OAR 436-040-0050
Reimbursement
(1)
Reimbursement will be made to the paying agency based on the percentage of reimbursement ordered by the division.(2)
Request for reimbursement shall not be made until the deductible has been met.(3)
Requests for reimbursement are not to include: costs incurred for conditions unrelated to the compensable claim; costs incurred due to inaccurate, untimely, or improper processing; expenses; and settlement amounts not approved by the division, to which the parties agreed after relief was granted.(4)
The division will authorize reimbursement to the paying agency quarterly after receipt and approval of documentation of compensation paid from the paying agency. Documentation shall include, but not be limited to:(a)
Net amounts paid separated into disability benefits by type, and medical benefits for corresponding quarterly time periods;(b)
The current Worker with a Disability Claim Reserve as defined in these rules;(c)
Payment certification statement; and(d)
Any other information deemed necessary by the director.(5)
For purposes of subsection 4(a) of this rule, “net amounts paid” means the total compensation paid less any recoveries, including but not limited to, third party recovery, Retroactive Program reimbursement and Rehabilitation Program reimbursement.(6)
Periodically the division will audit the physical file of the paying agency to validate the amount reimbursed. Reimbursement shall not be approved if, upon such audit, any of the following are found to apply:(a)
Compensation has been paid as a result of untimely, inaccurate, or improper claims processing;(b)
Compensation has been paid for treatment of any condition unrelated to the compensable claim for which Workers with Disabilities Program relief was granted.(c)
The compensability of the accepted claim is questionable and the rationale for acceptance has not been reasonably documented, as required under generally accepted claims management procedures;(d)
The separate payments of compensation have not been documented, as required under generally accepted accounting procedures;(e)
For applications received after January 1, 1990, the subject employer was no longer doing business at the time of application for the Workers with Disabilities Program determination; that the employer was on a retrospective rating plan that was closed prior to the application for the Workers with Disabilities Program determination; or, if not on an open retrospective rating plan, that the last valuation for experience rating modification purposes that could affect the employer was completed prior to the application for the Workers with Disabilities Program determination;(f)
The insurer did not adjust the claims reserve value used in dividend, retrospective evaluation, or any claim valuation for experience rating determination to the percentage level specified in the order of acceptance, allowing for the $1,000 compensation minimum, or did not make the necessary monetary adjustments with the employer; or(g)
The insurance carrier is not able to provide applicable records relating to experience rating, retrospective rating or dividend calculations at the time of audit or within ten working days thereafter. Any reimbursements received on claims, for which the insurer is unable to provide records, will be returned to the division at least until the next annual audit is conducted and all applicable records are reviewed.(7)
The division will authorize reimbursement to insurance companies only for compensation which could reasonably be projected at the first of either to occur;(a)
The last claim evaluation which would affect the employer’s experience rating modification or retrospective rating adjustment, whichever is later; or(b)
For applications received after January 1, 1990, the employer ceases to do business, if that occurs first.(8)
The insurance company shall submit a claim valuation to the division at the first to occur of:(a)
The last claim valuation date which would affect the employer’s experience rating modification or retrospective rating adjustment, whichever is later (usually three and one half years after the inception of the policy period); or(b)
For applications received after January 1, 1990, the employer ceases to do business. The valuation shall include future reserves for the claim at that time. The division will verify the future reserves are reasonable and based on the appropriate valuation date. If the division determines the submitted claim valuation is unreasonable or based on inappropriate information, the division may establish the claim valuation or adjust the claim valuation period. The claim valuation, when approved by the division, shall be the maximum Worker with a Disability Claim Reserve used as the basis for reimbursement for the claim.(9)
When a claim is settled by a Compromise and Release or a Disputed Claims Settlement, the department shall review and modify the final reserve to reflect resulting changes in liability. The paying agent shall be notified of any change in the final reserve. A director review of this action will be considered only when paid claim costs have exceeded the established reserve.(10)
In the event that a denied claim is found compensable by a hearing referee, the Workers’ Compensation Board, or the Court of Appeals, and that decision is reversed by a higher level of appeal, the paying agency shall receive reimbursement for claim payments required to be made while the claim was in accepted status.
Source:
Rule 436-040-0050 — Reimbursement, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-040-0050.