Or. Admin. Code § 125-160-0900 - Appealing Claims Decisions and Actions
(1) These shall be the rules of procedure for
appeals and contested case hearings for actions under these rules. Except as
noted, the administrative procedures act shall not apply.
(2) When these rules permit an action of the
Department to be contested by the claimant, the Department shall give the
notice required by ORS 183.415(2). The following three levels of appeal shall
then apply.
(a) Claimant shall first appeal
through request for review by Department:
(A)
One request for review of an action by Department may be made by the affected
claimant. It shall be received by the Department within 60 days after the date
of Department's contested decision unless the decision includes the grant of a
longer period.
(B) Claimant's
written request for review shall list and explain all contested matters of fact
and law in writing. It shall state the action the claimant is requesting. New
supporting documents, if consistent with these rules, may be enclosed. Any
revised attending physician's response or report shall be enclosed as part of
the request for review. A timely request for review that conforms to these
rules is a prerequisite to further appeal or hearing.
(C) Requests for review may contest
allegations of omitted fact, factual error, lack of required evidence for the
Department's pertinent findings and conclusions, or legal error by Department.
Any medical evidence shall be submitted to the attending physician, whose
report shall be provided with the request for review. Only issues subject to
the jurisdiction of these rules may be raised or contested.
(D) When the Department receives a request
for review, it shall consider the record it relied upon and any information
contained in or attached to the request for review. If the Department finds
that its action is not correct under these rules or is not supported by
substantial evidence, the Department shall modify its decision. The Department
shall respond to claimant's request for review by affirming, rescinding, or
modifying its decision.
(b) Upon completion of the review level of
appeal, claimant may request a contested case hearing as follows:
(A) Claimant may request a hearing if the
Department does not acknowledge a valid and complete request for review or does
not grant the relief requested.
(B) Written request for hearing shall be
received by the Department no later than 30 days after the request for review
is received by Department or after Department's final response to request for
review, whichever is later.
(C) A
request for contested case hearing shall list and explain each contested matter
of fact or law. It shall state the action the claimant is requesting. A request
for a contested case hearing shall raise no issues nor make any request that
was not in the request for review. A timely request for contested case hearing
that conforms to these rules is a prerequisite to any hearing.
(D) Hearings officers may only consider legal
error by Department and the sufficiency of evidence for the Department's
decision or action, as modified by any response to the request for review. Only
issues raised in claimant's request for review may be considered. A claimant
may not contest any issues of timeliness, inclusion or omission, or other
procedural requirements, unless claimant submitted to Department, with or
before request for review, clear and convincing evidence that met the
procedural requirement.
(c) Upon exhausting the review and hearings
levels of appeal, claimant may appeal the final decision of the director to the
Court of Appeals as provided by ORS 183.480 to 183.482.
(3) Only the following actions of the
Department may be appealed:
(a) Partial or
full claim denial based on Department's findings and conclusions.
(b) Partial or full denial of request for
reaffirmation or modification of initial estimate.
(c) Refusal to pay any requested payment or
benefit due to claimant under these rules.
(d) Termination, reduction, forfeiture, or
denial of retroactive restoration of any benefit already awarded to claimant
under these rules.
(e) Death
benefit determination or denial.
(f) Denial of a provider's billing or a
claimant's reimbursement request for medical services.
(4) The following actions of Department may
not be appealed under these rules:
(a)
Initial estimate by Department.
(b) Temporary suspension of payments.
(c) The form or procedure of
benefit payment chosen by the Department, including the amount of discount in
any lump sum payment, annuity, or settlement.
(d) Any medical service the attending
physician orders or refuses to order.
(e) Department's decision to require that the
claim must be proven by clear and convincing evidence.
(f) Denial of any request for increased or
additional benefit in a claim on which claimant did not appeal final award, or
exhausted appeals.
(g) Any action
taken by anyone other than Department or not solely within Department's
authority under these rules.
(h)
Any action of Department for which these rules do not expressly provide for
appeal.
(5) A claimant
may appeal a Department action once. After appeal under these rules is
exhausted, that issue may not be raised again.
Notes
Stat. Auth.: ORS 184.340, 278.405, 655.520 & 655.555
Stats. Implemented: ORS 655.505 - 655.555
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.