OAR 436-110-0330
Claim Cost Reimbursement
(1)
General provisions. Claim cost reimbursement provides reimbursement to the insurer for claim costs when a preferred worker files a claim for injury or occupational disease while employed under premium exemption as follows:(a)
Reimbursements will be made for the life of the claim;(b)
Reimbursable claim costs include disability benefits, medical benefits, vocational costs under OAR 436-120-0720 (Fee Schedule), claim disposition agreements under ORS 656.236 (Compromise and release of claim matters except for medical benefits), disputed claim settlements under ORS 656.289 (Orders of Administrative Law Judge), stipulations, attorney fees awarded the worker or the worker’s beneficiaries, and administrative costs;(c)
Reimbursable claim costs for denied claims include costs incurred up to the date of denial, but are limited to benefits the insurer is obligated to pay under ORS chapter 656 and diagnostic tests, including independent medical examinations necessary to determine compensability of the claim;(d)
The administrative cost factor that will apply to claim costs is published in Bulletin 316; and(e)
The claim may not be used for ratemaking, individual employer rating, dividend calculations, or in any manner that would affect the employer’s insurance premiums or premium assessments with the present or a future insurer. The insurer must be able to document that claim data will not affect the employer’s rates or dividend.(2)
Reimbursement request process. The insurer must request claim cost reimbursement as follows:(a)
A request for reimbursement must be submitted to the division within 15 months of the date on which payment was made;(b)
The insurer must use Form 3014, “Preferred Worker Program Quarterly Cost Reimbursement Request”; and(c)
Reimbursement documentation must include, but is not limited to:(A)
Net amounts paid. “Net amounts” means the total compensation paid less any recoveries, including, but not limited to, third-party recovery or reimbursement from the Retroactive Program, Reopened Claims Program, or the fund; and(B)
Any other information required by the director.(3)
Costs not reimbursable. Requests for reimbursement may not include:(a)
Claim costs for any injury that did not occur while the worker was employed with premium exemption;(b)
Costs incurred for conditions completely unrelated to the compensable claim;(c)
Costs incurred due to inaccurate, untimely, unreasonable, or improper processing of the claim;(d)
Penalties, fines, or filing fees;(e)
Disposition amounts in accordance with ORS 656.236 (Compromise and release of claim matters except for medical benefits) or 656.289 (Orders of Administrative Law Judge) not previously approved by the director;(f)
Costs reimbursed or outstanding requests for reimbursement from the Reopened Claims Program, Retroactive Program, or the fund; or(g)
Reimbursable Employer-at-Injury Program costs.(4)
Audit, disallowed amounts. Periodically, the director will audit the insurer’s file to validate the amount reimbursed. Reimbursed amounts must be refunded to the division and, as applicable, future reimbursements will be denied if, upon audit, any of the following is found to apply:(a)
Reimbursement has been made for any of the items specified in section (3) of this rule;(b)
If claim acceptance as a new injury rather than an aggravation is questionable and the rationale for acceptance has not been reasonably documented;(c)
The separate payments of compensation have not been documented;(d)
The insurer included claim costs in any dividend or retrospective rating or experience rating calculations; or(e)
The insurer is unable to provide applicable records relating to experience rating, retrospective rating, or dividend calculations at the time of audit or within 14 working days thereafter.(5)
Reinstatement of reimbursement. If the conditions described in subsections (4)(a) through (e) of this rule are corrected and all other criteria of the rules are met, eligibility for reimbursement may be reinstated. If reimbursement eligibility is reinstated, any monies previously reimbursed and then recovered will be reimbursed again according to these rules.(6)
Reimbursement of settlement amounts. A claim disposition agreement under ORS 656.236 (Compromise and release of claim matters except for medical benefits), a disputed claim settlement under ORS 656.289 (Orders of Administrative Law Judge), or any stipulation or agreement of a claim subject to claim cost reimbursement from the fund must meet the following requirements for reimbursement:(a)
The insurer must obtain prior written approval of the agreement from the director. The proposed agreement must be submitted to the division before being submitted to the Workers’ Compensation Board or administrative law judge for approval;(b)
A claim’s future liability and the proposed contribution from the fund must be a reasonable projection, as determined by the director, in order to be approved for reimbursement from the fund; and(c)
A request for approval of the proposed agreement must include:(A)
A copy of the proposed agreement, containing appropriate signatures and a signature line for director approval, that specifies the proposed assistance from the fund;(B)
A written explanation of how the calculations for the amount of assistance from the fund were made; and(C)
Other information as required by the director.
Source:
Rule 436-110-0330 — Claim Cost Reimbursement, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-110-0330.