Oregon Administrative Code

436-001-0296 Settlements and Dismissals (1) If, after a request for hearing is filed but before a proposed and final order is issued, an agreement under ORS 656.236 or 656.289(4) is approved that resolves all issues in the matter within the director’s jurisdiction, the administra…

436-001-0400 General Provisions and Requirements for Attorney Fees In addition to the specific provisions in OAR 436-001-0410 through 436-001-0440, the following provisions apply to attorney fees: (1) The attorney must file with the director a signed attorney retainer agreement. …

436-001-0410 Attorney Fees Under ORS 656.385(1) (Medical and Vocational Disputes) (1) In cases in which the director or administrative law judge orders a fee to be paid under ORS 656.385(1): (a) The fee must fall within the ranges of the matrix in subsection (d), unless extraordi…

436-001-0420 Attorney Fees Under ORS 656.262(11) (Late Payment of Compensation) In cases in which the director orders a fee to be paid under ORS 656.262(11): (1) OAR 438-015-0110 applies. (2) The director may use the matrix in OAR 436-001-0410 as a guide in determining the amount…

436-001-0430 Attorney Fees Under ORS 656.262(12) (Late Payment of DCS Proceeds) The matrix for determining the amount of the attorney fee under ORS 656.262(12) is in OAR 436-060, Appendix C (OAR 436-060-0400). Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: …

436-001-0432 Attorney Fees Under ORS 656.268(6)(c) (Additional Compensation at Reconsideration) For attorney fees under ORS 656.268(6)(c): (1) In addition to a signed retainer agreement required under OAR 436-001-0400(1), the attorney must submit the request for reconsideration o…

436-001-0435 Attorney Fees Under ORS 656.277(1) (Reclassification) (1) Attorney fees under ORS 656.277(1) will be based on a reasonable hourly rate multiplied by the time devoted by the attorney to obtaining the reclassification order. (2) The director will determine a reasonable…

436-001-0438 Attorney Fees Under ORS 656.383(1) (Temporary Disability Compensation Benefits) (1) An attorney fee under ORS 656.383(1) is payable after an order on reconsideration under ORS 656.268 is issued, as provided in this rule. If attorney fees under ORS 656.383(1) are at i…

436-001-0440 Time Within Which Attorney Fees Must Be Paid Attorney fees under OAR 436-001-0400 to 436-001-0438 must be paid within 14 days of the date the order addressing the fees becomes final. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemented: ORS 656.262, O…

436-001-0500 Refund of Overpayments When the director receives a payment in excess of the amount legally due and payable to the director, the director will refund or credit the excess amount. However, when the excess amount is less than $20 and the payment was for an assessment o…

436-001-0600 Multilingual Help Page (1) An insurer, self-insured employer, service company, or managed care organization (MCO) that sends a document to a worker that is required by OAR chapter 436 must simultaneously send Form 5377, “Workers’ Compensation Multilingual Help Page,”…

436-001-0610 Duty to Forward Misdirected Request If an employer or insurer receives a written request for hearing or administrative review from a worker, and the request should have been filed with the division, the employer or insurer must promptly forward the request to the div…

436-001-0700 Access to Public Records and Workers’ Compensation Claim Records (1) Access to public records. Department of Consumer and Business Services rules on Access of Public Records, Fees for Record Search and Copies of Public Records are in OAR 440-005, accessible at https:…

436-008-0001 Authority, Applicability, Purpose, and Administration of these Rules (1) These rules are promulgated under the director's authority contained in ORS 656.726(4) and specific authority under ORS 656.252. (2) These rules apply to all electronic medical billing transacti…

436-008-0004 Adoption of Standards (1) The director adopts, by reference, the following electronic medical bill processing standards: (a) Professional Billing: (A) The Accredited Standards Committee X12 (ASC X12) Standards for Electronic Data Interchange (EDI) Type 3 Technical Re…

436-008-0005 Definitions For the purpose of these rules and the Oregon Electronic Billing and Payment Companion Guide: (1) “Clearinghouse” means an entity that is an authorized agent of the insurer or health care provider, including billing services, re-pricing companies, communi…

436-008-0010 Electronic Medical Bills (1) Beginning Jan. 1, 2015, insurers must accept and process all electronically transmitted medical bills in accordance with these rules, the standards adopted under OAR 436-008-0004, and the companion guide. (2) An insurer is exempt from the…

436-008-0015 Electronic Medical Bill Attachments or Documentation (1) A unique attachment indicator number must be assigned to all documentation. The attachment indicator number populated on the document must include the report type code, the report transmission code, the attachm…

436-008-0020 Electronic Medical Bill Acknowledgements (1) If the electronic submission does not conform to the standards adopted under OAR 436-008-0004(1), then the insurer must send an acknowledgment adopted under 436-008-0004(2)(a) or 436-008-0004(2)(b) to the health care provi…

436-008-0025 Electronic Medical Bill Payments (1) Insurers that accept and process a complete electronic bill for services, under OAR 436-008-0010(1)(a) or (b), must pay for treatment related to the injury or disease, provided or authorized by the treating health care provider, o…

436-008-0030 Electronic Remittance Advice; Explanation of Benefits (1) An electronic remittance advice (ERA) or notification is an explanation of benefits (EOB) that the insurer submits electronically regarding payment or denial of a bill, reduction of a bill, or refund. An insur…

436-008-0040 Assessment of Civil Penalties Under ORS 656.745, the director may assess a civil penalty against an insurer that fails to comply with ORS Chapter 656, the director’s rules, or orders of the director. Statutory/Other Authority: ORS 656.726(4) Statutes/Other Implemente…

436-009-0001 Purpose and Applicability of These Rules (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…

436-009-0004 Adoption of Standards (1) The director adopts, by reference, the American Society of Anesthesiologists ASA, Relative Value Guide 2026 as a supplementary fee schedule for those anesthesia codes not found in Appendix B. To get a copy of the ASA Relative Value Guide 202…

436-009-0005 Definitions (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 de…

436-009-0008 Request for Review before the Director (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 di…

436-009-0010 Medical Billing and Payment (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 …

436-009-0012 Telehealth (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 …

436-009-0018 Discounts and Contracts (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…

436-009-0020 Hospitals (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 servi…

436-009-0023 Ambulatory Surgery Center (ASC) (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 use…

436-009-0025 Worker Reimbursement (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. (b) The w…

436-009-0030 Insurer’s Duties and Responsibilities (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…

436-009-0035 Interim Medical Benefits (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 he…

436-009-0040 Fee Schedule (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 A…

436-009-0060 Oregon Specific Codes (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 treatmen…

436-009-0080 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (1) Durable medical equipment (DME), such as Transcutaneous Electrical Nerve Stimulation (TENS), Microcurrent Electrical Nerve Stimulation (MENS), home traction devices, heating pads, reusable h…

436-009-0090 Pharmaceutical (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…

436-009-0110 Interpreters (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…

436-009-0998 Sanctions and Civil Penalties (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 incorr…

436-010-0001 Purpose and Applicability of These Rules (1) 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. (2) Applicability of Rules. (a) T…

436-010-0005 Definitions (1) Unless a term is specifically defined elsewhere in these rules or the context otherwise requires, the definitions of ORS chapter 656 are hereby incorporated by reference and made part of these rules. (2) “Administrative review” means any decision maki…

436-010-0008 Request for Review before the Director (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 di…

436-010-0200 Medical Advisory Committee 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 man…

436-010-0210 Attending Physician, Nurse Practitioner, and Temporary Disability Authorization (1) An attending physician is primarily responsible for the patient’s care, authorizes temporary disability, and prescribes and monitors ancillary care and specialized care. (a) No later …

436-010-0220 Choosing and Changing Medical Providers (1) The worker may have only one attending physician at a time. Concurrent treatment or services by other medical providers, including specialist physicians, must be sufficiently different that separate medical skills are neede…

436-010-0225 Choosing a Person to Provide Interpreter Services (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 …

436-010-0230 Medical Services and Treatment Guidelines (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 sta…

436-010-0240 Medical Records and Reporting Requirements for Medical Providers (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 …

436-010-0241 Form 827, Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims (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 82…