Oregon Administrative Claim Closure Requires Strict Compliance with the Rule
Administrative closure can be a useful tool for processing an Oregon Workers’ Compensation claim to closure where a worker is inconsistent or non-compliant with treatment requirements. In some circumstances, the law requires the use of administrative claim closure, and failure to close the claim accordingly can create a penalty issue under OAR 436-030-0020. Additionally, WCD audits finding failure to comply with the closure requirement may result in penalties. These systems are put in place to ensure compliance by the insurer/employer, but also because the goal is to restore the injured worker as soon as possible and as near as possible to a condition of self-support and maintenance as an able-bodied worker. ORS 656.268(1).
OAR 436-030-0034 catalogs five specific instances relevant for administrative closure:
- Closure is required where a worker who is not medically stationary fails to seek treatment for more than 30 days without the approval of the attending physician or authorized nurse practitioner for reasons within the worker’s control.
- Closure is required regardless of medically stationary status where a worker enrolled in an MCO fails to seek treatment for 30 days with an authorized healthcare provider.
- Closure is required regardless of medically stationary status where a worker fails to attend a mandatory closing exam for reasons within their control, or where a suspension order has been issued.
- The insurer may close a claim, regardless of medically stationary status, when the worker fails to attend a closing examination scheduled with the attending physician directly.
- The insurer may close a claim when a worker’s “otherwise compensable injury” is not medically stationary, and a major contributing cause denial has issued on an accepted combined condition.
The rule also outlines specific steps to take prior to administrative claim closure. If these steps are not followed meticulously, the ARU is likely to rescind the Notice of Closure where a worker requests reconsideration.
For example, when the insurer sends written notification to a worker regarding failure to treat, the letter must apprise the worker the claim will be closed unless the worker can establish, within 14 days from the date the letter was sent, that treatment has resumed by either attending an existing appointment or scheduling a new appointment, and the reasons for not treating were outside of the worker’s control. The ARU has rescinded Notices of Closure on the basis that a request for the worker to confirm they have established care with an authorized provider within 14 days is insufficient. The notification letter must inform the worker of their duty to confirm attendance or scheduling of a new appointment with an authorized provider.
The rules require strict compliance with the OAR 436-030-0034 for administrative closure to be found proper. Substantial compliance with the rule is not enough.
Processing a claim to closure in Oregon can be frustrating, and especially for administrative claim closure. If you have any questions regarding administrative closure requirements or would like assistance moving a claim toward closure, please contact me at or 503-595-6108.
Posted by Evan Novotny.
