Chapter 505
AN ACT
SB 504
Relating to attending physicians for workers’ compensation claims;
amending ORS 656.005 and 656.245.
Be It Enacted by the People of
the State of Oregon:
SECTION 1.
ORS 656.005 is amended to read:
656.005. (1) “Average
weekly wage” means the Oregon average weekly wage in covered employment, as
determined by the Employment Department, for the last quarter of the calendar
year preceding the fiscal year in which the injury occurred.
(2) “Beneficiary” means
an injured worker, and the husband, wife, child or dependent of a worker, who
is entitled to receive payments under this chapter. “Beneficiary” does not
include:
(a) A spouse of an
injured worker living in a state of abandonment for more than one year at the time
of the injury or subsequently. A spouse who has lived separate and apart from
the worker for a period of two years and who has not during that time received
or attempted by process of law to collect funds for support or maintenance is
considered living in a state of abandonment.
(b) A person who
intentionally causes the compensable injury to or death of an injured worker.
(3) “Board” means the
Workers’ Compensation Board.
(4) “Carrier-insured
employer” means an employer who provides workers’ compensation coverage with a
guaranty contract insurer.
(5) “Child” includes a
posthumous child, a child legally adopted prior to the injury, a child toward
whom the worker stands in loco parentis, an illegitimate child and a stepchild,
if such stepchild was, at the time of the injury, a member of the worker’s
family and substantially dependent upon the worker for support. An invalid
dependent child is a child, for purposes of benefits, regardless of age, so
long as the child was an invalid at the time of the accident and thereafter
remains an invalid substantially dependent on the worker for support. For
purposes of this chapter, an invalid dependent child is considered to be a
child under 18 years of age.
(6) “Claim” means a
written request for compensation from a subject worker or someone on the worker’s
behalf, or any compensable injury of which a subject employer has notice or
knowledge.
(7)(a) A “compensable
injury” is an accidental injury, or accidental injury to prosthetic appliances,
arising out of and in the course of employment requiring medical services or
resulting in disability or death; an injury is accidental if the result is an
accident, whether or not due to accidental means, if it is established by
medical evidence supported by objective findings, subject to the following
limitations:
(A) No injury or disease
is compensable as a consequence of a compensable injury unless the compensable
injury is the major contributing cause of the consequential condition.
(B) If an otherwise
compensable injury combines at any time with a preexisting condition to cause
or prolong disability or a need for treatment, the combined condition is
compensable only if, so long as and to the extent that the otherwise
compensable injury is the major contributing cause of the disability of the
combined condition or the major contributing cause of the need for treatment of
the combined condition.
(b) “Compensable injury”
does not include:
(A) Injury to any active
participant in assaults or combats which are not connected to the job
assignment and which amount to a deviation from customary duties;
(B) Injury incurred
while engaging in or performing, or as the result of engaging in or performing,
any recreational or social activities primarily for the worker’s personal pleasure;
or
(C) Injury the major
contributing cause of which is demonstrated to be by a preponderance of the
evidence the injured worker’s consumption of alcoholic beverages or the
unlawful consumption of any controlled substance, unless the employer permitted,
encouraged or had actual knowledge of such consumption.
(c) A “disabling
compensable injury” is an injury which entitles the worker to compensation for
disability or death. An injury is not disabling if no temporary benefits are
due and payable, unless there is a reasonable expectation that permanent
disability will result from the injury.
(d) A “nondisabling
compensable injury” is any injury which requires medical services only.
(8) “Compensation”
includes all benefits, including medical services, provided for a compensable
injury to a subject worker or the worker’s beneficiaries by an insurer or
self-insured employer pursuant to this chapter.
(9) “Department” means
the Department of Consumer and Business Services.
(10) “Dependent” means
any of the following-named relatives of a worker whose death results from any
injury: Father, mother, grandfather, grandmother, stepfather, stepmother,
grandson, granddaughter, brother, sister, half sister, half brother, niece or
nephew, who at the time of the accident, are dependent in whole or in part for
their support upon the earnings of the worker. Unless otherwise provided by
treaty, aliens not residing within the
(11) “Director” means
the Director of the Department of Consumer and Business Services.
(12)(a) “Doctor” or “physician”
means a person duly licensed to practice one or more of the healing arts in any
country or in any state, territory or possession of the
(b) Except as otherwise
provided for workers subject to a managed care contract, “attending physician”
means a doctor or physician who is primarily responsible for the treatment of a
worker’s compensable injury and who is:
(A) A medical doctor or
doctor of osteopathy licensed under ORS 677.100 to 677.228 by the Board of
Medical Examiners for the State of Oregon or an oral and maxillofacial surgeon
licensed by the Oregon Board of Dentistry or a similarly licensed doctor in any
country or in any state, territory or possession of the United States; or
(B) For a period of 30
days from the date of first visit on the initial claim or for 12 visits, whichever
first occurs, a doctor or physician licensed by the State Board of Chiropractic
Examiners for the State of Oregon or a similarly licensed doctor or physician
in any country or in any state, territory or possession of the United States.
(c) Except as
otherwise provided for workers subject to a managed care contract, “attending
physician” does not include a physician who provides care in a hospital
emergency room and refers the injured worker to a primary care physician for
follow-up care and treatment.
[(c)] (d) “Consulting physician” means a doctor or physician
who examines a worker or the worker’s medical record to advise the attending
physician or nurse practitioner authorized to provide compensable medical
services under ORS 656.245 regarding treatment of a worker’s compensable
injury.
(13)(a) “Employer” means
any person, including receiver, administrator, executor or trustee, and the
state, state agencies, counties, municipal corporations, school districts and
other public corporations or political subdivisions, who contracts to pay a
remuneration for and secures the right to direct and control the services of
any person.
(b) Notwithstanding
paragraph (a) of this subsection, for purposes of this chapter, the client of a
temporary service provider is not the employer of temporary workers provided by
the temporary service provider.
(c) As used in paragraph
(b) of this subsection, “temporary service provider” has the meaning for that
term provided in ORS 656.850.
(14) “Guaranty contract
insurer” and “insurer” mean the State Accident Insurance Fund Corporation or an
insurer authorized under ORS chapter 731 to transact workers’ compensation
insurance in this state or an assigned claims agent selected by the director
under ORS 656.054.
(15) “Consumer and
Business Services Fund” means the fund created by ORS 705.145.
(16) “Invalid” means one
who is physically or mentally incapacitated from earning a livelihood.
(17) “Medically
stationary” means that no further material improvement would reasonably be expected
from medical treatment, or the passage of time.
(18) “Noncomplying
employer” means a subject employer who has failed to comply with ORS 656.017.
(19) “Objective findings”
in support of medical evidence are verifiable indications of injury or disease
that may include, but are not limited to, range of motion, atrophy, muscle
strength and palpable muscle spasm. “Objective findings” does not include
physical findings or subjective responses to physical examinations that are not
reproducible, measurable or observable.
(20) “Palliative care”
means medical service rendered to reduce or moderate temporarily the intensity
of an otherwise stable medical condition, but does not include those medical
services rendered to diagnose, heal or permanently alleviate or eliminate a
medical condition.
(21) “Party” means a
claimant for compensation, the employer of the injured worker at the time of
injury and the insurer, if any, of such employer.
(22) “Payroll” means a
record of wages payable to workers for their services and includes commissions,
value of exchange labor and the reasonable value of board, rent, housing,
lodging or similar advantage received from the employer. However, “payroll”
does not include overtime pay, vacation pay, bonus pay, tips, amounts payable
under profit-sharing agreements or bonus payments to reward workers for safe
working practices. Bonus pay is limited to payments which are not anticipated
under the contract of employment and which are paid at the sole discretion of
the employer. The exclusion from payroll of bonus payments to reward workers
for safe working practices is only for the purpose of calculations based on
payroll to determine premium for workers’ compensation insurance, and does not
affect any other calculation or determination based on payroll for the purposes
of this chapter.
(23) “Person” includes
partnership, joint venture, association, limited liability company and
corporation.
(24)(a) “Preexisting
condition” means, for all industrial injury claims, any injury, disease,
congenital abnormality, personality disorder or similar condition that
contributes to disability or need for treatment, provided that:
(A) Except for claims in
which a preexisting condition is arthritis or an arthritic condition, the
worker has been diagnosed with such condition, or has obtained medical services
for the symptoms of the condition regardless of diagnosis; and
(B)(i) In claims for an
initial injury or omitted condition, the diagnosis or treatment precedes the
initial injury;
(ii) In claims for a new
medical condition, the diagnosis or treatment precedes the onset of the new
medical condition; or
(iii) In claims for a
worsening pursuant to ORS 656.273 or 656.278, the diagnosis or treatment
precedes the onset of the worsened condition.
(b) “Preexisting
condition” means, for all occupational disease claims, any injury, disease,
congenital abnormality, personality disorder or similar condition that
contributes to disability or need for treatment and that precedes the onset of
the claimed occupational disease, or precedes a claim for worsening in such
claims pursuant to ORS 656.273 or 656.278.
(c) For the purposes of
industrial injury claims, a condition does not contribute to disability or need
for treatment if the condition merely renders the worker more susceptible to
the injury.
(25) “Self-insured
employer” means an employer or group of employers certified under ORS 656.430
as meeting the qualifications set out by ORS 656.407.
(26) “State Accident
Insurance Fund Corporation” and “corporation” mean the State Accident Insurance
Fund Corporation created under ORS 656.752.
(27) “Subject employer”
means an employer who is subject to this chapter as provided by ORS 656.023.
(28) “Subject worker”
means a worker who is subject to this chapter as provided by ORS 656.027.
(29) “Wages” means the
money rate at which the service rendered is recompensed under the contract of
hiring in force at the time of the accident, including reasonable value of
board, rent, housing, lodging or similar advantage received from the employer,
and includes the amount of tips required to be reported by the employer
pursuant to section 6053 of the Internal Revenue Code of 1954, as amended, and
the regulations promulgated pursuant thereto, or the amount of actual tips reported,
whichever amount is greater. The State Accident Insurance Fund Corporation may
establish assumed minimum and maximum wages, in conformity with recognized
insurance principles, at which any worker shall be carried upon the payroll of
the employer for the purpose of determining the premium of the employer.
(30) “Worker” means any
person, including a minor whether lawfully or unlawfully employed, who engages
to furnish services for a remuneration, subject to the direction and control of
an employer and includes salaried, elected and appointed officials of the
state, state agencies, counties, cities, school districts and other public
corporations, but does not include any person whose services are performed as
an inmate or ward of a state institution or as part of the eligibility
requirements for a general or public assistance grant. For the purpose of
determining entitlement to temporary disability benefits or permanent total
disability benefits under this chapter, “worker” does not include a person who has
withdrawn from the workforce during the period for which such benefits are
sought.
(31) “Independent
contractor” has the meaning for that term provided in ORS 670.600.
SECTION 2.
ORS 656.005, as amended by section 2, chapter 811, Oregon Laws 2003, is amended
to read:
656.005. (1) “Average
weekly wage” means the Oregon average weekly wage in covered employment, as
determined by the Employment Department, for the last quarter of the calendar
year preceding the fiscal year in which the injury occurred.
(2) “Beneficiary” means
an injured worker, and the husband, wife, child or dependent of a worker, who
is entitled to receive payments under this chapter. “Beneficiary” does not
include:
(a) A spouse of an
injured worker living in a state of abandonment for more than one year at the
time of the injury or subsequently. A spouse who has lived separate and apart
from the worker for a period of two years and who has not during that time
received or attempted by process of law to collect funds for support or maintenance
is considered living in a state of abandonment.
(b) A person who
intentionally causes the compensable injury to or death of an injured worker.
(3) “Board” means the
Workers’ Compensation Board.
(4) “Carrier-insured
employer” means an employer who provides workers’ compensation coverage with a
guaranty contract insurer.
(5) “Child” includes a
posthumous child, a child legally adopted prior to the injury, a child toward
whom the worker stands in loco parentis, an illegitimate child and a stepchild,
if such stepchild was, at the time of the injury, a member of the worker’s
family and substantially dependent upon the worker for support. An invalid
dependent child is a child, for purposes of benefits, regardless of age, so
long as the child was an invalid at the time of the accident and thereafter
remains an invalid substantially dependent on the worker for support. For
purposes of this chapter, an invalid dependent child is considered to be a
child under 18 years of age.
(6) “Claim” means a
written request for compensation from a subject worker or someone on the worker’s
behalf, or any compensable injury of which a subject employer has notice or
knowledge.
(7)(a) A “compensable
injury” is an accidental injury, or accidental injury to prosthetic appliances,
arising out of and in the course of employment requiring medical services or
resulting in disability or death; an injury is accidental if the result is an
accident, whether or not due to accidental means, if it is established by
medical evidence supported by objective findings, subject to the following
limitations:
(A) No injury or disease
is compensable as a consequence of a compensable injury unless the compensable
injury is the major contributing cause of the consequential condition.
(B) If an otherwise
compensable injury combines at any time with a preexisting condition to cause
or prolong disability or a need for treatment, the combined condition is
compensable only if, so long as and to the extent that the otherwise
compensable injury is the major contributing cause of the disability of the
combined condition or the major contributing cause of the need for treatment of
the combined condition.
(b) “Compensable injury”
does not include:
(A) Injury to any active
participant in assaults or combats which are not connected to the job
assignment and which amount to a deviation from customary duties;
(B) Injury incurred
while engaging in or performing, or as the result of engaging in or performing,
any recreational or social activities primarily for the worker’s personal
pleasure; or
(C) Injury the major
contributing cause of which is demonstrated to be by a preponderance of the
evidence the injured worker’s consumption of alcoholic beverages or the
unlawful consumption of any controlled substance, unless the employer
permitted, encouraged or had actual knowledge of such consumption.
(c) A “disabling
compensable injury” is an injury which entitles the worker to compensation for
disability or death. An injury is not disabling if no temporary benefits are
due and payable, unless there is a reasonable expectation that permanent
disability will result from the injury.
(d) A “nondisabling
compensable injury” is any injury which requires medical services only.
(8) “Compensation”
includes all benefits, including medical services, provided for a compensable
injury to a subject worker or the worker’s beneficiaries by an insurer or
self-insured employer pursuant to this chapter.
(9) “Department” means
the Department of Consumer and Business Services.
(10) “Dependent” means
any of the following-named relatives of a worker whose death results from any
injury: Father, mother, grandfather, grandmother, stepfather, stepmother,
grandson, granddaughter, brother, sister, half sister, half brother, niece or
nephew, who at the time of the accident, are dependent in whole or in part for
their support upon the earnings of the worker. Unless otherwise provided by
treaty, aliens not residing within the
(11) “Director” means
the Director of the Department of Consumer and Business Services.
(12)(a) “Doctor” or “physician”
means a person duly licensed to practice one or more of the healing arts in any
country or in any state, territory or possession of the
(b) Except as otherwise
provided for workers subject to a managed care contract, “attending physician”
means a doctor or physician who is primarily responsible for the treatment of a
worker’s compensable injury and who is:
(A) A medical doctor or
doctor of osteopathy licensed under ORS 677.100 to 677.228 by the Board of
Medical Examiners for the State of Oregon or an oral and maxillofacial surgeon
licensed by the Oregon Board of Dentistry or a similarly licensed doctor in any
country or in any state, territory or possession of the United States; or
(B) For a period of 30
days from the date of first visit on the initial claim or for 12 visits,
whichever first occurs, a doctor or physician licensed by the State Board of
Chiropractic Examiners for the State of Oregon or a similarly licensed doctor
or physician in any country or in any state, territory or possession of the
United States.
(c) Except as
otherwise provided for workers subject to a managed care contract, “attending
physician” does not include a physician who provides care in a hospital
emergency room and refers the injured worker to a primary care physician for
follow-up care and treatment.
[(c)] (d) “Consulting physician” means a doctor or physician
who examines a worker or the worker’s medical record to advise the attending
physician regarding treatment of a worker’s compensable injury.
(13)(a) “Employer” means
any person, including receiver, administrator, executor or trustee, and the
state, state agencies, counties, municipal corporations, school districts and
other public corporations or political subdivisions, who contracts to pay a
remuneration for and secures the right to direct and control the services of
any person.
(b) Notwithstanding
paragraph (a) of this subsection, for purposes of this chapter, the client of a
temporary service provider is not the employer of temporary workers provided by
the temporary service provider.
(c) As used in paragraph
(b) of this subsection, “temporary service provider” has the meaning for that
term provided in ORS 656.850.
(14) “Guaranty contract
insurer” and “insurer” mean the State Accident Insurance Fund Corporation or an
insurer authorized under ORS chapter 731 to transact workers’ compensation
insurance in this state or an assigned claims agent selected by the director
under ORS 656.054.
(15) “Consumer and
Business Services Fund” means the fund created by ORS 705.145.
(16) “Invalid” means one
who is physically or mentally incapacitated from earning a livelihood.
(17) “Medically
stationary” means that no further material improvement would reasonably be
expected from medical treatment, or the passage of time.
(18) “Noncomplying
employer” means a subject employer who has failed to comply with ORS 656.017.
(19) “Objective findings”
in support of medical evidence are verifiable indications of injury or disease
that may include, but are not limited to, range of motion, atrophy, muscle
strength and palpable muscle spasm. “Objective findings” does not include
physical findings or subjective responses to physical examinations that are not
reproducible, measurable or observable.
(20) “Palliative care”
means medical service rendered to reduce or moderate temporarily the intensity
of an otherwise stable medical condition, but does not include those medical
services rendered to diagnose, heal or permanently alleviate or eliminate a
medical condition.
(21) “Party” means a claimant
for compensation, the employer of the injured worker at the time of injury and
the insurer, if any, of such employer.
(22) “Payroll” means a
record of wages payable to workers for their services and includes commissions,
value of exchange labor and the reasonable value of board, rent, housing,
lodging or similar advantage received from the employer. However, “payroll”
does not include overtime pay, vacation pay, bonus pay, tips, amounts payable
under profit-sharing agreements or bonus payments to reward workers for safe
working practices. Bonus pay is limited to payments which are not anticipated
under the contract of employment and which are paid at the sole discretion of
the employer. The exclusion from payroll of bonus payments to reward workers for
safe working practices is only for the purpose of calculations based on payroll
to determine premium for workers’ compensation insurance, and does not affect
any other calculation or determination based on payroll for the purposes of
this chapter.
(23) “Person” includes
partnership, joint venture, association, limited liability company and
corporation.
(24)(a) “Preexisting
condition” means, for all industrial injury claims, any injury, disease,
congenital abnormality, personality disorder or similar condition that
contributes to disability or need for treatment, provided that:
(A) Except for claims in
which a preexisting condition is arthritis or an arthritic condition, the
worker has been diagnosed with such condition, or has obtained medical services
for the symptoms of the condition regardless of diagnosis; and
(B)(i) In claims for an
initial injury or omitted condition, the diagnosis or treatment precedes the
initial injury;
(ii) In claims for a new
medical condition, the diagnosis or treatment precedes the onset of the new
medical condition; or
(iii) In claims for a
worsening pursuant to ORS 656.273 or 656.278, the diagnosis or treatment
precedes the onset of the worsened condition.
(b) “Preexisting
condition” means, for all occupational disease claims, any injury, disease,
congenital abnormality, personality disorder or similar condition that
contributes to disability or need for treatment and that precedes the onset of
the claimed occupational disease, or precedes a claim for worsening in such claims
pursuant to ORS 656.273 or 656.278.
(c) For the purposes of
industrial injury claims, a condition does not contribute to disability or need
for treatment if the condition merely renders the worker more susceptible to
the injury.
(25) “Self-insured
employer” means an employer or group of employers certified under ORS 656.430
as meeting the qualifications set out by ORS 656.407.
(26) “State Accident
Insurance Fund Corporation” and “corporation” mean the State Accident Insurance
Fund Corporation created under ORS 656.752.
(27) “Subject employer”
means an employer who is subject to this chapter as provided by ORS 656.023.
(28) “Subject worker”
means a worker who is subject to this chapter as provided by ORS 656.027.
(29) “Wages” means the
money rate at which the service rendered is recompensed under the contract of
hiring in force at the time of the accident, including reasonable value of
board, rent, housing, lodging or similar advantage received from the employer,
and includes the amount of tips required to be reported by the employer
pursuant to section 6053 of the Internal Revenue Code of 1954, as amended, and
the regulations promulgated pursuant thereto, or the amount of actual tips
reported, whichever amount is greater. The State Accident Insurance Fund
Corporation may establish assumed minimum and maximum wages, in conformity with
recognized insurance principles, at which any worker shall be carried upon the
payroll of the employer for the purpose of determining the premium of the
employer.
(30) “Worker” means any
person, including a minor whether lawfully or unlawfully employed, who engages
to furnish services for a remuneration, subject to the direction and control of
an employer and includes salaried, elected and appointed officials of the state,
state agencies, counties, cities, school districts and other public
corporations, but does not include any person whose services are performed as
an inmate or ward of a state institution or as part of the eligibility
requirements for a general or public assistance grant. For the purpose of
determining entitlement to temporary disability benefits or permanent total
disability benefits under this chapter, “worker” does not include a person who
has withdrawn from the workforce during the period for which such benefits are
sought.
(31) “Independent
contractor” has the meaning for that term provided in ORS 670.600.
SECTION 3.
ORS 656.245 is amended to read:
656.245. (1)(a) For
every compensable injury, the insurer or the self-insured employer shall cause
to be provided medical services for conditions caused in material part by the
injury for such period as the nature of the injury or the process of the
recovery requires, subject to the limitations in ORS 656.225, including such
medical services as may be required after a determination of permanent
disability. In addition, for consequential and combined conditions described in
ORS 656.005 (7), the insurer or the self-insured employer shall cause to be
provided only those medical services directed to medical conditions caused in
major part by the injury.
(b) Compensable medical
services shall include medical, surgical, hospital, nursing, ambulances and
other related services, and drugs, medicine, crutches and prosthetic
appliances, braces and supports and where necessary, physical restorative
services. A pharmacist or dispensing physician shall dispense generic drugs to
the worker in accordance with ORS 689.515. The duty to provide such medical
services continues for the life of the worker.
(c) Notwithstanding any
other provision of this chapter, medical services after the worker’s condition
is medically stationary are not compensable except for the following:
(A) Services provided to
a worker who has been determined to be permanently and totally disabled.
(B) Prescription
medications.
(C) Services necessary
to administer prescription medication or monitor the administration of
prescription medication.
(D) Prosthetic devices,
braces and supports.
(E) Services necessary
to monitor the status, replacement or repair of prosthetic devices, braces and
supports.
(F) Services provided
pursuant to an accepted claim for aggravation under ORS 656.273.
(G) Services provided
pursuant to an order issued under ORS 656.278.
(H) Services that are
necessary to diagnose the worker’s condition.
(I) Life-preserving
modalities similar to insulin therapy, dialysis and transfusions.
(J) With the approval of
the insurer or self-insured employer, palliative care that the worker’s
attending physician referred to in ORS 656.005 (12)(b)(A) prescribes and that
is necessary to enable the worker to continue current employment or a
vocational training program. If the insurer or self-insured employer does not
approve, the attending physician or the worker may request approval from the Director
of the Department of Consumer and Business Services for such treatment. The
director may order a medical review by a physician or panel of physicians
pursuant to ORS 656.327 (3) to aid in the review of such treatment. The
decision of the director is subject to review under ORS 656.704.
(K) With the approval of
the director, curative care arising from a generally recognized,
nonexperimental advance in medical science since the worker’s claim was closed
that is highly likely to improve the worker’s condition and that is otherwise
justified by the circumstances of the claim. The decision of the director is
subject to review under ORS 656.704.
(L) Curative care
provided to a worker to stabilize a temporary and acute waxing and waning of
symptoms of the worker’s condition.
(d) When the medically
stationary date in a disabling claim is established by the insurer or
self-insured employer and is not based on the findings of the attending
physician, the insurer or self-insured employer is responsible for reimbursement
to affected medical service providers for otherwise compensable services
rendered until the insurer or self-insured employer provides written notice to
the attending physician of the worker’s medically stationary status.
(e) Except for services
provided under a managed care contract, out-of-pocket expense reimbursement to
receive care from the attending physician or nurse practitioner authorized to
provide compensable medical services under this section shall not exceed the
amount required to seek care from an appropriate nurse practitioner or
attending physician of the same specialty who is in a medical community
geographically closer to the worker’s home. For the purposes of this paragraph,
all physicians and nurse practitioners within a metropolitan area are
considered to be part of the same medical community.
(2)(a) The worker may
choose an attending doctor, physician or nurse practitioner within the State of
(b) A medical service
provider who is not a member of a managed care organization is subject to the
following provisions:
(A) A medical service
provider who is not qualified to be an attending physician may provide
compensable medical service to an injured worker for a period of 30 days from
the date of injury or occupational disease or for 12 visits, whichever first
occurs, without the authorization of an attending physician. Thereafter,
medical service provided to an injured worker without the written authorization
of an attending physician is not compensable.
(B) A medical service
provider who is not an attending physician cannot authorize the payment of
temporary disability compensation. However, an emergency room physician who
is not authorized to serve as an attending physician under ORS 656.005 (12)(c)
may authorize temporary disability benefits for a maximum of 14 days.
Except as otherwise provided in this chapter, only the attending physician at
the time of claim closure may make findings regarding the worker’s impairment
for the purpose of evaluating the worker’s disability.
(C) Notwithstanding
subparagraphs (A) and (B) of this paragraph, a nurse practitioner licensed
under ORS 678.375 to 678.390 may:
(i) Provide compensable
medical services for 90 days from the date of the first visit on the claim;
(ii) Authorize the
payment of temporary disability benefits for a period not to exceed 60 days
from the date of the first visit on the initial claim; and
(iii) When an injured
worker treating with a nurse practitioner authorized to provide compensable
services under this section becomes medically stationary within the 90-day
period in which the nurse practitioner is authorized to treat the injured
worker, shall refer the injured worker to a physician qualified to be an
attending physician as defined in ORS 656.005 for the purpose of making
findings regarding the worker’s impairment for the purpose of evaluating the
worker’s disability. If a worker returns to the nurse practitioner after
initial claim closure for evaluation of a possible worsening of the worker’s
condition, the nurse practitioner shall refer the worker to an attending
physician and the insurer shall compensate the nurse practitioner for the
examination performed.
(3) Notwithstanding any
other provision of this chapter, the director, by rule, upon the advice of the
committee created by ORS 656.794 and upon the advice of the professional
licensing boards of practitioners affected by the rule, may exclude from
compensability any medical treatment the director finds to be unscientific,
unproven, outmoded or experimental. The decision of the director is subject to
review under ORS 656.704.
(4) Notwithstanding
subsection (2)(a) of this section, when a self-insured employer or the insurer
of an employer contracts with a managed care organization certified pursuant to
ORS 656.260 for medical services required by this chapter to be provided to
injured workers:
(a) Those workers who
are subject to the contract shall receive medical services in the manner
prescribed in the contract. Workers subject to the contract include those who
are receiving medical treatment for an accepted compensable injury or
occupational disease, regardless of the date of injury or medically stationary
status, on or after the effective date of the contract. If the managed care
organization determines that the change in provider would be medically
detrimental to the worker, the worker shall not become subject to the contract
until the worker is found to be medically stationary, the worker changes
physicians or nurse practitioners, or the managed care organization determines
that the change in provider is no longer medically detrimental, whichever event
first occurs. A worker becomes subject to the contract upon the worker’s
receipt of actual notice of the worker’s enrollment in the managed care
organization, or upon the third day after the notice was sent by regular mail
by the insurer or self-insured employer, whichever event first occurs. A worker
shall not be subject to a contract after it expires or terminates without renewal.
A worker may continue to treat with the attending physician or nurse
practitioner authorized to provide compensable medical services under this
section under an expired or terminated managed care organization contract if
the physician or nurse practitioner agrees to comply with the rules, terms and
conditions regarding services performed under any subsequent managed care
organization contract to which the worker is subject. A worker shall not be
subject to a contract if the worker’s primary residence is more than 100 miles
outside the managed care organization’s certified geographical area. Each such
contract must comply with the certification standards provided in ORS 656.260.
However, a worker may receive immediate emergency medical treatment that is compensable
from a medical service provider who is not a member of the managed care
organization. Insurers or self-insured employers who contract with a managed
care organization for medical services shall give notice to the workers of
eligible medical service providers and such other information regarding the
contract and manner of receiving medical services as the director may
prescribe. Notwithstanding any provision of law or rule to the contrary, a
worker of a noncomplying employer is considered to be subject to a contract
between the State Accident Insurance Fund Corporation as a processing agent or
the assigned claims agent and a managed care organization.
(b)(A) For initial or
aggravation claims filed after June 7, 1995, the insurer or self-insured employer
may require an injured worker, on a case-by-case basis, immediately to receive
medical services from the managed care organization.
(B) If the insurer or
self-insured employer gives notice that the worker is required to receive
treatment from the managed care organization, the insurer or self-insured
employer must guarantee that any reasonable and necessary services so received,
that are not otherwise covered by health insurance, will be paid as provided in
ORS 656.248, even if the claim is denied, until the worker receives actual
notice of the denial or until three days after the denial is mailed, whichever
event first occurs. The worker may elect to receive care from a primary care
physician or nurse practitioner authorized to provide compensable medical
services under this section who agrees to the conditions of ORS 656.260 (4)(g).
However, guarantee of payment is not required by the insurer or self-insured
employer if this election is made.
(C) If the insurer or
self-insured employer does not give notice that the worker is required to
receive treatment from the managed care organization, the insurer or
self-insured employer is under no obligation to pay for services received by
the worker unless the claim is later accepted.
(D) If the claim is denied,
the worker may receive medical services after the date of denial from sources
other than the managed care organization until the denial is reversed.
Reasonable and necessary medical services received from sources other than the
managed care organization after the date of claim denial must be paid as
provided in ORS 656.248 by the insurer or self-insured employer if the claim is
finally determined to be compensable.
(5) Notwithstanding any
other provision of this chapter, the director, by rule, shall authorize
physician assistants licensed by the Board of Medical Examiners for the State
of Oregon who practice in areas served by Type A or Type B rural hospitals
described in ORS 442.470 to authorize the payment of temporary disability
compensation for injured workers for a period not to exceed 30 days from the
date of the first visit on the claim. In addition, the director, by rule, may
authorize such assistants who practice in areas served by a Type C rural
hospital described in ORS 442.470 to authorize such payment.
(6) A nurse practitioner
licensed under ORS 678.375 to 678.390 who is not a member of the managed care
organization, is authorized to provide the same level of services as a primary
care physician as established by ORS 656.260 (4), if at the time the worker is
enrolled in the managed care organization, the nurse practitioner maintains the
worker’s medical records and with whom the worker has a documented history of
treatment, if that nurse practitioner agrees to refer the worker to the managed
care organization for any specialized treatment, including physical therapy, to
be furnished by another provider that the worker may require and if that nurse
practitioner agrees to comply with all the rules, terms and conditions
regarding services performed by the managed care organization.
(7) Subject to the
provisions of ORS 656.704, if a claim for medical services is disapproved, the
injured worker, insurer or self-insured employer may request administrative
review by the director pursuant to ORS 656.260 or 656.327.
SECTION 4.
ORS 656.245, as amended by section 4, chapter 811, Oregon Laws 2003, and
section 4, chapter 26, Oregon Laws 2005, is amended to read:
656.245. (1)(a) For
every compensable injury, the insurer or the self-insured employer shall cause
to be provided medical services for conditions caused in material part by the
injury for such period as the nature of the injury or the process of the
recovery requires, subject to the limitations in ORS 656.225, including such
medical services as may be required after a determination of permanent
disability. In addition, for consequential and combined conditions described in
ORS 656.005 (7), the insurer or the self-insured employer shall cause to be
provided only those medical services directed to medical conditions caused in
major part by the injury.
(b) Compensable medical
services shall include medical, surgical, hospital, nursing, ambulances and
other related services, and drugs, medicine, crutches and prosthetic
appliances, braces and supports and where necessary, physical restorative
services. A pharmacist or dispensing physician shall dispense generic drugs to
the worker in accordance with ORS 689.515. The duty to provide such medical
services continues for the life of the worker.
(c) Notwithstanding any
other provision of this chapter, medical services after the worker’s condition
is medically stationary are not compensable except for the following:
(A) Services provided to
a worker who has been determined to be permanently and totally disabled.
(B) Prescription
medications.
(C) Services necessary
to administer prescription medication or monitor the administration of
prescription medication.
(D) Prosthetic devices,
braces and supports.
(E) Services necessary
to monitor the status, replacement or repair of prosthetic devices, braces and
supports.
(F) Services provided
pursuant to an accepted claim for aggravation under ORS 656.273.
(G) Services provided
pursuant to an order issued under ORS 656.278.
(H) Services that are
necessary to diagnose the worker’s condition.
(I) Life-preserving
modalities similar to insulin therapy, dialysis and transfusions.
(J) With the approval of
the insurer or self-insured employer, palliative care that the worker’s
attending physician referred to in ORS 656.005 (12)(b)(A) prescribes and that
is necessary to enable the worker to continue current employment or a
vocational training program. If the insurer or self-insured employer does not
approve, the attending physician or the worker may request approval from the
Director of the Department of Consumer and Business Services for such
treatment. The director may order a medical review by a physician or panel of
physicians pursuant to ORS 656.327 (3) to aid in the review of such treatment.
The decision of the director is subject to review under ORS 656.704.
(K) With the approval of
the director, curative care arising from a generally recognized,
nonexperimental advance in medical science since the worker’s claim was closed
that is highly likely to improve the worker’s condition and that is otherwise
justified by the circumstances of the claim. The decision of the director is
subject to review under ORS 656.704.
(L) Curative care
provided to a worker to stabilize a temporary and acute waxing and waning of
symptoms of the worker’s condition.
(d) When the medically
stationary date in a disabling claim is established by the insurer or
self-insured employer and is not based on the findings of the attending
physician, the insurer or self-insured employer is responsible for
reimbursement to affected medical service providers for otherwise compensable
services rendered until the insurer or self-insured employer provides written
notice to the attending physician of the worker’s medically stationary status.
(e) Except for services
provided under a managed care contract, out-of-pocket expense reimbursement to
receive care from the attending physician shall not exceed the amount required
to seek care from an appropriate attending physician of the same specialty who
is in a medical community geographically closer to the worker’s home. For the
purposes of this paragraph, all physicians within a metropolitan area are
considered to be part of the same medical community.
(2)(a) The worker may
choose an attending doctor or physician within the State of
(b) A medical service
provider who is not a member of a managed care organization is subject to the
following provisions:
(A) A medical service
provider who is not qualified to be an attending physician may provide
compensable medical service to an injured worker for a period of 30 days from
the date of injury or occupational disease or for 12 visits, whichever first
occurs, without the authorization of an attending physician. Thereafter,
medical service provided to an injured worker without the written authorization
of an attending physician is not compensable.
(B) A medical service
provider who is not an attending physician cannot authorize the payment of
temporary disability compensation. However, an emergency room physician who
is not authorized to serve as an attending physician under ORS 656.005 (12)(c)
may authorize temporary disability benefits for a maximum of 14 days.
Except as otherwise provided in this chapter, only the attending physician at
the time of claim closure may make findings regarding the worker’s impairment
for the purpose of evaluating the worker’s disability.
(3) Notwithstanding any
other provision of this chapter, the director, by rule, upon the advice of the
committee created by ORS 656.794 and upon the advice of the professional
licensing boards of practitioners affected by the rule, may exclude from
compensability any medical treatment the director finds to be unscientific,
unproven, outmoded or experimental. The decision of the director is subject to
review under ORS 656.704.
(4) Notwithstanding
subsection (2)(a) of this section, when a self-insured employer or the insurer
of an employer contracts with a managed care organization certified pursuant to
ORS 656.260 for medical services required by this chapter to be provided to
injured workers:
(a) Those workers who
are subject to the contract shall receive medical services in the manner
prescribed in the contract. Workers subject to the contract include those who
are receiving medical treatment for an accepted compensable injury or
occupational disease, regardless of the date of injury or medically stationary
status, on or after the effective date of the contract. If the managed care
organization determines that the change in provider would be medically
detrimental to the worker, the worker shall not become subject to the contract
until the worker is found to be medically stationary, the worker changes
physicians or the managed care organization determines that the change in
provider is no longer medically detrimental, whichever event first occurs. A
worker becomes subject to the contract upon the worker’s receipt of actual
notice of the worker’s enrollment in the managed care organization, or upon the
third day after the notice was sent by regular mail by the insurer or
self-insured employer, whichever event first occurs. A worker shall not be
subject to a contract after it expires or terminates without renewal. A worker
may continue to treat with the attending physician under an expired or
terminated managed care organization contract if the physician agrees to comply
with the rules, terms and conditions regarding services performed under any
subsequent managed care organization contract to which the worker is subject. A
worker shall not be subject to a contract if the worker’s primary residence is
more than 100 miles outside the managed care organization’s certified
geographical area. Each such contract must comply with the certification
standards provided in ORS 656.260. However, a worker may receive immediate
emergency medical treatment that is compensable from a medical service provider
who is not a member of the managed care organization. Insurers or self-insured
employers who contract with a managed care organization for medical services
shall give notice to the workers of eligible medical service providers and such
other information regarding the contract and manner of receiving medical
services as the director may prescribe. Notwithstanding any provision of law or
rule to the contrary, a worker of a noncomplying employer is considered to be
subject to a contract between the State Accident Insurance Fund Corporation as
a processing agent or the assigned claims agent and a managed care
organization.
(b)(A) For initial or
aggravation claims filed after June 7, 1995, the insurer or self-insured
employer may require an injured worker, on a case-by-case basis, immediately to
receive medical services from the managed care organization.
(B) If the insurer or
self-insured employer gives notice that the worker is required to receive
treatment from the managed care organization, the insurer or self-insured
employer must guarantee that any reasonable and necessary services so received,
that are not otherwise covered by health insurance, will be paid as provided in
ORS 656.248, even if the claim is denied, until the worker receives actual
notice of the denial or until three days after the denial is mailed, whichever
event first occurs. The worker may elect to receive care from a primary care
physician who agrees to the conditions of ORS 656.260 (4)(g). However,
guarantee of payment is not required by the insurer or self-insured employer if
this election is made.
(C) If the insurer or
self-insured employer does not give notice that the worker is required to
receive treatment from the managed care organization, the insurer or
self-insured employer is under no obligation to pay for services received by
the worker unless the claim is later accepted.
(D) If the claim is
denied, the worker may receive medical services after the date of denial from
sources other than the managed care organization until the denial is reversed.
Reasonable and necessary medical services received from sources other than the
managed care organization after the date of claim denial must be paid as
provided in ORS 656.248 by the insurer or self-insured employer if the claim is
finally determined to be compensable.
(5) Notwithstanding any
other provision of this chapter, the director, by rule, shall authorize nurse
practitioners certified by the Oregon State Board of Nursing and physician
assistants licensed by the Board of Medical Examiners for the State of Oregon
who practice in areas served by Type A or Type B rural hospitals described in
ORS 442.470 to authorize the payment of temporary disability compensation for
injured workers for a period not to exceed 30 days from the date of the first
visit on the claim. In addition, the director, by rule, may authorize such
practitioners and assistants who practice in areas served by a Type C rural
hospital described in ORS 442.470 to authorize such payment.
(6) Subject to the
provisions of ORS 656.704, if a claim for medical services is disapproved, the
injured worker, insurer or self-insured employer may request administrative
review by the director pursuant to ORS 656.260 or 656.327.
Approved by the Governor June 20, 2007
Filed in the office of Secretary of State June 21, 2007
Effective date January 1, 2008
__________