OAR 436-015-0005

Unless a term is specifically defined elsewhere in these rules or the context otherwise requires, the definitions of ORS chapter 656 and OAR 436-010-0005 (Definitions) are hereby incorporated by reference and made a part of these rules.
(1) “Administrative review” means any decision making process of the director requested by a party aggrieved with an action taken under these rules except the hearing process described in OAR 436-001.
(2) “Come-along provider” means a primary care physician, a chiropractic physician, or an authorized nurse practitioner who is not a managed care organization (MCO) panel provider and who is authorized to continue to treat the worker when the worker becomes enrolled in an MCO.
(3) “Coordinated health care program” means an employer program providing for the coordination of a separate policy of group health insurance coverage with the medical portion of workers’ compensation coverage, for some or all of the employer’s workers, which provides workers with health care benefits even if a workers’ compensation claim is denied.
(4) “Division” means the Workers’ Compensation Division of the Department of Consumer and Business Services.
(5) “Geographic service area (GSA)” means an area of the state in which a managed care organization may be authorized by the director of the Department of Consumer and Business Services to provide managed care services. There are 15 geographic service areas in Oregon.
(6) “Good cause” means circumstances that are outside the control of a party or circumstances that are considered to be extenuating by the division.
(7) “Group of medical service providers” means individuals duly licensed to practice one or more of the healing arts who join together to provide medical services through a managed care organization, whether or not such providers have an ownership interest in the managed care organization.
(8) “Health care provider” means an entity or group of entities, organized to provide health care services or to provide administrative support services to entities providing health care services. An entity solely organized to become an MCO under these rules is not, in and of itself, a health care provider.
(9) “Insurer” means the State Accident Insurance Fund Corporation; an insurer authorized under ORS chapter 731 to transact workers’ compensation insurance in the state; or an employer or employer group that has been certified under ORS 656.430 (Certification of self-insured employer) and meets the qualifications of a self-insured employer under ORS 656.407 (Qualifications of insured employers).
(10) “Managed care organization” (“MCO”) means an organization formed to provide medical services and certified under these rules.
(11) “Medical provider” means a medical service provider, a hospital, a medical clinic, or a vendor of medical services.
(12) “Medical service” means any medical treatment or any medical, surgical, diagnostic, chiropractic, dental, hospital, nursing, ambulance, and other related services, and drugs, medicine, crutches and prosthetic appliances, braces and supports, and, where necessary, physical restorative services.
(13) “Medical service provider” means a person duly licensed to practice one or more of the healing arts.
(14) “Non-qualifying employer” means either:
(a) An insurer as defined in this rule, with respect to managed care services to be provided to any subject worker; or
(b) An employer as defined under ORS 656.005 (Definitions)(13), other than a health care provider, with respect to managed care services to such employer’s employees.
(15) “Primary care physician” means a physician qualified to be an attending physician according to ORS 656.005 (Definitions)(12)(b)(A) and who is a general practitioner, family practitioner, or internal medicine practitioner.
(16) “Show-cause hearing” means an informal meeting with the director or the director’s designee where the MCO is provided an opportunity to explain and present evidence regarding any proposed orders by the director to suspend or revoke the MCO’s certification.
Last Updated

Jun. 8, 2021

Rule 436-015-0005’s source at or​.us