OAR 436-009-0025
Worker Reimbursement
(a)
When the insurer accepts the claim the insurer must notify the worker in writing that:(A)
The insurer will reimburse claim-related services paid by the worker; and(B)
The worker has two years to request reimbursement.(b)
The worker must request reimbursement from the insurer in writing. The insurer may require reasonable documentation such as a sales slip, receipt, or other evidence to support the request. The worker may use Form 3921 – Request for Reimbursement of Expenses.(c)
Insurers must date stamp requests for reimbursement on the date received.(d)
The insurer or its representative must provide a written explanation to the worker for each type of out-of-pocket expense (mileage, lodging, medication, etc.) being paid or denied.(e)
The explanation to the worker must be in 10 point size font or larger and must include:(A)
The amount of reimbursement for each type of out-of-pocket expense requested.(B)
The specific reason for nonpayment, reduced payment, or discounted payment for each itemized out-of-pocket expense the worker submitted for reimbursement;(C)
An Oregon or toll-free phone number for the insurer or its representative, and a statement that the insurer or its representative must respond to a worker’s reimbursement question within two days, excluding weekends and legal holidays;(D)
The following notice, Web link, and phone number:(E)
Space for the worker’s signature and date; and(F)
A notice of right to administrative review as follows:(f)
According to ORS 656.325 (Required medical examination)(1)(f) and OAR 436-060-0095 (Medical Examinations; Suspension of Compensation; and Independent Medical Examination Notice)(4), when a worker attends an independent medical examination (IME), the insurer must reimburse the worker for related costs regardless of claim acceptance, deferral, or denial.(a)
The worker must submit a request for reimbursement of claim-related costs by whichever date is later:(A)
Two years from the date the costs were incurred or(B)
Two years from the date the claim or medical condition is finally determined compensable.(b)
The insurer may disapprove the reimbursement request if the worker requests reimbursement after two years as listed in subsection (a).(c)
On accepted claims the insurer must, within 30 days of receiving the reimbursement request, reimburse the worker if the request shows the costs are related to the accepted claim or disapprove the request if unreasonable or if the costs are not related to the accepted claim.(A)
The insurer may request additional information from the worker to determine if costs are related to the accepted claim within 30 days of receiving the reimbursement request.(B)
If additional information is needed, the time needed to obtain the information is not counted in the 30-day time frame for the insurer to issue reimbursement or disapprove the request.(d)
When the insurer receives a reimbursement request before claim acceptance, and the claim is ultimately accepted, the insurer must, within 30 days of receiving the reimbursement request or 14 days of claim acceptance, whichever is later, reimburse the worker if the request shows the costs are related to the accepted claim or disapprove the request if unreasonable or if the costs are not related to the accepted claim.(A)
The insurer may request additional information from the worker to determine if costs are related to the accepted claim within 30 days of receiving the reimbursement request or 14 days of claim acceptance, whichever is later.(B)
If additional information is needed, the time needed to obtain the information is not counted in the 30-day or 14-day time frame for the insurer to issue reimbursement or disapprove the request.(e)
When any action, other than those listed in subsections (c) and (d) of this section, causes the reimbursement request to be payable, the insurer must reimburse the worker within 14 days of the action.(f)
In a claim for aggravation or a new medical condition, reimbursement requests are not due and payable until the aggravation or new medical condition is accepted.(g)
If the claim is denied, requests for reimbursement must be returned to the worker within 14 days, and the insurer must retain a copy.(a)
Meal reimbursement is based on whether a meal is reasonably required by necessary travel to a claim-related appointment.(b)
Lodging reimbursement is based on the need for an overnight stay to attend an appointment.(c)
Meals and lodging are reimbursed at the actual cost or the rate published in Bulletin 112, whichever is less. Lodging reimbursement may exceed the maximum rate published in Bulletin 112 when special lodging is required or when the worker is unable to find lodging at or below the maximum rate within 10 miles of the appointment location.(a)
Insurers must reimburse workers for actual and reasonable costs for travel to medical providers paid by the worker under ORS 656.245 (Medical services to be provided)(1)(e), 656.325 (Required medical examination), and 656.327 (Review of medical treatment of worker).(b)
The insurer may limit worker reimbursement for travel to an attending physician if the insurer provides a prior written explanation and a written list of attending physicians that are closer for the worker, of the same specialty, and who are able and willing to provide similar medical services to the worker. The insurer may limit worker reimbursement for travel to an authorized nurse practitioner if the insurer provides a prior written explanation and a written list of authorized nurse practitioners that are closer for the worker, of the same specialty, and who are able and willing to provide similar medical services to the worker. The insurer must inform the worker that he or she may continue treating with the established attending physician or authorized nurse practitioner; however, reimbursement of transportation costs may be limited to the distance from the worker’s home to a provider on the written list.(c)
Within a metropolitan area the insurer may not limit worker reimbursement for travel to an attending physician or authorized nurse practitioner even if there are medical providers closer to the worker.(d)
Travel reimbursement dispute decisions will be based on principles of reasonableness and fairness within the context of the specific case circumstances as well as the spirit and intent of the law.(e)
Personal vehicle mileage is the reasonable actual distance based on the beginning and ending addresses. The mileage reimbursement is limited to the rate published in Bulletin 112.(f)
Public transportation or, if required, special transportation will be reimbursed based on actual cost.(a)
The insurer must reimburse the worker for other claim-related expenses based on actual cost. However, reimbursement for hearing aids is limited to the amounts listed in OAR 436-009-0080 (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)).(b)
For prescription medications, the insurer must reimburse the worker based on actual cost. When a provider prescribes a brand-name drug, pharmacies must dispense the generic drug (if available), according to ORS 689.515 (Regulation of generic drugs). When a worker insists on receiving the brand-name drug, and the prescribing provider has not prohibited substitution, the worker must either pay the total cost of the brand-name drug out of pocket or pay the difference between the cost of the brand-name drug and generic to the pharmacy. The worker may then request reimbursement from the insurer. However, if the insurer has previously notified the worker in writing that the worker is liable for the difference between the generic and brand-name drug, the insurer only has to reimburse the worker the generic price of the drug.(c)
For IMEs, child care costs are reimbursed at the rate prescribed by the State of Oregon Department of Human Services.(d)
Home health care provided by a worker’s family member is not required to be under the direct control and supervision of the attending physician. A worker may receive reimbursement for such home health care services only if the family member demonstrates competency to the satisfaction of the worker’s attending physician.
Source:
Rule 436-009-0025 — Worker Reimbursement, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-009-0025.