Oregon Administrative Code

436-010-0250 Elective Surgery (1) “Elective surgery” is surgery that may be required to recover from an injury or illness, but is not an emergency surgery to preserve life, function, or health. (2) Except as otherwise provided by the MCO: (a) The attending physician or specialist…

436-010-0265 Independent Medical Exams (IMEs) and Worker Requested Medical Exams (WRMEs) (1) General. (a) An independent medical exam (IME) means any medical exam (including a physical capacity or work capacity evaluation or consultation that includes an exam) that is requested b…

436-010-0270 Insurer’s Rights and Duties (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 s…

436-010-0280 Determination of Impairment/Closing Exams (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 …

436-010-0290 Medical Care After Medically Stationary (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…

436-010-0300 Requesting Exclusion of Medical Treatment from Compensability 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 tre…

436-010-0330 Medical Arbiters and Physician Reviewers (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 …

436-010-0335 Monitoring and Auditing Medical Providers (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…

436-010-0340 Sanctions and Civil Penalties (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 followin…

436-015-0001 Purpose and Applicability of These Rules (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 organization…

436-015-0005 Definitions Unless a term is specifically defined elsewhere in these rules or the context otherwise requires, the definitions of ORS chapter 656 and OAR 436-010-0005 are hereby incorporated by reference and made a part of these rules. (1) “Administrative review” mean…

436-015-0007 Entities Allowed to Manage Care (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 l…

436-015-0008 Request for Review before the Director (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 …

436-015-0009 Formed, Owned, or Operated (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 ent…

436-015-0010 Notice of Intent to Form an MCO (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 …

436-015-0030 Applying for Certification (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 th…

436-015-0035 Coverage Responsibility of an MCO (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 appro…

436-015-0037 MCO-Insurer Contracts (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…

436-015-0040 Reporting Requirements for an MCO (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 executi…

436-015-0050 Record Keeping and Place of Business (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…

436-015-0060 Commencement and Termination of Panel Providers (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 requirement…

436-015-0065 Monitoring and Auditing (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 …

436-015-0070 Come-along Providers (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 has been assigned an authorized nurse practitione…

436-015-0075 Worker Exams 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 Au…

436-015-0080 Suspension; Revocation (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;…

436-015-0090 Charges and Fees (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) Notwithsta…

436-015-0110 Dispute Resolution (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, …

436-015-0120 Sanctions and Civil Penalties (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 me…

436-030-0003 Purpose, Applicability, Forms, and Bulletins (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) Dete…

436-030-0005 Definitions 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) “Board” means the Workers’ Compensation Board and includes its Hearings Division.…

436-030-0007 Administrative Review (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, w…

436-030-0015 Insurer Responsibility (1) When an insurer issues a Notice of Closure (Form 1644), the insurer is responsible for: (a) Providing the director, the parties, and the worker’s attorney if the worker is represented, a copy of the Notice of Closure, a copy of the Notice o…

436-030-0017 Requests for Claim Closure by the Worker (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…

436-030-0020 Requirements for Claim Closure (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)…

436-030-0023 Correcting and Rescinding Notices of Closure (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 Notic…

436-030-0034 Administrative Claim Closure (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 and for reasons within the worker’s…

436-030-0035 Determining Medically Stationary Status (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 or a preponderance of medical opinion …

436-030-0036 Determining Temporary Disability (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 …

436-030-0038 Permanent Partial Disability 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. Statutory/Other Authority: ORS 656.268, 656.726, OL Ch. 332 1995 & Ch. 313 1999 Statutes/Ot…

436-030-0055 Determining Permanent Total Disability (1) A worker is permanently and totally disabled if permanently incapacitated from regularly performing work in a suitable and gainful occupation. For the purpose of this rule and OAR 436-030-0065: (a) "Incapacitated from regula…

436-030-0065 Review of Permanent Total Disability Awards (1) The insurer must reexamine each permanent total disability claim at least once every two years or when requested to do so by the director to determine if the worker has materially improved, either medically or vocationa…

436-030-0066 Review of Prior Permanent Partial Disability Awards 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, a…

436-030-0115 Reconsideration of Notices of Closure (1) A worker, insurer, or beneficiary may request reconsideration of a Notice of Closure as provided in ORS 656.268. (2) Under ORS 656.218(4), a worker’s estate may request reconsideration of a Notice of Closure if the worker die…

436-030-0125 Reconsideration Form and Format 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 ap…

436-030-0135 Reconsideration Procedure (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,…

436-030-0145 Reconsideration Time Frames and Postponements (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 …

436-030-0155 Reconsideration Record (1) The record for the reconsideration proceeding includes all documents and other material relied upon in issuing the Order on Reconsideration as well as any additional material submitted by the parties, but not considered in the reconsiderati…

436-030-0165 Medical Arbiter Examination Process (1) The director will select a medical arbiter or a panel of medical arbiters in accordance with ORS 656.268(8). (a) For the purpose of this rule, a "panel" is defined as two or three medical arbiters. (b) When a panel medical arbi…

436-030-0175 Fees and Penalties within the Reconsideration Proceeding (1) An insurer failing to provide information or documentation as set forth in OAR 436-030-0135, 436-030-0145, 436-030-0155 and 436-030-0165 may be assessed civil penalties under OAR 436-030-0580. Failure to co…

436-030-0185 Reconsideration: Settlements and Withdrawals (1) Contested matters arising out of a claim closure may be resolved by mutual agreement of the parties at any time after the claim has been closed under ORS 656.268 but before that claim closure has become final by operat…