reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2000 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1)  "340B" means Section 340B of the Public Health Service Act,
				"Limitation on Prices of Drugs Purchased by Covered Entities," and any and all
				related rules, guidance, interpretations, and operational directives adopted by
				the federal Health Resources and Services Administration (HRSA) or any other
				governmental agency with jurisdiction over the enforcement of Section
				340B.
(2)  "Administrator" means the Administrator of the Oregon
				Prescription Drug Program (OPDP).
(3)  "Authority" means the Oregon Health Authority.
(4)  A "Critical Access Pharmacy (CAP)" is defined as a pharmacy
				in Oregon that provides pharmacy services in communities at greatest risk of
				experiencing a pharmacy closure. To qualify as a CAP, except for (a) and (d)
				below, the pharmacy must have Oregon-based ownership, be public facing, and
				provide access to immunizations and either medication therapy management or
				pharmacist protocol-based prescribing. All pharmacies located on tribal lands
				or serving tribal communities will be designated as a CAP. In alignment with
				urban, rural, and frontier designations determined by the Office of Rural
				Health (ORH), a critical access pharmacy will meet the following
				criteria:
(a)  In a frontier county, a critical access pharmacy is one
				that is further than a ten-mile radius from any other pharmacy. (If one CAP's
				ten-mile radius intersects with that of another CAP, both shall be considered a
				CAP if either CAP's closure could result in impaired access for rural areas.)
				Additionally, if a county has three or fewer pharmacies, all pharmacies,
				regardless of ownership, will be considered a CAP.
(b)  In a rural zip code, a critical access pharmacy is one
				that is further than a ten-mile radius from any other pharmacy. (If one CAP's
				ten-mile radius intersects with that of another CAP, both shall be considered a
				CAP if either CAP's closure could result in impaired access for rural areas.)
				Additionally, if the pharmacy has Oregon based ownership and is located in a
				high poverty census tract (as defined by the US census bureau), it will be
				considered a CAP.
(c)  In an urban zip code, a pharmacy may be considered a CAP
				if the pharmacy has Oregon based ownership and is the sole pharmacy located in
				a high poverty census tract (as defined by the US census bureau).
(d)  A pharmacy may be designated as a CAP at the discretion of
				the Director of the OPDP accounting for factors related to pharmacy
				access.
(e)  Assessment of CAP designation will be conducted quarterly.
				Pharmacies that previously qualified as a CAP, but no longer meet the
				aforementioned criteria, will have 12 months before losing this
				designation.
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2005 - General Administration

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Administrator, or designee, may:
(a)
			 Negotiate price discounts and rebates on prescription drugs with prescription
			 drug manufacturers and GPOs;
(b)
			 Purchase prescription drugs on behalf of participating programs;
(c) Contract with a PDCP or PBM to adjudicate
			 pharmacy claims and transmit program prices to pharmacies;
(d) Determine program prices and reimburse or
			 replenish pharmacies for prescription drugs dispensed or transferred;
(e) Adopt and implement a PDL for
			 the OPDP;
(f) Develop a system for
			 allocating and distributing the operational costs of the program and any
			 rebates obtained to participating programs; and
(g) Cooperate with any state or regional
			 consortia in bulk purchasing of prescription drugs.
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2010 - Pharmacy Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The pharmacy
			 shall contract with the Authority, or its designated entity, and must be
			 licensed with their state Board of Pharmacy to be a pharmacy provider for the
			 OPDP.
(2) The pharmacy provider
			 must sign a pharmacy provider contract and comply with all applicable state and
			 federal laws, regulations, rules, and the terms and conditions of the contract.
			 The contract authorizes the pharmacy provider to serve members in the OPDP and
			 outlines program compliance requirements.
(3) A contract may be issued to a qualified
			 pharmacy provider upon:
(a) Completion and
			 signature of the contract by the pharmacy provider or a person authorized by
			 the pharmacy provider to bind the organization;
(b) Verification of Pharmacy licensing with
			 their State Board of Pharmacy; and
(c) Approval of the contract by the Authority
			 or its designated entity.
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2020 - Program Price

Current through Register Vol. 63, No. 7, July 1, 2024
(1)  The price for a prescription drug a pharmacy provider may
				charge a member under the OPDP is the lesser of the following on the date of
				the transaction:
(a)  The program price, or
(b)  The pharmacy provider's usual and customary price,
				including program cost and dispensing fee.
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2030 - Preferred Drug List

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Administrator shall consider any PDL developed and recommended by OHPR that
			 identifies preferred choices of prescription drugs within therapeutic classes
			 for particular diseases and conditions, including generic alternatives, for use
			 in the OPDP by participating programs.
(2) The OPDP shall develop a PDL that
			 participating programs may choose to adopt for beneficiaries of their
			 prescription drug benefit program. The PDL shall include the most effective
			 prescription drugs at the lowest possible prices, taking into account
			 negotiated price discounts and rebates available to the OPDP, while allocating
			 and distributing the operational costs of the OPDP.
(3) If a participating program uses the PDL
			 developed by the OPDP, it must be used in conjunction with that participating
			 program's benefit plan including all pharmacy management programs the
			 participating program has or adopts.
(4) OPDP shall make the PDL available to
			 individuals enrolled in the OPDP.
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2050 - Enrollment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Participating
			 programs, other than the DCP, shall enroll for participation through the
			 designated entity chosen by the OPDP to administer the participating program's
			 enrollment and claims processing.
(a)
			 Eligibility for members of a participating program shall be maintained
			 electronically between the participating program and designated entity.
(b) Participating programs or
			 designated entities shall issue identification cards to members at initial
			 enrollment and renewal, and between those times as needed.
Oregon Administrative Rules › Chapter 431 - OREGON HEALTH AUTHORITY, OREGON PRESCRIPTION DRUG PROGRAM › Division 121 - OREGON PRESCRIPTION DRUG PROGRAM › Section 431-121-2065 - Contracted Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Administrator may procure goods and services to perform any of the functions of
			 OPDP.
(2) The Administrator shall
			 delegate procurement authority to the Authority's designated Procurement
			 Officer for OPDP goods and services, except as the Administrator determines to
			 retain such authority in a particular case and as otherwise provided in section
			 (4) of this rule.
(3) The
			 Administrator shall act as the Authority's representative for each contract.
			 The Administrator may delegate in writing the representative's responsibilities
			 to a designee. The agency's representative may participate with the Authority's
			 designated Procurement Officer in all aspects of procurement.
(4) OPDP's mechanism for and administration
			 of the enrollment of participating groups shall not constitute procurements
			 subject to this rule.
Stat. Auth.: ORS
				  414.312
Stats. Implemented: ORS
				  414.312,
				  414.314,
				  414.316 &
				  414.318
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0003 - Applicability and Purpose of these Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(1) OAR
			 436-001-0005 through
			 436-001-0009 establish
			 supplemental procedures for rulemaking under ORS chapter 183 and apply to all
			 division rulemaking on or after the date the rules are effective.
(2) OAR
			 436-001-0019 through
			 436-001-0296 establish
			 supplemental procedures for hearings on matters within the director's
			 jurisdiction.
(a) In general, the rules of the
			 Workers' Compensation Board in OAR chapter 438 apply to the conduct of
			 hearings, unless these rules provide otherwise.
(b) Except for OAR
			 436-001-0030, these rules do not
			 apply to hearings requested under ORS
			 656.740.
(c) These rules apply to hearings held on or
			 after the date the rules are effective.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0004 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Unless a term
			 is defined in these rules or the context otherwise requires, the definitions of
			 ORS chapter 656 and ORS
			 183.310 are incorporated by
			 reference and made a part of these rules.
(2) For the purpose of these rules:
(a) "
Administrative law judge
"
			 means an administrative law judge appointed by the Workers' Compensation Board,
			 as defined in OAR 438-005-0040.
(b) "
Board
" means the Workers'
			 Compensation Board and includes its Hearings Division.
(c) "
Delivered
" means physical
			 delivery to the division's Salem office during regular business
			 hours.
(d) "
Director
"
			 means the director of the Department of Consumer and Business Services or the
			 director's designee.
(e)
			 "
Division
" means the Workers' Compensation Division of the
			 Department of Consumer and Business Services.
(f) "
Filed
" means mailed, faxed,
			 emailed, delivered, or otherwise submitted to the division in a method
			 allowable under these rules.
(g)
			 "
Final order
" means a final, written action of the
			 director.
(h) "
Mailed
"
			 means addressed to the last known address, with sufficient postage and placed
			 in the custody of the U.S. Postal Service.
(i) "
Party
" refers to a party to
			 the hearing and may include, but is not limited to, a worker, an employer, an
			 insurer, a self-insured employer, a managed care organization, a medical
			 provider, or the division.
(j)
			 "
Proposed and final order
" means an order subject to revision by
			 the director that becomes final unless exceptions are timely filed or the
			 director issues a notice of intent to review the proposed and final
			 order.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0005 - Model Rules For Rulemaking

Current through Register Vol. 63, No. 7, July 1, 2024
The Model Rules for Rulemaking, OAR
				137-001-0005 through
				137-001-0100, in effect on Jan.
				1, 2008, adopted by the Oregon Department of Justice under ORS
				183.341, are adopted as the
				rules of procedure for rulemaking actions of the division. [NOTE: The full text
				of the Model Rules is available from the Department of Justice, the Workers'
				Compensation Division, or on the Oregon State Archives website at
https://secure.sos.state.or.us/oard/displayDivisionRules.action?selectedDivision=281
.]
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  183.325 -
				  183.410
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0009 - Notice of Division Rulemaking

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Except when adopting a temporary rule, the division will give prior public
			 notice of the proposed adoption, amendment, or repeal of any rule by:
(a) Publishing notice of the proposed
			 rulemaking action in the Secretary of State's Oregon Bulletin at least 21 days
			 before the effective date of the rule;
(b) Notifying interested people and
			 organizations on the division's notification lists of proposed rulemaking
			 actions under ORS 183.335; and
(c) Providing notice to legislators as
			 required by ORS 183.335(15).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0019 - Requests for Hearing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A
			 request for hearing on a matter within the director's jurisdiction must be
			 filed with the division no later than the filing deadline. Filing deadlines
			 will not be extended except as provided in section (7) of this rule.
(2) A request for hearing must be in writing.
			 A party may use the division's Form 2839, "Workers' Compensation Division
			 Request for Hearing," available on the division's website at
http://wcd.oregon.gov/forms/Pages/forms.aspx
.
			 A request for hearing must include the following information, as applicable:
(a) The name, address, and phone number of
			 the party making the request;
(b)
			 Whether the party making the request is the worker, insurer, medical provider,
			 employer, any other party, or an attorney on behalf of a party;
(c) The number of the administrative order
			 being appealed;
(d) The worker's
			 name, address, and phone number;
(e) The name, address, and phone number of
			 the worker's attorney, if any;
(f)
			 The date of injury;
(g) The
			 insurer's or self-insured employer's claim number;
(h) The division's file number; and
(i) The reason for requesting a
			 hearing.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0023 - Other Filings and Submissions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Except as provided in section (3) of this
			 rule, any filing, motion, request, document, or correspondence filed or
			 submitted in a matter within the director's jurisdiction must be filed or
			 submitted:
(a) To the division before the
			 dispute is referred to the board;
(b) To the administrative law judge after the
			 dispute is referred to the board but before the administrative law judge issues
			 a proposed and final order; and
(c)
			 To the division after the administrative law judge issues a proposed and final
			 order, unless it is a request for correction of errors in the proposed and
			 final order under OAR
			 436-001-0246(7).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0027 - Timeliness; Calculation of Time

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Timeliness of any document required by these rules to be filed 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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0030 - Role of the Workers' Compensation Division

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In any
			 hearing, the director may request to:
(a)
			 Receive notice of all matters;
(b)
			 Receive copies of all documents; and
(c) Present evidence, testimony, and
			 argument.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0170 - Duties and Powers of the Administrative Law Judge

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The administrative law judge may conduct
			 the hearing in any manner consistent with these rules that will achieve
			 substantial justice.
(2) Unless
			 provided otherwise by statute or rule and except as stated in section (3) of
			 this rule, any order issued by an administrative law judge regarding a matter
			 within the director's jurisdiction is a proposed and final order subject to
			 review by the director under OAR
			 436-001-0246.
(3) When appropriate, the administrative law
			 judge may issue an interim order. An interim order is not subject to review by
			 the director under OAR
			 436-001-0246.
(4) The administrative law judge may dismiss
			 requests for hearing as provided in OAR
			 436-001-0296.
(5) When appropriate, the administrative law
			 judge may remand a dispute to the director for further administrative
			 action.
(6) The administrative law
			 judge may consolidate matters in which there are common parties or common
			 issues of law or fact.
(7) The
			 administrative law judge may separate matters to promote efficient disposition
			 of the matters.
(8) Consolidation of
			 matters under section (6) of this rule or under ORS
			 656.704(3)(c)
			 is only for the purpose of hearing. The administrative law judge must issue a
			 separate order for matters other than those concerning a claim.
(9) On the motion of a party, the division,
			 or the administrative law judge, the administrative law judge may continue a
			 hearing to allow the presentation of oral or written legal argument by the
			 Department of Justice.
(10) The
			 administrative law judge may send the division a written question regarding
			 which rules or statutes apply to a matter, or regarding the division's
			 interpretation of the rules and statutes. If the administrative law judge sends
			 such a question, the administrative law judge must provide a written summary of
			 the context in which the question arises, provide a reasonable time for the
			 division to respond, and send a copy to all parties.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.704
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0225 - Scope of Review/Limitations on the Record

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Except for the matters listed in sections
			 (2) and (3) of this rule and unless otherwise provided by statute or
			 administrative rule:
(a) The administrative
			 law judge reviews all matters within the director's jurisdiction de novo;
			 and
(b) New evidence may be
			 admitted and considered.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0240 - The Record

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Not more
			 than 30 days after referring a request for hearing to the board, the division
			 will provide the parties and the administrative law judge with copies of all
			 documents in the director's record.
(2) Not less than 28 days before the hearing,
			 or within seven days of receipt of the director's record, whichever is later,
			 the insurer or self-insured employer must provide the other parties legible
			 copies of all documents, from the director's record, that the insurer or
			 self-insured employer will rely on at hearing. The documents must be numbered
			 and indexed as provided in OAR
			 438-007-0018(1).
(3) Not less than 14 days before the hearing,
			 or within seven days of receipt of the insurer's or self-insured employer's
			 documents and index, whichever is later, the other parties must provide legible
			 copies of any additional documents, from the director's record, that they will
			 rely on at hearing. The documents must be numbered and indexed as provided in
			 OAR 438-007-0018(2).
(4) The parties may include with their
			 documents and indexes documents that are not included in the director's record
			 only if new evidence is allowed under OAR
			 436-001-0225.
(5) Before or at the hearing, the parties
			 must submit their documents and indexes to the administrative law judge as
			 provided in OAR 438-007-0018 or as otherwise
			 required by the administrative law judge.
(6) Unless withdrawn, all documents offered
			 by a party will be included in the hearing file, whether or not they are
			 admitted into the evidentiary record by the administrative law judge.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.704
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0246 - Proposed and Final Orders - Exceptions, Correction, Director Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Under ORS
			 656.704(2)(a),
			 a party must seek director review of a proposed and final order before
			 petitioning for judicial review under ORS
			 183.482.
(2) The parties or the division may initiate
			 director review of a proposed and final order by filing exceptions as follows:
(a) Written exceptions, including any
			 argument, must be filed with the division within 30 days of the mailing date of
			 the proposed and final order.
(b)
			 A written response to the exceptions must be filed within 20 days of the date
			 the exceptions were filed.
(c) A
			 written reply to the response, if any, must be filed within 10 days of the date
			 the response was filed.
(d)
			 Exceptions, responses, and replies may be filed in any of the following ways:
(A) By mail, to the following address:
WCD Hearings
Workers' Compensation Division
P.O. Box 14480
Salem, OR 97309-0405
(B) By hand-delivery, to the following
			 address:
WCD Hearings
350 Winter Street NE, 2nd floor
Salem, OR 97301
(C) By fax, to 503-947-7511, if the document
			 transmitted indicates that it has been delivered by fax, is sent to the correct
			 fax number, and indicates the date the document was sent.
(D) By email, to
			 wcd.hearings@dcbs.oregon.gov. If the exception, response, or reply is in an
			 attachment to the email, the attachment must be in a format that Microsoft Word
			 2010® (.docx, .doc, .txt, .rtf) or Adobe Reader® (.pdf) can open. Image
			 formats that can be viewed in Internet Explorer® (.tif, .jpg) are also
			 acceptable.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0252 - Stay of Director and Administrative Review

Current through Register Vol. 63, No. 7, July 1, 2024
The director may stay director review, administrative review,
				or referral of a matter if there is another pending matter concerning a claim
				that may affect the outcome of the matter within the director's
				jurisdiction.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.704
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0259 - Ex Parte Communication

Current through Register Vol. 63, No. 7, July 1, 2024
An ex parte communication is an oral or written communication
				to the director during director review of the matter not made in the presence
				of all parties to the dispute, concerning a fact in issue, but does not include
				communication from division staff or the Department of Justice about legal
				issues or facts in the record. Ex parte communications received during director
				review will be promptly disclosed to all parties, and the parties will be
				allowed a reasonable opportunity to respond.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.704 & OL 2005, Ch.
				  26
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0296 - Settlements and Dismissals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) If,
			 after a request for hearing is filed but before a proposed and final order is
			 issued, an agreement under ORS
			 656.236 or
			 656.289(4) is
			 approved that resolves all issues in the matter within the director's
			 jurisdiction, the administrative law judge may issue a proposed and final order
			 dismissing the request for hearing.
(2) If, after a request for hearing is filed
			 but before a proposed and final order is issued, the parties reach agreement on
			 all issues in the matter within the director's jurisdiction, the administrative
			 law judge may issue a proposed and final order approving the agreement and
			 dismissing the request for hearing.
(3) If the matter within the director's
			 jurisdiction is consolidated with matters concerning a claim and the parties
			 reach agreement on all issues in the matter within the director's jurisdiction
			 before issuance of a proposed and final order, the administrative law judge may
			 issue a proposed and final order approving the agreement and dismissing the
			 request for hearing.
(4)
			 Notwithstanding OAR 436-001-0170(2),
			 the administrative law judge may issue a final order of dismissal when the
			 requesting party withdraws the request for hearing and no cross-request for
			 hearing has been filed.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.704
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0400 - General Provisions and Requirements for Attorney Fees Awarded by the Director

Current through Register Vol. 63, No. 7, July 1, 2024
In addition to the specific provisions in OAR
				436-001-0410 through
				436-001-0435, the following
				provisions apply when the director awards an attorney fee:
(1) In order to be awarded an attorney fee,
			 the attorney must file with the director a signed attorney retainer
			 agreement.
(2) In cases in which
			 time devoted is a factor 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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0410 - Attorney Fees Awarded under ORS 656.385(1)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In cases in
			 which the director or administrative law judge awards a fee under ORS
			 656.385(1):
(a) The fee must fall within the ranges of
			 the matrix in subsection (1)(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 (1)(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 awarded under ORS
			 656.385(1) will
			 not be adjusted for that year.
(d)
			 See attached table.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0420 - Attorney Fees Awarded under ORS 656.262(11)

Current through Register Vol. 63, No. 7, July 1, 2024
In cases in which the director awards a fee 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 & 2015 OL, ch. 521
				  & sec. 2
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0430 - Attorney Fees Awarded under ORS 656.262(12)

Current through Register Vol. 63, No. 7, July 1, 2024
The matrix for determining the amount of the attorney fee
				assessed 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
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0432 - Attorney Fees Under ORS 656.268(6)(c) (Additional Compensation at Reconsideration)

Current through Register Vol. 63, No. 7, July 1, 2024
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)
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0435 - Attorney Fees Awarded under ORS 656.277(1)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Attorney fees
			 awarded 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 $275 per hour and no more than $400 per
			 hour.
(3) When determining the time
			 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)
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0438 - Attorney Fees Under ORS 656.383(1) (Temporary Disability Compensation Benefits)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An attorney fee
			 under ORS 656.383(1) is
			 payable after an order on reconsideration under ORS
			 656.268 is issued, as provided
			 in this rule. If attorney fees under ORS
			 656.383(1) are
			 at issue at hearing or on board review, the rules in OAR chapter 438
			 apply.
(2) Using the matrix in
			 section (5) of this rule, the insurer must calculate the amount of and pay to
			 the worker's attorney a fee when:
(a) The
			 worker disagrees with the temporary disability dates shown on the Notice of
			 Closure and raises it as an issue in the request for reconsideration under ORS
			 656.268;
(b) The reconsideration order issued under
			 ORS 656.268 modifies the temporary
			 disability dates shown on the Notice of Closure;
(c) As a result of the modification of the
			 temporary disability dates, the insurer determines additional temporary
			 disability compensation benefits are due and payable to the worker;
			 and
(d) The worker was represented
			 by an attorney in the reconsideration proceeding.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0440 - Time Within Which Attorney Fees Must Be Paid

Current through Register Vol. 63, No. 7, July 1, 2024
Attorney fees assessed under OAR
				436-001-0400 to
				436-001-0440 must be paid within
				14 days of the date the order awarding the fees becomes final.
Statutory/Other Authority: ORS
				  656.385(1)
				  & 656.726(4)
Statutes/Other Implemented: ORS
				  656.262,
				  656.385,
				  656.388 &
				  656.704
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0500 - Refund of Overpayments

Current through Register Vol. 63, No. 7, July 1, 2024
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
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0600 - Multilingual Help Page

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 1 - PROCEDURAL RULES, ATTORNEY FEES, AND GENERAL PROVISIONS › Section 436-001-0610 - Duty to Forward Misdirected Request

Current through Register Vol. 63, No. 7, July 1, 2024
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
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0001 - Authority, Applicability, Purpose, and Administration of these Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  656.252,
				  656.254 &
				  656.726(4)
Stats. Implemented: ORS
				  656.252,
				  656.254 &
				  656.726(4)
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0004 - Adoption of Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 director adopts, by reference, the following electronic medical bill processing
			 standards:
(a) Professional Billing:
(A) The Accredited Standards Committee X12
			 (ASC X12) Standards for Electronic Data Interchange (EDI) Type 3 Technical
			 Reports (TR3);
(B) Health Care
			 Claim: Professional (837), May 2006, ASC X12, 005010X222; and
(C) Type 3 Errata to Health Care Claim:
			 Professional (837), June 2010, ASC X12, 005010X222A1.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
For the purpose of these rules and the Oregon Electronic
				Billing and Payment Companion Guide:
(1) "Clearinghouse" means an entity that is
			 an authorized agent of the insurer or health care provider, including billing
			 services, re-pricing companies, community health management information systems
			 or community health information systems, and "value-added" networks and
			 switches that does either of the following functions:
(a) Processes or facilitates the processing
			 of health information received from another entity in a nonstandard format or
			 containing nonstandard data content into standard data elements or a standard
			 transaction.
(b) Receives a
			 standard transaction from another entity and processes or facilitates the
			 processing of health information into nonstandard format or nonstandard data
			 content for the receiving entity.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0010 - Electronic Medical Bills

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  656.252,
				  656.254 &
				  656.726(4)
Stats. Implemented: ORS
				  656.252 &
				  656.254
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0015 - Electronic Medical Bill Attachments or Documentation

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0020 - Electronic Medical Bill Acknowledgements

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  656.252,
				  656.254 &
				  656.726(4)
Stats. Implemented: ORS
				  656.252 &
				  656.254
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0025 - Electronic Medical Bill Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Stat. Auth.: ORS
				  656.252,
				  656.254 &
				  656.726(4)
Stats. Implemented: ORS
				  656.252 &
				  656.254
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0030 - Electronic Remittance Advice; Explanation of Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 8 - ELECTRONIC MEDICAL BILLING › Section 436-008-0040 - Assessment of Civil Penalties

Current through Register Vol. 63, No. 7, July 1, 2024
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.
Stat. Authority: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.252 &
				  656.254