Oregon Medical Fee And Payment Rules Oregon
DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOregon Medical Fee and Payment RulesOregon Administrative RulesChapter 436, Division 009Effective April 1, 2016Table of Contents436-009-0001Administration of These Rules . 1Authority for Rules . 1Purpose. 1Applicability of Rules. . 1436-009-0004Adoption of Standards . 2436-009-0005Definitions . 4436-009-0008Request for Review before the Director . 10General. 10Time Frames and Conditions . 10Form and Required Information. . 12Dispute Resolution by Agreement (Alternative Dispute Resolution) . 13Director Order and Reconsideration . 14Hearings. 14Other Proceedings . 15436-009-0010Medical Billing and Payment . 16General. 16Billing Timelines (For payment timelines see OAR 436-009-0030.) . 17Billing Forms. 18Billing Codes. 20Modifiers. 20Physician Assistants and Nurse Practitioners . 21Chart Notes. 21Challenging the Provider’s Bill . 21Billing the Patient / Patient Liability. . 22Disputed Claim Settlement (DCS). . 22Payment Limitations. . 23Excluded Treatment. . 23Missed Appointment (No Show). . 24436-009-0018Discounts and Contracts . 25Medical Service Providers and Medical Clinics. . 25i
DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONDiscounts. 25Fee Discount Agreements. . 26Fee Discount Agreement Modifications and Terminations. . 26Other Medical Providers. . 27436-009-0020Hospitals . 28Inpatient. 28Outpatient. 28Specific Circumstances. . 29Out-of-State Hospitals. . 29Calculation of Cost to Charge Ratio Published in Bulletin 290. 30436-009-0023Ambulatory Surgery Center (ASC) . 33Billing FormASC Facility FeeASC BillingASC Payment436-009-0025. 33. 33. 34. 34Worker Reimbursement. 36General. 36Timeframes. 37Meal and Lodging Reimbursement. . 38Travel Reimbursement . 39Other Reimbursements. 40Advancement Request. . 40436-009-0030Insurer's Duties and Responsibilities . 41General. 41Bill Processing. 41Payment Requirements. . 42Communication with Providers. . 44EDI Reporting. 44436-009-0035Interim Medical Benefits . 45436-009-0040Fee Schedule . 47Fee Schedule Table . 47Anesthesia. 47Surgery. 48Radiology Services . 52Pathology and Laboratory Services. . 52Physical Medicine and Rehabilitation Services . 53Reports. 53Nurse Practitioners and Physician Assistants. . 54ii
DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISION436-009-0060Oregon Specific Codes . 55Multidisciplinary Services. . 55Table of all Oregon Specific Codes . 55CARF / JCAHO Accredited Programs. . 60436-009-0080Durable Medical Equipment, Prosthetics, Orthotics, and Supplies(DMEPOS) . 61436-009-0090Pharmaceutical. 65General. 65Pharmaceutical Billing and Payment . 65Clinical Justification Form 4909 . 66Dispensing by Medical Service Providers. . 67436-009-0110Interpreters. 68Billing. 68Billing and Payment Limitations. . 69Billing Timelines . 69Billing Form. 70Payment Calculations. 70Payment Requirements. . 71436-009-0998Sanctions and Civil Penalties . 74Appendix AOregon hospitals required to include Medicare Severity DiagnosisRelated Group codes on hospital inpatient billsunder OAR 436-009-0020. 75Appendix A - Matrix for health care provider types. 76Appendix B(physician fee schedule) containing the maximum allowable paymentamounts for services provided by medical service providers. [EffectiveApril 1, 2016] . 77Appendix C(ambulatory surgery center fee schedule amounts for surgicalprocedures), containing the maximum allowable payment amounts forsurgical procedures including packaged procedures. [Effective April 1,2016] . 77Appendix D (ambulatory surgery center fee schedule amounts for ancillary services)containing the maximum allowable payment amounts for ancillaryservices integral to the surgical procedure. [Effective April 1, 2016] . 77Appendix E (durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS))containing the maximum allowable payment amounts for durablemedical equipment, prosthetics, orthotics, and supplies. [Effective April1, 2016] . 77Order of Adoption.79Certificate and Order for Filing Permanent Administrative Rules .81iii
DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONHistorical rules: http://wcd.oregon.gov/laws/Documents/Rule history/436 history.pdfNOTE: Revisions are marked as follows:Deleted text has a "strike-through" style, as inAdded text is underlined, as inDeletedAddedThe Workers' Compensation Division (WCD) adopts, by reference, the American Societyof 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 Anesthesiologists520 N. Northwest Highway, Park Ridge, IL 60068-2573Phone 847-825-5586http://www.asahq.org/Ask for: 20145 Relative Value GuideTo order the CPT 2016, or the CPT Assistant, contact:American Medical Association515 North State Street, Chicago, IL 60610Phone 800-621-8335http://www.ama-assn.org/amaTo order the NCPDP Manual Claim Forms Reference Implementation Guide Version 1.24(7/2015), contact:National Council for Prescription Drug Programs (NCPDP)9240 East Raintree DriveScottsdale, AZ 85260-7518Phone: 480.477.1000www.ncpdp.orgTo order the NUBC UB-04 Data Specifications Manual, contact:National Uniform Billing CommitteeAmerican Hospital AssociationOne North Franklin, 29th Floor, Chicago, IL 60606Phone 312-422-3390www.nubc.orgAsk to: Become a subscriber of the NUBC UB-04 Specifications ManualTo order the Healthcare Common Procedure Coding System, contact:National Technical Information ServiceSpringfield, VA 22161Phone 800-621- ist.aspiv
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES436-009-0001 Administration of These Rules(1) Any orders issued by the division in carrying out the director’s authority to enforceOregon Revised Statute (ORS) chapter 656 and Oregon Administrative Rule (OAR)chapter 436, are considered orders of the director of the Department of Consumer andBusiness Services.(2) Authority for Rules.These rules are promulgated under the director’s general rulemaking authority of ORS656.726(4) and specific authority under ORS 656.248.(3) Purpose.The purpose of these rules is to establish uniform guidelines for administering thepayment 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 otherwiseobligated by statute.Stat. Auth.: ORS 656.726(4)Stats. Implemented: ORS 656.248Hist: Amended 3/12/14 as Admin. Order 14-052, eff. 4/1/14Amended 3/7/16 as Admin. Order 16-050, eff. 4/1/16See also the Index to Rule History: http://wcd.oregon.gov/laws/Documents/Rule history/436 history.pdf.436-009-0001Page 1436-009-0001
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES436-009-0004 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 codesnot found in Appendix B. To get a copy of the ASA Relative Value Guide 2015, contactthe American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL60068-2573, 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 20156), Fourth Edition Revised, 20145, forbilling by medical providers. The definitions, descriptions, and guidelines found in CPT must be used as guides governing the descriptions of services, except as otherwiseprovided in these rules. The guidelines are adopted as the basis for determining level ofservice.(3) The director adopts, by reference, the AMA’s CPT Assistant, Volume 0, Issue 041990 through Volume 245, Issue 12, 20145. 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 20156 or the CPT Assistant, contact the AmericanMedical Association, 515 North State Street, Chicago, IL60610, 800-621-8335, or on theWeb at: http://www.ama-assn.org.(5) The director adopts, by reference, only the alphanumeric codes from the CMSHealthcare Common Procedure Coding System (HCPCS). These codes are to be usedwhen billing for services, but only to identify products, supplies, and services that are notdescribed 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 HCPCSedits, 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 Webat: lpha-NumericHCPCS.html.436-009-0004Page 2436-009-0004
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES(6) The director adopts, by reference, CDT 20156: Dental Procedure Codes, to be usedwhen billing for dental services. To get a copy, contact the American Dental Associationat American Dental Association, 211 East Chicago Ave., Chicago, IL 60611-2678, or onthe 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 bythe 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 Manual2015 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 ReferenceImplementation Guide Version 1.34 (7/2015) 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 onthe Web at: www.ncpdp.org.(10) Specific provisions contained in OAR chapter 436, divisions 009, 010, and 015control over any conflicting provision in ASA Relative Value Guide 2015, CPT 20156,CPT Assistant, HCPCS 20156, CDT 20156, Dental Procedure Codes, 1500 HealthInsurance Claim Form Reference Instruction Manual, Official UB-04 Data SpecificationsManual, or NCPDP Manual Claim Forms Reference Implementation Guide.(11) Copies of the standards referenced in this rule are also available for review duringregular business hours at the Workers’ Compensation Division, Medical ResolutionTeam, 350 Winter Street NE, Salem OR 97301, 503-947-7606.Stat Auth: ORS 656.248, 656.726(4)Stats Implemented: ORS 656.248Hist: Amended 3/12/15 as Admin. Order 15-058, eff. 4/1/15Amended 3/7/16 as Admin. Order 16-050, eff. 4/1/16See also the Index to Rule History: http://wcd.oregon.gov/laws/Documents/Rule history/436 history.pdf.436-009-0004Page 3436-009-0004
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES436-009-0005 Definitions(1) Unless a term is specifically defined elsewhere in these rules or the context otherwiserequires, the definitions of ORS chapter 656 are hereby incorporated by reference andmade part of these rules.(2) Abbreviations used in these rules are either defined in the rules in which they are usedor defined as follows:(a) ANSI means the American National Standards Institute.(b) ASC means ambulatory surgery center.(c)(a) CMS means Centers for Medicare & Medicaid Services.(d)(b) CPT means Current Procedural Terminology published by the American MedicalAssociation.(e) DME means durable medical equipment.(f)(c) DMEPOS means durable medical equipment, prosthetics, orthotics, and supplies.(g)(d) EDI means electronic data interchange.(h)(e) HCPCS means Healthcare Common Procedure Coding System published by CMS.(i) IAIABC means International Association of Industrial Accident Boards andCommissions.(j)(f) ICD-9-CM means International Classification of Diseases, Ninth Revision, ClinicalModification, Vol. 1, 2 & 3 by US Department of Health and Human Services.(k)(g) 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)(h) MCO means managed care organization certified by the director.(n)(i) NPI means national provider identifier.(o)(j) OSC means Oregon specific code.(p)(k) PCE means physical capacity evaluation.(q)(l) WCE means work capacity evaluation.(3) “Administrative review” means any decision making process of the directorrequested by a party aggrieved with an action taken under these rules except the hearingprocess 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 thepurpose of providing surgical services to patients not requiring hospitalization; or436-009-0005Page 4436-009-0005
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES(b) Any entity outside of Oregon similarly licensed, or certified by Medicare or anationally recognized agency as an ASC.(5) “Attending physician” has the same meaning as described in ORS 656.005(12)(b).See Appendix AF, “Matrix for Health Care Provider Types”.(6) “Authorized nurse practitioner” means a nurse practitioner licensed under ORS678.375 to 678.390 who has certified to the director that the nurse practitioner hasreviewed informational materials about the workers’ compensation system provided bythe director and who has been assigned an authorized nurse practitioner number by thedirector.(7) “Board” means the Workers’ Compensation Board and includes its HearingsDivision.(8) “Chart note” means a notation made in chronological order in a medical record inwhich the medical service provider records such things as subjective and objectivefindings, diagnosis, treatment rendered, treatment objectives, and return to work goalsand status.(9) “Clinic” means a group practice in which several medical service providers workcooperatively.(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 ProceduralTerminology codes and terminology published by the American MedicalAssociation unless otherwise specified in these rules.(12) “Date stamp” means to stamp or display the initial receipt date and the recipient’sname on a paper or electronic document, regardless of whether the document is printed ordisplayed electronically.(13) “Days” means calendar days.436-009-0005Page 5436-009-0005
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES(14) “Director” means the director of the Department of Consumer and BusinessServices or the director’s designee.(14)(15) “Division” means the Workers’ Compensation Division of the Department ofConsumer and Business Services.(15)(16) “Enrolled” means an eligible worker has received notification from the insurerthat the worker is being required to receive treatment under the provisions of a managedcare organization (MCO). However, a worker may not be enrolled who would otherwisebe subject to an MCO contract if the worker’s primary residence is more than 100 milesoutside the MCO’s certified geographical service area.(16)(17) “Fee discount agreement” means a direct contract entered into between amedical service provider or clinic and an insurer to discount fees to the medical serviceprovider or clinic under OAR 436-009-0018.(17)(18) “Hearings Division” means the Hearings Division of the Workers’Compensation Board.(18)(19) “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 pastmidnight for treatment and lodging.(b) “Outpatient” means a patient not admitted to a hospital prior to and extending pastmidnight for treatment and lodging. Medical services provided by a health care providersuch as emergency room services, observation room, or short stay surgical treatments thatdo not result in admission are also considered outpatient services.(19)(20) “Initial claim” means the first open period on the claim immediately followingthe original filing of the occupational injury or disease claim until the worker is firstdeclared to be medically stationary by an attending physician or authorized nursepractitioner. For nondisabling claims, the “initial claim” means the first period of medicaltreatment immediately following the original filing of the occupational injury or diseaseclaim ending when the attending physician or authorized nurse practitioner does notanticipate further improvement or need for medical treatment, or there is an absence oftreatment for an extended period.436-009-0005Page 6436-009-0005
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES(20)(21) “Insurer” means the State Accident Insurance Fund Corporation; an insurerauthorized under ORS chapter 731 to transact workers’ compensation insurance in thestate; or, an employer or employer group that has been certified under ORS 656.430 andmeets the qualifications of a self-insured employer under ORS 656.407.(21)(22) “Interim medical benefits” means those services provided under ORS 656.247on initial claims with dates of injury on or after January 1, 2002, that are not deniedwithin 14 days of the employer’s notice of the claim.(22)(23) “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 orsign language translation. It does not include a medical provider, medical provider’semployee, or a family member or friend of the patient.(23)(24) “Interpreter services” means the act of orally translating between a medicalprovider and a patient who speak different languages, including sign language. It includesreasonable time spent waiting at the location for the medical provider to examine or treatthe patient as well as reasonable time spent on necessary paperwork for the provider’soffice.(24)(25) “Mailed or mailing date” means the date a document is postmarked. Requestssubmitted by facsimile or “fax” are considered mailed as of the date printed on the bannerautomatically produced by the transmitting fax machine. Hand-delivered requests will beconsidered mailed as of the date stamped by the Workers’ Compensation Division. Phoneor in-person requests, where allowed under these rules, will be considered mailed as ofthe date of the request.(25)(26) “Managed care organization” or “MCO” means an organization formed toprovide medical services and certified in accordance with OAR chapter 436, division015.(26)(27) “Medical provider” means a medical service provider, a hospital, a medicalclinic, or a vendor of medical services.436-009-0005Page 7436-009-0005
ORDER NO. 16-050DEPARTMENT OF CONSUMER AND BUSINESS SERVICESWORKERS’ COMPENSATION DIVISIONOREGON MEDICAL FEE AND PAYMENT RULES(27)(28) “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 wherenecessary, physical restorative services.(28)(29) “Medical service provider” means a person duly licensed to practice one ormore of the healing arts.(29)(30) “Medical treatment” means the management and care of a patient for thepurpose of combating disease, injury, or disorder. Restrictions on activities are notconsidered treatment unless the primary purpose of the restrictions is to improve theworker’s condition through conservati
(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. Stat
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8. Is the TT 35.00 enrolment fee part of the compulsory fees? No. The TT 35.00 enrolment fee is an administrative (maintenance) fee and is not part of the compulsory fees. 9. Do I need to pay the TT 35 enrolment fee if I am not paying online? Yes. This fee is to be paid regardless of the payment method
