Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Unless a term is specifically defined
			 elsewhere in these rules or the context otherwise requires, the definitions of
			 ORS chapter 656 are hereby incorporated by reference and made part of these
			 rules.
(2)
"Administrative
			 review"
means any decision making process of the director requested by a
			 party aggrieved with an action taken under these rules except the hearing
			 process described in OAR 436-001.
(3)
"Attending physician"
has
			 the same meaning as described in ORS
			 656.005(12)(b).
			 See Appendix A "Matrix for Health Care Provider Types."
(4)
"Authorized nurse
			 practitioner"
means a nurse practitioner licensed under ORS
			 678.375 to
			 678.390 who has certified to the
			 director that the nurse practitioner has reviewed informational materials about
			 the workers' compensation system provided by the director and who has been
			 assigned an authorized nurse practitioner number by the director.
(5)
"Board"
means the Workers'
			 Compensation Board and includes its Hearings Division.
(6)
"Chart note"
means a
			 notation made in chronological order in a medical record in which the medical
			 service provider records information such as subjective and objective findings,
			 diagnosis, treatment rendered, treatment objectives, and return-to-work goals
			 and status.
(7)
"Come-along
			 provider"
means a primary care physician, chiropractic physician,
			 physician associate or an authorized nurse practitioner who is not a managed
			 care organization (MCO) panel provider and who is authorized to continue to
			 treat the worker when the worker becomes enrolled in an MCO. (See OAR
			 436-015-0070.)
(8)
"Date stamp"
means to stamp
			 or display the initial receipt date and the recipient's name on a paper or
			 electronic document, regardless of whether the document is printed or displayed
			 electronically.
(9)
"Days"
means calendar days.
(10)
"Direct control and
			 supervision"
means the physician is on the same premises, at the same
			 time, as the person providing a medical service ordered by the physician. The
			 physician can modify, terminate, extend, or take over the medical service at
			 any time.
(11)
"Direct
			 medical sequela"
means a condition that is clearly established medically
			 and originates or stems from an accepted condition. For example: The accepted
			 condition is low back strain with herniated disc at L4-5. The worker develops
			 permanent weakness in the leg and foot due to the accepted condition. The
			 weakness is considered a "direct medical sequela."
(12)
"Director"
means the
			 director of the Department of Consumer and Business Services or the director's
			 designee.
(13)
"Division"
means the Workers' Compensation Division of the
			 Department of Consumer and Business Services.
(14)
"Eligible worker"
means a
			 worker who has filed a claim or who has an accepted claim and whose employer is
			 located in an MCO's authorized geographical service area, covered by an insurer
			 that has a contract with that MCO.
(15)
"Enrolled"
means an
			 eligible worker has received notification from the insurer that the worker is
			 being required to treat under the provisions of a managed care organization
			 (MCO). However, a worker may not be enrolled who would otherwise be subject to
			 an MCO contract if the worker's primary residence is more than 100 miles
			 outside the managed care organization's certified geographical service
			 area.
(16)
"Health care
			 practitioner or health care provider"
has the same meaning as a "medical
			 service provider."
(17)
"Home
			 health care"
means necessary medical and medically related services
			 provided in the patient's home environment. These services may include, but are
			 not limited to, nursing care, medication administration, personal hygiene, or
			 assistance with mobility and transportation.
(18)
"Hospital"
means an
			 institution licensed by the State of Oregon as a hospital.
(19)
"Initial claim"
means the
			 first open period on the claim immediately following the original filing of the
			 occupational injury or disease claim until the worker is first declared to be
			 medically stationary by an attending physician or authorized nurse
			 practitioner. For nondisabling claims, the "initial claim" means the first
			 period of medical treatment immediately following the original filing of the
			 occupational injury or disease claim ending when the attending physician or
			 authorized nurse practitioner does not anticipate further improvement or need
			 for medical treatment, or there is an absence of treatment for an extended
			 period.
(20)
"Insurer"
means the State Accident Insurance Fund Corporation; an insurer authorized
			 under ORS chapter 731 to transact workers' compensation insurance in the state;
			 or, an employer or employer group that has been certified under ORS
			 656.430 that meets the
			 qualifications of a self-insured employer under ORS
			 656.407.
(21)
"Interim medical benefits"
means those services provided under ORS
			 656.247 on initial claims with
			 dates of injury on or after January 1, 2002 that are not denied within 14 days
			 of the employer's notice of the claim.
(22)
"Mailed or mailing date"
means the date a document is postmarked. Requests submitted by facsimile or
			 "fax" are considered mailed as of the date printed on the banner automatically
			 produced by the transmitting fax machine. Hand-delivered requests will be
			 considered mailed as of the date stamped by the division. Phone or in-person
			 requests, where allowed under these rules, will be considered mailed as of the
			 date of the request.
(23)
"Managed care organization" or "MCO"
means an organization formed
			 to provide medical services and certified in accordance with OAR chapter 436,
			 division 015.
(24)
"Medical
			 evidence"
includes, but is not limited to: expert written testimony;
			 written statements; written opinions, sworn affidavits, and testimony of
			 medical professionals; records, reports, documents, laboratory, X-ray and test
			 results authored, produced, generated, or verified by medical professionals;
			 and medical research and reference material used, produced, or verified by
			 medical professionals who are physicians or medical record reviewers in the
			 particular case under consideration.
(25)
"Medical provider"
means a
			 medical service provider, a hospital, a medical clinic, or a vendor of medical
			 services.
(26)
"Medical
			 service"
means any medical treatment or any medical, surgical,
			 diagnostic, chiropractic, dental, hospital, nursing, ambulances, or other
			 related services; drugs, medicine, crutches, prosthetic appliances, braces, and
			 supports; and where necessary, physical restorative services.
(27)
"Medical service provider"
means a person duly licensed to practice one or more of the healing
			 arts.
(28)
"Medical
			 treatment
" means the management and care of a patient for the purpose of
			 combating disease, injury, or disorder. Restrictions on activities are not
			 considered treatment unless the primary purpose of the restrictions is to
			 improve the worker's condition through conservative care.
(29)
"Parties"
mean the worker,
			 insurer, MCO, attending physician, and other medical provider, unless a
			 specific limitation or exception is expressly provided for in the
			 statute.
(30)
"Patient"
means the same as worker as defined in ORS
			 656.005(28).
(31)
"Physical capacity
			 evaluation"
means an objective, directly observed, measurement of a
			 worker's ability to perform a variety of physical tasks combined with
			 subjective analyses of abilities by worker and evaluator. Physical tolerance
			 screening, Blankenship's Functional Capacity Evaluation, and Functional
			 Capacity Assessment have the same meaning as Physical Capacity
			 Evaluation.
(32)
"Physical
			 restorative services
" means those services prescribed by the attending
			 physician or authorized nurse practitioner to address permanent loss of
			 physical function due to hemiplegia or a spinal cord injury, or to address
			 residuals of a severe head injury. Services are designed to restore and
			 maintain the patient's highest functional ability consistent with the patient's
			 condition.
(33)
"Report"
means medical information transmitted in written form
			 containing relevant subjective or objective findings. Reports may take the form
			 of brief or complete narrative reports, a treatment plan, a closing examination
			 report, or any forms as prescribed by the director.
(34)
"Residual functional
			 capacity"
means a patient's remaining ability to perform work-related
			 activities. A residual functional capacity evaluation includes, but is not
			 limited to, capability for lifting, carrying, pushing, pulling, standing,
			 walking, sitting, climbing, balancing, bending/stooping, twisting, kneeling,
			 crouching, crawling, and reaching, and the number of hours per day the patient
			 can perform each activity.
(35)
"Specialist physician"
means a licensed physician who qualifies as
			 an attending physician and who examines a patient at the request of the
			 attending physician or authorized nurse practitioner to aid in evaluation of
			 disability, diagnosis, or provide temporary specialized treatment. A specialist
			 physician may provide specialized treatment for the compensable injury or
			 illness and give advice or an opinion regarding the treatment being rendered,
			 or considered, for a patient's compensable injury.
(36)
"Work capacity evaluation"
means a physical capacity evaluation with special emphasis on the ability to
			 perform a variety of vocationally oriented tasks based on specific job demands.
			 Work Tolerance Screening has the same meaning as Work Capacity
			 Evaluation.
Publications referenced are available from the
				  agency.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS 656.000 et seq. & ORS
				  656.005