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
