Or. Admin. Code § 436-009-0010 - [Effective 6/6/2025] Medical Billing and Payment
(1)
General.
(a) Only treatment that
falls within the scope and field of the medical provider 's license to practice
will be paid under a workers' compensation claim. Except for emergency services
or as otherwise provided for by statute or these rules, treatments and medical
services are only payable if approved by the worker's attending physician or
authorized nurse practitioner . Fees for services by more than one physician at
the same time are payable only when the services are sufficiently different
that separate medical skills are needed for proper care.
(b) All billings must include the patient 's
full name, date of injury, and the employer's name. If available, billings must
also include the insurer 's claim number and the provider's NPI. If the provider
does not have an NPI, then the provider must provide its license number and the
billing provider's FEIN. For provider types not licensed by the state, "99999"
must be used in place of the state license number. Bills must not contain a
combination of ICD-9 and ICD-10 codes.
(c) The medical provider must bill their
usual fee charged to the general public. The submission of the bill by the
medical provider is a warrant that the fee submitted is the usual fee of the
medical provider for the services rendered. The director may require
documentation from the medical provider establishing that the fee under
question is the medical provider 's usual fee charged to the general public. For
purposes of this rule, "general public" means any person who receives medical
services, except those persons who receive medical services subject to specific
billing arrangements allowed under the law that require providers to bill other
than their usual fee .
(d) Medical
providers must not submit false or fraudulent billings, including billing for
services not provided. As used in this section, "false or fraudulent" means an
intentional deception or misrepresentation with the knowledge that the
deception could result in unauthorized benefit to the provider or some other
person. A request for pre-payment for a deposition is not considered false or
fraudulent.
(e) When a provider
treats a patient with two or more compensable claims, the provider must bill
individual medical services for each claim separately.
(f) When rebilling, medical providers must
indicate that the charges have been previously billed.
(g) If a patient requests copies of medical
bills in writing, medical providers must provide copies within 30 days of the
request, and provide any copies of future bills during the regular billing
cycle.
(2)
Billing
Timelines. (For payment timelines see OAR
436-009-0030.)
(a) Medical providers must bill within:
(A) 60 days of the date of service;
(B) 60 days after the medical provider has
received notice or knowledge of the responsible workers' compensation insurer
or processing agent; or
(C) 60 days
after any litigation affecting the compensability of the service is final, if
the provider receives written notice of the final litigation from the
insurer .
(b) If the
provider bills past the timelines outlined in subsection (a) of this section,
the provider may be subject to civil penalties as provided in ORS
656.254 and OAR
436-010-0340.
(c) When submitting a bill later than
outlined in subsection (a) of this section, a medical provider must establish
good cause .
(d) When a provider
submits a bill within 12 months of the date of service, the insurer may not
reduce payment due to late billing.
(e) When a provider submits a bill more than
12 months after the date of service, the bill is not payable, except when a
provision of subsection (2)(a) is the reason the billing was submitted after 12
months.
(3)
Billing
Forms.
(a) All medical providers must
submit bills to the insurer unless a contract directs the provider to bill the
managed care organization (MCO ).
(b) Medical providers must submit bills on a
completed current UB-04 (CMS 1450) or CMS 1500 except for:
(A) Dental billings, which must be submitted
on American Dental Association dental claim forms;
(B) Pharmacy billings, which must be
submitted on a current National Council for Prescription Drug Programs (NCPDP)
form; or
(C) Electronic billing
transmissions of medical bills (see OAR 436-008).
(c) Notwithstanding subsection (3)(b) of this
rule, a medical service provider doing an IME may submit a bill in the form or
format agreed to by the insurer and medical service provider .
(d) Medical providers may use
computer-generated reproductions of the appropriate forms.
(e) Unless different instructions are
provided in the table below, the provider should use the instructions provided
in the National Uniform Claim Committee 1500 Claim Form Reference Instruction
Manual. [See attached table.]
(4)
Billing Codes.
(a) When billing for medical services, a
medical provider must use codes listed in CPT® 2024, or Oregon specific
codes (OSC) listed in OAR
436-009-0060 that accurately
describe the service. If there is no specific CPT® code or OSC, a medical
provider must use the appropriate HCPCS or dental code, if available, to
identify the medical supply or service. If there is no specific code for the
medical service , the medical provider must use the unlisted code at the end of
each medical service section of CPT® 2024, or the appropriate unlisted
HCPCS code, and provide a description of the service provided. A medical
provider must include the National Drug Code (NDC) to identify the drug or
biological when billing for pharmaceuticals.
(b) Only one office visit code may be used
for each visit except for those code numbers relating specifically to
additional time.
(5)
Modifiers.
(a) When billing,
unless otherwise provided by these rules, medical providers must use the
appropriate modifiers found in CPT® 2024, HCPCS ' level II national
modifiers, or anesthesia modifiers, when applicable.
(b) Modifier 22 identifies a service provided
by a medical service provider that requires significantly greater effort than
typically required. Modifier 22 may only be reported with surgical procedure
codes with a global period of 0, 10, or 90 days as listed in Appendix B. The
bill must include documentation describing the additional work. It is not
sufficient to simply document the extent of the patient 's comorbid condition
that caused the additional work. When a medical service provider appropriately
bills for an eligible procedure with modifier 22, the payment rate is 125% of
the fee published in Appendix B, or the fee billed, whichever is less. For all
services identified by modifier 22, two or more of the following factors must
be present:
(A) Unusually lengthy
procedure;
(B) Excessive blood loss
during the procedure;
(C) Presence
of an excessively large surgical specimen (especially in abdominal
surgery);
(D) Trauma extensive
enough to complicate the procedure and not billed as separate procedure
codes;
(E) Other pathologies,
tumors, malformations (genetic, traumatic, or surgical) that directly interfere
with the procedure but are not billed as separate procedure codes; or
(F) The services rendered are significantly
more complex than described for the submitted CPT® .
(6)
Physician Associates and
Nurse Practitioners. Physician associates and nurse practitioners must
document in the chart notes that they provided the medical service . If
physician associates or nurse practitioners provide services as surgical
assistants during surgery, they must bill using modifier "81."
(7)
Chart Notes.
(a) All original medical provider billings
must be accompanied by legible chart notes. The chart notes must document the
services that have been billed and identify the person performing the
service.
(b) Chart notes must not
be kept in a coded or semi-coded manner unless a legend is provided with each
set of records.
(c) When processing
electronic bills, the insurer may waive the requirement that bills be
accompanied by chart notes. The insurer remains responsible for payment of only
compensable medical services. Medical providers may submit their chart notes
separately or at regular intervals as agreed with the insurer .
(8)
Challenging the
Provider's Bill. For services where the fee schedule does not establish
a fixed dollar amount, an insurer may challenge the reasonableness of a
provider's bill on a case by case basis by asking the director to review the
bill under OAR 436-009-0008. If the director
determines the amount billed is unreasonable, the director may establish a
different fee to be paid to the provider based on at least one of, but not
limited to, the following: reasonableness, the usual fees of similar providers,
fees for similar services in similar geographic regions, or any extenuating
circumstances.
(9)
Billing
the Patient and Patient Liability.
(a)
A patient is not liable to pay for any medical service related to an accepted
compensable injury or illness or any amount reduced by the insurer according to
OAR chapter 436, and a medical provider must not attempt to collect payment for
any medical service from a patient , except as follows:
(A) If the patient seeks treatment for
conditions not related to the accepted compensable injury or illness;
(B) If the patient seeks treatment for a
service that has not been prescribed by the attending physician or authorized
nurse practitioner , or a specialist physician upon referral of the attending
physician or authorized nurse practitioner . This would include, but is not
limited to, ongoing treatment by nonattending physicians in excess of the
30-day/12-visit period or by nurse practitioners in excess of the 180-day
period, as set forth in ORS
656.245 and OAR
436-010-0210;
(C) If the insurer notifies the patient that
they are medically stationary and the patient seeks palliative care that is not
authorized by the insurer or the director under OAR
436-010-0290;
(D) If an MCO -enrolled patient seeks
treatment from the provider outside the provisions of a governing MCO contract;
or
(E) If the patient seeks
treatment listed in section (12) of this rule after the patient has been
notified that such treatment is unscientific, unproven, outmoded, or
experimental.
(b) If the
director issues an order declaring an already rendered medical service or
treatment inappropriate, or otherwise in violation of the statute or
administrative rules, the worker is not liable for such services.
(c) A provider may bill a patient for a
missed appointment under section (13) of this rule.
(10)
Disputed Claim Settlement
(DCS). The insurer must pay a medical provider for any bill related to
the claimed condition received by the insurer on or before the date the terms
of a DCS were agreed on, but was either not listed in the approved DCS or was
not paid to the medical provider as set forth in the approved DCS. Payment must
be made by the insurer as prescribed by ORS
656.313(4)(d)
and OAR 438-009-0010(2)(g)
as if the bill had been listed in the approved settlement or as set forth in
the approved DCS, except, if the DCS payments have already been made, the
payment must not be deducted from the settlement proceeds. Payment must be made
within 45 days of the insurer 's knowledge of the outstanding bill.
(11)
Payment Limitations.
(a) Insurers do not have to pay providers for
the following:
(A) Completing forms 827 and
4909;
(B) Providing chart notes
with the original bill;
(C)
Preparing a written treatment plan;
(D) Supplying progress notes that document
the services billed;
(E) Completing
a work release form or completion of a PCE form, when no tests are
performed;
(F) A missed appointment
"no show" (see exceptions below under section (13) Missed Appointment "No
Show"); or
(G) More than three
mechanical muscle testing sessions per treatment program or when not prescribed
and approved by the attending physician or authorized nurse
practitioner .
(b)
Mechanical muscle testing includes a copy of the computer printout from the
machine, written interpretation of the results, and documentation of time spent
with the patient . Additional mechanical muscle testing may be paid for only
when authorized in writing by the insurer prior to the testing.
(c) Dietary supplements including, but not
limited to, minerals, vitamins, and amino acids are not reimbursable unless a
specific compensable dietary deficiency has been clinically established in the
patient .
(d) Vitamin B-12
injections are not reimbursable unless necessary for a specific dietary
deficiency of malabsorption resulting from a compensable gastrointestinal
condition.
(12)
Excluded Treatment. The following medical treatments (or treatment
of side effects) are not compensable and insurers do not have to pay for:
(a) Dimethyl sulfoxide (DMSO), except for
treatment of compensable interstitial cystitis;
(b) Intradiscal electrothermal therapy
(IDET);
(c) Surface
electromyography (EMG) tests;
(d)
Rolfing;
(e)
Prolotherapy;
(f)
Thermography;
(g) Lumbar artificial
disc replacement, unless it is a single level replacement with an unconstrained
or semi-constrained metal on polymer device and:
(A) The single level artificial disc
replacement is between L3 and S1;
(B) The patient is 16 to 60 years
old;
(C) The patient underwent a
minimum of six months unsuccessful exercise based rehabilitation; and
(D) The procedure is not found inappropriate
under OAR 436-010-0230;
(h) Cervical artificial disc replacement,
unless the procedure is a single level or a two level contiguous cervical
artificial disc replacement with a device that has Food and Drug Administration
(FDA) approval for the procedure; and
(i) Platelet rich plasma (PRP)
injections.
(13)
Missed Appointment (No Show).
(a)
In general, the insurer does not have to pay for "no show" appointments.
However, insurers must pay for "no show" appointments for arbiter exams,
director required medical exams, independent medical exams, worker requested
medical exams, and closing exams. If the patient does not give 48 hours notice,
the insurer must pay the provider 50 percent of the exam or testing fee and 100
percent for any review of the file that was completed prior to cancellation or
missed appointment.
(b) Other than
missed appointments for arbiter exams, director required medical exams,
independent medical exams, worker requested medical exams, and closing exams, a
provider may bill a patient for a missed appointment if:
(A) The provider has a written
missed-appointment policy that applies not only to workers' compensation
patients, but to all patients;
(B)
The provider routinely notifies all patients of the missed-appointment
policy;
(C) The provider's written
missed-appointment policy shows the cost to the patient ; and
(D) The patient has signed the
missed-appointment policy.
(c) The implementation and enforcement of
subsection (b) of this section is a matter between the provider and the
patient . The division is not responsible for the implementation or enforcement
of the provider's policy.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 656.245, ORS 656.248, ORS 656.252, ORS 656.254 & ORS 656.726(4)
Statutes/Other Implemented: ORS 656.245, ORS 656.248, ORS 656.252 & ORS 656.254
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