reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 10 - MEDICAL SERVICES › Section 436-010-0340 - Sanctions and Civil Penalties

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 If the director finds any medical provider in violation of the medical
			 reporting requirements established under ORS
			 656.245,
			 656.252,
			 656.254, or
			 656.325, or OAR 436-009 or
			 436-010, the director may impose one or more of the following sanctions:
(a) Reprimand by the director;
(b) Nonpayment, reduction, or recovery of
			 fees in part or whole for medical services provided;
(c) Referral to the appropriate licensing
			 board;
(d) Civil penalty not to
			 exceed $1,000 for each occurrence. In determining the amount of penalty to be
			 assessed, the director will consider:
(A) The
			 degree of harm inflicted on the worker or the insurer;
(B) Whether there have been previous
			 violations; and
(C) Whether there
			 is evidence of willful violations; or
(e) A penalty of $100 for each violation of
			 ORS 656.325(1)(c)(C).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0001 - 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 and provide policies, procedures, and requirements
			 to administer, evaluate, and enforce statutes relating to the delivery of
			 medical services by managed care organizations (MCOs) to workers within the
			 workers' compensation system.
(2)
Applicability of Rules
.
(a) These
			 rules apply on and after the effective date and govern all MCOs and insurers
			 contracting with an MCO.
(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 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0007 - Entities Allowed to Manage Care

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Only an MCO may provide managed care
			 services as described in ORS
			 656.260(4)(d) and
			 (21)(a), except as allowed under OAR
			 436-015-0009.
(2) An insurer or someone acting on behalf of
			 an insurer may not manage the care of workers by limiting the choice of medical
			 providers, or by requiring medical providers to abide by specific treatment
			 standards, treatment guidelines, or treatment protocols.
Statutory/Other Authority: ORS
				  656.726(4)
				  & ORS 656.260
Statutes/Other Implemented: ORS
				  656.260
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0008 - Request for Review before the Director

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The process for administrative review is
			 as follows:
(a) Any party that disagrees with
			 an action of an MCO must first use the MCO's dispute resolution process. If the
			 party does not appeal the MCO's decision, in writing and within 30 days of the
			 mailing date of the decision, the party will lose all rights to further appeal
			 the decision unless the party can show good cause. When the aggrieved party is
			 a represented worker, and the worker's attorney has given written notice of
			 representation to the insurer, the 30-day time frame begins when the attorney
			 receives written notice or has actual knowledge of the MCO decision. When a
			 party mistakenly sends an appeal of an MCO action or decision to the division,
			 the division will forward the appeal to the MCO. The MCO must use the original
			 mailing date of the appeal mistakenly sent to the division when determining
			 timeliness of the appeal.
(b)
			 Within 60 days of the date the MCO issues a final decision under the MCO's
			 dispute resolution process, the aggrieved party must file a written request for
			 administrative review with the division. The request must specify the grounds
			 upon which the action is contested. If a party has been denied access to an MCO
			 dispute resolution process because the complaint or dispute was not included in
			 the MCO's dispute resolution process or because the MCO's dispute resolution
			 process was not completed for reasons beyond a party's control, the party must
			 request administrative review within 60 days of the failure of the MCO to issue
			 a decision. When the aggrieved party is a represented worker, and the worker's
			 attorney had given written notice of representation to the insurer at the time
			 the MCO issued its decision, the 60-day time frame begins when the MCO issues
			 its final decision to the attorney.
(c) The director will create a documentary
			 record sufficient for judicial review. The director may require and allow the
			 parties to submit input and information appropriate to complete the
			 review.
(d) The director will
			 review the record and issue an order. The order must specify that it will
			 become final within 30 days of the mailing date of the order unless a written
			 request for hearing is filed with the division.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0009 - Formed, Owned, or Operated

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The director will not certify an MCO formed, owned, or operated by a
			 non-qualifying employer.
(2) For
			 purposes of this rule, "staff" means any individual who is an employee of a
			 non-qualifying employer or of any parent or subsidiary entity of a
			 non-qualifying employer.
(3) A
			 non-qualifying employer or any of its staff, or their immediate family, may
			 not:
(a) Directly participate in the
			 formation, certification, or incorporation of the MCO;
(b) Nominate, assume a position as, or act in
			 the role of, a director, officer, agent, or employee of the MCO;
(c) Arrange for, lend, guarantee, or
			 otherwise provide financing for any organizational costs of the MCO;
(d) Arrange for, lend, guarantee, or
			 otherwise provide financial support to the MCO (financial support does not
			 include contracted fees for services rendered by an MCO);
(e) Have any ownership or similar financial
			 interest in or right to payment from the MCO;
(f) Make or exercise any control over
			 business, operational, or policy decisions of the MCO;
(g) Possess or control the ownership of
			 voting securities of the MCO. The director will presume possession or control
			 exists if any person, directly or indirectly, holds the power to vote or holds
			 proxies of any other person representing 10 percent or more of the voting
			 securities of the MCO;
(h) Provide
			 MCO services other than as allowed by section (4) of this rule;
(i) Enter into any contract with the MCO that
			 limits the ability of the MCO to accept business from any other source;
			 or
(j) Direct or interfere with the
			 MCO's delivery of medical and health care services.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0010 - Notice of Intent to Form an MCO

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any health care provider or group of
			 medical service providers initiating an MCO under ORS
			 656.260 must submit a "Notice of
			 Intent to Form" to the director, by certified mail. Form 2737 may be used for
			 this purpose.
(2) The Notice of
			 Intent to Form must include the following:
(a) The identity of each person who
			 participates in discussions intended to result in the formation of an MCO. If
			 the person is a member of a closely held corporation, the notice must include
			 the identity of the shareholders;
(b) The name, address, and telephone number
			 of a contact person; and
(c) A
			 summary of the information that will be shared in discussions preceding the
			 application for MCO certification.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0020 - Qualifying

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Any health care
			 provider or group of medical service providers as defined in these rules must
			 qualify as an MCO prior to submission of an application for certification. To
			 qualify, the applicant must:
(a) Submit a
			 proposed plan for the MCO to the administrator of the Workers' Compensation
			 Division in which the applicant outlines the manner in which the proposed MCO
			 will meet the requirements of ORS
			 656.260 and OAR
			 436-015-0030;
(b) Identify in the plan the specific persons
			 to be directors of the proposed MCO, the person to be the president of the
			 proposed MCO, the title and name of the person to be the day-to-day
			 administrator of the MCO, and the title and name of the person to be the
			 administrator of the financial affairs of the proposed MCO; and
(c) Provide affidavits signed by each person
			 identified in subsection (1)(b) above which certifies that the individual has
			 no interest in an insurance company pursuant to OAR
			 436-015-0009.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0030 - Applying for Certification

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
General.
The MCO must establish one place of business in Oregon
			 where it administers the plan and keeps membership and other records as
			 required by OAR 436-015-0050.
(2) An applicant for MCO certification must
			 submit the following to the director:
(a) One
			 copy of the application;
(b) A
			 nonrefundable fee of $1,500, payable to the Department of Consumer and Business
			 Services, which will be deposited in the Consumer and Business Services
			 Fund;
(c) Affidavits of each person
			 identified in section (3) of this rule, certifying that the individuals have no
			 interest in a non-qualifying employer under OAR
			 436-015-0009;
(d) An affidavit of an authorized officer or
			 agent of the MCO, certifying that the MCO is financially sound and able to meet
			 all requirements necessary to ensure delivery of services under the plan, and
			 in full satisfaction of the MCO's obligations under ORS
			 656.260 and OAR 436-015;
			 and
(e) A complete organizational
			 chart.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0035 - Coverage Responsibility of an MCO

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The director will designate an MCO's
			 initial geographic service area (GSA). GSAs are established by postal zip code
			 (See
http://wcd.oregon.gov/Bulletins/bul_248.pdf
).
			 The MCO may only provide contract services in those GSAs approved by the
			 director. Workers are not subject to an MCO contract unless the director has
			 approved the GSA.
(2) Any expansion
			 of an MCO's service area must be approved by the director. The request for
			 expansion must identify the new GSA and include evidence that the MCO has an
			 adequate provider panel which meets the minimum requirements under OAR
			 436-015-0030. The director may
			 approve the MCO's new GSA without the minimum categories of medical service
			 providers when the MCO establishes that there are not an adequate number of
			 providers in a given category able or willing to become members of the MCO. For
			 categories where the MCO has fewer than three providers, the MCO must allow
			 workers to seek treatment outside the MCO from providers in those categories.
			 Treatment provided to workers must be consistent with the MCO's treatment and
			 utilization standards. Such providers, unlike come-along providers, cannot be
			 required to comply with the terms and conditions regarding services performed
			 by members of the MCO. However, while such providers are not themselves bound
			 by the MCO's treatment and utilization standards, workers are subject to those
			 standards.
Statutory/Other Authority: ORS
				  656.726(4)
				  & 656.260
Statutes/Other Implemented: ORS
				  656.245 &
				  656.260
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0037 - MCO-Insurer Contracts

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An MCO
			 must provide comprehensive medical services to all enrolled workers covered by
			 the MCO-insurer contract according to the MCO's certification.
(2) An MCO may not contract exclusively with
			 a single insurer. However, an MCO has up to one year from the effective date of
			 its first contract to obtain contracts with more than one insurer. If the MCO
			 has not obtained additional contracts within this time period, the MCO must
			 provide the director with a report documenting the MCO's efforts to obtain
			 additional contracts.
(3) An MCO
			 may contract only with insurers. The contract must include the following terms
			 and conditions:
(a) Who is governed by the
			 contract;
(b) The covered place of
			 employment must be within the authorized geographic service area;
(c) Insurers may contract with multiple MCOs
			 to provide coverage for employers. All workers at any specific employer's
			 location must be governed by the same MCO(s). When insurers contract with
			 multiple MCOs each worker must have initial choice at the time of injury to
			 select which MCO will manage their care except when the employer provides a
			 coordinated health care program;
(d) Workers enrolled in anMCO must receive
			 medical services as prescribed by the terms and conditions of the contract;
			 and
(e) A continuity of care
			 provision specifying how workers will receive medical services on open claims,
			 including the following:
(A) Upon enrollment,
			 allowing workers to continue to treat with the current medical service
			 providers for at least 14 days after the mailing date of the notice of
			 enrollment; and
(B) Upon
			 termination or expiration of the MCO-insurer contract, allowing workers to
			 continue treatment under ORS
			 656.245(4)(a).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0040 - Reporting Requirements for an MCO

Current through Register Vol. 63, No. 7, July 1, 2024
(1) In order to
			 ensure the MCO complies with the requirements of these rules, each MCO must
			 provide the director with a copy of the entire text of any MCO-insurer
			 contract, signed by the insurer and the MCO, within 30 days of execution of
			 such contracts. The MCO must submit any amendments, addenda, or cancellations
			 to the director within 30 days of execution.
(2) When an MCO-insurer contract contains a
			 specific expiration or termination date, the MCO must provide the director with
			 a copy of a contract extension, signed by the insurer and MCO, no later than
			 the contract's date of expiration or termination. If the MCO does not provide
			 the director with a copy of the signed contract extension, workers will no
			 longer be subject to the contract after it expires or terminates.
(3) The MCO must submit any amendments to the
			 certified plan to the director for approval. The MCO must not take any action
			 based on a proposed amendment until the director approves the
			 amendment.
(4) Within 45 days of
			 the end of each calendar quarter, each MCO must provide the following
			 information to the director, current on the last day of the quarter, as
			 described in Bulletin 247:
(a) The quarter
			 being reported;
(b) MCO
			 certification number; and
(c)
			 Membership listings by category of medical service provider (in coded form),
			 including:
(A) Provider names;
(B) Specialty (in coded form);
(C) Tax ID number;
(D) National Provider Identifier (NPI)
			 number; and
(E) Business address
			 and phone number. When a medical service provider has multiple offices, only
			 one office location in each geographic service area needs to be
			 reported.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0050 - Record Keeping and Place of Business

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Every MCO must give the director notice
			 of one Oregon location and mailing address where the MCO keeps records of the
			 following:
(a) Up-to-date membership listings
			 of all MCO members;
(b) Sanctions
			 or punitive actions taken by the MCO against its members;
(c) Actions taken by the MCO's peer review
			 committee;
(d) Utilization reviews
			 performed identifying cases reviewed, issues involved, and action
			 taken;
(e) A profile analysis of
			 each provider in the MCO;
(f)
			 Enrolled workers receiving treatment by come-along providers; and
(g) All other records as necessary to ensure
			 compliance with the certification requirements under OAR
			 436-015-0030.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0060 - Commencement and Termination of Panel Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prospective new panel providers of an MCO
			 must submit an application to the MCO. The directors, executive director, or
			 administrator may approve the application for membership according to the
			 membership requirements of the MCO. The MCO must verify that each new member
			 meets all licensing, registration, and certification requirements necessary to
			 practice in Oregon. If the MCO requires a membership fee, the fee must be the
			 same for every category of medical service provider. An MCO may not require
			 membership fees or other MCO administrative fees to be paid by come-along
			 providers.
(2) Individual panel
			 providers may elect to terminate their participation in the MCO or be subject
			 to cancellation by the MCO according to the membership requirements of the MCO
			 plan. Upon termination of a panel provider, the MCO must:
(a) Make alternate arrangements to provide
			 continuing medical services for any affected workers under the plan;
			 and
(b) Replace any terminated panel
			 provider when necessary to maintain an adequate number of each category of
			 medical service provider.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0065 - Monitoring and Auditing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 director will monitor and conduct periodic audits of an MCO as necessary to
			 ensure compliance with the MCO certification and performance
			 requirements.
(2) All records of an
			 MCO and its individual panel providers must be disclosed upon the director's
			 request. These records must be legible and cannot be kept in a coded or
			 semi-coded manner unless a legend is provided for the codes.
Statutory/Other Authority: ORS
				  656.260 & ORS
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.260
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0070 - Come-along Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The MCO must
			 authorize a physician, physician associate, or nurse practitioner who is not an
			 MCO panel provider to provide medical services to an enrolled worker if:
(a) The nurse practitioner is an authorized
			 nurse practitioner under ORS
			 656.245, the chiropractic
			 physician or physician associate has certified to the director that the
			 chiropractic physician or physician associate has reviewed required materials
			 under ORS 656.799, or the physician is a
			 primary care physician under ORS
			 656.260(4)(g);
(b) The physician, physician associate, or
			 authorized nurse practitioner agrees to comply with MCO treatment standards,
			 protocols, utilization review, peer review, dispute resolution, billing and
			 reporting procedures, and fees for services under OAR
			 436-015-0090; and
(c) The physician, physician associate, or
			 authorized nurse practitioner agrees to refer the worker to the MCO for
			 specialized care that the worker may require, including physical
			 therapy.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0075 - Worker Exams

Current through Register Vol. 63, No. 7, July 1, 2024
When the MCO schedules a worker exam that includes a
				psychological evaluation, the appointment letter must:
(1) Inform the worker that a psychological
			 evaluation is part of the exam; and
(2) State the reason for the psychological
			 exam.
Statutory/Other Authority: 656.726(4) & ORS
				  656.260
Statutes/Other Implemented: ORS
				  656.260
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0080 - Suspension; Revocation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Under
			 ORS 656.260, the director may
			 suspend or revoke an MCO's certification if:
(a) The director finds a serious danger to
			 the public health or safety;
(b)
			 The MCO is not providing services according to the terms of the certified MCO
			 plan;
(c) There is a change in
			 legal entity of the MCO that does not conform to the requirements of these
			 rules;
(d) The MCO fails to comply
			 with ORS chapter 656, OAR 436-009, 436-010, 436-015, or orders of the
			 director;
(e) The MCO or any of its
			 members commits any violation for which a civil penalty could be assessed under
			 ORS 656.254 or
			 656.745;
(f) Any false or misleading information is
			 submitted by the MCO or any member of the organization;
(g) The MCO continues to use the services of
			 a health care practitioner whose license has been suspended or revoked by the
			 licensing board; or
(h) The
			 director determines that the MCO was or is formed, owned, or operated by a
			 non-qualifying employer.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0090 - Charges and Fees

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Billings for medical services under an MCO must be submitted in the form and
			 format as prescribed in OAR 436-009. The payment of medical services may be
			 less than, but must not exceed, the maximum amounts allowed under OAR
			 436-009.
(2) Notwithstanding
			 section (1) of this rule, fees paid for medical services provided by come-along
			 providers must not be less than fees paid to MCO panel providers for similar
			 medical services.
(3) Payments to
			 medical providers who are not under contract with the MCO are not subject to an
			 MCO discount.
Statutory/Other Authority: ORS
				  656.260 &
				  656.726(4)
Statutes/Other Implemented: ORS
				  656.260 & ORS
				  656.245
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0110 - Dispute Resolution

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Disputes which arise between any party and an MCO must first be processed
			 through the dispute resolution process of the MCO.
(2) The MCO must promptly provide a written
			 summary of the MCO's dispute resolution process to anyone who requests it, or
			 to any party or their representative disputing any action of the MCO or
			 affected by a dispute. The written summary must include at least the following:
(a) The title, address, and telephone number
			 of the contact person at the MCO who is responsible for the dispute resolution
			 process;
(b) The types of issues
			 the MCO will consider in its dispute resolution process;
(c) A description of the procedures and time
			 frames for submission, processing, and decision at each level of the dispute
			 resolution process including the right of an aggrieved party to request
			 administrative review by the director if the party disagrees with the final
			 decision of the MCO; and
(d) A
			 statement that absent a showing of good cause, failure to timely appeal to the
			 MCO shall preclude appeal to the director.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 15 - MANAGED CARE ORGANIZATIONS › Section 436-015-0120 - Sanctions and Civil Penalties

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Complaints pertaining to violations of these rules must be sent to the
			 director.
(2) The director may
			 investigate an alleged rule violation. The investigation may include, but is
			 not limited to, request for and review of pertinent medical treatment and
			 payment records, interviews with the parties to the complaint, or consultation
			 with an appropriate panel of the medical provider's peers, chosen in the manner
			 provided in OAR 436-010-0330.
(3) If the director finds any violation of
			 OAR 436-015, or if the MCO fails to meet any of the requirements of the
			 certified plan, the director may impose one or more of the following sanctions
			 against an MCO:
(a) Reprimand by the
			 director;
(b) Civil penalty as
			 provided under ORS 656.745(2). In
			 determining the amount of penalty to be assessed, the director will consider:
(A) The degree of harm inflicted on the
			 worker, insurer, or medical provider;
(B) Previous violations; and
(C) Evidence of willful violation;
			 or
(c) Suspension or
			 revocation of the MCO's certification under OAR
			 436-015-0080.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0001

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.268,
				  656.726, 1995 OL Ch. 332 &
				  1999 OL Ch. 313
Stats. Implemented: ORS
				  656.268,
				  656.726, OL Ch. 332 1995 &
				  Ch. 313 1999
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0002

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  656.268,
				  656.726
Stats. Implemented: ORS
				  656.206,
				  656.210,
				  656.212,
				  656.262,
				  656.268,
				  656.273,
				  656.325
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0003 - Purpose, Applicability, Forms, and Bulletins

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Purpose.
The purpose of the rules in OAR 436-030 is to provide
			 standards, conditions, procedures, and reporting requirements for:
(a) Requests for closure by the
			 worker;
(b) Claim closure under ORS
			 656.268(1);
(c) Determining medically stationary
			 status;
(d) Determining temporary
			 disability benefits;
(e) Awards of
			 permanent partial disability;
(f)
			 Determining permanent total disability awards;
(g) Review for reduction of permanent total
			 disability awards;
(h) Review of
			 prior permanent partial disability awards; and
(i) Reconsideration of notices of
			 closure.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0005 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
Unless a term is defined in these rules or the context
				otherwise requires, the definitions of ORS chapter 656 are incorporated by
				reference and made part of these rules.
(1)
"Authorized nurse
			 practitioner"
means a nurse practitioner authorized to provide
			 compensable medical services under ORS
			 656.245 and OAR
			 436-010.
(2)
"Board"
means the Workers' Compensation Board and includes its Hearings
			 Division.
(3)
"Day"
means calendar day unless otherwise specified (e.g., "working day").
(4)
"Direct medical sequela"
means a condition that is clearly established medically and originates or stems
			 from an accepted condition.
(5)
"Director"
means the director of the Department of Consumer and
			 Business Services, or the director's designee.
(6)
"Division"
means the
			 Workers' Compensation Division of the Department of Consumer and Business
			 Services.
(7)
"Instant
			 fatality"
means a compensable claim for death benefits when the worker
			 dies within 24 hours of the injury.
(8)
"Insurer"
means the State
			 Accident Insurance Fund; an insurer authorized under ORS chapter 731 to
			 transact workers' compensation insurance in Oregon, a self-insured employer, or
			 a self-insured employer group.
(9)
"Irreversible findings"
has the same meaning as described in OAR
			 436-035-0005(7).
(10)
"Mailed" or "mailing date,"
for the purposes of determining timeliness under these rules, means the date a
			 document is postmarked. Requests submitted by fax will be considered mailed as
			 of the date printed on the banner automatically produced by the transmitting
			 fax machine. Hand-delivered requests will be considered mailed as of the date
			 received by the division. Phone or in-person requests, where allowed under
			 these rules, will be considered mailed as of the date of the request.
(11)
"Notice of Closure"
means a
			 notice to the worker, estate, or beneficiary issued by the insurer to:
(a) Close an accepted disabling claim,
			 including fatal claims;
(b)
			 Correct, rescind, or rescind and reissue a Notice of Closure previously issued;
			 or
(c) Reduce permanent total
			 disability to permanent partial disability.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0007 - Administrative Review

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Notices of Closure issued by insurers are
			 appealed to the director and processed in accordance with the reconsideration
			 procedures described in OAR
			 436-030-0115 through OAR
			 436-030-0185, except Notices of
			 Closure under (3)(b) of this rule, when:
(a)
			 The worker was determined medically stationary after July 1, 1990; or
(b) The claim qualifies for closure under ORS
			 656.268(1)(b) or
			 (c).
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0017 - Requests for Claim Closure by the Worker

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A worker may request claim closure from
			 the insurer. The insurer must issue a Notice of Closure or Notice of Refusal to
			 Close within 10 days of receipt of a written request for claim closure from the
			 worker or the worker's attorney.
(2) If an insurer issues a Notice of Refusal
			 to Close, the notice must be clearly titled "Notice of Refusal to Close" and it
			 must include:
(a) Name of the
			 worker;
(b) Date of
			 injury;
(c) Insurer's claim
			 number;
(d) Mailing date of the
			 notice;
(e) The accepted and denied
			 conditions;
(f) Rationale for the
			 insurer's decision; and
(g) The
			 following language, in bold print:
"If you disagree with this Notice of Refusal to Close
				your claim, you must file a letter of disagreement with the Workers'
				Compensation Board within sixty (60) days from the date of this notice. Your
				letter must state that you want a hearing, note your address, and include the
				date of your accident if known. You must mail your letter of disagreement to
				the Workers' Compensation Board, 2601 25th Street SE, Suite 150, Salem, OR
				97302-1280. If your claim qualifies and you request it, you may receive an
				expedited hearing (within 30 days). Your request cannot, by law, affect your
				employment. If you do not file your letter of disagreement within sixty (60)
				days from the date of this notice, your hearing will be denied as the appeal
				time has passed. You may be represented by an attorney if you
				choose."
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0020 - Requirements for Claim Closure

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
Issuance
			 of a Notice of Closure.
Unless the worker is enrolled and actively
			 engaged in an authorized training plan under OAR 436-120, the insurer must
			 issue a Notice of Closure on an accepted disabling claim within 14 days when:
(a) Medical information establishes that
			 there is sufficient information to determine the extent of permanent disability
			 and indicates that the worker is medically stationary;
(b) The compensable injury is no longer the
			 major contributing cause of the worker's combined or consequential
			 condition(s), a major contributing cause denial has been issued, and there is
			 sufficient information to determine the extent of permanent
			 disability;
(c) The worker fails to
			 seek medical treatment for 30 days for reasons within the worker's control and
			 the requirements for claim closure under OAR
			 436-030-0034 have been
			 met;
(d) The worker fails to attend
			 a mandatory closing examination for reasons within the worker's control and the
			 requirements for claim closure under OAR
			 436-030-0034 have been met;
			 or
(e) A worker receiving permanent
			 total disability benefits has materially improved and is capable of regularly
			 performing work at a gainful and suitable occupation.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0023 - Correcting and Rescinding Notices of Closure

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An insurer may rescind or correct its
			 Notice of Closure prior to the expiration of the appeal period for that notice
			 and prior to or on the same day that the director receives a request for
			 reconsideration of the Notice of Closure.
(2) The form, format, and completion of the
			 Correcting and Rescinding Notices of Closure are the same as those of the
			 Notice of Closure except that, to correct a Notice of Closure, a Form 1644c
			 must be used and, to rescind a Notice of Closure, a Form 1644r must be used. An
			 insurer may rescind and reissue a Notice of Closure by using a Form 1644 when
			 such actions can be accomplished at the same time, the claim remains closed,
			 and other provisions of these rules are met.
(3) The "Date of closure (mailing date)" on
			 the Correcting or Rescinding Notice of Closure must be the date the correction
			 or rescission is mailed. The mailing date of the Notice of Closure being
			 rescinded or corrected must be identified within the body of the Correcting or
			 Rescinding Notice of Closure.
(4)
			 The worker's copy of the Correcting and Rescinding Notices of Closure must be
			 mailed by both regular mail and certified mail return receipt requested,
			 consistent with OAR 436-030-0020(8) and
			 (10).
(5) Rescinding Notices of Closure, Form
			 1644r, are used to rescind the Notice of Closure and return the claim to open
			 status. Examples of appropriate uses of Rescinding Notices of Closure include,
			 but are not limited to:
(a) The worker was not
			 medically stationary at the time the Notice of Closure was issued;
			 and
(b) The closure was otherwise
			 premature.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0034 - Administrative Claim Closure

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 insurer must close a claim when the worker is not medically stationary and the
			 worker fails to seek treatment for more than 30 days without the instruction or
			 approval of the attending physician or authorized nurse practitioner and for
			 reasons within the worker's control. In order to close a claim under this
			 section, the insurer must:
(a) Wait for the
			 30-day lack of treatment period to expire or any additional time period
			 recommended by the attending physician or authorized nurse practitioner before
			 sending the worker written notification by certified and regular mail, with a
			 copy sent to the worker's attorney if the worker is represented, informing the
			 worker of the following:
(A) The worker's
			 responsibility to seek medical treatment in a timely manner;
(B) The consequences for failing to seek
			 treatment in a timely manner which include, but are not limited to, claim
			 closure and possible loss or reduction of a disability award; and
(C) The claim will be closed unless the
			 worker establishes within 14 days from the date the letter was sent certified
			 mail that:
(i) Treatment has resumed by
			 attending an existing appointment or scheduling a new appointment; or
(ii) The reasons for not treating were
			 outside the worker's control.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0035 - Determining Medically Stationary Status

Current through Register Vol. 63, No. 7, July 1, 2024
(1) A worker is
			 medically stationary in the following circumstances:
(a)
In initial injury claims.
In
			 an initial injury claim, a worker is medically stationary when the attending
			 physician, authorized nurse practitioner, or a preponderance of medical opinion
			 declares that all accepted conditions and direct medical sequelae of accepted
			 conditions are either "medically stationary" or "medically stable" or when the
			 provider uses other language meaning the same thing.
(b)
In new or omitted condition
			 claims.
In a new or omitted condition claim, a worker is medically
			 stationary when the attending physician, authorized nurse practitioner, or a
			 preponderance of medical opinion declares that all accepted new or omitted
			 conditions and direct medical sequelae of accepted new or omitted conditions
			 are either "medically stationary" or "medically stable" or when the provider
			 uses other language meaning the same thing.
(c)
In aggravation claims.
In an
			 aggravation claim, a worker is medically stationary when the attending
			 physician, authorized nurse practitioner, or a preponderance of medical opinion
			 declares that all accepted worsened conditions and direct medical sequelae of
			 accepted worsened conditions are either "medically stationary" or "medically
			 stable" or when the provider uses other language meaning the same
			 thing.
(d)
In occupational
			 disease claims.
In an occupational disease claim, a worker is medically
			 stationary when the attending physician, authorized nurse practitioner, or a
			 preponderance of medical opinion declares that all accepted occupational
			 diseases and direct medical sequela of accepted occupational diseases are
			 either "medically stationary" or "medically stable" or when the provider uses
			 other language meaning the same thing.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0036 - Determining Temporary Disability

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Temporary disability must be determined under ORS chapter 656, OAR 436-060, and
			 this rule, less time worked. Beginning and ending dates of each authorized
			 period of temporary total disability and temporary partial disability must be
			 noted on the Notice of Closure, as well as the statements "Less time worked"
			 and "Temporary disability was determined in accordance with the law."
(2) Except as provided in section (3) of this
			 rule and ORS 656.268(10), a
			 worker is not entitled to any award of temporary disability for any period of
			 time in which the worker is medically stationary.
(3) Awards of temporary disability must
			 include the day the worker is medically stationary or the date the claim
			 otherwise qualifies for closure, unless temporary disability is not authorized
			 for another reason at that time.
Stat. Auth.: ORS
				  656.268,
				  656.726
Stats. Implemented: ORS
				  656.005,
				  656.160,
				  656.210,
				  656.212,
				  656.236,
				  656.245,
				  656.262,
				  656.268,
				  656.726,
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0038 - Permanent Partial Disability

Current through Register Vol. 63, No. 7, July 1, 2024
The standards developed under ORS
				656.726(4) and
				contained in OAR 436-035 must be applied when evaluating a worker's permanent
				partial disability.
Stat. Auth.: ORS
				  656.268,
				  656.726, OL Ch. 332 1995 &
				  Ch. 313 1999
Stats. Implemented: ORS
				  656.214,
				  656.268,
				  656.726, OL Ch. 332 1995 &
				  Ch. 313 1999
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0066 - Review of Prior Permanent Partial Disability Awards

Current through Register Vol. 63, No. 7, July 1, 2024
For claims having a date of injury prior to January 1, 2005,
				which involve unscheduled body parts, areas, or systems as defined by OAR
				436-035-0005, and all claims
				with dates of injury on or after January 1, 2005, an award of permanent partial
				disability is subject to periodic examination and adjustment under ORS
				656.268 and
				656.325 and in accordance with
				the following conditions:
(1) Requests
			 for review and adjustment must be made in writing to the division.
(2) The party requesting review of permanent
			 disability must send a copy of the request to all involved parties at the time
			 the request is made. The worker may submit any information in
			 rebuttal.
(3) All pertinent
			 medical, vocational, and other applicable evidence must be submitted with the
			 request, including sufficient information to determine the extent of permanent
			 partial disability. The request must state the basis for the request and
			 provide supporting evidence. If the director finds that the worker has failed
			 to accept treatment as provided in this rule, the director will make any
			 necessary adjustments allowed under OAR 436-035.
(4) The basis for the request for adjustment
			 in the permanent disability award must be asserted to be failure of the worker
			 to make a reasonable effort to reduce the disability.
Statutory/Other Authority: ORS
				  656.268,
				  656.726, OL Ch. 332 1995 &
				  OL Ch. 313 1999
Statutes/Other Implemented: ORS
				  656.268,
				  656.726, OL Ch. 332 1995, OL Ch.
				  313 1999, 656.325 & 656.331
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0125 - Reconsideration Form and Format

Current through Register Vol. 63, No. 7, July 1, 2024
A request for reconsideration may be in the form and format the
				director provides in Bulletin 227. A reconsideration request should include at
				least the following:
(1) Worker's
			 name;
(2) Date of injury;
(3) Date of the closure being
			 appealed;
(4) Any specific issues
			 regarding the Notice of Closure;
(5) The name of the worker's attorney, if
			 any;
(6) The name of the insurer's
			 attorney, if any;
(7) If the
			 request is made by a beneficiary of the worker or the worker's estate, the
			 identity and name of the requester, the name of the requester's attorney, if
			 any, and contact information;
(8)
			 Any special language needs;
(9)
			 Whether there is disagreement with the specific impairment findings used to
			 determine permanent disability at the time of claim closure;
(10) Any information and documentation deemed
			 necessary to correct or clarify any part of the claim record believed to be
			 erroneous; and
(11) Any medical
			 evidence that should have been but was not submitted at the time of the claim
			 closure including clarification or correction of the medical record based on
			 the examination(s) at, before, or pertaining to claim closure.
Statutory/Other Authority: ORS
				  656.726
Statutes/Other Implemented: ORS
				  656.268
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0135 - Reconsideration Procedure

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Within
			 14 days from the date of the director's notice of the start of the
			 reconsideration proceeding, the insurer must provide, in chronological order by
			 document date, all documents pertaining to the claim including, but not limited
			 to, the complete medical record and all official action and notices on the
			 claim, to:
(a) The director;
(b) The worker or the worker's attorney;
(c) The beneficiary or
			 beneficiary's attorney, if the request was made by the beneficiary; and
(d) The estate or estate's
			 attorney, if the request was made by the worker's estate.
Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 30 - CLAIM CLOSURE AND RECONSIDERATION › Section 436-030-0145 - Reconsideration Time Frames and Postponements

Current through Register Vol. 63, No. 7, July 1, 2024
(1) When appealing a Notice of Closure for
			 claims that are medically stationary or that statutorily qualified for closure
			 on or after June 7, 1995, a request for reconsideration must be mailed within:
(a) Sixty (60) days of the mailing date of
			 the Notice of Closure for a worker's request.
(b) Seven (7) days of the mailing date of the
			 Notice of Closure for an insurer's request. An insurer's request for
			 reconsideration is limited to the findings used to rate impairment.
(c) Sixty (60) days of the mailing date of
			 the Notice of Closure for a beneficiary's request if the Notice of Closure was
			 mailed to the beneficiary under ORS
			 656.268(5)(b).
(d) One year of the date the Notice of
			 Closure was mailed to the estate of the worker if the Notice of Closure was not
			 mailed to the beneficiary under ORS
			 656.268(5)(b).