reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0001 - Purpose and Applicability of These Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0004 - Adoption of Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 director adopts, by reference, the American Society of Anesthesiologists ASA,
			 Relative Value Guide 2024 as a supplementary fee schedule for those anesthesia
			 codes not found in Appendix B. To get a copy of the ASA Relative Value Guide
			 2024, contact the American Society of Anesthesiologists, 1061 American Lane,
			 Schaumberg, IL 60173, 847-825-5586, or
www.asahq.org
.
(2) The director adopts, by reference, the
			 American Medical Association's (AMA) Current Procedural Terminology (CPT®
			 2024), Fourth Edition Revised, 2023, for billing by medical providers. The
			 definitions, descriptions, and guidelines found in CPT® 2024 govern the
			 descriptions of services, except as otherwise provided in these rules. The
			 guidelines are adopted as the basis for determining level of service.
(3) The director adopts, by reference, the
			 AMA's CPT® Assistant, Volume 0, Issue 04 1990 through Volume 32, Issue 12,
			 2023. If there is a conflict between CPT® 2024 and the CPT® Assistant,
			 CPT® 2024 is the controlling resource.
(4) To get a copy of the CPT® 2023,
			 CPT® 2024, or the CPT® Assistant, contact the American Medical
			 Association, AMA Plaza, 330 N. Wabash Ave., Suite 39300, Chicago, IL
			 60611-5885, 312-464-4782, or
www.ama-assn.org
.
(5) The director adopts, by reference, only
			 the alphanumeric codes from the CMS Healthcare Common Procedure Coding System
			 (HCPCS). These codes are to be used when billing for services, but only to
			 identify products, supplies, and services that are not described by CPT®
			 codes or that provide more detail than a CPT® code.
(a) Except as otherwise provided in these
			 rules, the director does not adopt the HCPCS edits, processes, exclusions,
			 color-coding and associated instructions, age and sex edits, notes, status
			 indicators, or other policies of CMS.
(b) To get a copy of the HCPCS, contact the
			 National Technical Information Service, Springfield, VA 22161, 800-621-8335 or
www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html
.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0005 - 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) Abbreviations used in
			 these rules are either defined in the rules in which they are used or defined
			 as follows:
(a) CMS means Centers for Medicare
			 & Medicaid Services.
(b)
			 CPT® means Current Procedural Terminology published by the American Medical
			 Association.
(c) DMEPOS means
			 durable medical equipment, prosthetics, orthotics, and supplies.
(d) EDI means electronic data
			 interchange.
(e) HCPCS means
			 Healthcare Common Procedure Coding System published by CMS.
(f) ICD-9-CM means International
			 Classification of Diseases, Ninth Revision, Clinical Modification, Vol. 1, 2
			 & 3 by US Department of Health and Human Services.
(g) ICD-10-CM means International
			 Classification of Diseases, Tenth Revision, Clinical Modification.
(h) MCO means managed care organization
			 certified by the director.
(i) NPI
			 means national provider identifier.
(j) OSC means Oregon specific code.
(k) PCE means physical capacity
			 evaluation.
(l) WCE means work
			 capacity evaluation.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0008 - Request for Review before the Director

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) Except as otherwise provided in ORS
			 656.704, the director has
			 exclusive jurisdiction to resolve all disputes concerning medical fees,
			 nonpayment of compensable medical bills, and medical service and treatment
			 disputes arising under ORS
			 656.245,
			 656.247,
			 656.248,
			 656.260,
			 656.325, and
			 656.327. Disputes about whether
			 a medical service provided after a worker is medically stationary is
			 compensable within the meaning of ORS
			 656.245(1)(c),
			 or whether a medical treatment is unscientific, unproven, outmoded, or
			 experimental under ORS
			 656.245(3), are
			 subject to administrative review before the director.
(b) As provided in ORS
			 656.704(3)(b),
			 the following disputes are in the jurisdiction of the board and will be
			 transferred:
(A) A dispute that requires a
			 determination of the compensability of the medical condition for which medical
			 services are proposed; and
(B) A
			 dispute that requires a determination of whether a sufficient causal
			 relationship exists between medical services and an accepted claim.
(c) A party does not need to be
			 represented to participate in the administrative review before the
			 director.
(d) Any party may request
			 that the director provide voluntary mediation or alternative dispute resolution
			 after a request for administrative review or hearing is filed.
(e) A request for administrative review under
			 this rule may also be filed as prescribed in OAR 438-005.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0010 - Medical Billing and Payment

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) Only treatment that
			 falls within the scope and field of the medical provider's license to practice
			 will be paid under a workers' compensation claim. Except for emergency services
			 or as otherwise provided for by statute or these rules, treatments and medical
			 services are only payable if approved by the worker's attending physician or
			 authorized nurse practitioner. Fees for services by more than one physician at
			 the same time are payable only when the services are sufficiently different
			 that separate medical skills are needed for proper care.
(b) All billings must include the patient's
			 full name, date of injury, and the employer's name. If available, billings must
			 also include the insurer's claim number and the provider's NPI. If the provider
			 does not have an NPI, then the provider must provide its license number and the
			 billing provider's FEIN. For provider types not licensed by the state, "99999"
			 must be used in place of the state license number. Bills must not contain a
			 combination of ICD-9 and ICD-10 codes.
(c) The medical provider must bill their
			 usual fee charged to the general public. The submission of the bill by the
			 medical provider is a warrant that the fee submitted is the usual fee of the
			 medical provider for the services rendered. The director may require
			 documentation from the medical provider establishing that the fee under
			 question is the medical provider's usual fee charged to the general public. For
			 purposes of this rule, "general public" means any person who receives medical
			 services, except those persons who receive medical services subject to specific
			 billing arrangements allowed under the law that require providers to bill other
			 than their usual fee.
(d) Medical
			 providers must not submit false or fraudulent billings, including billing for
			 services not provided. As used in this section, "false or fraudulent" means an
			 intentional deception or misrepresentation with the knowledge that the
			 deception could result in unauthorized benefit to the provider or some other
			 person. A request for pre-payment for a deposition is not considered false or
			 fraudulent.
(e) When a provider
			 treats a patient with two or more compensable claims, the provider must bill
			 individual medical services for each claim separately.
(f) When rebilling, medical providers must
			 indicate that the charges have been previously billed.
(g) If a patient requests copies of medical
			 bills in writing, medical providers must provide copies within 30 days of the
			 request, and provide any copies of future bills during the regular billing
			 cycle.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0012 - Telehealth

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Definitions.
(a) For the purpose
			 of this rule, "
telehealth
" means providing healthcare remotely by
			 means of telecommunications technology, including but not limited to
			 telemedicine and telephonic or online digital services.
(b) For the purpose of this rule,
			 "
telemedicine
" means synchronous medical services provided via a
			 real-time interactive audio and video telecommunications system between a
			 patient at an originating site and a provider at a distant site.
(c) "
Distant site
" means the
			 place where the provider providing medical services to a patient through
			 telehealth is located.
(d)
			 "
Originating site
" means the place where the patient receiving
			 medical services through telehealth is located.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0018 - Discounts and Contracts

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Discounts.
(a) An insurer may
			 only apply the following discounts to a medical service provider's or clinic's
			 fee:
(A) A fee agreed to under a fee discount
			 agreement that conforms to this rule and has been reported to the director;
			 or
(B) A fee agreed to by the
			 medical service provider or clinic under an MCO contract to cover services
			 provided to a worker enrolled in the MCO.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0020 - Hospitals

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Inpatient.
(a) For the purposes
			 of this rule, hospital inpatient services are those services that are billed
			 with codes "0111" through "0118" in form locator #4 on the UB-04 billing
			 form.
(b) Hospital inpatient bills
			 must include:
(A) For dates of service prior
			 to Oct. 1, 2015, ICD-9-CM codes, and for dates of service on and after Oct. 1,
			 2015, ICD-10-CM codes;
(B) When
			 applicable, procedural codes;
(C)
			 The hospital's NPI; and
(D) The
			 Medicare Severity Diagnosis Related Group (MS-DRG) code, except for:
(i) Bills from critical access hospitals,
			 (See Bulletin 290); or
(ii) Bills
			 containing revenue code 002x.
(c) Unless otherwise provided by contract,
			 the insurer must pay the audited bill for hospital inpatient services by
			 multiplying the amount charged by the hospital's adjusted cost-to-charge ratio
			 (See Bulletin 290). The insurer must pay in-state hospitals not listed in
			 Bulletin 290 at 80 percent of billed charges for inpatient services.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0023 - Ambulatory Surgery Center (ASC)

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Billing Form.
(a) The ASC must submit bills on a completed,
			 current CMS 1500 form (see OAR
			 436-009-0010
			 (3)) unless the ASC submits medical bills
			 electronically. Computer-generated reproductions of the CMS 1500 form may also
			 be used.
(b) The ASC must add a
			 modifier "SG" in box 24D of the CMS 1500 form to identify the facility
			 charges.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0025 - Worker Reimbursement

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) When the insurer
			 accepts the claim the insurer must notify the worker in writing that:
(A) The insurer will reimburse claim-related
			 services paid by the worker; and
(B) The worker has two years to request
			 reimbursement.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0030 - Insurer's Duties and Responsibilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) The insurer must pay for medical services
			 related to a compensable injury claim, except as provided by OAR
			 436-060-0055.
(b) The insurer, or its designated agent, may
			 request from the medical provider any and all necessary records needed to
			 review accuracy of billings. The medical provider may charge an appropriate fee
			 for copying documents under OAR
			 436-009-0060. If the evaluation
			 of the records must be conducted on-site, the provider must furnish a
			 reasonable work-site for the records to be reviewed at no cost. These records
			 must be provided or made available for review within 14 days of a
			 request.
(c) The insurer must
			 establish an audit program for bills for all medical services to determine that
			 the bill reflects the services provided, that appropriate prescriptions and
			 treatment plans are completed in a timely manner, that payments do not exceed
			 the maximum fees adopted by the director, and that bills are submitted in a
			 timely manner. The audit must be continuous and must include no fewer than 10
			 percent of medical bills. The insurer must provide upon the director's request
			 documentation establishing that the insurer is conducting a continuous audit of
			 medical bills. This documentation must include, but not be limited to, medical
			 bills, internal audit forms, and any medical charge summaries prepared by
			 private medical audit companies.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0035 - Interim Medical Benefits

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0040 - Fee Schedule

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Fee
			 Schedule Table.
(a) Unless otherwise
			 provided by contract or fee discount agreement allowed by these rules, insurers
			 must pay according to the following table: [See attached table.]
(b) The global period is listed in the column
			 'Global Days' of Appendix B.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0060 - Oregon Specific Codes

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Multidisciplinary Services.
(a)
			 Services provided by multidisciplinary programs not otherwise described by
			 CPT® codes must be billed under Oregon specific codes.
(b) Bills using the multidisciplinary codes
			 must include copies of the treatment record that specifies:
(A) The type of service rendered,
(B) The medical provider who provided the
			 service,
(C) Whether treatment was
			 individualized or provided in a group session, and
(D) The amount of time treatment was rendered
			 for each service billed.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0080 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Durable medical equipment
(DME), such as Transcutaneous Electrical
			 Nerve Stimulation (TENS), Microcurrent Electrical Nerve Stimulation (MENS),
			 home traction devices, heating pads, reusable hot/cold packs, etc., is
			 equipment that:
(a) Is primarily and
			 customarily used to serve a medical purpose,
(b) Can withstand repeated use,
(c) Could normally be rented and used by
			 successive patients,
(d) Is
			 appropriate for use in the home, and
(e) Is not generally useful to a person in
			 the absence of an illness or injury.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0090 - Pharmaceutical

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) Unless otherwise
			 provided by an MCO contract, prescription medications do not require prior
			 approval even after the patient is medically stationary.
(b) When a provider prescribes a brand-name
			 drug, pharmacies must dispense the generic drug (if available), according to
			 ORS 689.515. However, a patient may
			 insist on receiving the brand-name drug and either pay the total cost of the
			 brand-name drug out of pocket or pay the difference between the cost of the
			 brand-name drug and generic to the pharmacy.
(c) Unless otherwise provided by MCO
			 contract, the patient may select the pharmacy.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0110 - Interpreters

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Choosing
			 an Interpreter.
(a) A worker may
			 choose a person to communicate with a medical provider when the worker and the
			 medical provider speak different languages, including sign language. The worker
			 may choose a family member, a friend, an employee of the medical provider, or
			 an interpreter. However, for signed language interpretation services, the
			 worker may only choose an interpreter who is a medical sign language
			 interpreter licensed under Oregon Laws 2023, chapter 414, section 6. A
			 representative of the worker's employer may not provide interpreter services.
			 The medical provider may disapprove of the worker's choice at any time the
			 medical provider feels the interpreter services are not improving communication
			 with the worker, or feels the interpretation is not complete or
			 accurate.
(b) When a worker asks an
			 insurer to arrange for interpreter services, the insurer must:
(A) For interpretation services, other than
			 signed language interpretation services, use a certified or qualified health
			 care interpreter listed on the Oregon Health Care Interpreter Registry of the
			 Oregon Health Authority available at:
http://www.oregon.gov/OHA/OEI/Pages/HCI-Program.aspx
.
			 The interpreter's certification or qualification must be in effect on the date
			 the interpreter services are provided. If no certified or qualified health care
			 interpreter is available, the insurer may schedule an interpreter of its choice
			 subject to the limits in subsection (a) of this section.
(B) For signed language interpretation
			 services, use a sign language interpreter licensed under Oregon Laws 2023,
			 chapter 414.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 9 - OREGON MEDICAL FEE AND PAYMENT › Section 436-009-0998 - Sanctions and Civil Penalties

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The director may impose sanctions upon a medical provider or insurer for
			 violation of these rules in accordance with OAR
			 436-010-0340.
(2) If an insurer applies a contract or fee
			 discount agreement to a provider's bill that is incorrect, the insurer must pay
			 the provider's bill at the provider's usual fee or according to the fee
			 schedule, whichever is less, and the insurer may be subject to a civil penalty.
(3) Although insurers may contract
			 with provider networks for certain services, the insurer is responsible for
			 their own actions as well as the actions of others acting on the insurer's
			 behalf. If an insurer or someone acting on the insurer's behalf violates any
			 provision of these rules, the director may impose a civil penalty against the
			 insurer.
(4) If the director finds
			 a pattern and practice, or an egregious violation of applying incorrect
			 discounts to providers' fees under these rules, by an insurer or someone acting
			 on the insurer's behalf, the director may issue a civil penalty up to the
			 amount allowed under ORS Chapter 656.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.245,
				  656.254,
				  656.745
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0001 - Administration of These Rules

Current through Register Vol. 63, No. 7, July 1, 2024
(1) 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.
(2)
Authority for Rules.
These rules are promulgated under the
			 director's general rulemaking authority of ORS
			 656.726(4) for
			 administration of and pursuant to ORS chapter 656, particularly: ORS
			 656.245,
			 656.248,
			 656.250,
			 656.252,
			 656.254,
			 656.256,
			 656.260,
			 656.268,
			 656.273,
			 656.313,
			 656.325,
			 656.327,
			 656.331,
			 656.704, and
			 656.794.
(3)
Purpose.
The purpose of
			 these rules is to establish uniform standards for administering the delivery of
			 and payment for medical services to workers within the workers' compensation
			 system.
(4)
Applicability of
			 Rules.
(a) These rules apply on or
			 after the effective date to carry out the provisions of ORS
			 656.245,
			 656.247,
			 656.248,
			 656.250,
			 656.252,
			 656.254,
			 656.256,
			 656.260,
			 656.268,
			 656.313,
			 656.325,
			 656.327,
			 656.331,
			 656.704, and
			 656.794, and govern all
			 providers of medical services licensed or authorized to provide a product or
			 service under ORS chapter 656.
(b)
			 The director may waive procedural rules as justice requires, unless otherwise
			 obligated by statute.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0002 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.245, ORS
				  656.248, ORS
				  656.252, ORS
				  656.254, ORS
				  656.256, ORS
				  656.260, ORS
				  656.268, ORS
				  656.325, ORS
				  656.327 & ORS
				  656.794(3)
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0003 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.245,
				  656.248,
				  656.250,
				  656.252,
				  656.254,
				  656.256,
				  656.260,
				  656.268,
				  656.273,
				  656.313,
				  656.325,
				  656.327,
				  656.331,
				  656.704 &
				  656.794
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0006 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.726
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0008 - Request for Review before the Director

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
(a) Except as otherwise provided in ORS
			 656.704, the director has
			 exclusive jurisdiction to resolve all disputes concerning medical fees,
			 nonpayment of compensable medical bills, and medical service and treatment
			 disputes arising under ORS
			 656.245,
			 656.247,
			 656.248,
			 656.260,
			 656.325, and
			 656.327. Disputes about whether
			 a medical service provided after a worker is medically stationary is
			 compensable within the meaning of ORS
			 656.245(1)(c),
			 or whether a medical treatment is unscientific, unproven, outmoded, or
			 experimental under ORS
			 656.245(3), are
			 subject to administrative review before the director.
(b) As provided in ORS
			 656.704(3)(b),
			 the following disputes are in the jurisdiction of the board and will be
			 transferred:
(A) A dispute that requires a
			 determination of the compensability of the medical condition for which medical
			 services are proposed; and
(B) A
			 dispute that requires a determination of whether a sufficient causal
			 relationship exists between medical services and an accepted claim.
(c) A party does not need to be
			 represented to participate in the administrative review before the
			 director.
(d) Any party may request
			 that the director provide voluntary mediation or alternative dispute resolution
			 after a request for administrative review or hearing is filed.
(e) All issues pertaining to disagreements
			 about medical services within a managed care organization (MCO), including
			 disputes under ORS 656.245(4)(a)
			 about whether a change of provider will be medically detrimental to the worker,
			 are subject to ORS 656.260. A party dissatisfied
			 with an action or decision of the MCO must first apply for and complete the
			 internal dispute resolution process within the MCO before requesting an
			 administrative review of the matter before the director.
(f) The director may, on the director's own
			 motion, initiate a review of medical services or medical treatment at any
			 time.
(g) If the director issues an
			 order declaring an already rendered medical treatment or medical service
			 inappropriate, or otherwise in violation of the statute or medical rules, the
			 worker is not obligated to pay for such.
(h) A request for administrative review under
			 this rule may also be filed as prescribed in OAR 438-005.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0200 - Medical Advisory Committee

Current through Register Vol. 63, No. 7, July 1, 2024
The Medical Advisory Committee members are appointed by the
				director of the Department of Consumer and Business Services. The committee
				must include one insurer representative, one employer representative, one
				worker representative, one managed care organization representative, and a
				diverse group of health care providers representative of those providing
				medical care to injured or ill workers.
The director may appoint other persons as may be determined
				necessary to carry out the purpose of the committee. Health care providers must
				comprise a majority of the committee at all times. When appointing members, the
				director should select health care providers who will consider the perspective
				of specialty care, primary care, and ancillary care providers and consider the
				ability of members to represent the interests of the community at
				large.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.794
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0210 - Attending Physician, Authorized Nurse Practitioner, and Temporary Disability Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An attending
			 physician or authorized nurse practitioner is primarily responsible for the
			 patient's care, authorizes temporary disability, and prescribes and monitors
			 ancillary care and specialized care.
(a) No
			 later than five days after becoming a patient's attending physician or
			 authorized nurse practitioner, the provider must notify the insurer using Form
			 827. Regardless of whether Form 827 is filed, the facts of the case and the
			 actions of the provider determine if the provider is the attending physician or
			 authorized nurse practitioner.
(b)
			 Type A, type B, and type C attending physicians and authorized nurse
			 practitioners may authorize temporary disability and manage medical services
			 subject to the limitations of ORS chapter 656 or a managed care organization
			 contract. (See Appendix A "Matrix for Health Care Provider Types"
			 [Attached])
(c) Except for
			 emergency services, or otherwise provided for by statute or these rules, all
			 treatments and medical services must be approved by the worker's attending
			 physician or authorized nurse practitioner.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0220 - Choosing and Changing Medical Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The worker may
			 have only one attending physician or authorized nurse practitioner at a time.
			 Concurrent treatment or services by other medical providers, including
			 specialist physicians, must be sufficiently different that separate medical
			 skills are needed for proper care, and must be based on a written referral by
			 the attending physician or authorized nurse practitioner. The referral must
			 specify any limitations and a copy must be sent to the insurer. A specialist
			 physician is authorized to provide or order all compensable medical services
			 and treatment the physician considers appropriate, unless the referral is for a
			 consultation only. The attending physician or authorized nurse practitioner
			 continues to be responsible for authorizing temporary disability even if the
			 specialist physician is providing or authorizing medical services and
			 treatment. Physicians who provide the following services are not considered
			 attending physicians:
(a) Emergency
			 services;
(b) Insurer or director
			 requested examinations;
(c) A
			 Worker Requested Medical Examination;
(d) Consultations or referrals for
			 specialized treatment or services initiated by the attending physician or
			 authorized nurse practitioner; and
(e) Diagnostic studies provided by
			 radiologists and pathologists upon referral.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0225 - Choosing a Person to Provide Interpreter Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A worker may
			 choose a person to communicate with a medical provider when the worker and the
			 medical provider speak different languages, including sign language. The worker
			 may choose a family member, a friend, an employee of the medical provider, or
			 someone who provides interpreter services as a profession. However, a
			 representative of the worker's employer may not provide interpreter services.
			 The medical provider may disapprove of the worker's choice at any time the
			 medical provider feels the interpreter services are not improving communication
			 with the worker, or feels the interpretation is not complete or
			 accurate.
(2) When a worker asks an
			 insurer to arrange for interpreter services, the insurer must use a certified
			 or qualified health care interpreter listed on the Oregon Health Care
			 Interpreter Registry of the Oregon Health Authority, available at:
http://www.oregon.gov/OHA/OEI/Pages/HCI-Program.aspx
.
			 The interpreter's certification or qualification must be in effect on the date
			 the interpreter services are provided. If no certified or qualified health care
			 interpreter is available, the insurer may schedule an interpreter of its choice
			 subject to the limits in section (1) of this rule.
(3) For the purpose of this rule, interpreter
			 services means the act of orally translating between a medical provider and a
			 patient who speak different languages, including sign language. It includes
			 reasonable time spent waiting at the location for the medical provider to
			 examine or treat the patient as well as reasonable time spent on necessary
			 paperwork for the provider's office.
Statutory/Other Authority: ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.245
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0230 - Medical Services and Treatment Guidelines

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Medical
			 services provided to the worker must not be more than the nature of the
			 compensable injury or the process of recovery requires. Services that are
			 unnecessary or inappropriate according to accepted professional standards are
			 not reimbursable.
(2) If the
			 provider's chart notes do not provide evidence of frequency, extent, and
			 efficacy of treatment and services, the insurer may request additional
			 information from the provider.
(3)
			 All medical service providers must notify the patient at the time of the first
			 visit of how they can provide compensable medical services and authorize
			 temporary disability. Providers must also notify patients that they may be
			 personally liable for noncompensable medical services. Such notification should
			 be made in writing or documented in the patient's medical record.
(4)
Consent to Attend a Medical
			 Appointment
.
(a) An employer or insurer
			 representative, such as a nurse case manager, may not attend a patient's
			 medical appointment without written consent of the patient. The patient has the
			 right to refuse such attendance.
(A) The
			 consent form must be written in a way that allows the patient to understand it
			 and to overcome language or cultural differences.
(B) The consent form must state that the
			 patient's benefits cannot be suspended if the patient refuses to have an
			 employer or insurer representative present.
(C) The insurer must keep a copy of the
			 signed consent form in the claim file.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0240 - Medical Records and Reporting Requirements for Medical Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Medical
			 Records and Reports.
(a) Medical
			 providers must maintain records necessary to document the extent of medical
			 services provided.
(b) All records
			 must be legible and cannot be kept in a coded or semi-coded manner unless a
			 legend is provided with each set of records.
(c) Reports may be handwritten and must
			 include all relevant or requested information such as the anticipated date of
			 release to return to work, medically stationary date, etc.
(d) Diagnoses stated on all reports,
			 including Form 827, must conform to terminology found in the appropriate
			 International Classification of Disease (ICD).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0241 - Form 827, Worker's and Health Care Provider's Report for Workers' Compensation Claims

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
First
			 Visit
.
(a) When the patient has filed
			 an initial claim or wants to file an initial claim, the patient and the first
			 medical service provider must complete and sign Form 827. The provider must
			 send the form to the insurer no later than 72 hours after the patient's first
			 visit. Saturdays, Sundays, and legal holidays are not counted in the 72-hour
			 period. Legal holidays are those listed in ORS
			 187.010 and
			 187.020.
(b) Form 3283 ("A Guide for Workers Recently
			 Hurt on the Job") is included with Form 827. All medical service providers must
			 give a copy of Form 3283 and Form 827 to the patient.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0260 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.252
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0270 - Insurer's Rights and Duties

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Notifications.
(a) Immediately
			 following receipt of notice or knowledge of a claim, the insurer must notify
			 the worker in writing about how to receive medical services for compensable
			 injuries.
(b) Within 10 days of any
			 change in the status of a claim, (e.g., acceptance or denial of a claim, or a
			 new or omitted medical condition), the insurer must notify the attending
			 physician or authorized nurse practitioner, if known, and the MCO, if
			 any.
(c) In disabling and
			 nondisabling claims, immediately following notice or knowledge that the worker
			 is medically stationary, the insurer must notify the worker and the attending
			 physician or authorized nurse practitioner in writing which medical services
			 remain compensable. This notice must list all benefits the worker is entitled
			 to receive under ORS 656.245
			 (1)(c).
(d) When the insurer establishes a medically
			 stationary date that is not based on the findings of an attending physician or
			 authorized nurse practitioner, the insurer must notify all medical service
			 providers of the worker's medically stationary status. For all injuries
			 occurring on or after October 23, 1999, the insurer must pay all medical
			 service providers for services rendered until the insurer provides notice of
			 the medically stationary date to the attending physician or authorized nurse
			 practitioner.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0275 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.252,
				  656.325,
				  656.245,
				  656.248,
				  656.260,
				  656.264
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0280 - Determination of Impairment/Closing Exams

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When a worker
			 becomes medically stationary and there is a reasonable expectation of permanent
			 disability, the attending physician must complete a closing exam or refer the
			 worker to a consulting physician for all or part of the closing exam. If the
			 worker is under the care of an authorized nurse practitioner, physician
			 associate, or a naturopathic physician, the provider must refer the worker to a
			 type A attending physician to do a closing exam.
(2) The closing exam must be completed under
			 OAR 436-030 and 436-035 and Bulletin 239. (See Appendix A "Matrix for Health
			 Care Provider Types".)
(3) When the
			 attending physician completes the closing exam, the attending physician has 14
			 days from the medically stationary date to send the closing report to the
			 insurer. When the attending physician does not complete the closing exam, the
			 attending physician must arrange, or ask the insurer to arrange, a closing exam
			 with a consulting physician within seven days of the medically stationary
			 date.
(4) When an attending
			 physician or authorized nurse practitioner requests a consulting physician to
			 do the closing exam, the consulting physician has seven days from the date of
			 the exam to send the report to the attending physician for concurrence or
			 objections. Within seven days of receiving the closing exam report, the
			 attending physician must state in writing whether the physician concurs with or
			 objects to all or part of the findings of the exam, and send the concurrence or
			 objections with the report to the insurer.
(5) The attending physician must specify the
			 worker's residual functional capacity if:
(a)
			 The attending physician has not released the worker to the job held at the time
			 of injury because of a permanent work restriction caused by the compensable
			 injury, and
(b) The worker has not
			 returned to the job held at the time of injury, because of a permanent work
			 restriction caused by the compensable injury.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0290 - Medical Care After Medically Stationary

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A worker is found medically stationary
			 when no further material improvement would reasonably be expected from medical
			 treatment or the passage of time. Medical services after a worker's condition
			 is medically stationary are compensable only when services are:
(a) Palliative care under section (2) of this
			 rule;
(b) Curative care under
			 sections (3) and (4) of this rule;
(c) Provided to a worker who has been
			 determined permanently and totally disabled;
(d) Prescription medications;
(e) Necessary to administer or monitor
			 administration of prescription medications;
(f) Prosthetic devices, braces, or
			 supports;
(g) To monitor the status
			 of, to replace, or to repair prosthetic devices, braces, and
			 supports;
(h) Provided under an
			 accepted claim for aggravation;
(i)
			 Provided under Board's Own Motion;
(j) Necessary to diagnose the worker's
			 condition; or
(k) Life-preserving
			 modalities similar to insulin therapy, dialysis, and transfusions.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0300 - Requesting Exclusion of Medical Treatment from Compensability

Current through Register Vol. 63, No. 7, July 1, 2024
If a worker or insurer believes that any medical treatment is
				unscientific, unproven as to its effectiveness, outmoded, or experimental,
				either party may initiate a request for exclusion of the medical treatment from
				compensability under ORS
				656.245(3). The
				request must include documentation on why the medical treatment should be
				excluded from compensability for workers' compensation claims. The director
				will request advice from the licensing boards of practitioners that might be
				affected and the Medical Advisory Committee. The director will issue an order
				and may adopt a rule declaring the treatment to be noncompensable. The decision
				of the director is appealable under ORS
				656.704. Request for
				administrative review of an individual worker's treatment under ORS
				656.327 does not initiate review
				under this process. Excluded treatments are listed in OAR
				436-009-0010.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.245
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0330 - Medical Arbiters and Physician Reviewers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The director will establish and maintain
			 a list of arbiters. The director will appoint a medical arbiter or a panel of
			 medical arbiters from this list under ORS
			 656.268.
(2) The director will establish and maintain
			 a list of physician reviewers. The director will appoint an appropriate
			 physician or a panel of physicians from this list to review medical treatment
			 or medical services disputes under ORS
			 656.245 and
			 656.327.
(3) When a worker is required to attend an
			 examination under this rule, the director will provide notice of the
			 examination to the worker and all affected parties. The notice will inform all
			 parties of the time, date, location, and purpose of the examination.
			 Examinations will be at a place reasonably convenient to the worker, if
			 possible.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.268,
				  656.325 &
				  656.327
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0335 - Monitoring and Auditing Medical Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The director may monitor and conduct
			 periodic audits of medical providers to ensure compliance with ORS chapter 656
			 and chapter 436 of the administrative rules.
(2) All records maintained or required to be
			 maintained must be disclosed upon request of the director.
Stat. Auth.: ORS
				  656.726(4)
Stats. Implemented: ORS
				  656.245,
				  656.254,
				  656.745