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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,

WORKERS' COMPENSATION DIVISION










 

DIVISION 9
OREGON MEDICAL FEE AND PAYMENT RULES

436-009-0001
Administration of These Rules
(1) Any orders issued by the division
in carrying out the director’s authority to enforce ORS chapter 656 and OAR
chapter 436, are considered orders of the director.
(2) Authority for Rules.
These rules are promulgated under the director’s general rulemaking authority
of ORS 656.726(4) and specific authority under ORS 656.248.
(3) Purpose. The purpose
of these rules is to establish uniform guidelines for administering the payment
for medical benefits to workers within the workers’ compensation system.
(4) 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.
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 12-1996, f. 5-6-96,
cert. ef. 6-1-96; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2014, f. 3-12-14,
cert. ef. 4-1-14
436-009-0004
Adoption of Standards
(1) The director adopts, by reference,
the American Society of Anesthesiologists ASA, Relative Value Guide 2015
as a supplementary fee schedule for those anesthesia codes not found in Appendix
B. To get a copy of the ASA Relative Value Guide 2015, contact the American Society
of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068-2573, 847-825-5586,
or on the Web at: http://www.asahq.org.
(2) The director adopts,
by reference, the American Medical Association’s (AMA) Current Procedural
Terminology (CPT® 2015), Fourth Edition Revised, 2014, for billing by medical
providers. The definitions, descriptions, and guidelines found in CPT® must
be used as guides governing 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 24, Issue 12, 2014. If there is a conflict between the CPT® manual and
CPT® Assistant, the CPT® manual is the controlling resource.
(4) To get a copy of the
CPT® 2015 or the CPT® Assistant, contact the American Medical Association,
515 North State Street, Chicago, IL60610, 800-621-8335, or on the Web at: http://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 on the Web at: www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.
(6) The director adopts,
by reference, CDT 2015: Dental Procedure Codes, to be used when billing for dental
services. To get a copy, contact the American Dental Association at American Dental
Association, 211 East Chicago Ave., Chicago, IL 60611-2678, or on the Web at: www.ada.org.
(7) The director adopts,
by reference, the 02/12 1500 Claim Form and Version 1.1 06/13 (for the 02/12 form)
1500 Health Insurance Claim Form Reference Manual published by the National Uniform
Claim Committee (NUCC). To get copies, contact the NUCC, American Medical Association,
515 N. State St., Chicago, IL 60654, or on the Web at: www.nucc.org.
(8) The director adopts,
by reference, the Official UB-04 Data Specifications Manual 2015 Edition, published
by National Uniform Billing Committee (NUBC). To get a copy, contact the NUBC, American
Hospital Association, One North Franklin, 29th Floor, Chicago, IL 60606, 312-422-3390,
or on the Web at: www.nubc.org.
(9) The director adopts,
by reference, the NCPDP Manual Claim Forms Reference Implementation Guide Version
1.3 and the NCPDP Workers’ Compensation/Property & Casualty Universal
Claim Form (WC/PC UCF) Version 1.1 – 5/2009. To get a copy, contact the National
Council for Prescription Drug Programs (NCPDP), 9240 East Raintree Drive, Scottsdale,
AZ 85260-7518, 480-477-1000, or on the Web at: www.ncpdp.org.
(10) Specific provisions
contained in OAR chapter 436, divisions 009, 010, and 015 control over any conflicting
provision in ASA Relative Value Guide 2015, CPT® 2015, CPT® Assistant,
HCPCS 2015, CDT 2015, Dental Procedure Codes, 1500 Health Insurance Claim Form Reference
Instruction Manual, Official UB-04 Data Specifications Manual, or NCPDP Manual Claim
Forms Reference Implementation Guide.
(11) Copies of the standards
referenced in this rule are also available for review during regular business hours
at the Workers’ Compensation Division, Medical Resolution Team, 350 Winter
Street NE, Salem OR 97301, 503-947-7606.
[Publications: Publications referenced
are available from the agency.]
Stat. Auth.: ORS 656.248
& 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00; WCD 2-2001, f. 3-8-01,
cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03,
cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05,
cert. ef. 4-1-05; WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07,
cert. ef. 7-1-07; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 1-2009, f. 5-22-09,
cert. ef. 7-1-09; WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10; WCD 1-2011, f. 3-1-11,
cert. ef. 4-1-11; WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12; WCD 2-2013, f. 3-11-13,
cert. ef. 4-1-13; WCD 7-2013, f. 11-12-13, cert. ef. 1-1-14; WCD 3-2014, f. 3-12-14,
cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 defined in the rules in which they are used or defined as
follows:
(a) ANSI means the American
National Standards Institute.
(b) ASC means ambulatory
surgery center.
(c) CMS means Centers for
Medicare & Medicaid Services.
(d) CPT® means Current
Procedural Terminology published by the American Medical Association.
(e) DME means durable medical
equipment.
(f) DMEPOS means durable
medical equipment, prosthetics, orthotics, and supplies.
(g) EDI means electronic
data interchange.
(h) HCPCS means Healthcare
Common Procedure Coding System published by CMS.
(i) IAIABC means International
Association of Industrial Accident Boards and Commissions.
(j) ICD-9-CM means International
Classification of Diseases, Ninth Revision, Clinical Modification, Vol. 1, 2 &
3 by US Department of Health and Human Services.
(k) ICD-10-CM means International
Classification of Diseases, Tenth Revision, Clinical Modification.
(l) ICD-10-PCS means International
Classification of Diseases, Tenth Revision, Procedure Coding System.
(m) MCO means managed care
organization certified by the director.
(n) NPI means national provider
identifier.
(o) OSC means Oregon specific
code.
(p) PCE means physical capacity
evaluation.
(q) WCE means work capacity
evaluation.
(3) “Administrative
review” means any decision making process of the director requested by a party
aggrieved with an action taken under these rules except the hearing process described
in OAR 436-001.
(4) “Ambulatory surgery
center” (ASC) means:
(a) Any distinct entity licensed
by the state of Oregon, and operated exclusively for the purpose of providing surgical
services to patients not requiring hospitalization; or
(b) Any entity outside of
Oregon similarly licensed, or certified by Medicare or a nationally recognized agency
as an ASC.
(5) “Attending physician”
has the same meaning as described in ORS 656.005(12)(b). See Appendix F, “Matrix
for Health Care Provider Types”.
(6) “Authorized nurse
practitioner” means a nurse practitioner licensed under ORS
678.375 to 678.390 who has
certified to the director that the nurse practitioner has reviewed informational
materials about the workers’ compensation system provided by the director
and who has been assigned an authorized nurse practitioner number by the director.
(7) “Board” means
the Workers’ Compensation Board and includes its Hearings Division.
(8) “Chart note”
means a notation made in chronological order in a medical record in which the medical
service provider records such things as subjective and objective findings, diagnosis,
treatment rendered, treatment objectives, and return to work goals and status.
(9) “Clinic”
means a group practice in which several medical service providers work cooperatively.
(10) “CMS form 2552”
(Hospital and Hospital Health Care Complex Cost Report) means the annual report
a hospital makes to Medicare.
(11) “Current procedural
terminology” or “CPT”® means the Current Procedural Terminology
codes and terminology published by the American Medical Association unless otherwise
specified in these rules.
(12) “Date stamp”
means to stamp or display the initial receipt date and the recipient’s name
on a paper or electronic document, regardless of whether the document is printed
or displayed electronically.
(13) “Days” means
calendar days.
(14) “Division”
means the Workers’ Compensation Division of the Department of Consumer and
Business Services.
(15) “Enrolled”
means an eligible worker has received notification from the insurer that the worker
is being required to receive treatment under the provisions of a managed care organization
(MCO). However, a worker may not be enrolled who would otherwise be subject to an
MCO contract if the worker’s primary residence is more than 100 miles outside
the MCO’s certified geographical service area.
(16) “Fee discount
agreement” means a direct contract entered into between a medical service
provider or clinic and an insurer to discount fees to the medical service provider
or clinic under OAR 436-009-0018.
(17) “Hearings Division”
means the Hearings Division of the Workers’ Compensation Board.
(18) “Hospital”
means an institution licensed by the State of Oregon as a hospital.
(a) “Inpatient”
means a patient who is admitted to a hospital prior to and extending past midnight
for treatment and lodging.
(b) “Outpatient”
means a patient not admitted to a hospital prior to and extending past midnight
for treatment and lodging. Medical services provided by a health care provider such
as emergency room services, observation room, or short stay surgical treatments
that do not result in admission are also considered outpatient services.
(19) “Initial claim”
means the first open period on the claim immediately following the original filing
of the occupational injury or disease claim until the worker is first declared to
be medically stationary by an attending physician or authorized nurse practitioner.
For nondisabling claims, the “initial claim” means the first period
of medical treatment immediately following the original filing of the occupational
injury or disease claim ending when the attending physician or authorized nurse
practitioner does not anticipate further improvement or need for medical treatment,
or there is an absence of treatment for an extended period.
(20) “Insurer”
means the State Accident Insurance Fund Corporation; an insurer authorized under
ORS Chapter 731 to transact workers’ compensation insurance in the state;
or, an employer or employer group that has been certified under 656.430 and meets
the qualifications of a self-insured employer under 656.407.
(21) “Interim medical
benefits” means those services provided under ORS 656.247 on initial claims
with dates of injury on or after January 1, 2002, that are not denied within 14
days of the employer’s notice of the claim.
(22) “Interpreter”
means a person who:
(a) Provides oral or sign
language translation; and
(b) Owns, operates, or works
for a business that receives income for providing oral or sign language translation.
It does not include a medical provider, medical provider’s employee, or a
family member or friend of the patient.
(23) “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.
(24) “Mailed or mailing
date” means the date a document is postmarked. Requests submitted by facsimile
or “fax” are 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 stamped by the Workers’ Compensation
Division. Phone or in-person requests, where allowed under these rules, will be
considered mailed as of the date of the request.
(25) “Managed care
organization” or “MCO” means an organization formed to provide
medical services and certified in accordance with OAR chapter 436, division 015.
(26) “Medical provider”
means a medical service provider, a hospital, a medical clinic, or a vendor of medical
services.
(27) “Medical service”
means any medical treatment or any medical, surgical, diagnostic, chiropractic,
dental, hospital, nursing, ambulances, and other related services, and drugs, medicine,
crutches and prosthetic appliances, braces and supports and where necessary, physical
restorative services.
(28) “Medical service
provider” means a person duly licensed to practice one or more of the healing
arts.
(29) “Medical treatment”
means the management and care of a patient for the purpose of combating disease,
injury, or disorder. Restrictions on activities are not considered treatment unless
the primary purpose of the restrictions is to improve the worker’s condition
through conservative care.
(30) “Parties”
mean the worker, insurer, MCO, attending physician, and other medical provider,
unless a specific limitation or exception is expressly provided for in the statute.
(31) “Patient”
means the same as worker as defined in ORS 656.005(30).
(32) “Physical capacity
evaluation” means an objective, directly observed, measurement of a patient’s
ability to perform a variety of physical tasks combined with subjective analyses
of abilities by patient and evaluator. Physical tolerance screening, Blankenship’s
Functional Capacity Evaluation, and Functional Capacity Assessment have the same
meaning as Physical Capacity Evaluation.
(33) “Provider network”
means a health service intermediary other than an MCO that facilitates transactions
between medical providers and insurers through a series of contractual arrangements.
(34) “Report”
means medical information transmitted in written form containing relevant subjective
or objective findings. Reports may take the form of brief or complete narrative
reports, a treatment plan, a closing examination report, or any forms as prescribed
by the director.
(35) “Residual functional
capacity” means a patient’s remaining ability to perform work-related
activities. A residual functional capacity evaluation includes, but is not limited
to, capability for lifting, carrying, pushing, pulling, standing, walking, sitting,
climbing, balancing, bending/stooping, twisting, kneeling, crouching, crawling,
and reaching, and the number of hours per day the patient can perform each activity.
(36) “Specialist physician”
means a licensed physician who qualifies as an attending physician and who examines
a patient at the request of the attending physician or authorized nurse practitioner
to aid in evaluation of disability, diagnosis, or provide temporary specialized
treatment. A specialist physician may provide specialized treatment for the compensable
injury or illness and give advice or an opinion regarding the treatment being rendered,
or considered, for a patient’s compensable injury.
(37) “Type A attending
physician” means an attending physician under ORS 656.005(12)(b)(A). See Appendix
F, “Matrix for Health Care Provider Types”.
(38) “Type B attending
physician” means an attending physician under ORS 656.005(12)(b)(B). See Appendix
F. “Matrix for Health Care Provider Types”.
(39) “Usual fee”
means the medical provider’s fee charged to the general public for a given
service.
(40) “Work capacity
evaluation” means a physical capacity evaluation with special emphasis on
the ability to perform a variety of vocationally oriented tasks based on specific
job demands. Work Tolerance Screening has the same meaning as Work Capacity Evaluation.
(41) “Work hardening”
means an individualized, medically prescribed and monitored, work-oriented treatment
process. The process involves the patient participating in simulated or actual work
tasks that are structured and graded to progressively increase physical tolerances,
stamina, endurance, and productivity to return the patient to a specific job.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.000
et seq., 656.005, 656.726(4)
Hist.: WCD 12-1996, f. 5-6-96,
cert. ef. 6-1-96; WCD 20-1996, f. 10-2-96, cert. ef. 1-1-97; WCD 5-1998, f. 4-3-98,
cert. ef. 7-1-98; WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04
cert. ef. 4-1-04; WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07,
cert. ef. 7-1-07; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 5-2008, f. 12-15-08,
cert. ef. 1-1-09; WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10; WCD 1-2011, f. 3-1-11,
cert. ef. 4-1-11; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 1-2015, f. 1-29-15,
cert. ef. 3-1-15; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
436-009-0008
Request for Review by the Director
(1) General.
(a) Administrative review
before the director:
(A) Except as otherwise provided
in ORS 656.704, the director has exclusive jurisdiction to resolve all disputes
concerning medical fees, non-payment of compensable medical bills, and medical service
and treatment disputes arising under 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 656.245(1)(c), or whether
a medical treatment is unscientific, unproven, outmoded, or experimental under 656.245(3),
are subject to administrative review before the director.
(B) A party does not need
to be represented to participate in the administrative review before the director.
(C) Any party may request
that the director provide voluntary mediation or alternative dispute resolution
after a request for administrative review or hearing is filed.
(b) Except for disputes regarding
interim medical benefits under ORS 656.247, when there is a formal denial of the
compensability of the underlying claim, or a denial of the causal relationship between
the medical service or treatment and the accepted condition or the underlying condition,
the parties may file a request for hearing with the Hearings Division of the Workers’
Compensation Board to resolve the compensability issue.
(2) Time Frames and Conditions.
(a) The following time frames
and conditions apply to requests for administrative review before the director under
this rule:
(b) For MCO-enrolled claims,
a party that disagrees with an action or decision of the MCO must first use the
MCO’s dispute resolution process. If the party does not appeal the MCO’s
decision using the MCO’s dispute resolution process, in writing and within
30 days of the mailing date of the decision, the party will lose all rights to further
appeal the decision absent a showing of 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.
(c) For MCO-enrolled claims,
if a party disagrees with the final action or decision of the MCO, the aggrieved
party must request administrative review before the director within 60 days of the
MCO’s final decision. When the aggrieved party is a represented worker, and
the worker’s attorney has given written notice of representation to the insurer,
the 60-day time frame begins when the attorney receives written notice or has actual
knowledge of the dispute. If a party has been denied access to the MCO dispute resolution
process, or the process has not been completed for reasons beyond a party's control,
the party may request director review within 60 days of the failure of the MCO process.
If the MCO does not have a process for resolving a particular type of dispute, the
insurer or the MCO must advise the medical provider or worker that they may request
review before the director.
(d) For claims not enrolled
in an MCO, or for disputes that do not involve an action or decision of an MCO:
(A) A worker must request
administrative review before the director within 90 days of the date the worker
knew, or should have known, there was a dispute over the provision of medical services.
If the worker is represented, and the worker’s attorney has given notice of
representation to the insurer, the 90 day time frame begins when the attorney receives
written notice or has actual knowledge of the dispute.
(B) A medical provider must
request administrative review within 90 days of the mailing date of the most recent
explanation of benefits or a similar notification the provider received regarding
the disputed service or fee. Rebillings without any relevant changes will not provide
a new 90 day period to request administrative review.
(C) An insurer must request
administrative review within 90 days of the date action on the bill was due under
OAR 436-009-0030.
(D) For disputes regarding
interim medical benefits on denied claims, the date the insurer should have known
of the dispute is no later than one year from the claim denial, or 45 days after
the bill is perfected, whichever occurs last. A request for administrative review
under this rule may also be filed as prescribed in OAR chapter 438, division 5.
(e) Within 180 days of the
date a bill is paid, an insurer may request a refund from a provider for any amount
it determines was overpaid for a compensable medical service. If the provider does
not respond to the request, or disagrees that a service was overpaid, the insurer
may request director review within 90 days of requesting the refund.
(f) Medical provider bills
for treatment or services that are under review before the director are not payable
during the review.
(3) Form and Required Information.
(a) Requests for administrative
review before the director should be made on Form 2842 as described in Bulletin
293. When an insurer or a worker’s representative submits a request without
the required information, the director may dismiss the request or hold initiation
of the administrative review until the required information is submitted. Unrepresented
workers may ask the director for help in meeting the filing requirements.
(A) The requesting party
must simultaneously notify all other interested parties and their representatives,
if known, of the dispute. The notice must: identify the worker's name, date of injury,
insurer, and claim number; specify the issues in dispute and the relief sought;
and provide the specific dates of the unpaid disputed treatment or services.
(B) If the request for review
is submitted by either the insurer or the medical provider, it must state specific
codes of services in dispute and include enough documentation to support the request,
including copies of original bills, chart notes, bill analyses, operative reports,
any correspondence between the parties regarding the dispute, and any other documentation
necessary to review the dispute. The insurer or medical provider requesting review
must provide all involved parties a copy of: the request for review; any attached
supporting documentation; and if known, an indication of whether or not there is
an issue of causation or compensability of the underlying claim or condition.
(b) In addition to medical
evidence relating to the dispute, all parties may submit other relevant information,
including written factual information, sworn affidavits, or legal argument, for
incorporation into the record. Such information may also include timely written
responses and other evidence to rebut the documentation and arguments of an opposing
party. The director may take or obtain additional evidence consistent with statute,
such as pertinent medical treatment and payment records. The director may also interview
parties to the dispute, or consult with an appropriate committee of the medical
provider’s peers. When a party receives a written request for additional information
from the director, the party must respond within 14 days.
(c) When a request for administrative
review is filed under ORS 656.247, the insurer must provide a record packet, at
no charge, to the director and all other parties or their representatives as follows:
(A) The packet must include
a complete, indexed copy of the worker’s medical record and other documents
that are arguably related to the medical dispute, arranged in chronological order,
with oldest documents on top, and numbered in Arabic numerals in the lower right
corner of each page. The number must be preceded by the designation “Ex.”
and pagination of the multiple page documents must be designated by a hyphen followed
by the page number. For example, page two of document 10 must be designated “Ex.
10-2.” The index must include the document numbers, description of each document,
author, number of pages, and date of the document. The packet must include the following
notice in bold type:
We hereby notify you that
the director is being asked to review the medical care of this worker. The director
may issue an order that could affect reimbursement for the disputed medical service(s).
(B) If the insurer requests
review, the packet must accompany the request, with copies sent simultaneously to
the other parties.
(C) If the requesting party
is other than the insurer, or if the director has initiated the review, the director
will request the record from the insurer. The insurer must provide the record within
14 days of the director’s request as described in this rule.
(D) If the insurer fails
to submit the record in the time and format specified in this rule, the director
may sanction the insurer under OAR 436-010-0340.
(4) Dispute Resolution by
Agreement (Alternative Dispute Resolution).
(a) A dispute may be resolved
by agreement between the parties to the dispute. The agreement must be in writing
and approved by the director. The director may issue a letter of agreement instead
of an administrative order, which will become final on the 10th day after the letter
of agreement is issued unless the agreement specifies otherwise. Once the agreement
becomes final, the director may revise the agreement or reinstate the review only
under one or more of the following conditions:
(A) A party fails to honor
the agreement;
(B) The agreement was based
on misrepresentation;
(C) Implementation of the
agreement is not feasible because of unforeseen circumstances; or
(D) All parties request revision
or reinstatement of the dispute.
(b) Any mediated agreement
may include an agreement on attorney fees, if any, to be paid to the worker’s
attorney.
(5) Director Order and Reconsideration.
(a) The director may, on
the director’s own motion, reconsider or withdraw any order that has not become
final by operation of law. A party also may request reconsideration of an administrative
order upon an allegation of error, omission, misapplication of law, incomplete record,
or the discovery of new information that could not reasonably have been discovered
and produced during the review. The director may grant or deny a request for reconsideration
at the director’s sole discretion. A request must be mailed to the director
before the administrative order becomes final.
(b) During any reconsideration
of the administrative order, the parties may submit new material evidence consistent
with this rule and may respond to such evidence submitted by others.
(c) Any party requesting
reconsideration or responding to a reconsideration request must simultaneously notify
all other interested parties of its contentions and provide them with copies of
all additional information presented.
(d) Attorney fees in administrative
review will be awarded as provided in ORS 656.385(1) and OAR 436-001-0400 through
436-001-0440.
(6) Hearings.
(a) Any party that disagrees
with an action or administrative order under these rules may obtain review of the
action or order by filing a request for hearing as provided in OAR 436-001-0019
within 30 days of the mailing date of the order under ORS 656.245, 656.248, 656.260,
or 656.327, or within 60 days of the mailing date of an order under 656.247. OAR
436-001 applies to the hearing.
(b) In the review of orders
issued under ORS 656.245(3) or 656.247, no new medical evidence or issues will be
admitted at hearing. In these reviews, an administrative order may be modified at
hearing only if it is not supported by substantial evidence in the record or if
it reflects an error of law.
(c) Contested case hearings
of sanctions and civil penalties: Under ORS 656.740, any party that disagrees with
a proposed order or proposed assessment of a civil penalty issued by the director
under 656.254 or 656.745 may request a hearing by the Hearings Division of the board
as follows:
(A) A written request for
a hearing must be mailed to the administrator of the Workers’ Compensation
Division. The request must specify the grounds upon which the proposed order or
assessment is contested.
(B) The request must be mailed
to the division within 60 days after the mailing date of the order or notice of
assessment.
(C) The division will forward
the request and other pertinent information to the board.
(7) Other Proceedings.
(a) Director’s administrative
review of other actions not covered under sections (1) through (6) of this rule:
Any party seeking an action or decision by the director, or any party aggrieved
by an action taken by another party, may request administrative review before the
director. Any party may request administrative review as follows:
(b) A written request for
review must be sent to the administrator of the Workers’ Compensation Division
within 90 days of the disputed action and must specify the grounds upon which the
action is contested.
(c) The division may require
and allow such input and information as it deems appropriate to complete the review.
Stat. Auth.: ORS 656.704, 656.726(4)
Stats. Implemented: ORS 656.704
Hist.: WCD 5-1982(Admin),
f. 2-23-82, ef. 3-1-82; WCD 1-1984(Admin), f. & ef. 1-16-84; Renumbered from
436-069-0901, 5-1-85 WCD 1-1988, f. 1-20-88, cert. ef. 2-1-88; WCD 1-1990, f. 1-5-90,
cert. ef. 2-1-89, (Former sections (3), (4), & (7) Renumbered to 436-010-0130);
WCD 12-1990(Temp), f. 6-20-90, cert. ef. 7-1-90; WCD 30-1990, f. 12-10-90, cert.
ef. 12-26-90;WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92; WCD 13-1994, f. 12-20-94,
cert. ef. 2-1-95; WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0110;
WCD 5-1998, f. 4-3-98, cert. ef. 7-1-98; WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99;
WCD 13-1999(Temp), f. & cert. ef. 10-25-99 thru 4-21-00; WCD 2-2000, f. 3-15-00,
cert. ef. 4-1-00; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 14-2003(Temp), f.
12-15-03, cert. ef. 1-1-04 thru 6-28-04; WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04;
WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05; WCD 7-2005, f. 10-20-05, cert. ef. 1-2-06;
WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07;
WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09;
WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14;
WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 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 department 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.
(2) Billing Timelines. (For
payment timelines see OAR 436-009-0030.)
(a) Medical providers must
bill within:
(A) 60 days of the date of
service;
(B) 60 days after the medical
provider has received notice or knowledge of the responsible workers’ compensation
insurer or processing agent; or
(C) 60 days after any litigation
affecting the compensability of the service is final, if the provider receives written
notice of the final litigation from the insurer.
(b) If the provider bills
past the timelines outlined in subsection (a) of this section, the provider may
be subject to civil penalties as provided in ORS 656.254 and OAR 436-010-0340.
(c) When submitting a bill
later than outlined in subsection (a) of this section, a medical provider must establish
good cause. Good cause may include, but is not limited to, such issues as extenuating
circumstances or circumstances considered outside the control of the provider.
(d) When a provider submits
a bill within 12 months of the date of service, the insurer may not reduce payment
due to late billing.
(e) When a provider submits
a bill more than 12 months after the date of service, the bill is not payable, except
when a provision of subsection (2)(a) is the reason the billing was submitted after
12 months.
(3) Billing Forms.
(a) All medical providers
must submit bills to the insurer unless a contract directs the provider to bill
the managed care organization (MCO).
(b) Medical providers must
submit bills on a completed current UB-04 (CMS 1450) or
CMS 1500 except for:
(A) Dental billings, which
must be submitted on American Dental Association dental claim forms;
(B) Pharmacy billings, which
must be submitted on a current National Council for Prescription Drug Programs (NCPDP)
form; or
(C) Electronic billing transmissions
of medical bills (see OAR 436-008).
(c) Notwithstanding subsection
(3)(a) of this rule, a medical service provider doing an IME may submit a bill in
the form or format agreed to by the insurer and medical service provider.
(d) Medical providers may
use computer-generated reproductions of the appropriate forms.
(e) Unless different instructions
are provided in the table below, the provider should use the instructions provided
in the National Uniform Claim Committee 1500 Claim Form Reference Instruction Manual.
[Table not included. See ED. NOTE.]
(4) Billing Codes.
(a) When billing for medical
services, a medical provider must use codes listed in CPT® 2015 or Oregon specific
codes (OSC) listed in OAR 436-009-0060 that accurately describe the service. If
there is no specific CPT® code or OSC, a medical provider must use the appropriate
HCPCS or dental code, if available, to identify the medical supply or service. If
there is no specific code for the medical service, the medical provider must use
the unlisted code at the end of each medical service section of CPT® 2015 or
the appropriate unlisted HCPCS code, and provide a description of the service provided.
A medical provider must include the National Drug Code (NDC) to identify the drug
or biological when billing for pharmaceuticals.
(b) Only one office visit
code may be used for each visit except for those code numbers relating specifically
to additional time.
(5) Modifiers.
(a) When billing, unless
otherwise provided by these rules, medical providers must use the appropriate modifiers
found in CPT® 2015, HCPCS’ level II national modifiers, or anesthesia
modifiers, when applicable.
(b) Modifier 22 identifies
a service provided by a medical service provider that requires significantly greater
effort than typically required. Modifier 22 may only be reported with surgical procedure
codes with a global period of 0, 10, or 90 days as listed in Appendix B. The bill
must include documentation describing the additional work. It is not sufficient
to simply document the extent of the patient’s comorbid condition that caused
the additional work. When a medical service provider appropriately bills for an
eligible procedure with modifier 22, the payment rate is 125% of the fee published
in Appendix B, or the fee billed, whichever is less. For all services identified
by modifier 22, two or more of the following factors must be present:
(A) Unusually lengthy procedure;
(B) Excessive blood loss
during the procedure;
(C) Presence of an excessively
large surgical specimen (especially in abdominal surgery);
(D) Trauma extensive enough
to complicate the procedure and not billed as separate procedure codes;
(E) Other pathologies, tumors,
malformations (genetic, traumatic, or surgical) that directly interfere with the
procedure but are not billed as separate procedure codes; or
(F) The services rendered
are significantly more complex than described for the submitted CPT®.
(6) Physician Assistants
and Nurse Practitioners.
Physician assistants and
nurse practitioners must document in the chart notes that they provided the medical
service. If physician assistants or nurse practitioners provide services as surgical
assistants during surgery, they must bill using modifier “81.”
(7) Chart Notes.
(a) All original medical
provider billings must be accompanied by legible chart notes. The chart notes must
document the services that have been billed and identify the person performing the
service.
(b) Chart notes must not
be kept in a coded or semi-coded manner unless a legend is provided with each set
of records.
(c) When processing electronic
bills, the insurer may waive the requirement that bills be accompanied by chart
notes. The insurer remains responsible for payment of only compensable medical services.
Medical providers may submit their chart notes separately or at regular intervals
as agreed with the insurer.
(8) Challenging the Provider’s
Bill.
For services where the fee
schedule does not establish a fixed dollar amount, an insurer may challenge the
reasonableness of a provider’s bill on a case by case basis by asking the
director to review the bill under OAR 436-009-0008. If the director determines the
amount billed is unreasonable, the director may establish a different fee to be
paid to the provider based on at least one of, but not limited to, the following:
reasonableness, the usual fees of similar providers, fees for similar services in
similar geographic regions, or any extenuating circumstances.
(9) Billing the Patient/Patient
Liability.
(a) A patient is not liable
to pay for any medical service related to an accepted compensable injury or illness
or any amount reduced by the insurer according to OAR chapter 436. However, the
patient may be liable, and the provider may bill the patient:
(A) If the patient seeks
treatment for conditions not related to the accepted compensable injury or illness;
(B) If the patient seeks
treatment for a service that has not been prescribed by the attending physician
or authorized nurse practitioner, or a specialist physician upon referral of the
attending physician or authorized nurse practitioner. This would include, but is
not limited to, ongoing treatment by non-attending physicians in excess of the 30-day/12-visit
period or by nurse practitioners in excess of the 180-day period, as set forth in
ORS 656.245 and OAR 436-010-0210;
(C) If the insurer notifies
the patient that he or she is medically stationary and the patient seeks palliative
care that is not authorized by the insurer or the director under OAR 436-010-0290;
(D) If an MCO-enrolled patient
seeks treatment from the provider outside the provisions of a governing MCO contract;
or
(E) If the patient seeks
treatment listed in section (12) of this rule after the patient has been notified
that such treatment is unscientific, unproven, outmoded, or experimental.
(b) If the director issues
an order declaring an already rendered medical service or treatment inappropriate,
or otherwise in violation of the statute or administrative rules, the worker is
not liable for such services.
(10) Disputed Claim Settlement
(DCS).
The insurer must pay a medical
provider for any bill related to the claimed condition received by the insurer on
or before the date the terms of a DCS were agreed on, but was either not listed
in the approved DCS or was not paid to the medical provider as set forth in the
approved DCS. Payment must be made by the insurer as prescribed by ORS 656.313(4)(d)
and OAR 438-009-0010(2)(g) as if the bill had been listed in the approved settlement
or as set forth in the approved DCS, except, if the DCS payments have already been
made, the payment must not be deducted from the settlement proceeds. Payment must
be made within 45 days of the insurer’s knowledge of the outstanding bill.
(11) Payment Limitations.
(a) Insurers do not have
to pay providers for the following:
(A) Completing forms 827
and 4909;
(B) Providing chart notes
with the original bill;
(C) Preparing a written treatment
plan;
(D) Supplying progress notes
that document the services billed;
(E) Completing a work release
form or completion of a PCE form, when no tests are performed;
(F) A missed appointment
“no show” (see exceptions below under section (13) Missed Appointment
“No Show”); or
(G) More than three mechanical
muscle testing sessions per treatment program or when not prescribed and approved
by the attending physician or authorized nurse practitioner.
(b) Mechanical muscle testing
includes a copy of the computer printout from the machine, written interpretation
of the results, and documentation of time spent with the patient. Additional mechanical
muscle testing may be paid for only when authorized in writing by the insurer prior
to the testing.
(c) Dietary supplements including,
but not limited to, minerals, vitamins, and amino acids are not reimbursable unless
a specific compensable dietary deficiency has been clinically established in the
patient.
(d) Vitamin B-12 injections
are not reimbursable unless necessary for a specific dietary deficiency of malabsorption
resulting from a compensable gastrointestinal condition.
(12) Excluded Treatment.
The following medical treatments (or treatment of side effects) are not compensable
and insurers do not have to pay for:
(a) Dimethyl sulfoxide (DMSO),
except for treatment of compensable interstitial cystitis;
(b) Intradiscal electrothermal
therapy (IDET);
(c) Surface electromyography
(EMG) tests;
(d) Rolfing;
(e) Prolotherapy;
(f) Thermography;
(g) Lumbar artificial disc
replacement, unless it is a single level replacement with an unconstrained or semi-constrained
metal on polymer device and:
(A) The single level artificial
disc replacement is between L3 and S1;
(B) The patient is 16 to
60 years old;
(C) The patient underwent
a minimum of six months unsuccessful exercise based rehabilitation; and
(D) The procedure is not
found inappropriate under OAR 436-010-0230; and
(h) Cervical artificial disc
replacement, unless it is a single level replacement with a semi-constrained metal
on polymer or a semi-constrained metal on metal device and:
(A) The single level artificial
disc replacement is between C3 and C7;
(B) The patient is 16 to
60 years old;
(C) The patient underwent
unsuccessful conservative treatment;
(D) There is intraoperative
visualization of the surgical implant level; and
(E) The procedure is not
found inappropriate under OAR 436-010-0230.
(13) Missed Appointment (No
Show). In general, the insurer does not have to pay for “no show” appointments.
However, insurers must pay for “no show” appointments for arbiter exams,
director required medical exams, independent medical exams, worker requested medical
exams, and closing exams. If the patient does not give 48 hours notice, the insurer
must pay the provider 50 percent of the exam or testing fee and 100 percent for
any review of the file that was completed prior to cancellation or missed appointment.
[[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
[Publications: Publications
referenced are available from the agency.]
Stat. Auth.: ORS 656.245,
656.252, 656.254
Stats. Implemented: ORS 656.245,
656.252, 656.254
Hist.: WCD 12-1996, f. 5-6-96,
cert. ef. 6-1-96; WCD 20-1996, f. 10-2-96, cert. ef. 1-1-97;
WCD 5-1998, f. 4-3-98, cert. ef. 7-1-98; WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00; WCD 2-2001, f. 3-8-01,
cert. ef. 4-1-01; WCD 8-2001, f. 9-13-01, cert. ef. 9-17-01; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04
cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05; WCD 3-2006, f. 3-14-06,
cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07; WCD 10-2007, f. 11-1-07,
cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 1-2009, f. 5-22-09,
cert. ef. 7-1-09; WCD 3-2009, f. 12-1-09, cert. ef. 1-1-10; WCD 3-2010, f. 5-28-10,
cert. ef. 7-1-10; WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11; WCD 1-2012, f. 2-16-12,
cert. ef. 4-1-12; WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13; WCD 3-2014, f. 3-12-14,
cert. ef. 4-1-14; WCD 4-2014(Temp), f. & cert. ef. 4-15-14 thru 10-11-14; WCD
6-2014, f. 6-13-14, cert. ef. 7-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15

436-009-0018
Discounts and Contracts
(1) Medical Service Providers and Medical
Clinics.
For the purpose of this rule:
(a) “Medical Service
Provider” means a person duly licensed to practice one or more of the healing
arts.
(b)“Clinic” means
a group practice in which several medical service providers work cooperatively.
(2) 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.
(b) If the insurer has multiple
contracts with a medical service provider or clinic, and one of the contracts is
through an MCO for services provided to an enrolled worker, the insurer may only
apply the discount under the MCO’s contract.
(c) Any discount under a
fee discount agreement cannot be more than 10 percent of the fee schedule amount.
(d) An insurer may not apply
a fee discount until the medical service provider or clinic and the insurer have
signed the fee discount agreement.
(3) Fee Discount Agreements.
(a) The fee discount agreement
between the parties must be on the provider’s letterhead and contain all the
information listed on Form 3659. Bulletin 352 provides further information. The
agreement must include the following:
(A) A statement that the
medical service provider or clinic understands and voluntarily agrees with the terms
of the fee discount agreement;
(B) The effective and end
dates of the agreement;
(C) The discount rate or
rates under the agreement;
(D) A statement that the
insurer or employer may not direct patients to the provider or clinic, and that
the insurer or employer may not direct or manage the care a patient receives;
(E) A statement that the
agreement only applies to patients who are being treated for Oregon workers’
compensation claims;
(F) A statement that the
fee discount agreement may not be amended. A new fee discount agreement must be
executed to change the terms between the parties;
(G) A statement that either
party may terminate the agreement by providing the other party with 30 days written
notice;
(H) The name and address
of the singular insurer or self-insured employer that will apply the discounts;
(I) The national provider
identifier (NPI) for the provider or clinic; and
(J) Other terms and conditions
to which the medical service provider or clinic and the insurer agree and that are
consistent with these rules.
(b) Once the fee discount
agreement has been signed by the insurer and medical service provider or clinic,
the insurer must report the fee discount agreement to the director by completing
the director’s online form. The following information must be included:
(A) The insurer’s name
that will apply the discounts under the fee discount agreement;
(B) The medical service provider’s
or clinic’s name;
(C) The effective date of
the agreement;
(D) The end date of the agreement;
(E) The discount rate under
the agreement; and
(F) An indication that all
the terms required under section (3)(a) of this rule are included in the signed
fee discount agreement.
(4) Fee Discount Agreement
Modifications and Terminations.
(a) When the medical service
provider or clinic and the insurer agree to modify an existing fee discount agreement,
the parties must enter into a new fee discount agreement.
(b) Either party to the fee
discount agreement may terminate the agreement by providing 30 days written notice
to the other party. The insurer must report the termination to the director prior
to the termination taking effect by completing the director’s online form.
The following information must be reported:
(A) The insurer’s name;
(B) The medical service provider’s
or clinic’s name; and
(C) The termination date
of the agreement.
(5) Other Medical Providers.
(a) For the purpose of this
rule, “other medical providers” means providers such as hospitals, ambulatory
surgery centers, or vendors of medical services and does not include medical service
providers or clinics.
(b) The insurer may apply
a discount to the medical provider’s fee if a written or verbal contract exists.
(c) If the insurer and the
medical provider have multiple contracts, only one discount may be applied.
(d) If the insurer has multiple
contracts with a provider and one of the contracts is through an MCO for services
provided to an enrolled worker, the insurer may only apply the discount under the
MCO’s contract.
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 5-2008, f. 12-15-08,
cert. ef. 1-1-09; WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09; WCD 3-2014, f. 3-12-14,
cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 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 for bills from those hospitals listed in Appendix
A.
(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.
(2) Outpatient.
(a) For the purposes of this
rule, hospital outpatient services are those services that are billed with codes
“0131” through “0138” in form locator #4 on the UB-04 billing
form.
(b) Hospital outpatient bills
must, when applicable, include the following:
(A) Revenue codes;
(B) 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,
(C) CPT® codes and HCPCS
codes; and
(D) The hospital’s
NPI (c) Unless otherwise provided by contract, the insurer must pay for hospital
outpatient services as follows: [Table not included. See ED. NOTE.]
(3) Specific Circumstances.
When a patient is seen initially in an emergency department and is then admitted
to the hospital for inpatient treatment, the services provided immediately prior
to admission are considered part of the inpatient treatment. Diagnostic testing
done prior to inpatient treatment is considered part of the hospital services subject
to the hospital inpatient fee schedule.
(4) Out-of-State Hospitals.
(a) The payment to out-of-state
hospitals may be negotiated between the insurer and the hospital.
(b) Any agreement for payment
less than the billed amount must be in writing and signed by the hospital and insurer
representative.
(c) The agreement must include
language that the hospital will not bill the patient any remaining balance and that
the negotiated amount is considered payment in full.
(d) If the insurer and the
hospital are unable to reach an agreement within 45 days of the insurer's receipt
of the bill, either party may bring the issue to the director for resolution. The
director may order payment up to the amount billed considering factors such as,
but not limited to, reasonableness, usual fees for similar services by facilities
in similar geographic areas, case specific services, and any extenuating circumstances.
(5) Calculation of Cost-to-Charge
Ratio Published in Bulletin 290.
(a) Each hospital's CMS 2552
form and financial statement is the basis for determining its adjusted cost-to-charge
ratio. If a current form 2552 is not available, then financial statements may be
used to develop estimated data. If the adjusted cost–to-charge ratio is determined
from estimated data, the hospital will receive the lower ratio of either the hospital's
last published cost-to-charge ratio or the hospital's cost-to-charge ratio based
on estimated data.
(b) The basic cost-to-charge
ratio is developed by dividing the total net expenses for allocation shown on Worksheet
A, and as modified in subsection (c), by the total patient revenues from Worksheet
G-2.
(c) The net expenses for
allocation derived from Worksheet A is modified by adding, from Worksheet A-8, the
expenses for:
(A) Provider-based physician
adjustment;
(B) Patient expenses such
as telephone, television, radio service, and other expenses determined by the department
to be patient-related expenses; and
(C) Expenses identified as
for physician recruitment.
(d) The basic cost-to-charge
ratio is further modified to allow a factor for bad debt and the charity care provided
by each hospital. The adjustment for bad debt and charity care is calculated in
two steps. Step one: Add the dollar amount for net bad debt to the dollar amount
for charity care. Divide this sum by the dollar amount of the total patient revenues,
from Worksheet G-2, to compute the bad debt and charity ratio. Step two: Multiply
the bad debt and charity ratio by the basic cost-to-charge ratio calculated in subsection
(5)(b) to obtain the factor for bad debt and charity care.
(e) The basic cost-to-charge
ratio is further modified to allow an adequate return on assets. The director will
determine a historic real growth rate in the gross fixed assets of Oregon hospitals
from the audited financial statements. This real growth rate and the projected growth
in a national fixed weight price deflator will be added together to form a growth
factor. This growth factor will be multiplied by the total fund balance, from Worksheet
G of each hospital's CMS 2552 to produce a fund balance amount. The fund balance
amount is then divided by the total patient revenues from Worksheet G-2, to compute
the fund balance factor.
(f) The factors resulting
from subsections (5)(d) and (5)(e) of this rule is added to the ratio calculated
in subsection (5)(b) of this rule to obtain the adjusted cost-to-charge ratio. In
no event will the adjusted cost-to-charge ratio exceed 1.00.
(g) The adjusted cost-to-charge
ratio for each hospital will be revised annually, at a time based on their fiscal
year, as described by bulletin. Each hospital must submit a copy of its CMS 2552
and financial statements each year within 150 days of the end of the hospital’s
fiscal year to the Information Technology and Research Section, Department of Consumer
and Business Services. The adjusted cost-to-charge ratio schedule will be published
by bulletin twice yearly, effective for the six-month period beginning April 1 and
the six-month period beginning October 1.
(h) For newly formed or established
hospitals for which no CMS 2552 has been filed or for which there is insufficient
data, or for those hospitals that do not file Worksheet G-2 with the submission
of their CMS 2552, the division determines an adjusted cost–to-charge ratio
for the hospital based upon the adjusted cost to charge ratios of a group of hospitals
of similar size or geographic location.
(i) If the financial circumstances
of a hospital unexpectedly or dramatically change, the division may revise the hospital's
adjusted cost-to-charge ratio to allow equitable payment.
(j) If audit of a hospital's
CMS 2552 by the CMS produces significantly different data from that obtained from
the initial filing, the division may revise the hospital's adjusted cost-to-charge
ratio to reflect the data developed subsequent to the initial calculation.
(k) Notwithstanding subsections
(1)(c), (2)(b), and (2)(c) of this rule, the director may exclude rural hospitals
from imposition of the adjusted cost-to-charge ratio based upon a determination
of economic necessity. The rural hospital exclusion will be based on the financial
health of the hospital reflected by its financial flexibility index. All rural hospitals
having a financial flexibility index at or below the median for critical access
hospitals nationwide qualify for the rural exemption. Rural hospitals that are designated
as critical access hospitals under the Oregon Medicare Rural Hospital Flexibility
Program are automatically exempt from imposition of the adjusted cost-to-charge
ratio.
[ED. NOTE:
Appendices referenced are not included in rule text. Click here for PDF copy of appendices.]
[Publications: Publications
& forms referenced are available from the agency.]
Stat. Auth.: ORS 656.726(4),
656.012, 656.236(5), 656.327(2) & 656.313(4)(d)
Stats. Implemented: ORS 656.248,
656.252 & 656.256
Hist.: WCD 5-1982(Admin),
f. 2-23-82, ef. 3-1-82; WCD 1-1984(Admin), f. & ef. 1-16-84; WCD 2-1985(Admin),
f. 4-29-85, ef. 6-3-85; Renumbered from 436-069-0701, 5-1-85; WCD 3-1985(Admin)(Temp),
f. & ef. 9-4-85; WCD 4-1985(Admin)(Temp), f. & ef. 9-11-85; WCD 6-1985(Admin),
f. 12-10-85, ef. 1-1-86; WCD 1-1986(Admin)(Temp), f. 2-5-86, ef. 2-6-86; WCD 2-1986(Admin),
f. 3-10-86, ef. 3-17-86; WCD 2-1987(Admin), f. 2-20-87, ef. 3-16-87; WCD 1-1988,
f. 1-20-88, cert. ef. 2-1-88; WCD 6-1988, f. 9-6-88, cert. ef. 9-15-88; WCD 2-1989,
f. 8-21-89, cert. ef. 9-1-89; WCD 1-1990, f. 1-5-90, cert. ef. 2-1-90; WCD 12-1990(Temp),
f. 6-20-90, cert. ef. 7-1-90; WCD 15-1990, f. & cert. ef. 8-7-90; WCD 30-1990,
f. 12-10-90, cert. ef. 12-26-90; WCD 11-1992, f. 6-11-92, cert. ef. 7-1-92; WCD
13-1994, f. 12-20-94, cert. ef. 2-1-95; WCD 18-1995(Temp), f. & cert. ef. 12-4-95;
WCD 12-1996, f. 5-6-96, cert. ef. 6-1-96, Renumbered from 436-010-0090; WCD 20-1996,
f. 10-2-96, cert. ef. 1-1-97; WCD 5-1997, f. 4-21-97, cert. ef. 7-1-97; Administrative
correction 6-18-97; WCD 8-1997(Temp), f. & cert. ef. 7-9-97; WCD 16-1997, f.
& cert. ef. 12-15-97; WCD 5-1998, f. 4-3-98, cert. ef. 7-1-98; WCD 9-1999, f.
5-27-99, cert. ef. 7-1-99; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2002,
f. 2-25-02 cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 3-2004,
f. 3-5-04 cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05; WCD 3-2006,
f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07; WCD 10-2007,
f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 3-2008(Temp),
f. & cert. ef. 7-7-08 thru 1-2-09; WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09;
WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09; WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10;
WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11; WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13;
WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 4-2014(Temp), f. & cert. ef. 4-15-14
thru 10-11-14; WCD 6-2014, f. 6-13-14, cert. ef. 7-1-14; WCD 3-2015, f. 3-12-15,
cert. ef. 4-1-15

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 used.
(b) The ASC must add a modifier
“SG” in box 24D of the CMS 1500 form to identify the facility charges.
(2) ASC Facility Fee.
(a) The following services
are included in the ASC facility fee and the ASC may not receive separate payment
for them:
(A) Nursing, technical, and
related services;
(B) Use of the facility where
the surgical procedure is performed;
(C) Drugs and biologicals
designated as packaged in Appendix D, surgical dressings, supplies, splints, casts,
appliances, and equipment directly related to the provision of the surgical procedure;
(D) Radiology services designated
as packaged in Appendix D;
(E) Administrative, record-keeping,
and housekeeping items and services;
(F) Materials for anesthesia;
(G) Supervision of the services
of an anesthetist by the operating surgeon; and
(H) Packaged services identified
in Appendix C or D.
(b) The payment for the surgical
procedure (i.e., the ASC facility fee) does not include physician’s services,
laboratory, X-ray, or diagnostic procedures not directly related to the surgical
procedures, prosthetic devices, orthotic devices, durable medical equipment (DME),
or anesthetists’ services.
(3) ASC Billing.
(a) The ASC should not bill
for packaged codes as separate line-item charges when the payment amount says “packaged”
in Appendices C or D.
(b) When the ASC provides
packaged services (see Appendices C and D) with a surgical procedure, the billed
amount should include the charges for the packaged services.
(c) For the purpose of this
rule, an implant is an object or material inserted or grafted into the body. When
the ASC’s cost for an implant is $100 or more, the ASC may bill for the implant
as a separate line item. The ASC must provide the insurer a receipt of sale showing
the ASC’s cost of the implant.
(4) ASC Payment.
(a) Unless otherwise provided
by contract, insurers must pay ASCs for services according to this rule.
(b) Insurers must pay for
surgical procedures (i.e., ASC facility fee) and ancillary services the lesser of:
(A) The maximum allowable
payment amount for the HCPCS code found in Appendix C for surgical procedures, and
in Appendix D for ancillary services integral to a surgical procedure; or
(B) The ASC’s usual
fee for surgical procedures and ancillary services.
(c) When more than one procedure
is performed in a single operative session, insurers must pay the principal procedure
at 100 percent of the maximum allowable fee, and the secondary and all subsequent
procedures at 50 percent of the maximum allowable fee. A diagnostic arthroscopic
procedure performed preliminary to an open operation is considered a secondary procedure
and should be paid accordingly. The multiple surgery discount described in this
section does not apply to codes listed in Appendix C with an “N” in
the “Subject to Multiple Procedure Discounting” column.
(d) The table below lists
packaged surgical codes that ASCs may perform without any other surgical procedure.
In this case do not use Appendix C to calculate payment, use the rates listed below
instead. [Appendix not included. See ED. NOTE.]
(e) When the ASC’s
cost of an implant is more than $100, insurers must pay for the implants at 110
percent of the ASC’s actual cost documented on a receipt of sale and not according
to Appendix D or E.
(f) When the ASC’s
cost of an implant is less than $100, insurers are not required to pay separately
for the implant. An implant may consist of several separately billable components,
some of which may cost less than $100. For payment purposes, insurers must add the
costs of all the components for the entire implant and use that total amount to
calculate payment for the implant.
(g) The insurer does not
have to pay the ASC when the ASC provides services to a patient who is enrolled
in a managed care organization (MCO) and:
(A) The ASC is not a contracted
facility for the MCO;
(B) The MCO has not pre-certified
the service provided; or
(C) The surgeon is not an
MCO panel provider.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.245,
656.248 & 656.252
Hist.: WCD 3-2014, f. 3-12-14,
cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 worker must request
reimbursement from the insurer in writing. The insurer may require reasonable documentation
such as a sales slip, receipt, or other evidence to support the request. The worker
may use Form 3921 — Request for Reimbursement of Expenses.
(c) Insurers must date stamp
requests for reimbursement on the date received.
(d) The insurer or its representative
must provide a written explanation to the worker for each type of out-of-pocket
expense (mileage, lodging, medication, etc.) being paid or denied.
(e) The explanation to the
worker must be in 10 point size font or larger and must include:
(A) The amount of reimbursement
for each type of out-of-pocket expense requested.
(B) The specific reason for
non-payment, reduced payment, or discounted payment for each itemized out-of-pocket
expense the worker submitted for reimbursement;
(C) An Oregon or toll-free
phone number for the insurer or its representative, and a statement that the insurer
or its representative must respond to a worker’s reimbursement question within
48 hours, excluding weekends and legal holidays;
(D) The following notice,
Web link, and phone number: “To access Bulletin 112 with information about
reimbursement amounts for travel, food, and lodging costs visit www.oregonwcdoc.info
or call 503-947-7606.”;
(E) Space for the worker’s
signature and date; and
(F) A notice of right to
administrative review as follows: “If you disagree with this decision about
this payment, please contact {the insurer or its representative} first. If you are
not satisfied with the response you receive, you may request administrative review
by the Director of the Department of Consumer and Business Services. Your request
for review must be made within 90 days of the mailing date of this explanation.
To request review, sign and date in the space provided, indicate what you believe
is incorrect about the payment, and mail this document with the required supporting
documentation to the Workers’ Compensation Division, Medical Resolution Team,
PO Box 14480, Salem, OR 97309-0405. Or you may fax the request to the director at
503-947-7629. You must also send a copy of the request to the insurer. You should
keep a copy of this document for your records.”
(f) According to ORS 656.325(1)(f)
and OAR 436-060-0095(5)(f), when a worker attends an independent medical examination
(IME), the insurer must reimburse the worker for related costs regardless of claim
acceptance, deferral, or denial.
(2) Timeframes.
(a) The worker must submit
a request for reimbursement of claim-related costs by whichever date is later:
(A) Two years from the date
the costs were incurred or
(B) Two years from the date
the claim or medical condition is finally determined compensable.
(b) If the worker requests
reimbursement after two years as listed in subsection (a), the insurer may disapprove
the reimbursement request.
(c) On accepted claims the
insurer must, within 30 days of receiving the reimbursement request:
(A) Reimburse the worker
if the request shows the costs are related to the accepted claim;
(B) Disapprove the request
if unreasonable or if the costs are not related to the accepted claim; or
(C) Request additional information
from the worker to determine if costs are related to the accepted claim. If additional
information is needed, the time needed to obtain the information is not counted
in the 30-day time frame for the insurer to issue reimbursement.
(d) When the insurer receives
a reimbursement request before claim acceptance, and the claim is ultimately accepted,
by whichever date is later the insurer must:
(A) Within 30 days of receiving
the reimbursement request: reimburse the worker if the request shows the costs are
related, disapprove the request if unreasonable or if the costs are not related,
or request additional information. If additional information is needed, the time
needed to obtain the information is not counted in the 30-day time frame for the
insurer to issue reimbursement; or
(B) Within 14 days of claim
acceptance: reimburse the worker if the request shows the costs are related, disapprove
the request if unreasonable or if the costs are not related, or request additional
information. If additional information is needed, the time needed to obtain the
information is not counted in the 14-day time frame for the insurer to issue reimbursement.
(e) In a claim for aggravation
or a new medical condition, reimbursement requests are not due and payable until
the aggravation or new medical condition is accepted.
(f) If the claim is denied,
requests for reimbursement must be returned to the worker within 14 days, and the
insurer must retain a copy.
(3) Meal and Lodging Reimbursement.
(a) Meal reimbursement is
based on whether a meal is reasonably required by necessary travel to a claim-related
appointment.
(b) Lodging reimbursement
is based on the need for an overnight stay to attend an appointment.
(c) Meals and lodging are
reimbursed at the actual cost or the rate published in Bulletin 112, whichever is
less. Lodging reimbursement may exceed the maximum rate published in Bulletin 112
when special lodging is required or when the worker is unable to find lodging at
or below the maximum rate within 10 miles of the appointment location.
(4) Travel Reimbursement.
(a) Insurers must reimburse
workers for actual and reasonable costs for travel to medical providers paid by
the worker under ORS 656.245(1)(e), 656.325, and 656.327.
(b) The insurer may limit
worker reimbursement for travel to an attending physician if the insurer provides
a prior written explanation and a written list of attending physicians that are
closer for the worker, of the same specialty, and who are able and willing to provide
similar medical services to the worker. The insurer may limit worker reimbursement
for travel to an authorized nurse practitioner if the insurer provides a prior written
explanation and a written list of authorized nurse practitioners that are closer
for the worker, of the same specialty, and who are able and willing to provide similar
medical services to the worker. The insurer must inform the worker that he or she
may continue treating with the established attending physician or authorized nurse
practitioner; however, reimbursement of transportation costs may be limited to the
distance from the worker’s home to a provider on the written list.
(c) Within a metropolitan
area the insurer may not limit worker reimbursement for travel to an attending physician
or authorized nurse practitioner even if there are medical providers closer to the
worker.
(d) Travel reimbursement
dispute decisions will be based on principles of reasonableness and fairness within
the context of the specific case circumstances as well as the spirit and intent
of the law.
(e) Personal vehicle mileage
is the reasonable actual distance based on the beginning and ending addresses. The
mileage reimbursement is limited to the rate published in Bulletin 112.
(f) Public transportation
or, if required, special transportation will be reimbursed based on actual cost.
(5) Other Reimbursements.
(a) The insurer must reimburse
the worker for other claim-related expenses based on actual cost. However, reimbursement
for hearing aids is limited to the amounts listed in OAR 436-009-0080.
(b) For prescription medications,
the insurer must reimburse the worker based on actual cost. When a provider prescribes
a brand-name drug, pharmacies must dispense the generic drug (if available), according
to ORS 689.515. When a worker insists on receiving the brand-name drug, and the
prescribing provider has not prohibited substitution, the worker must 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. The worker may then
request reimbursement from the insurer. However, if the insurer has previously notified
the worker in writing that the worker is liable for the difference between the generic
and brand-name drug, the insurer only has to reimburse the worker the generic price
of the drug.
(c) For IMEs, child care
costs are reimbursed at the rate prescribed by the State of Oregon Department of
Human Services.
(d) Home health care provided
by a worker’s family member is not required to be under the direct control
and supervision of the attending physician. A worker may receive reimbursement for
such home health care services only if the family member demonstrates competency
to the satisfaction of the worker’s attending physician.
(6) Advancement Request.
If necessary to attend a medical appointment, the worker may request an advance
for transportation and lodging expenses. Such a request must be made to the insurer
in sufficient time to allow the insurer to process the request.
Stat. Auth: ORS 656.245, 656.325, 656.704
& 656.726(4)
Stats. Implemented: ORS 656.245,
656.704 & 656.726(4)
Hist.: WCB 6-1969, f. 10-23-69,
ef. 10-29-69; WCD 1-1980(Admin), f. & ef. 1-11-80; WCD 6-1981(Admin), f. 12-23-81,
ef. 1-1-82; WCD 8-1983(Admin), f. 12-29-83, ef. 1-1-84; Renumbered from 436-054-0270,
5-1-85; WCD 8-1985(Admin), f. 12-12-85, ef. 1-1-86; WCD 4-1987, f. 12-18-87, ef.
1-1-88; WCD 6-1989, f. 12-22-89, cert. ef. 1-1-90; WCD 29-1990, f. 11-30-90, cert.
ef. 12-26-90; WCD 1-1992, f. 1-3-92, cert. ef. 2-1-92; WCD 5-1996, f. 2-6-96, cert.
ef. 2-12-96; WCD 13-2001, f. 12-17-01, cert. ef. 1-1-02, Renumbered from 436-060-0070;
WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04; WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06;
WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07; WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10;
WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14;
WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 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.
(2) Bill Processing.
(a) Insurers must date stamp
medical bills, chart notes, and other documentation upon receipt. Bills not submitted
according to OAR 436-009-0010(1)(b) and (2) must be returned to the medical provider
within 20 days of receipt of the bill with a written explanation describing why
the bill was returned and what needs to be corrected. A request for chart notes
on EDI billings must be made to the medical provider within 20 days of the receipt
of the bill. The number of days between the date the insurer returns the bill or
requests chart notes and the date the insurer receives the corrected bill or chart
notes, does not count toward the 45 days within which the insurer is required to
make payment.
(b) The insurer must retain
a copy of each medical provider’s bill received by the insurer or must be
able to reproduce upon request data relevant to the bill, including but not limited
to, provider name, date of service, date the insurer received the bill, type of
service, billed amount, coding submitted by the medical provider as described in
OAR 436-009-0010(1)(b) and (3)(a), and insurer action, for any non-payment or fee
reduction. This includes all bills submitted to the insurer even when the insurer
determines no payment is due.
(c) Any service billed with
a code number commanding a higher fee than the services provided must be returned
to the medical provider for correction or paid at the value of the service provided.
(3) Payment Requirements.
(a) Insurers must pay bills
for medical services on accepted claims within 45 days of receipt of the bill, if
the bill is submitted in proper form according to OAR 436-009-0010(1)(b), (3)(a)
through (7)(c), and clearly shows that the treatment is related to the accepted
compensable injury or disease.
(b) The insurer or its representative
must provide a written explanation of benefits (EOB) of the services being paid
or denied. If the billing is done electronically, the insurer or its representative
may provide this explanation electronically. The insurer or its representative must
send the explanation to the medical provider that billed for the services. For the
purpose of this rule an EOB has the same meaning as an explanation of review (EOR).
(c) The written EOB must
be in 10 point size font or larger. Electronic and written explanations must include:
(A) The amount of payment
for each service billed. When the payment covers multiple patients, the explanation
must clearly separate and identify payments for each patient;
(B) The specific reason for
non-payment, reduced payment, or discounted payment for each service billed;
(C) An Oregon or toll-free
phone number for the insurer or its representative, and a statement that the insurer
or its representative must respond to a medical provider’s payment question
within 48 hours, excluding weekends and legal holidays;
(D) The following notice,
Web link, and phone number: “To access information about Oregon’s Medical
Fee and Payment Rules, visit www.oregonwcdoc.info or call 503-947-7606.”;
(E) Space for the provider’s
signature and date; and
(F) A notice of right to
administrative review as follows: “If you disagree with this decision about
this payment, please contact {the insurer or its representative} first. If you are
not satisfied with the response you receive, you may request administrative review
by the Director of the Department of Consumer and Business Services. Your request
for review must be made within 90 days of the mailing date of this explanation.
To request review, sign and date in the space provided, indicate what you believe
is incorrect about the payment, and mail this document with the required supporting
documentation to the Workers’ Compensation Division, Medical Resolution Team,
PO Box 14480, Salem, OR 97309-0405. Or you may fax the request to the director at
503-947-7629. You must also send a copy of the request to the insurer. You should
keep a copy of this document for your records.”
(d) Payment of medical bills
is required within 14 days of any action causing the service to be payable, or within
45 days of the insurer’s receipt of the bill, whichever is later.
(e) Failure to pay for medical
services timely may render the insurer liable to pay a reasonable monthly service
charge for the period payment was delayed, if the provider customarily applies such
a service charge to the general public.
(f) When there is a dispute
over the amount of a bill or the appropriateness of services rendered, the insurer
must, within 45 days, pay the undisputed portion of the bill and at the same time
provide specific reasons for non-payment or reduction of each medical service code.
(g) Bills for medical services
rendered at the request of the insurer and bills for information submitted at the
request of the insurer, which are in addition to those required in OAR 436-010-0240
must be paid within 45 days of receipt by the insurer even if the claim is denied.
(h) If an insurer determines
that it has made an overpayment to a provider for medical services, the insurer
may request a refund from the provider. The insurer must make the request within
180 days of the payment date. Resolution of overpayment disputes must be made under
OAR 436-009-0008.
(4) Communication with Providers.
(a) The insurer or its representative
must respond to a medical provider’s inquiry about a medical payment within
48 hours, not including weekends or legal holidays. The insurer or its representative
may not refer the medical provider to another entity to obtain an answer.
(b) An insurer or its representative
and a medical provider may agree to send and receive payment information by email
or other electronic means. Electronic records sent are subject to the Oregon Consumer
Identity Theft Protection Act under ORS 646A.600 to 646A.628 and federal law.
(5) EDI Reporting. For medical
bill reporting requirements, see OAR 436-160 Electronic Data Interchange Medical
Bill Data rules.
[ED. NOTE: Appendices referenced are
available from the agency.]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.252,
656.325, 656.245, 656.248, 656.260 & 656.264
Hist.: WCD 12-1996, f. 5-6-96,
cert. ef. 6-1-96; WCD 20-1996, f. 10-2-96, cert. ef. 1-1-97; WCD 5-1997, f. 4-21-97,
cert. ef. 7-1-97; WCD 5-1998, f. 4-3-98, cert. ef. 7-1-98; WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04
cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05; WCD 3-2006, f. 3-14-06,
cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07; WCD 10-2007, f. 11-1-07,
cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 3-2008(Temp), f.
& cert. ef. 7-7-08 thru 1-2-09; WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09; WCD
1-2009, f. 5-22-09, cert. ef. 7-1-09; WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10;
WCD 6-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11;
WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12; WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13;
WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 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.
(2) Claim Acceptance. If
the insurer accepts the claim:
(a) The insurer must pay
medical providers for services according to these rules; and
(b) The provider, after receiving
payment from the insurer, must reimburse the worker and the health benefit plan
for any medical expenses, co-pays, co-insurance, or deductibles, paid by the worker
or the health benefit plan.
(3) Claim Denial. If the
insurer denies the claim:
(a) The insurer must notify
the medical provider as provided in OAR 436-060-0140 that an initial claim has been
denied; and
(b) The medical provider
must bill the health benefit plan, unless the medical provider has previously billed
the health benefit plan. The provider must forward a copy of the workers’
compensation denial letter to the health benefit plan.
Stat. Auth.: ORS 656.245, 656.704, 656.726(4)
Stats. Implemented: ORS 656.247
Hist.: WCD 13-2001, f. 12-17-01,
cert. ef. 1-1-02; WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 5-2008, f. 12-15-08,
cert. ef. 1-1-09; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 11-2014, f. 10-17-14,
cert. ef. 1-1-15; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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: [Table not included. See ED. NOTE.]
(b) The global period is
listed in the column ‘Global Days’ of Appendix B.
(2) Anesthesia.
(a) When using the American
Society of Anesthesiologists Relative Value Guide, a basic unit value is determined
by reference to the appropriate anesthesia code. The total anesthesia value is made
up of a basic unit value and, when applicable, time and modifying units.
(b) Physicians or certified
nurse anesthetists may use basic unit values only when they personally administer
the general anesthesia and remain in constant attendance during the procedure for
the sole purpose of providing the general anesthesia.
(c) Attending surgeons may
not add time units to the basic unit value when administering local or regional
block for anesthesia during a procedure. The modifier ‘NT’ (no time)
must be on the bill.
(d) Local infiltration, digital
block, or topical anesthesia administered by the operating surgeon is included in
the payment for the surgical procedure.
(e) In calculating the units
of time, use 15 minutes per unit. If a medical provider bills for a portion of 15
minutes, round the time up to the next 15 minutes and pay one unit for the portion
of time.
(f) The maximum allowable
payment amount for anesthesia codes is determined by multiplying the anesthesia
value by a conversion factor of $58.00.
Unless otherwise provided
by contract or fee discount agreement permitted by these rules, the insurer must
pay the lesser of: the maximum allowable payment amount for anesthesia codes; or
the provider’s usual fee.
(g) When the anesthesia code
is designated by IC (individual consideration), unless otherwise provided by a contract
or fee discount agreement, the insurer must pay 80 percent of the provider's usual
fee.
(3) Surgery.
Unless otherwise provided
by contract or fee discount agreement permitted by these rules, insurers must pay
multiple surgical procedures performed in the same session according to the following:
(a) One surgeon: [Appendix
not included. See ED. NOTE.]
(b) Two or more surgeons:
[Appendix not included. See ED. NOTE.]
(c) Assistant surgeons: [Appendix
not included. See ED. NOTE.]
(d) Nurse practitioners or
physician assistants: [Appendix not included. See ED. NOTE.]
(e) Self-employed surgical
assistants who work under the direct control and supervision of a physician: [Appendix
not included. See ED. NOTE.]
(f) When a surgeon performs
surgery following severe trauma, and the surgeon does not think the fees should
be reduced under the multiple surgery rule, the surgeon may request special consideration
by the insurer. The surgeon must provide written documentation and justification.
Based on the documentation, the insurer may pay for each procedure at 100 percent.
(g) If the surgery is non-elective,
the physician is entitled to payment for the initial evaluation of the patient in
addition to the global fee for the surgical procedure(s) performed. However, the
pre-operative visit for elective surgery is included in the listed global value
of the surgical procedure, even if the pre-operative visit is more than one day
before surgery.
(4) Radiology Services.
(a) Insurers only have to
pay for X-ray films of diagnostic quality that include a report of the findings.
Insurers will not pay for 14" x 36" lateral views.
(b) When multiple contiguous
areas are examined by computerized axial tomography (CAT) scan, computerized tomography
angiography (CTA), magnetic resonance angiography (MRA), or magnetic resonance imaging
(MRI), then the technical component must be paid 100 percent for the first area
examined and 75 percent for all subsequent areas. These reductions do not apply
to the professional component. The reductions apply to multiple studies done within
two days, unless the ordering provider provides a reasonable explanation of why
the studies needed to be done on separate days.
(5) Pathology and Laboratory
Services.
(a) The payment amounts in
Appendix B apply only when there is direct physician involvement.
(b) Laboratory fees must
be billed in accordance with ORS 676.310. If a physician submits a bill for laboratory
services that were performed in an independent laboratory, the bill must show the
amount charged by the laboratory and any service fee that the physician charges.
(6) Physical Medicine and
Rehabilitation Services.
(a) Time-based CPT®
codes must be billed and paid according to this table: [Table not included. See
ED. NOTE.]
(b) Except for CPT®
codes 97001, 97002, 97003, or 97004, payment for modalities and therapeutic procedures
is limited to a total of three separate CPT®-coded services per day for each
provider, identified by their federal tax ID number. An additional unit of time
for the same CPT® code does not count as a separate code.
(c) CPT® codes 97032,
97033, 97034, 97035, 97036, and 97039 are time-based codes and require constant
attendance. Chart notes must clearly indicate the time treatment begins and the
time treatment ends for the day or the amount of time spent providing the treatment.
(d) CPT® codes 97010
through 97028 are not payable unless they are performed in conjunction with other
procedures or modalities that require constant attendance or knowledge and skill
of the licensed medical provider.
(e) When multiple treatments
are provided simultaneously by one machine, device, or table there must be a notation
on the bill that treatments were provided simultaneously by one machine, device,
or table and there must be only one charge.
(7) Reports.
(a) Except as otherwise provided
in OAR 436-009-0060, when another medical provider, or an insurer or its representative
asks a medical provider to prepare a report, or review records or reports, the medical
provider should bill the insurer for their report or review of the records using
CPT® codes such as 99080. The bill should include documentation of time spent
reviewing the records or reports.
(b) If the insurer asks the
medical service provider to review the IME report and respond, the medical service
provider must bill for the time spent reviewing and responding using OSC D0019.
The bill should include documentation of time spent.
(8) Nurse Practitioners and
Physician Assistants.
Services provided by authorized
nurse practitioners, physician assistants, or out-of-state nurse practitioners must
be paid at 85 percent of the amount calculated in section (1) of this rule.
[ED. NOTE:
Appendices referenced are not included in rule text. Click here for PDF copy of appendices.]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00; WCD 2-2001, f. 3-8-01,
cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03,
cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05,
cert. ef. 4-1-05; WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07,
cert. ef. 7-1-07; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08,
cert. ef. 7-1-08; WCD 3-2008(Temp), f. & cert. ef. 7-7-08 thru 1-2-09; WCD 5-2008,
f. 12-15-08, cert. ef. 1-1-09; WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09; WCD 3-2010,
f. 5-28-10, cert. ef. 7-1-10; WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11; WCD 1-2012,
f. 2-16-12, cert. ef. 4-1-12; WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13; WCD 3-2014,
f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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) When an attending physician
or authorized nurse practitioner approves a multidisciplinary treatment program
for a patient, he or she must provide the insurer with a copy of the approved treatment
program within 14 days of the beginning of the treatment program.
(c) 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.
(2) Table of all Oregon Specific
Codes (For OSC fees, see Appendix B.) [Appendix not included. See ED. NOTE.]
(3) CARF/JCAHO Accredited
Programs.
(a) Treatment in a chronic
pain management program, physical rehabilitation program, work hardening program,
or a substance abuse program will not be paid unless the program is accredited for
that purpose by the Commission on Accreditation of Rehabilitation Facilities (CARF)
or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
(b) Organizations that have
applied for CARF accreditation, but have not yet received accreditation, may receive
payment for multidisciplinary programs upon providing evidence to the insurer that
an application for accreditation has been filed with and acknowledged by CARF. The
organizations may provide multidisciplinary services under this section for a period
of up to six months from the date CARF provided notice to the organization that
the accreditation process has been initiated, or until such time as CARF accreditation
has been received or denied, whichever occurs first.
(c) Notwithstanding OAR 436-009-0010(4)(a),
program fees for services within a multidisciplinary program may be used based upon
written pre-authorization from the insurer. Programs must identify the extent, frequency,
and duration of services to be provided. (d) All job site visits and ergonomic consultations
must be preauthorized by the insurer.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 14-2003(Temp), f.
12-15-03, cert. ef. 1-1-04 thru 6-28-04; WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04;
WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 1-2009, f. 5-22-09, cert. ef. 7-1-09;
WCD 3-2010, f. 5-28-10, cert. ef. 7-1-10; 2010, f. 5-28-10, cert. ef. 7-1-10; WCD
1-2011, f. 3-1-11, cert. ef. 4-1-11; WCD 2-2013, f. 3-11-13, cert. ef. 4-1-13; WCD
3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
436-009-0080
Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS)
(1) Durable medical equipment (DME)
is equipment that: is primarily and customarily used to serve a medical purpose,
can withstand repeated use, could normally be rented and used by successive patients,
is appropriate for use in the home, and is not generally useful to a person in the
absence of an illness or injury.
Examples: Transcutaneous
Electrical Nerve Stimulation (TENS), Microcurrent Electrical Nerve Stimulation (MENS),
home traction devices, heating pads, reusable hot/cold packs, etc.
(2) A prosthetic is an artificial
substitute for a missing body part or any device aiding performance of a natural
function. Examples: hearing aids, eye glasses, crutches, wheelchairs, scooters,
artificial limbs, etc. The insurer must pay for the repair or replacement of prosthetic
appliances damaged as a result of a compensable injury, even if the worker received
no other injury. If the appliance is not repairable, the insurer must replace the
appliance with a new appliance comparable to the one damaged. If the worker chooses
to upgrade the prosthetic appliance, the worker may do so but must pay the difference
in price.
(3) An orthosis is an orthopedic
appliance or apparatus used to support, align, prevent or correct deformities, or
to improve the function of a moveable body part. Examples: brace, splint, shoe insert
or modification, etc.
(4) Supplies are materials
that may be reused multiple times by the same person, but a single supply is not
intended to be used by more than one person, including, but not limited to incontinent
pads, catheters, bandages, elastic stockings, irrigating kits, sheets, and bags.
(5) When billing for durable
medical equipment, prosthetics, orthotics, and supplies (DMEPOS), providers must
use the following modifiers, when applicable:
(a) NU for purchased, new
equipment
(b) UE for purchased, used
equipment
(c) RR for rented equipment
(6) Unless otherwise provided
by contract or sections (7) through (11) of this rule, insurers must pay for DMEPOS
according to the following table: [Table not included. See ED. NOTE.]
(7) Unless a contract establishes
a different rate, the table below lists maximum monthly rental rates for the codes
listed (do not use Appendix E or section (6) to determine the rental rates for these
codes): [Appendix not included. See ED. NOTE.]
(8) For items rented, unless
otherwise provided by contract:
(a) The maximum daily rental
rate is one thirtieth (1/30) of the monthly rate established in sections (6) and
(7) of this rule.
(b) After a rental period
of 13 months, the item is considered purchased, if the insurer so chooses.
(c) The insurer may purchase
a rental item anytime within the 13-month rental period, with 75 percent of the
rental amount paid applied towards the purchase.
(9) For items purchased,
unless otherwise provided by contract, the insurer must pay for labor and reasonable
expenses at the provider’s usual rate for:
(a) Any labor and reasonable
expenses directly related to any repairs or modifications subsequent to the initial
set-up; or
(b) The provider may offer
a service agreement at an additional cost.
(10) Hearing aids must be
prescribed by the attending physician, authorized nurse practitioner, or specialist
physician. Testing must be done by a licensed audiologist or an otolaryngologist.
The preferred types of hearing aids for most patients are programmable behind the
ear (BTE), in the ear (ITE), and completely in the canal (CIC) multichannel. Any
other types of hearing aids needed for medical conditions will be considered based
on justification from the attending physician or authorized nurse practitioner.
Unless otherwise provided by contract, insurers must pay the provider’s usual
fee for hearing services billed with HCPCS codes V5000 through V5999. However, without
approval from the insurer or director, the payment for hearing aids may not exceed
$5000 for a pair of hearing aids, or $2500 for a single hearing aid.
(11) Unless otherwise provided
by contract, insurers must pay the provider’s usual fee for vision services
billed with HCPCS codes V0000 through V2999.
(12) The worker may select
the service provider. For claims enrolled in a managed care organization (MCO) the
worker may be required to select a provider from a list specified by the MCO.
(13) Except as provided in
section (10) of this rule, the payment amounts established by this rule do not apply
to a worker’s direct purchase of DMEPOS. Workers are entitled to reimbursement
for actual out-of-pocket expenses under OAR 436-009-0025.
(14) DMEPOS dispensed by
a hospital (inpatient or outpatient) must be billed and paid according to OAR 436-009-0020.
[ED. NOTE:
Tables and appendices referenced are not included in rule text. Click here for PDF copy of tables.]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-04;
WCD 3-2004, f. 3-5-04 cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05;
WCD 3-2006, f. 3-14-06, cert. ef. 4-1-06; WCD 2-2007, f. 5-23-07, cert. ef. 7-1-07;
WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09; WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11;
WCD 4-2011(Temp) f. 6-30-11, cert. ef. 7-5-11 thru 12-31-11; WCD 5-2011, f. 11-18-11,
cert. ef. 1-1-12; WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12; WCD 2-2012(Temp), f.
4-13-12, cert. ef. 4-23-12 thru 10-19-12; WCD 4-2012, f. 9-21-12, cert. ef. 10-20-12;
WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
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 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.
(2) Pharmaceutical Billing
and Payment.
(a) Pharmaceutical billings
must contain the National Drug Code (NDC) to identify the drug or biological billed.
(b) All bills from pharmacies
must include the prescribing provider’s NPI or license number.
(c) Unless otherwise provided
by contract, insurers must pay medical providers for prescription medication, including
injectable drugs, at the medical provider’s usual fee, or the maximum allowable
fee, whichever is less. However, drugs provided by a hospital (inpatient or outpatient)
must be billed and paid according to OAR 436-009-0020.
(d) Unless directly purchased
by the worker (see 009-0025(5)), the maximum allowable fee for pharmaceuticals is
calculated according to the following table: [Table not included. See ED. NOTE.]
NOTE: “AWP” means the Average
Wholesale Price effective on the date the drug was dispensed.
(e) Insurers must use a nationally published
prescription pricing guide for calculating payments to the provider, e.g., First
DataBank, RED BOOK, or Medi-Span.
(3) Clinical Justification
Form 4909.
(a) The prescribing provider
must fill out Form 4909, Pharmaceutical Clinical Justification for Workers’
Compensation, and submit it to the insurer when prescribing more than a five day
supply of the following drugs:
(A) Celebrex®,
(B) Cymbalta®,
(C) Fentora®,
(D) Kadian®,
(E) Lidoderm®,
(F) Lyrica®, or
(G) OxyContin®.
(b) Insurers may not challenge
the adequacy of the clinical justification. However, they may challenge whether
or not the medication is excessive, inappropriate, or ineffectual under ORS 656.327.
(c) The prescribing provider
is not required to fill out Form 4909 for refills of medications listed on that
form.
(d) If a prescribing provider
does not submit Form 4909, Pharmaceutical Clinical
Justification for Workers’
Compensation, to the insurer, the insurer may file a complaint with the director.
(4) Dispensing by Medical
Service Providers.
(a) Except in an emergency,
prescription drugs for oral consumption dispensed by a physician’s or authorized
nurse practitioner’s office are compensable only for the initial supply to
treat the patient, up to a maximum of 10 days.
(b) For dispensed over-the-counter
medications, the insurer must pay the retail-based fee.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.248
Hist.: WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2001, f. 3-8-01, cert. ef. 4-1-01; WCD 3-2002, f. 2-25-02
cert. ef. 4-1-02; WCD 6-2003, f. 5-28-03, cert. ef. 7-1-03; WCD 3-2004, f. 3-5-04
cert. ef. 4-1-04; WCD 2-2005, f. 3-24-05, cert. ef. 4-1-05; WCD 3-2006, f. 3-14-06,
cert. ef. 4-1-06; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 3-2008(Temp), f.
& cert. ef. 7-7-08 thru 1-2-09; WCD 5-2008, f. 12-15-08, cert. ef. 1-1-09; WCD
1-2009, f. 5-22-09, cert. ef. 7-1-09; WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11; WCD
1-2012, f. 2-16-12, cert. ef. 4-1-12; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14;
WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15
Interpreter Billing Procedures
436-009-0110
Interpreters
(1) Choosing an Interpreter. A patient
may choose a person to communicate with a medical provider when the patient and
the medical provider speak different languages, including sign language. The patient
may choose a family member, a friend, an employee of the medical provider, or an
interpreter. The medical provider may disapprove of the patient’s choice at
any time the medical provider feels the interpreter services are not improving communication
with the patient, or feels the interpretation is not complete or accurate.
(2) Billing.
(a) Interpreters must charge
the usual fee they charge to the general public for the same service.
(b) Interpreters may only
bill an insurer or, if provided by contract, a managed care organization (MCO).
However, if the insurer denies the claim, interpreters may bill the patient.
(c) Interpreters may bill
for interpreter services and for mileage when the round-trip mileage is 15 or more
miles. For the purpose of this rule, “mileage” means the number of miles
traveling from the interpreter’s starting point to the exam or treatment location
and back to the interpreter’s starting point.
(d) If the interpreter arrives
at the provider’s office for an appointment that was required by the insurer
or the director, e.g., an independent medical exam, a physician review exam, or
an arbiter exam, the interpreter may bill for interpreter services and mileage according
to section (2)(c) of this rule even if:
(A) The patient fails to
attend the appointment; or
(B) The provider has to cancel
or reschedule the appointment.
(e) If interpreters do not
know the workers’ compensation insurer responsible for the claim, they may
contact the Department of Consumer and Business Services’, Workers’
Compensation Division at 503-947-7814. They may also access insurance policy information
at http://www4.cbs.state.or.us/ex/wcd/cov/index.cfm.
(3) Billing and Payment Limitations.
(a) When an appointment was
not required by the insurer or director, interpreters may not bill any amount for
interpreter services or mileage if:
(A) The patient fails to
attend the appointment: or
(B) The provider cancels
or reschedules the appointment.
(b) The insurer is not required
to pay for interpreter services or mileage when the services are provided by:
(A) A family member or friend
of the patient; or
(B) A medical provider’s
employee.
(4) Billing Timelines.
(a) Interpreters must bill
within:
(A) 60 days of the date of
service;
(B) 60 days after the interpreter
has received notice or knowledge of the responsible workers’ compensation
insurer or processing agent; or
(C) 60 days after any litigation
affecting the compensability of the service is final, if the interpreter receives
written notice of the final litigation from the insurer.
(b) If the interpreter bills
past the timelines outlined in subsection (a) of this section, the interpreter may
be subject to civil penalties as provided in ORS 656.254 and OAR 436-010-0340.
(c) When submitting a bill
later than outlined in subsection (a) of this section, an interpreter must establish
good cause. Good cause may include, but is not limited to, extenuating circumstances
or circumstances considered outside the control of the interpreter.
(d) A bill is considered
sent by the date the envelope is post-marked or the date the document is faxed.
(5) Billing Form.
(a) Interpreters must use
an invoice when billing for interpreter services and mileage and use Oregon specific
code:
(A) D0004 for interpreter
services except American Sign Language,
(B) D0005 for American Sign
Language interpreter services, and
(C) D0041 for mileage.
(b) An interpreter’s
invoice must include:
(A) The interpreter’s
name, the interpreter’s company name, if applicable, billing address, and
phone number;
(B) The patient’s name;
(C) The patient’s workers’
compensation claim number, if known;
(D) The correct Oregon specific
codes for the billed services (D0004, D0005, or D0041);
(E) The workers’ compensation
insurer’s name and address;
(F) The date interpreter
services were provided;
(G) The name and address
of the medical provider that conducted the exam or provided treatment;
(H) The total amount of time
interpreter services were provided; and
(I) The mileage, if the round
trip was 15 or more miles.
(6) Payment Calculations.
(a) Unless otherwise provided
by contract, insurers must pay the lesser of the maximum allowable payment amount
or the interpreter’s usual fee.
(b) Insurers must use the
following table to calculate the maximum allowable payment for interpreters: [Table
not included. See ED. NOTE.]
(7) Payment Requirements.
(a) When the medical exam
or treatment is for an accepted claim or condition, the insurer must pay for interpreter
services and mileage if the round-trip mileage is 15 or more miles.
(b) When the patient fails
to attend or the provider cancels or reschedules a medical exam required by the
director or the insurer, the insurer must pay the no-show fee and mileage if the
round-trip mileage is 15 or more miles.
(c) The insurer must pay
the interpreter within:
(A) 14 days of the date of
claim acceptance or any action causing the service to be payable, or 45 days of
receiving the invoice, whichever is later; or
(B) 45 days of receiving
the invoice for an exam required by the insurer or director.
(d) When an interpreter bills
within 12 months of the date of service, the insurer may not reduce payment due
to late billing.
(e) When an interpreter bills
over 12 months after the date of service, the bill is not payable, except when a
provision of subsection (4)(c) of this rule is the reason the billing was submitted
after 12 months.
(f) If the insurer does not
receive all the information to process the invoice, the insurer must return the
invoice to the interpreter within 20 days of receipt. The insurer must provide specific
information about what is needed to process the invoice.
(g) When there is a dispute
over the amount of a bill or the appropriateness of services rendered, the insurer
must, within 45 days, pay the undisputed portion of the bill and at the same time
provide specific reasons for non-payment or reduction of each service billed.
(h) The insurer must provide
a written explanation of benefits for services paid or denied and must send the
explanation to the interpreter that billed for the services. If the billing is done
electronically, the insurer or its representative may provide this explanation electronically.
All the information on the written explanation must be in 10 point size font or
larger.
(i) Electronic and written
explanations must include:
(A) The payment amount for
each service billed. When the payment covers multiple patients, the explanation
must clearly separate and identify payments for each patient;
(B) The specific reason for
non-payment, reduced payment, or discounted payment for each service billed;
(C) An Oregon or toll-free
phone number for the insurer or its representative, and a statement that the insurer
or its representative must respond to an interpreter’s payment questions within
48 hours, excluding weekends and legal holidays;
(D) The following notice,
Web link, and phone number:
“To access the information
about Oregon’s Medical Fee and Payment rules, visit www.oregonwcdoc.info or
call 503-947-7606”;
(E) Space for a signature
and date; and
(F) A notice of the right
to administrative review as follows: “If you disagree with this decision about
this payment, please contact {the insurer or its representative} first. If you are
not satisfied with the response you receive, you may request administrative review
by the Director of the Department of Consumer and Business Services. Your request
for review must be made within 90 days of the mailing date of this explanation.
To request review, sign and date in the space provided, indicate what you believe
is incorrect about the payment, and mail this document with the required supporting
documentation to the Workers’ Compensation Division, Medical Resolution Team,
PO Box 14480, Salem, OR 97309-0405. Or you may fax the request to the director at
503-947-7629. You must also send a copy of the request to the insurer. You should
keep a copy of this document for your records.”
(j) The insurer or its representative
must respond to an interpreter’s inquiry about payment within 48 hours, not
including weekends or legal holidays. The insurer or its representative may not
refer the interpreter to another entity to obtain the answer.
(k) The insurer or its representative
and an interpreter may agree to send and receive payment information by email or
other electronic means. Electronic records sent are subject to the Oregon Consumer
Identity Theft Protection Act under ORS 646A.600 to 646A.628 and federal law.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.245,
656.248
Hist.: WCD 3-2010, f. 5-28-10,
cert. ef. 7-1-10; WCD 1-2012, f. 2-16-12, cert. ef. 4-1-12; WCD 2-2013, f. 3-11-13,
cert. ef. 4-1-13; WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15,
cert. ef. 4-1-15
Ambulatory Surgery Centers —
Payment Calculations Sanctions and Civil Penalties
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 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
Hist.: WCD 12-1996, f. 5-6-96,
cert. ef. 6-1-96; WCD 20-1996, f. 10-2-96, cert. ef. 1-1-97; WCD 5-1998, f. 4-3-98,
cert. ef. 7-1-98; WCD 9-1999, f. 5-27-99, cert. ef. 7-1-99; WCD 9-1999, f. 5-27-99,
cert. ef. 7-1-99; WCD 2-2000, f. 3-15-00, cert. ef. 4-1-00; WCD 5-2008, f. 12-15-08,
cert. ef. 1-1-09; Renumbered from 436-009-0100 by WCD 3-2010, f. 5-28-10, cert.
ef. 7-1-10; Renumbered from 436-009-0199, WCD 1-2011, f. 3-1-11, cert. ef. 4-1-11;
WCD 3-2014, f. 3-12-14, cert. ef. 4-1-14; WCD 3-2015, f. 3-12-15, cert. ef. 4-1-15

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contained in the Administrative Order filed at the Archives Division,
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published version are satisfied in favor of the Administrative Order.
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