April 30, 2024
by Kevin Anderson

Surgery in Oregon? Here’s What to Know

The Oregon Workers’ Compensation Division recently added some new deadlines to be aware of when dealing with surgery requests in the MCO context. You can read more about the changes here. But, dealing with a surgery request can still be complicated with a lot of short deadlines, so here is a brief overview of the steps you should be taking.

For Non-MCO Cases:

The medical provider must notify the insurer when they propose elective surgery. The provider can use Form 5425 to initiate the surgery request. They are not required to use that form, but they must include all the information contained on the form. Chart notes alone are insufficient to initiate the surgery request. See Bulletin 309.

Within 7 days of receiving the notice of intent to perform surgery, the insurer must notify the provider, worker, and worker’s attorney using Form 3228 (Elective Surgery Response) to confirm if the surgery is approved, not approved, or not approved pending consultation.

The insurer has 28 days from issuing the Elective Surgery Response to complete the consultation exam. The insurer also has 7 days from the exam to provide the findings to the requesting medical provider.

The requesting medical provider must sign/return the Elective Surgery Response to the insurer if they disagree with the insurer’s recommendation on the surgery. The insurer then has 21 days to initiate an MRT dispute on the surgery.

If the insurer fails to send the initial notice within 7 days or fails to request MRT review within 21 days of the recommending provider’s response, the insurer is barred from challenging whether the surgery is excessive, inappropriate, or ineffective.

Please note if the insurer is disapproving of the surgery for reasons other than excessive, inappropriate, or ineffective treatment, the Elective Surgery notice requirements do not apply. Most commonly, this would be disapproving of a surgery as not compensably related to the claim. The insurer should still notify the recommending provider and claimant of this, and claimant would have 90 days to appeal the surgery disapproval.

For MCO Cases:

The medical provider should notify the insurer of a proposed surgery, or the provider can directly request pre-certification from the MCO.

The insurer must notify the MCO of the request for surgery within 7 days of receiving the request.

The MCO process does not specifically address setting a consulting exam (like an Elective Surgery process), but as compensability and appropriateness concerns are often both at issue, we recommend setting a consultation as soon as possible once you receive a surgery request.

Now, with the new rule, once the MCO pre-certifies a surgery as medically appropriate, the insurer has 45 days to notify the provider, worker, and worker’s attorney whether the surgery is approved.

If the insurer disagrees with the MCO on the appropriateness of the surgery, the insurer must appeal the decision with the MCO within 60 days before possibly proceeding to the MRT.

If the insurer disapproves of the surgery for reasons other than excessive/ineffectual treatment (such as compensability), there is required appeal language that needs to be included and the worker has 90 days to appeal.

If you have any questions regarding the surgery deadlines or procedures, please feel free to contact me at 503-595-2130 or .

Posted by: Kevin Anderson