justicedao/ipfs_state_laws huggingface dataset:
436-015-0009 Formed, Owned, or Operated (1) The director will not certify an MCO formed, owned, or operated by a non-qualifying employer. (2) For purposes of this rule, “staff” means any individual who is an employee of a non-qualifying employer or of any parent or subsidiary entity of a non-qualifying employer. (3) A non-qualifying employer or any of its staff, or their immediate family, may not: (a) Directly participate in the formation, certification, or incorporation of the MCO; (b) Nominate, assume a position as, or act in the role of, a director, officer, agent, or employee of the MCO; (c) Arrange for, lend, guarantee, or otherwise provide financing for any organizational costs of the MCO; (d) Arrange for, lend, guarantee, or otherwise provide financial support to the MCO (financial support does not include contracted fees for services rendered by an MCO); (e) Have any ownership or similar financial interest in or right to payment from the MCO; (f) Make or exercise any control over business, operational, or policy decisions of the MCO; (g) Possess or control the ownership of voting securities of the MCO. The director will presume possession or control exists if any person, directly or indirectly, holds the power to vote or holds proxies of any other person representing 10 percent or more of the voting securities of the MCO; (h) Provide MCO services other than as allowed by section (4) of this rule; (i) Enter into any contract with the MCO that limits the ability of the MCO to accept business from any other source; or (j) Direct or interfere with the MCO’s delivery of medical and health care services. (4) Notwithstanding section (3) of this rule, an MCO may contract with an insurer to provide certain managed care services. However, such insurer-provided services must be according to protocols and standards established by the certified MCO plan. The insurer may not provide or participate in the provision of managed care services related to dispute resolution, service utilization review, or physician peer review. 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 1-2008, f. 6-13-08, cert. ef. 7-1-08 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
436-015-0010 Notice of Intent to Form an MCO (1) Any health care provider or group of medical service providers initiating an MCO under ORS 656.260 must submit a “Notice of Intent to Form” to the director, by certified mail. Form 2737 may be used for this purpose. (2) The Notice of Intent to Form must include the following: (a) The identity of each person who participates in discussions intended to result in the formation of an MCO. If the person is a member of a closely held corporation, the notice must include the identity of the shareholders; (b) The name, address, and telephone number of a contact person; and (c) A summary of the information that will be shared in discussions preceding the application for MCO certification. 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 1-2008, f. 6-13-08, cert. ef. 7-1-08 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
436-015-0035 Coverage Responsibility of an MCO (1) The director will designate an MCO's initial geographic service area (GSA). GSAs are established by postal zip code (See http://wcd.oregon.gov/Bulletins/bul_248.pdf). The MCO may only provide contract services in those GSAs approved by the director. Workers are not subject to an MCO contract unless the director has approved the GSA. (2) Any expansion of an MCO's service area must be approved by the director. The request for expansion must identify the new GSA and include evidence that the MCO has an adequate provider panel which meets the minimum requirements under OAR 436-015-0030. The director may approve the MCO’s new GSA without the minimum categories of medical service providers when the MCO establishes that there are not an adequate number of providers in a given category able or willing to become members of the MCO. For categories where the MCO has fewer than three providers, the MCO must allow workers to seek treatment outside the MCO from providers in those categories. Treatment provided to workers must be consistent with the MCO's treatment and utilization standards. Such providers, unlike come-along providers, cannot be required to comply with the terms and conditions regarding services performed by members of the MCO. However, while such providers are not themselves bound by the MCO's treatment and utilization standards, workers are subject to those standards. Statutory/Other Authority: ORS 656.726(4) & 656.260 Statutes/Other Implemented: ORS 656.245 & 656.260 History: WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 7-2013, f. 11-12-13, cert. ef. 1-1-14 WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02 WCD 4-2000, f. 4-4-00, cert. ef. 4-21-00 WCD 13-1999(Temp), f. & cert. ef. 10-25-99 thru 4-21-00 WCD 12-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 13-1996, f. 5-6-96, cert. ef. 6-1-96 WCD 14-1994, f. 12-20-94, cert. ef. 2-1-95 Reverted to WCD 2-1992, f. 1-10-92, cert. ef. 2-1-92 WCD 7-1992(Temp), f. & cert. ef. 4-15-92 WCD 2-1992, f. 1-10-92, cert. ef. 2-1-92 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
436-015-0037 MCO-Insurer Contracts (1) An MCO must provide comprehensive medical services to all enrolled workers covered by the MCO-insurer contract according to the MCO’s certification. (2) An MCO may not contract exclusively with a single insurer. However, an MCO has up to one year from the effective date of its first contract to obtain contracts with more than one insurer. If the MCO has not obtained additional contracts within this time period, the MCO must provide the director with a report documenting the MCO’s efforts to obtain additional contracts. (3) An MCO may contract only with insurers. The contract must include the following terms and conditions: (a) Who is governed by the contract; (b) The covered place of employment must be within the authorized geographic service area; (c) Insurers may contract with multiple MCOs to provide coverage for employers. All workers at any specific employer's location must be governed by the same MCO(s). When insurers contract with multiple MCOs each worker must have initial choice at the time of injury to select which MCO will manage their care except when the employer provides a coordinated health care program; (d) Workers enrolled in an MCO must receive medical services as prescribed by the terms and conditions of the contract; and (e) A continuity of care provision specifying how workers will receive medical services on open claims, including the following: (A) Upon enrollment, allowing workers to continue to treat with the current medical service providers for at least 14 days after the mailing date of the notice of enrollment; and (B) Upon termination or expiration of the MCO-insurer contract, allowing workers to continue treatment under ORS 656.245(4)(a). (4) Notwithstanding the requirements of this rule, failure of the MCO to provide medical services does not relieve the insurers of their responsibility to ensure benefits are provided to workers under ORS chapter 656. Statutory/Other Authority: ORS 656.260 & 656.726(4) Statutes/Other Implemented: ORS 656.260 & 656.245 History: WCD 2-2019, amend filed 03/11/2019, effective 04/01/2019 WCD 5-2018, adopt filed 03/15/2018, effective 04/01/2018
436-015-0050 Record Keeping and Place of Business (1) Every MCO must give the director notice of one Oregon location and mailing address where the MCO keeps records of the following: (a) Up-to-date membership listings of all MCO members; (b) Sanctions or punitive actions taken by the MCO against its members; (c) Actions taken by the MCO’s peer review committee; (d) Utilization reviews performed identifying cases reviewed, issues involved, and action taken; (e) A profile analysis of each provider in the MCO; (f) Enrolled workers receiving treatment by come-along providers; and (g) All other records as necessary to ensure compliance with the certification requirements under OAR 436-015-0030. (2) Records required by section (1) of this rule must be retained at the authorized Oregon location for three full calendar years. (3) Each MCO provider must maintain medical records as provided by OAR 436-010-0240. 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 6-2004, f. 6-14-04, cert. ef. 6-29-04 WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-03 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 2-1992, f. 1-10-92, cert. ef. 2-1-92 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
436-015-0060 Commencement and Termination of Panel Providers (1) Prospective new panel providers of an MCO must submit an application to the MCO. The directors, executive director, or administrator may approve the application for membership according to the membership requirements of the MCO. The MCO must verify that each new member meets all licensing, registration, and certification requirements necessary to practice in Oregon. If the MCO requires a membership fee, the fee must be the same for every category of medical service provider. An MCO may not require membership fees or other MCO administrative fees to be paid by come-along providers. (2) Individual panel providers may elect to terminate their participation in the MCO or be subject to cancellation by the MCO according to the membership requirements of the MCO plan. Upon termination of a panel provider, the MCO must: (a) Make alternate arrangements to provide continuing medical services for any affected workers under the plan; and (b) Replace any terminated panel provider when necessary to maintain an adequate number of each category of medical service provider. 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 6-2004, f. 6-14-04, cert. ef. 6-29-04 WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-03 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 2-1992, f. 1-10-92, cert. ef. 2-1-92 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
436-015-0065 Monitoring and Auditing (1) The director will monitor and conduct periodic audits of an MCO as necessary to ensure compliance with the MCO certification and performance requirements. (2) All records of an MCO and its individual panel providers must be disclosed upon the director’s request. These records must be legible and cannot be kept in a coded or semi-coded manner unless a legend is provided for the codes. Statutory/Other Authority: ORS 656.260 & ORS 656.726(4) Statutes/Other Implemented: ORS 656.260 History: WCD 5-2018, adopt filed 03/15/2018, effective 04/01/2018
436-015-0075 Worker Exams When the MCO schedules a worker exam that includes a psychological evaluation, the appointment letter must: (1) Inform the worker that a psychological evaluation is part of the exam; and (2) State the reason for the psychological exam. Statutory/Other Authority: 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
436-015-0090 Charges and Fees (1) Billings for medical services under an MCO must be submitted in the form and format as prescribed in OAR 436-009. The payment of medical services may be less than, but must not exceed, the maximum amounts allowed under OAR 436-009. (2) Notwithstanding section (1) of this rule, fees paid for medical services provided by come-along providers must not be less than fees paid to MCO panel providers for similar medical services. (3) Payments to medical providers who are not under contract with the MCO are not subject to an MCO discount. Statutory/Other Authority: ORS 656.260 & 656.726(4) Statutes/Other Implemented: ORS 656.260 & ORS 656.245 History: WCD 5-2018, amend filed 03/15/2018, effective 04/01/2018 WCD 7-2013, f. 11-12-13, cert. ef. 1-1-14 WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10 WCD 6-2004, f. 6-14-04, cert. ef. 6-29-04 WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-03 WCD 12-1998, f. 12-16-98, cert. ef. 1-1-99 WCD 13-1996, f. 5-6-96, cert. ef. 6-1-96 WCD 14-1994, f. 12-20-94, cert. ef. 2-1-95 WCD 2-1992, f. 1-10-92, cert. ef. 2-1-92 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
436-015-0120 Sanctions and Civil Penalties (1) Complaints pertaining to violations of these rules must be sent to the director. (2) The director may investigate an alleged rule violation. The investigation may include, but is not limited to, request for and review of pertinent medical treatment and payment records, interviews with the parties to the complaint, or consultation with an appropriate panel of the medical provider’s peers, chosen in the manner provided in OAR 436-010-0330. (3) If the director finds any violation of OAR 436-015, or if the MCO fails to meet any of the requirements of the certified plan, the director may impose one or more of the following sanctions against an MCO: (a) Reprimand by the director; (b) Civil penalty as provided under ORS 656.745(2). In determining the amount of penalty to be assessed, the director will consider: (A) The degree of harm inflicted on the worker, insurer, or medical provider; (B) Previous violations; and (C) Evidence of willful violation; or (c) Suspension or revocation of the MCO’s certification under OAR 436-015-0080. (4) If the director determines that an insurer has entered into a contract with an MCO that violates OAR 436-015 or the MCO’s certified plan, the insurer will be subject to civil penalties as provided in ORS 656.745. (5) If an insurer or someone who is not a certified MCO acting on the insurer's behalf engages in managed care activities prohibited under these rules, the director may impose a sanction or civil penalty. Statutory/Other Authority: ORS 656.260 & 656.726(4) Statutes/Other Implemented: ORS 656.260 & 656.745 History: 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 5-2008, f. 12-15-08, cert. ef. 1-1-09 WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08 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 13-1996, f. 5-6-96, cert. ef. 6-1-96 WCD 14-1994, f. 12-20-94, cert. ef. 2-1-95 WCD 2-1992, f. 1-10-92, cert. ef. 2-1-92 WCD 4-1991, f. & cert. ef. 6-14-91 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
436-030-0007 Administrative Review (1) Notices of Closure issued by insurers are appealed to the director and processed in accordance with the reconsideration procedures described in OAR 436-030-0115 through OAR 436-030-0185, except Notices of Closure under (3)(b) of this rule, when: (a) The worker was determined medically stationary after July 1, 1990; or (b) The claim qualifies for closure under ORS 656.268(1)(b) or (c). (2) The director may abate, withdraw, or amend the Order on Reconsideration during the 30-day appeal period for the Order on Reconsideration. (3) The following matters are brought before the board: (a) Orders on Reconsideration issued under these rules. (b) Notices of Closure that rescind permanent total disability under ORS 656.206. (c) Any other action taken under these rules where a worker’s right to compensation or the amount thereof is directly an issue under ORS chapter 656. (4) Contested Case Hearings of Sanctions and Civil Penalties: Under ORS 656.740, any party aggrieved by a proposed order or proposed assessment of a civil penalty issued by the director under ORS 656.254, 656.735, or 656.745 may request a hearing by the board as follows: (a) The party must send the request for hearing in writing to the director within 60 days after the mailing date of the proposed order or assessment. The request must specify the grounds upon which the proposed order or assessment is contested. (b) The division will forward the request and other pertinent information to the board. (c) An Administrative Law Judge from the board, acting on behalf of the director, will conduct the hearing in accordance with ORS 656.740 and ORS Chapter 183. (5) Director’s Administrative Review of other actions: Except as covered under sections (1) through (4) of this rule, any party seeking an action or decision by the director or aggrieved by an action taken by any other party under these rules, may request administrative review by the director subject to the following: (a) The party must send the request in writing to the director within 90 days of the disputed action and must specify the grounds upon which the action is disputed; and (b) The director may require and allow such evidence as is deemed appropriate to complete the review. Statutory/Other Authority: ORS 656.268 & 656.726 Statutes/Other Implemented: ORS 656.268, 656.726 & 656.740 History: WCD 19-2024, minor correction filed 06/18/2024, effective 06/18/2024 WCD 3-2020, amend filed 02/07/2020, effective 03/01/2020 WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 11-2007, f. 11-1-07, cert. ef. 1-2-08 WCD 8-2005, f. 12-6-05, cert. ef. 1-1-06 WCD 9-2004, f. 10-26-04, cert. ef. 1-1-05 WCD 2-2004, f. 2-19-04, cert. ef. 2-29-04 WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-03 WCD 10-2001, f. 11-16-01, cert. ef. 1-1-02 WCD 9-2000, f. 11-13-00, cert. ef. 1-1-01 WCD 17-1997, f. 12-22-97, cert. ef. 1-15-98 WCD 12-1994, f. 11-18-94, cert. ef. 1-1-95
436-030-0017 Requests for Claim Closure by the Worker (1) A worker may request claim closure from the insurer. The insurer must issue a Notice of Closure or Notice of Refusal to Close within 10 days of receipt of a written request for claim closure from the worker or the worker’s attorney . (2) If an insurer issues a Notice of Refusal to Close, the notice must be clearly titled “Notice of Refusal to Close” and it must include: (a) Name of the worker; (b) Date of injury; (c) Insurer’s claim number; (d) Mailing date of the notice; (e) The accepted and denied conditions; (f) Rationale for the insurer’s decision; and (g) The following language, in bold print: "If you disagree with this Notice of Refusal to Close your claim, you must file a letter of disagreement with the Workers’ Compensation Board within sixty (60) days from the date of this notice. Your letter must state that you want a hearing, note your address, and include the date of your accident if known. You must mail your letter of disagreement to the Workers’ Compensation Board, 2601 25th Street SE, Suite 150, Salem, OR 97302-1280 . If your claim qualifies and you request it, you may receive an expedited hearing (within 30 days). Your request cannot, by law, affect your employment. If you do not file your letter of disagreement within sixty (60) days from the date of this notice, your hearing will be denied as the appeal time has passed. You may be represented by an attorney if you choose." (3) If the worker disagrees with the Notice of Refusal to Close, the worker may request a hearing from the board. Statutory/Other Authority: ORS 656.268 Statutes/Other Implemented: ORS 656.268, 656.726, 656.319 & 656.745 History: WCD 3-2020, amend filed 02/07/2020, effective 03/01/2020 WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10 WCD 2-2004, f. 2-19-04, cert. ef. 2-29-04 WCD 10-2001, f. 11-16-01, cert. ef. 1-1-02 WCD 9-2000, f. 11-13-00, cert. ef. 1-1-01 WCD 17-1997, f. 12-22-97, cert. ef. 1-15-98 WCD 8-1996, f. 2-14-96, cert. ef. 2-17-96 WCD 12-1994, f. 11-18-94, cert. ef. 1-1-95
436-030-0036 Determining Temporary Disability (1) Temporary disability must be determined under ORS Chapter 656, OAR 436-060, and this rule, less time worked. Beginning and ending dates of each authorized period of temporary total disability and temporary partial disability must be noted on the Notice of Closure, as well as the statements “Less time worked” and “Temporary disability was determined in accordance with the law.” (2) Except as provided in section (3) of this rule and ORS 656.268(10), a worker is not entitled to any award of temporary disability for any period of time in which the worker is medically stationary. (3) Awards of temporary disability must include the day the worker is medically stationary or the date the claim otherwise qualifies for closure, unless temporary disability is not authorized for another reason at that time. Statutory/Other Authority: ORS 656.268 & 656.726 Statutes/Other Implemented: ORS 656.005, 656.160, 656.210, 656.212, 656.236, 656.245, 656.262, 656.268 & 656.726 History: WCD 5-2011, f. 11-18-11, cert. ef. 1-1-12 WCD 9-2004, f. 10-26-04, cert. ef. 1-1-05 WCD 2-2004, f. 2-19-04 cert. ef. 2-29-04 WCD 9-2000, f. 11-13-00, cert. ef. 1-1-01 WCD 17-1997, f. 12-22-97, cert. ef. 1-15-98 WCD 8-1996, f. 2-14-96, cert. ef. 2-17-96 WCD 12-1994, f. 11-18-94, cert. ef. 1-1-95 WCD 5-1992, f. 1-17-92, cert. ef. 2-20-92 WCD 31-1990, f. 12-10-90, cert. ef. 12-26-90 WCD 5-1990(Temp), f. 6-18-90, cert. ef. 7-1-90
436-030-0038 Permanent Partial Disability The standards developed under ORS 656.726(4) and contained in OAR 436-035 must be applied when evaluating a worker’s permanent partial disability. Statutory/Other Authority: ORS 656.268, 656.726, OL Ch. 332 1995 & Ch. 313 1999 Statutes/Other Implemented: ORS 656.214, 656.268, 656.726, OL Ch. 332 1995 & Ch. 313 1999 History: WCD 2-2004, f. 2-19-04 cert. ef. 2-29-04 WCD 9-2000, f. 11-13-00, cert. ef. 1-1-01 WCD 17-1997, f. 12-22-97, cert. ef. 1-15-98 WCD 12-1994, f. 11-18-94, cert. ef. 1-1-95