Oregon Medical Fee and Payment Rules ... - State of Oregon

DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS' COMPENSATION DIVISION

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

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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS' COMPENSATION DIVISION

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. ASC Facility Fee. ASC Billing. ASC Payment.

.......................................................................................................................33 .......................................................................................................................33 .......................................................................................................................34 .......................................................................................................................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 Interim 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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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS' COMPENSATION DIVISION

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...........................................................................................60

436-009-0080 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).........................................................................................................61

436-009-0090 Pharmaceutical..................................................................................................65

General.

.......................................................................................................................65

Pharmaceutical Billing and Payment. ............................................................................................65

Clinical Justification Form 4909. ...................................................................................................66

Dispensing by Medical Service Providers......................................................................................67

436-009-0110 Interpreters........................................................................................................68

Billing.

.......................................................................................................................68

Billing and Payment Limitations....................................................................................................69

Billing Timelines. .......................................................................................................................69

Billing Form.

.......................................................................................................................70

Payment Calculations.....................................................................................................................70

Payment Requirements...................................................................................................................71

436-009-0998 Sanctions and Civil Penalties ...........................................................................74

Appendix A

Oregon hospitals required to include Medicare Severity Diagnosis Related Group codes on hospital inpatient bills under OAR 436-0090020 ....................................................................................................................75

Fee schedule tables ? introduction (The tables are not attached to these rules.)........................76 Appendix B (physician fee schedule) [Effective Jan. 1, 2016] Appendix C (ambulatory surgery center fee schedule amounts for surgical procedures) [Effective Jan. 1, 2016] Appendix D (ambulatory surgery center fee schedule amounts for ancillary services) [Effective Jan. 1, 2016] Appendix E (durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)) [Effective Jan. 1, 2016] Appendix F (matrix for health care provider types) [Effective Jan. 1, 2016]................................77 Order of Adoption and Certificate and Order for Filing Temporary Rules ...................................78

Historical rules:

NOTE: New text is underlined. Deletions have a strike-through style.

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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES WORKERS' COMPENSATION DIVISION

The Workers' Compensation Division (WCD) adopts, by reference, the American Society of Anesthesiologists (ASA) Relative Value Guide and Current Procedural Terminology (CPT?). See OAR 436-009-0004 for details and updated citations.

To order the ASA Relative Value Guide, contact: American Society of Anesthesiologists 520 N. Northwest Highway, Park Ridge, IL 60068-2573 Phone 847-825-5586 Ask for: 20145 Relative Value Guide To order the CPT? 2015 or the CPT Assistant, contact: American Medical Association 515 North State Street, Chicago, IL 60610 Phone 800-621-8335

To order the NCPDP Manual Claim Forms Reference Implementation Guide Version 1.2, contact: National Council for Prescription Drug Programs (NCPDP) 9240 East Raintree Drive Scottsdale, AZ 85260-7518 Phone: 480.477.1000

To order the NUBC UB-04 Data Specifications Manual, contact: National Uniform Billing Committee American Hospital Association One North Franklin, 29th Floor, Chicago, IL 60606 Phone 312-422-3390 Ask to: Become a subscriber of the NUBC UB-04 Specifications Manual

To order the Healthcare Common Procedure Coding System, contact: National Technical Information Service Springfield, VA 22161 Phone 800-621- 8335 cms.HCPCSReleaseCodeSets/ANHCPCS/list.asp

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ORDER NO. 15-066 DEPARTMENT OF CONSUMER AND BUSINESS SERVICES

WORKERS' COMPENSATION DIVISION 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: Amended 3/12/14 as Admin. Order 14-052, eff. 4/1/14 See also the Index to Rule History: .

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