656.340, the value of vocational assistance or a training plan, unless determined to be otherwise, falls within the highest range of the matrix for benefit achieved . In addition, the following may be considered in determining the value of the results achieved or the benefit to the worker: (a) The actual or projected cost of the service at issue. (b) The maximum spending limit in the fee schedule for vocational assistance costs in OAR 436-120-0720 (as published in Bulletin 124, available on the division’s website at http://wcd.oregon.gov/Bulletins/bul_124.pdf ) for the service at issue. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.] Statutory/Other Authority: ORS 656.385(1) & ORS 656.726(4) Statutes/Other Implemented: ORS 656.385 History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 4-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 9-2015, f. 12-10-15, cert. ef. 1-1-16 WCD 7-2012, f. 11-16-12, cert. ef. 12-28-12 WCD 3-2012(Temp), f. 6-13-12, cert. ef. 7-1-12 thru 12-27-12 Renumbered from 436-001-0265, WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08 WCD 7-2005, f. 10-20-05, cert. ef. 1-2-06 WCD 6-2005, f. 6-9-05, cert. ef. 7-1-05 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 8-1998, f. 8-10-98, cert. ef. 9-15-98 WCD 7-1996, f. & cert. ef. 2-12-96 WCD 6-1995(Temp), f. & cert. ef. 7-14-95
436-001-0420 Attorney Fees Under ORS 656.262(11) (Late Payment of Compensation) In cases in which the director orders a fee to be paid under ORS 656.262(11): (1) OAR 438-015-0110 applies. (2) The director may use the matrix in OAR 436-001-0410 as a guide in determining the amount of the fee. (3) The director must consider the proportionate benefit to the worker when determining the amount of the fee. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.262 History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 9-2015, f. 12-10-15, cert. ef. 1-1-16 WCD 7-2012, f. 11-16-12, cert. ef. 12-28-12 WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10
436-001-0430 Attorney Fees Under ORS 656.262(12) (Late Payment of DCS Proceeds) The matrix for determining the amount of the attorney fee under ORS 656.262(12) is in OAR 436-060, Appendix C (OAR 436-060-0400). Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.262 History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 4-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 7-2012, f. 11-16-12, cert. ef. 12-28-12 WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10
436-001-0432 Attorney Fees Under ORS 656.268(6)(c) (Additional Compensation at Reconsideration) For attorney fees under ORS 656.268(6)(c): (1) In addition to a signed retainer agreement required under OAR 436-001-0400(1), the attorney must submit the request for reconsideration on behalf of the worker. (2) The insurer must pay the attorney 10 percent out of any additional compensation awarded. “Additional compensation” includes an increase in a permanent or temporary disability award. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.268(6)(c) History: WCD 6-2022, adopt filed 07/05/2022, effective 09/01/2022
436-001-0435 Attorney Fees Under ORS 656.277(1) (Reclassification) (1) Attorney fees under ORS 656.277(1) will be based on a reasonable hourly rate multiplied by the time devoted by the attorney to obtaining the reclassification order. (2) The director will determine a reasonable hourly rate of no less than $292 per hour and no more than $425 per hour. These amounts will be adjusted annually by the same percentage increase, if any, to the average weekly wage defined in ORS 656.211. Adjusted amounts will be published before July 1 of each year in Bulletin 356 (available on the division’s website at http://wcd.oregon.gov/Bulletins/bul_356.pdf). Dollar amounts will be rounded to the nearest whole dollar. If the average weekly wage does not change or decreases, amounts will not be adjusted for that year. (3) When determining the t ime devoted by the attorney to obtain the reclassification order, the director may consider time devoted by the attorney to request reclassification from the insurer or self-insured employer and investigate issues related to the classification of the worker’s claim. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.277(1) History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 4-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 9-2015, f. 12-10-15, cert. ef. 1-1-16
436-001-0440 Time Within Which Attorney Fees Must Be Paid Attorney fees under OAR 436-001-0400 to 436-001-0438 must be paid within 14 days of the date the order addressing the fees becomes final. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.262, ORS 656.268, ORS 656.277, ORS 656.383 & ORS 656.385 History: WCD 6-2022, amend filed 07/05/2022, effective 09/01/2022 WCD 4-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10
436-001-0500 Refund of Overpayments When the director receives a payment in excess of the amount legally due and payable to the director, the director will refund or credit the excess amount. However, when the excess amount is less than $20 and the payment was for an assessment or civil penalty issued under OAR chapter 436 or ORS Chapter 656, the director will refund or credit the excess amount only if a written request for refund or credit is received within two years of the date that the excess amount was received by the director. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.506, 656.612, 656.614, 656.735, 656.745, 656.780 & 293.445 History: WCD 18-2024, minor correction filed 06/18/2024, effective 06/18/2024 WCD 9-2015, f. 12-10-15, cert. ef. 1-1-16
436-001-0600 Multilingual Help Page (1) An insurer, self-insured employer, service company, or managed care organization (MCO) that sends a document to a worker that is required by OAR chapter 436 must simultaneously send Form 5377, “Workers’ Compensation Multilingual Help Page,” if the document includes: (a) Appeal rights; (b) A deadline for action required to obtain or preserve a right or benefit, including dates of required medical examinations or vocational evaluations; or (c) Notice of action required to prevent or reverse a suspension or reduction of benefits. (2) Form 5377 is published under Bulletin 379. (3) Bulletin 379 lists the notices described by subsections (1)(a) through (c). (4) Failure to send Form 5377 with a document as required by this rule does not affect the validity of the document, but may subject the insurer, self-insured employer, service company, or MCO to civil penalties under ORS 656.745. (5) Form 5377 must be sent as provided by section (1) of this rule for documents sent to a worker on or after June 1, 2019. Statutory/Other Authority: ORS 656.726(4) & 656.260 Statutes/Other Implemented: ORS 656.726(4) & 656.260 History: WCD 1-2019, adopt filed 03/11/2019, effective 04/01/2019
436-001-0610 Duty to Forward Misdirected Request If an employer or insurer receives a written request for hearing or administrative review from a worker, and the request should have been filed with the division, the employer or insurer must promptly forward the request to the division. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.704 History: WCD 1-2019, adopt filed 03/11/2019, effective 04/01/2019
436-008-0001 Authority, Applicability, Purpose, and Administration of these Rules (1) These rules are promulgated under the director's authority contained in ORS 656.726(4) and specific authority under ORS 656.252. (2) These rules apply to all electronic medical billing transactions generated on or after the effective date of these rules. (3) The purpose of these rules is to establish uniform guidelines for the exchange of electronic medical billing transactions within the workers' compensation system. (4) The director may waive procedural rules as justice requires, unless otherwise obligated by statute. (5) Orders issued by the division in carrying out the director's authority to enforce ORS chapter 656 are considered orders of the director. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252, 656.254 & 656.726(4) History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0010 Electronic Medical Bills (1) Beginning Jan. 1, 2015, insurers must accept and process all electronically transmitted medical bills in accordance with these rules, the standards adopted under OAR 436-008-0004, and the companion guide. (2) An insurer is exempt from the requirement to accept medical bills electronically from health care providers on or after Jan. 1, 2015, if a written notice is sent to the division, and approved by the director, on or before close of business on Dec. 31, 2014. The notice must explain in detail that the cost of electronic medical bill implementation will create an unreasonable financial hardship. (3) Health care providers that elect to submit electronic medical bills to insurers must do so in accordance with these rules, the standards adopted under OAR 436-008-0004, and companion guide. (4) All electronic medical billing transactions must be populated with current and valid values defined in the applicable standard set forth in OAR 436-008-0004. (5) The health care provider, health care facility, third-party biller or assignee and the insurer may mutually agree to use nonstandard formats, but those formats must include all data elements required under the applicable standard, as set forth in OAR 436-008-0004. (6) Health care providers and insurers may contract with other entities for electronic medical bill processing. (7) Insurers and health care providers are responsible for the acts or omissions of their agents executed in the performance of electronic medical billing services. (8) The data elements transmitted as part of a Trading Partner Agreement must at a minimum contain all the same required data elements found within the ASC X12 Type 3 Technical Reports and the jurisdiction-specific companion guide. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252 & 656.254 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0015 Electronic Medical Bill Attachments or Documentation (1) A unique attachment indicator number must be assigned to all documentation. The attachment indicator number populated on the document must include the report type code, the report transmission code, the attachment control qualifier, and the attachment control number. (2) Documentation in support of electronic medical bills may be submitted by fax, secure email, regular mail, electronic transmission using the prescribed format, or by a mutually agreed upon format. (3) Documentation in support of electronic medical bills must be submitted within five days of submission of the bill and include the following elements: (a) Patient name (ill or injured worker); (b) Date of birth (if available); (c) Employer name; (d) Insurer name; (e) Date of service; (f) Claim number (if no claim number then use “UNKNOWN”); and (g) Unique attachment indicator number. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252 & 656.254 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0020 Electronic Medical Bill Acknowledgements (1) If the electronic submission does not conform to the standards adopted under OAR 436-008-0004(1), then the insurer must send an acknowledgment adopted under 436-008-0004(2)(a) or 436-008-0004(2)(b) to the health care provider. This acknowledgement must be sent within one day of receipt of the electronic bill unless the electronic submission lacks sufficient identifiers to create an acknowledgment. (2) If the electronic submission does conform to a standard adopted under OAR 436-008-0004(1), then the insurer must send an acknowledgment adopted under 436-008-0004(2)(c) to the health care provider within two days. (3) Any acknowledgment of a medical bill, as provided in (1) or (2) of this rule is not an admission of liability by the insurer. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252 & 656.254 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0025 Electronic Medical Bill Payments (1) Insurers that accept and process a complete electronic bill for services, under OAR 436-008-0010(1)(a) or (b), must pay for treatment related to the injury or disease, provided or authorized by the treating health care provider, on accepted claims within 14 days of any action causing the service to be payable, or within 45 days of receipt of the electronic bill, whichever is later. (2) If an insurer requires additional information before a payment decision can be made, a request for this information must be made to the medical provider within 20 days of receipt of the bill. (3) The insurer must provide an explanation (EOB) of services being paid or denied. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252 & 656.254 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0030 Electronic Remittance Advice; Explanation of Benefits (1) An electronic remittance advice (ERA) or notification is an explanation of benefits (EOB) that the insurer submits electronically regarding payment or denial of a bill, reduction of a bill, or refund. An insurer must submit an EOB no later than five days after generating a payment. (2) The EOB must include: (a) The amount of payment for each service billed. When the payment covers multiple patients, the explanation must clearly separate and identify payments for each patient; (b) The specific reason for non-payment, reduced payment, or discounted payment for each service billed; and (c) An Oregon or toll-free phone number for the insurer or its representative, and a statement that the insurer or its representative must respond to a health care provider’s payment question within 48 hours, excluding weekends and legal holidays. (3) The insurer must make available, to health care providers, the applicable information specified under OAR 436-009-0030(3)(c)(A) through (F), including: “If you disagree with this decision about this payment, please contact {the insurer or its representative} first. If you are not satisfied with the response you receive, you may request administrative review by the director of the Department of Consumer and Business Services. Your request for review must be made within 90 calendar days of the send/receive date of this explanation. To request a review, provide information that shows what you believe is incorrect about the payment, and send this information and required supporting documentation to the Workers’ Compensation Division, Medical Resolution Team, P.O. Box 14480, Salem, OR 97309-0405. You may fax the request to the director at 503-947-7629. You must also send a copy of the request to the insurer. You should keep a copy of this information for your records.” (4) Any information required under sections (1) through (3) of this rule that cannot be submitted on the electronic EOB must be made available on the insurer’s website or by any other means reasonably convenient for the EOB recipient. Statutory/Other Authority: ORS 656.252, 656.254 & 656.726(4) Statutes/Other Implemented: ORS 656.252 & 656.254 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-008-0040 Assessment of Civil Penalties Under ORS 656.745, the director may assess a civil penalty against an insurer that fails to comply with ORS Chapter 656, the director’s rules, or orders of the director. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.254 & 656.745 History: WCD 9-2014, f. 7-14-14, cert. ef. 1-1-15
436-009-0001 Purpose and Applicability of These Rules (1) Purpose . The purpose of these rules is to establish uniform standards for administering the payment for medical benefits to workers within the workers’ compensation system. (2) Applicability of Rules . (a) These rules apply to all services rendered on or after the effective date of these rules. (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 656.248 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 1-2016, f. 3-7-16, cert. ef. 4-1-16 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01 WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96
436-009-0035 Interim Medical Benefits (1) General. (a) Interim medical benefits under ORS 656.247 only apply to initial claims when the patient has a health benefit plan, i.e., the patient’s private health insurance. For the purpose of this rule the Oregon Health Plan is not a health benefit plan. (b) Interim medical benefits are not due on claims: (A) When the patient is enrolled in an MCO prior to claim acceptance or denial under ORS 656.245(4)(b)(B); or (B) When the insurer denies the claim within 14 days of the employer’s notice of the claim. (c) Interim medical benefits cover services provided from the date of employer’s notice or knowledge of the claim to the date the insurer accepts or denies the claim. Interim medical benefits do not include treatments excluded under OAR 436-009-0010(12). (d) When billing for interim medical benefits, the medical provider must bill the workers’ compensation insurer according to these rules, and the health benefit plan according to the plan’s requirements. The provider may submit a pre-authorization request to the health benefit plan prior to claim acceptance or denial. (e) If the medical provider knows that the patient filed a work-related claim, the medical provider may not collect any health benefit plan co-pay, co-insurance, or deductible from the patient during the interim period. (2) Claim Acceptance. If the insurer accepts the claim: (a) The insurer must pay medical providers for services according to these rules; and (b) The provider, after receiving payment from the insurer, must reimburse the worker and the health benefit plan for any medical expenses, co-pays, co-insurance, or deductibles, paid by the worker or the health benefit plan. (3) Claim Denial. If the insurer denies the claim: (a) The insurer must notify the medical provider as provided in OAR 436-060-0140 that an initial claim has been denied; and (b) The medical provider must bill the health benefit plan, unless the medical provider has previously billed the health benefit plan. The provider must forward a copy of the workers’ compensation denial letter to the health benefit plan. Statutory/Other Authority: ORS 656.245, 656.704 & 656.726(4) Statutes/Other Implemented: ORS 656.247 History: WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15 WCD 11-2014, f. 10-17-14, cert. ef. 1-1-15 WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14 WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09 WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06 WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02