Or. Admin. Code § 436-009-0005 - Definitions
(1) Unless a term is specifically defined
elsewhere in these rules or the context otherwise requires, the definitions of
ORS chapter 656 are hereby incorporated by reference and made part of these
rules.
(2) Abbreviations used in
these rules are either defined in the rules in which they are used or defined
as follows:
(a) CMS means Centers for Medicare
& Medicaid Services.
(b)
CPT® means Current Procedural Terminology published by the American Medical
Association.
(c) DMEPOS means
durable medical equipment, prosthetics, orthotics, and supplies.
(d) EDI means electronic data
interchange.
(e) HCPCS means
Healthcare Common Procedure Coding System published by CMS.
(f) ICD-9-CM means International
Classification of Diseases, Ninth Revision, Clinical Modification, Vol. 1, 2
& 3 by US Department of Health and Human Services.
(g) ICD-10-CM means International
Classification of Diseases, Tenth Revision, Clinical Modification.
(h) MCO means managed care organization
certified by the director.
(i) NPI
means national provider identifier.
(j) OSC means Oregon specific code.
(k) PCE means physical capacity
evaluation.
(l) WCE means work
capacity evaluation.
(3)
"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.
(4)
"Ambulatory surgery center"
or "ASC" means:
(a) Any distinct entity
licensed by the state of Oregon, and operated exclusively for the purpose of
providing surgical services to patients not requiring hospitalization;
or
(b) Any entity outside of Oregon
similarly licensed, or certified by Medicare or a nationally recognized agency
as an ASC.
(5)
"Attending physician" has the same meaning as described in ORS
656.005(12)(b).
See Appendix A, "Matrix for Health Care Provider Types." [Attached.]
(6)
"Authorized nurse
practitioner" means a nurse practitioner licensed under ORS
678.375 to
678.390 who has certified to the
director that the nurse practitioner has reviewed informational materials about
the workers' compensation system provided by the director and who has been
assigned an authorized nurse practitioner number by the director.
(7)
"Board" means the Workers'
Compensation Board and includes its Hearings Division.
(8)
"Chart note" means a
notation made in chronological order in a medical record in which the medical
service provider records such things as subjective and objective findings,
diagnosis, treatment rendered, treatment objectives, and return to work goals
and status.
(9)
"Clinic" means a group practice in which several medical service
providers work cooperatively.
(10)
"CMS form 2552" (Hospital and Hospital Health Care Complex Cost
Report) means the annual report a hospital makes to Medicare.
(11)
"Current procedural
terminology" or "CPT®" means the Current Procedural Terminology
codes and terminology published by the American Medical Association unless
otherwise specified in these rules.
(12)
"Date stamp" means to stamp
or display the initial receipt date and the recipient's name on a paper or
electronic document, regardless of whether the document is printed or displayed
electronically.
(13)
"Days" means calendar days.
(14)
"Director" means the
director of the Department of Consumer and Business Services or the director's
designee.
(15)
"Division" means the Workers' Compensation Division of the
Department of Consumer and Business Services.
(16)
"Enrolled" means an
eligible worker has received notification from the insurer that the worker is
being required to receive treatment under the provisions of a managed care
organization (MCO). However, a worker may not be enrolled who would otherwise
be subject to an MCO contract if the worker's primary residence is more than
100 miles outside the MCO's certified geographical service area.
(17)
"Fee discount agreement"
means a direct contract entered into between a medical service provider or
clinic and an insurer to discount fees to the medical service provider or
clinic under OAR 436-009-0018.
(18)
"Good Cause" means
circumstances that are outside the control of a party or circumstances that are
considered to be extenuating by the division.
(19)
"Hospital" means an
institution licensed by the State of Oregon as a hospital.
(a)
"Inpatient" means a patient
who is admitted to a hospital prior to and extending past midnight for
treatment and lodging.
(b)
"Outpatient" means a patient not admitted to a hospital prior to
and extending past midnight for treatment and lodging. Medical services
provided by a health care provider such as emergency room services, observation
room, or short stay surgical treatments that do not result in admission are
also considered outpatient services.
(20)
"Initial claim" means the
first open period on the claim immediately following the original filing of the
occupational injury or disease claim until the worker is first declared to be
medically stationary by an attending physician or authorized nurse
practitioner. For nondisabling claims, the "initial claim" means the first
period of medical treatment immediately following the original filing of the
occupational injury or disease claim ending when the attending physician or
authorized nurse practitioner does not anticipate further improvement or need
for medical treatment, or there is an absence of treatment for an extended
period.
(21)
"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 and meets the
qualifications of a self-insured employer under ORS
656.407.
(22)
"Interim medical benefits"
means those services provided under ORS
656.247 on initial claims with
dates of injury on or after January 1, 2002, that are not denied within 14 days
of the employer's notice of the claim.
(23)
"Interpreter" means a
person who:
(a) Provides oral or sign language
translation; and
(b) Owns,
operates, or works for a business that receives income for providing oral or
sign language translation. It does not include a medical provider, medical
provider's employee, or a family member or friend of the worker.
(24)
"Interpreter
services" means the act of orally translating between a medical provider
and a worker who speak different languages, including sign language. It
includes reasonable time spent waiting at the location for the medical provider
to examine or treat the worker as well as reasonable time spent on necessary
paperwork for the provider's office.
(25)
"Legal holidays" means
holidays listed in ORS
187.010 and
187.020.
(26)
"Mailed or mailing date"
means the date a document is postmarked. Requests submitted by facsimile or
"fax" are considered mailed as of the date printed on the banner automatically
produced by the transmitting fax machine. Hand-delivered requests will be
considered mailed as of the date stamped by the division. Phone or in-person
requests, where allowed under these rules, will be considered mailed as of the
date of the request.
(27)
"Managed care organization" or "MCO" means an organization formed
to provide medical services and certified in accordance with OAR chapter 436,
division 015.
(28)
"Medical
provider" means a medical service provider, a hospital, a medical
clinic, or a vendor of medical services.
(29)
"Medical service" means any
medical treatment or any medical, surgical, diagnostic, chiropractic, dental,
hospital, nursing, ambulances, and other related services, and drugs, medicine,
crutches and prosthetic appliances, braces and supports and where necessary,
physical restorative services.
(30)
"Medical service provider" means a person duly licensed to
practice one or more of the healing arts.
(31)
"Medical treatment" means
the management and care of a patient for the purpose of combating disease,
injury, or disorder. Restrictions on activities are not considered treatment
unless the primary purpose of the restrictions is to improve the worker's
condition through conservative care.
(32)
"Parties" mean the worker,
insurer, MCO, attending physician, and other medical provider, unless a
specific limitation or exception is expressly provided for in the
statute.
(33)
"Patient" means the same as worker as defined in ORS
656.005(28).
(34)
"Physical capacity
evaluation" means an objective, directly observed, measurement of a
patient's ability to perform a variety of physical tasks combined with
subjective analyses of abilities by patient and evaluator. Physical tolerance
screening, Blankenship's Functional Capacity Evaluation, and Functional
Capacity Assessment have the same meaning as Physical Capacity
Evaluation.
(35)
"Provider
network" means a health service intermediary other than an MCO that
facilitates transactions between medical providers and insurers through a
series of contractual arrangements.
(36)
"Report" means medical
information transmitted in written form containing relevant subjective or
objective findings. Reports may take the form of brief or complete narrative
reports, a treatment plan, a closing examination report, or any forms as
prescribed by the director.
(37)
"Residual functional capacity" means a patient's remaining ability
to perform work-related activities. A residual functional capacity evaluation
includes, but is not limited to, capability for lifting, carrying, pushing,
pulling, standing, walking, sitting, climbing, balancing, bending/stooping,
twisting, kneeling, crouching, crawling, and reaching, and the number of hours
per day the patient can perform each activity.
(38)
"Specialist physician"
means a licensed physician who qualifies as an attending physician and who
examines a patient at the request of the attending physician or authorized
nurse practitioner to aid in evaluation of disability, diagnosis, or provide
temporary specialized treatment. A specialist physician may provide specialized
treatment for the compensable injury or illness and give advice or an opinion
regarding the treatment being rendered, or considered, for a patient's
compensable injury.
(39)
"Type A attending physician" means an attending physician under
ORS 656.005(12)(b)(A).
See Appendix A, "Matrix for Health Care Provider Types." [Attached.]
(40)
"Type B attending
physician" means an attending physician under ORS
656.005(12)(b)(B).
See Appendix A, "Matrix for Health Care Provider Types." [Attached.]
(41)
"Usual fee" means the
medical provider's fee charged to the general public for a given
service.
(42)
"Work capacity
evaluation" means a physical capacity evaluation with special emphasis
on the ability to perform a variety of vocationally oriented tasks based on
specific job demands. Work Tolerance Screening has the same meaning as Work
Capacity Evaluation.
(43)
"Work hardening" means an individualized, medically prescribed and
monitored, work-oriented treatment process. The process involves the patient
participating in simulated or actual work tasks that are structured and graded
to progressively increase physical tolerances, stamina, endurance, and
productivity to return the patient to a specific job.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 656.726(4)
Statutes/Other Implemented: ORS 656.726(4), ORS 656.000 et seq. & ORS 656.005
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.