Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
Unless a term is specifically defined elsewhere in these rules
				or the context otherwise requires, the definitions of ORS chapter 656 and OAR
				436-010-0005 are hereby
				incorporated by reference and made a part of these rules.
(1)
"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.
(2)
"Come-along provider"
means a primary care physician, a
			 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.
(3)
"Coordinated health care program"
means an employer program
			 providing for the coordination of a separate policy of group health insurance
			 coverage with the medical portion of workers' compensation coverage, for some
			 or all of the employer's workers, which provides workers with health care
			 benefits even if a workers' compensation claim is denied.
(4)
"Division"
means the
			 Workers' Compensation Division of the Department of Consumer and Business
			 Services.
(5)
"Geographic
			 service area (GSA)"
means an area of the state in which a managed care
			 organization may be authorized by the director of the Department of Consumer
			 and Business Services to provide managed care services. There are 15 geographic
			 service areas in Oregon.
(6)
"Good cause"
means circumstances that are outside the control of a
			 party or circumstances that are considered to be extenuating by the
			 division.
(7)
"Group of
			 medical service providers"
means individuals duly licensed to practice
			 one or more of the healing arts who join together to provide medical services
			 through a managed care organization, whether or not such providers have an
			 ownership interest in the managed care organization.
(8)
"Health care provider"
means
			 an entity or group of entities, organized to provide health care services or to
			 provide administrative support services to entities providing health care
			 services. An entity solely organized to become an MCO under these rules is not,
			 in and of itself, a health care provider.
(9)
"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 and meets the
			 qualifications of a self-insured employer under ORS
			 656.407.
(10)
"Managed care organization"
			 ("MCO")
means an organization formed to provide medical services and
			 certified under these rules.
(11)
"Medical provider"
means a medical service provider, a hospital, a
			 medical clinic, or a vendor of medical services.
(12)
"Medical service"
means any
			 medical treatment or any medical, surgical, diagnostic, chiropractic, dental,
			 hospital, nursing, ambulance, and other related services, and drugs, medicine,
			 crutches and prosthetic appliances, braces and supports, and, where necessary,
			 physical restorative services.
(13)
"Medical service provider"
means a person duly licensed to
			 practice one or more of the healing arts.
(14)
"Non-qualifying employer"
means either:
(a) An insurer as defined in
			 this rule, with respect to managed care services to be provided to any subject
			 worker; or
(b) An employer as
			 defined under ORS 656.005(13),
			 other than a health care provider, with respect to managed care services to
			 such employer's employees.