New Rules Impacting MCO Enrolled Claims in Oregon – Effective April 1, 2024 and October 1, 2024
The Department of Consumer and Business Services Workers’ Compensation Division amended several provisions of the OAR that will directly impact MCO enrolled claims in Oregon. The net effect of the amended OAR is essentially more claim processing, and in the worst-case scenario, potential exposure for increased claim costs, litigation costs, attorney fees and penalty for non-compliance.
SBH attorney Kevin J. Anderson and SAIF submitted argumentative testimony against the changes, which the Agency considered when formalizing the final Rule changes.
Changes Effective April 1, 2024
OAR 436-010-0220(5) is amended to include a timeframe of 14 days for the MCO to provide a list of three providers who are willing to treat the worker within a reasonable period of time.
OAR 436-010-0270 is amended to add section (k), which addresses what the insurer must do when the MCO pre-certifies a surgical service as medically appropriate. Effective April 1, 2024, the insurer must, within 45 days from the date of the MCO decision, inform the worker, the worker’s representative, the provider, and the MCO whether the surgery is compensable. If the insurer disagrees with the appropriateness of the decision of the MCO, then the insurer must appeal the decision to the MCO within 30 days under OAR 436-015-0110(4).
The amendment also considers the worker’s appeal rights in the event the worker seeks to appeal the insurer’s disapproval of the surgery. The appeal rights will advise the worker, the worker’s attorney, and the medical provider they have 90 days to appeal the disapproval if the disapproval is for reasons other than appropriateness. The new, required appeal language will be located within OAR 436-010-0270.
OAR 436-015-0030(6) is amended to include a specific time frame for MCOs to provide a list of providers to workers. Effective April 1, 2024, the MCO is now required, within 14 days, to provide a list of three providers within a specific category (i.e., acupuncture, chiropractic, dentist, optometrist, etc.) willing to treat the worker within a reasonable time.
Changes Effective October 1, 2024
The Division also took the opportunity to update mandatory appeal language in several additional sections. The new appeal language is effective October 1, 2024.
OAR 436-015-0110(4), (5), and (6) are amended to update the mandatory appeal language the MCO must include whenever the MCO issues determinations, which could include a denial of services or a decision when the MCO resolves a dispute. By October 1, 2024, the MCO must update their denials to include the new, required language, which is provided in OAR 436-015-0110(4)(b), OAR 436-015-0110(5)(b) and OAR 436-015-0110(6)(b).
With respect to determinations issued regarding palliative care, the new, required appeal language is provided in OAR 436-010-0290(2)(c)(B).
With respect to determinations issued regarding worker reimbursements, the new, required appeal language is provided in OAR 436-009-0025(1)(e)(G).
With respect to bill payments and the written explanation of benefits, the new, required appeal language is provided in OAR 436-009-0030(c)(G).
With respect to determinations issued in response to interpreter services billing, the new, required appeal language is provided in OAR 436-009-0110(7)(i)(G).
We at SBH understand that 2024 has ushered in a slew of new statutory and rule changes. SBH attorneys advocate for our clients at every step of the rulemaking process. With these changes, we are committed to working closely with you to ensure timely and appropriate determinations are issued in response to triggering claim events. If you have any questions regarding the new rule changes, and/or any other Oregon workers’ compensation topics, please contact me at 971-977-5970 or .
Posted by Kat Wolfe.
