Click here to load reader

Oregon Medical Fee and Payment Rules · PDF file Association at American Dental Association, 211 East Chicago Ave., Chicago, IL 60611- 2678, or . (7) The director adopts, by reference,

  • View
    4

  • Download
    0

Embed Size (px)

Text of Oregon Medical Fee and Payment Rules · PDF file Association at American Dental Association,...

  • DEPARTMENT OF CONSUMER AND BUSINESS SERVICES

    WORKERS’ COMPENSATION DIVISION

    i

    Oregon Medical Fee and Payment Rules

    Oregon Administrative Rules

    Chapter 436, Division 009

    Effective Jan 1, 2019

    Table of Contents

    Summary of changes effective Jan. 1, 2019 ...................................................................................v

    436-009-0001 Administration of These Rules ..........................................................................1

    Authority for Rules. ......................................................................................................................... 1 Purpose. ......................................................................................................................... 1 Applicability of Rules. ..................................................................................................................... 1

    436-009-0004 Adoption of Standards (Temporary rule) ..........................................................2

    436-009-0005 Definitions ............................................................................................................4

    436-009-0008 Request for Review before the Director .........................................................10

    General. ....................................................................................................................... 10 Time Frames and Conditions. ........................................................................................................ 10 Form and Required Information. ................................................................................................... 11 Dispute Resolution by Agreement (Alternative Dispute Resolution). ........................................... 13 Director Order and Reconsideration. ............................................................................................. 13 Hearings. ....................................................................................................................... 14 Other Proceedings. ....................................................................................................................... 14

    436-009-0010 Medical Billing and Payment (Temporary rule) .............................................16

    General. ....................................................................................................................... 16 Billing Timelines. (For payment timelines see OAR 436-009-0030.) ........................................... 17 Billing Forms. ....................................................................................................................... 17 Billing Codes. ....................................................................................................................... 18 Modifiers. ....................................................................................................................... 19 Physician Assistants and Nurse Practitioners. ............................................................................... 19 Chart Notes. ....................................................................................................................... 20 Challenging the Provider’s Bill. .................................................................................................... 20 Billing the Patient / Patient Liability. ............................................................................................ 20 Disputed Claim Settlement (DCS). ................................................................................................ 21 Payment Limitations. ..................................................................................................................... 21 Excluded Treatment. ...................................................................................................................... 22 Missed Appointment (No Show). .................................................................................................. 22

  • DEPARTMENT OF CONSUMER AND BUSINESS SERVICES

    WORKERS’ COMPENSATION DIVISION

    ii

    436-009-0018 Discounts and Contracts ..................................................................................24

    Medical Service Providers and Medical Clinics. ........................................................................... 24 Discounts. ....................................................................................................................... 24 Fee Discount Agreements. ............................................................................................................. 24 Fee Discount Agreement Modifications and Terminations. .......................................................... 25 Other Medical Providers. ............................................................................................................... 26

    436-009-0020 Hospitals ............................................................................................................27

    Inpatient. ....................................................................................................................... 27 Outpatient. ....................................................................................................................... 27 Specific Circumstances. ................................................................................................................. 28 Out-of-State Hospitals. .................................................................................................................. 28 Calculation of Cost-to-Charge Ratio Published in Bulletin 290. ................................................... 29

    436-009-0023 Ambulatory Surgery Center (ASC) (Temporary rule) ...................................31

    Billing Form. ....................................................................................................................... 31 ASC Facility Fee. ....................................................................................................................... 31 ASC Billing. ....................................................................................................................... 31 ASC Payment. ....................................................................................................................... 32

    436-009-0025 Worker Reimbursement...................................................................................34

    General. ....................................................................................................................... 34 Timeframes. ....................................................................................................................... 35 Meal and Lodging Reimbursement. ............................................................................................... 36 Travel Reimbursement. .................................................................................................................. 36 Other Reimbursements................................................................................................................... 37 Advancement Request. .................................................................................................................. 37

    436-009-0030 Insurer's Duties and Responsibilities ..............................................................39

    General. ....................................................................................................................... 39 Bill Processing. ....................................................................................................................... 39 Payment Requirements. ................................................................................................................. 40 Electronic Payment. ....................................................................................................................... 41 Communication with Providers. .................................................................................................... 42 EDI Reporting. ....................................................................................................................... 42

    436-009-0035 Interim Medical Benefits ..................................................................................43

    General. ....................................................................................................................... 43 Claim Acceptance. ....................................................................................................................... 43 Claim Denial. ....................................................................................................................... 43

    436-009-0040 Fee Schedule (Temporary rule).........................................................................45

    Fee Schedule Table . ...................................................................................................................... 45 Anesthesia. ....................................................................................................................... 45 Surgery. ....................................................................................................................... 47 Radiology Services. ....................................................................................................................... 50 Pathology and Laboratory Services. .............................................................................................. 50

  • DEPARTMENT OF CONSUMER