Oregon Medical Fee and Payment Rules Oregon Administrative ... · PDF file Dental Association at American Dental Association, 211 East Chicago Ave., Chicago, IL 60611-2678, or on the

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS’ COMPENSATION DIVISION

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Oregon Medical Fee and Payment Rules Oregon Administrative Rules Chapter 436, Division 009

Effective Jan. 1, 2016

Table of Contents 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)..................................................................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.....................................................................................................12 Dispute Resolution by Agreement (Alternative Dispute Resolution). ...........................................13 Director Order and Reconsideration...............................................................................................14 Hearings. .......................................................................................................................14 Other Proceedings. .......................................................................................................................15

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

General. .......................................................................................................................16 Billing Timelines. (For payment timelines see OAR 436-009-0030.) ...........................................17 Billing Forms. .......................................................................................................................18 Billing Codes. .......................................................................................................................19 Modifiers. .......................................................................................................................20 Physician Assistants and Nurse Practitioners.................................................................................21 Chart Notes. .......................................................................................................................21 Challenging the Provider’s Bill......................................................................................................21 Billing the Patient / Patient Liability..............................................................................................21 Disputed Claim Settlement (DCS). ................................................................................................22 Payment Limitations.......................................................................................................................22 Excluded Treatment. ......................................................................................................................23 Missed Appointment (No Show)....................................................................................................24

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS’ COMPENSATION DIVISION

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436-009-0018 Discounts and Contracts ..................................................................................25 Medical Service Providers and Medical Clinics. ...........................................................................25 Discounts. .......................................................................................................................25 Fee Discount Agreements. .............................................................................................................26 Fee Discount Agreement Modifications and Terminations............................................................26 Other Medical Providers. ...............................................................................................................27

436-009-0020 Hospitals............................................................................................................28

Inpatient. .......................................................................................................................28 Outpatient. .......................................................................................................................28 Specific Circumstances. .................................................................................................................29 Out-of-State Hospitals....................................................................................................................29 Calculation of Cost-to-Charge Ratio Published in Bulletin 290. ...................................................30

436-009-0023 Ambulatory Surgery Center (ASC) ................................................................33

Billing Form. .......................................................................................................................33 ASC Facility Fee. .......................................................................................................................33 ASC Billing. .......................................................................................................................34 ASC Payment. .......................................................................................................................34

436-009-0025 Worker Reimbursement...................................................................................36

General. .......................................................................................................................36 Timeframes. .......................................................................................................................37 Meal and Lodging Reimbursement. ...............................................................................................38 Travel Reimbursement. ..................................................................................................................39 Other Reimbursements...................................................................................................................40 Advancement Request....................................................................................................................40

436-009-0030 Insurer 's Duties and Responsibilities..............................................................41

General. .......................................................................................................................41 Bill Processing. .......................................................................................................................41 Payment Requirements...................................................................................................................42 Communication with Providers......................................................................................................44 EDI Reporting. 44

436-009-0035 Inter im Medical Benefits..................................................................................45 436-009-0040 Fee Schedule......................................................................................................47

Fee Schedule Table.......................................................................................................................47 Anesthesia. .......................................................................................................................47 Surgery. .......................................................................................................................48 Radiology Services. .......................................................................................................................52 Pathology and Laboratory Services................................................................................................52 Physical Medicine and Rehabilitation Services. ............................................................................53 Reports. .......................................................................................................................53 Nurse Practitioners and Physician Assistants.................................................................................54

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436-009-0060 Oregon Specific Codes......................................................................................55

Multidisciplinary Services..............................................................................................................55 Table of all Oregon Specific Codes (For OSC fees, see Appendix B.)..........................................55 CARF / JCAHO Accredited Programs............................