Or. Admin. Code § 436-010-0220 - Choosing and Changing Medical Providers
(1) The worker may
have only one attending physician or authorized nurse practitioner at a time.
Concurrent treatment or services by other medical providers, including
specialist physicians, must be sufficiently different that separate medical
skills are needed for proper care, and must be based on a written referral by
the attending physician or authorized nurse practitioner. The referral must
specify any limitations and a copy must be sent to the insurer. A specialist
physician is authorized to provide or order all compensable medical services
and treatment the physician considers appropriate, unless the referral is for a
consultation only. The attending physician or authorized nurse practitioner
continues to be responsible for authorizing temporary disability even if the
specialist physician is providing or authorizing medical services and
treatment. Physicians who provide the following services are not considered
attending physicians:
(a) Emergency
services;
(b) Insurer or director
requested examinations;
(c) A
Worker Requested Medical Examination;
(d) Consultations or referrals for
specialized treatment or services initiated by the attending physician or
authorized nurse practitioner; and
(e) Diagnostic studies provided by
radiologists and pathologists upon referral.
(2)
Changing Attending Physician or
Authorized Nurse Practitioner. The worker may choose to change attending
physician or authorized nurse practitioner only twice after the initial choice.
When the worker requests a referral by the attending physician or authorized
nurse practitioner to another attending physician or authorized nurse
practitioner, the change will count as one of the worker's choices. The
limitation of the worker's right to choose attending physicians or authorized
nurse practitioners begins with the date of injury and extends through the life
of the claim. The following are not considered changes of attending physician
or authorized nurse practitioner initiated by the worker and do not count
toward the worker's two changes:
(a) When the
worker has an attending physician or authorized nurse practitioner who works in
a group setting/facility and the worker sees another group member due to team
practice, coverage, or on-call routines;
(b) When the worker's attending physician or
authorized nurse practitioner is not available and the worker sees a medical
provider who is covering for that provider in their absence; or
(c) When the worker is required to change
attending physician or authorized nurse practitioner due to conditions beyond
the worker's control. This could include, but is not limited to:
(A) When the attending physician or
authorized nurse practitioner terminates practice or leaves the area;
(B) When the attending physician or
authorized nurse practitioner is no longer willing to treat the
worker;
(C) When the worker moves
out of the area requiring more than a 50 mile commute to the attending
physician or authorized nurse practitioner;
(D) When the period for treatment or services
by a type B or type C attending physician or an authorized nurse practitioner
has expired (See Appendix A "Matrix for Health Care Provider Types");
(E) When the physician associate or
authorized nurse practitioner is required to refer the worker to an attending
physician for a closing examination or because of a possible worsening of the
worker's condition following claim closure;
(F) When the worker becomes subject to a
managed care organization (MCO) contract and must change to an attending
physician or authorized nurse practitioner on the MCO's panel;
(G) When the worker who, at the time of MCO
enrollment was required to change attending physician or authorized nurse
practitioner, is disenrolled from an MCO; or
(H) When the worker has to change because
their attending physician or authorized nurse practitioner is no longer
qualified as an attending physician or authorized to continue providing
compensable medical services.
(3)
Insurer Notice to the
Worker. When the worker has changed attending physicians or authorized
nurse practitioners twice by choice or has reached the maximum number of
changes established by the MCO, the insurer must notify the worker by certified
mail that any additional changes by choice must be approved by the insurer or
the director. If the insurer fails to provide such notice and the worker later
chooses another attending physician or authorized nurse practitioner, the
insurer must pay for compensable medical services rendered prior to notice to
the worker. The insurer must notify the newly selected provider that the worker
was not allowed to change attending physician or authorized nurse practitioner
without approval of the insurer or director, and therefore any future services
will not be paid. The insurer must pay for appropriate medical services
rendered prior to this notification.
(4)
Worker Requesting Additional
Changes of Attending Physician or Authorized Nurse Practitioner.
(a) If a worker not enrolled in an MCO has
changed attending physicians or authorized nurse practitioners by choice twice
(or for MCO enrolled workers, the maximum allowed by the MCO) and wants to
change again, the worker must request approval from the insurer. The worker
must make the request in writing or by signing Form 827. The insurer must
respond to the worker within 14 days of receiving the request whether the
change is approved. If the insurer objects to the change, the insurer must:
(A) Send the worker a written explanation of
the reasons;
(B) Send the worker
Form 2332 (Worker's Request to Change Attending Physician or Authorized Nurse
Practitioner); and
(C) Inform the
worker that the worker may request director approval by sending Form 2332 to
the director.
(b) When
the worker submits a request to the director for an additional change of
attending physician or authorized nurse practitioner, the director may request,
in writing, additional information. If the director requests additional
information, the parties must respond in writing within 14 days of the
director's request.
(c) The
director will issue an order advising whether the request for change of
attending physician or authorized nurse practitioner is approved. On a
case-by-case basis the director will consider circumstances, such as:
(A) Whether there is medical justification
for a change, e.g., whether the attending physician or authorized nurse
practitioner can provide the type of treatment or service that is appropriate
for the worker's condition.
(B)
Whether the worker has moved to a new area and wants to establish an attending
physician or authorized nurse practitioner closer to the worker's
residence.
(d) Any party
that disagrees with the director's order may request a hearing by filing a
request for hearing as provided in OAR
436-001-0019 within 30 days of
the mailing date of the order.
(5)
Managed Care Organization
(MCO) Enrolled Workers.
(a) An
MCO enrolled worker must choose:
(A) A panel
provider unless the MCO approves a non-panel provider, or
(B) A "come-along provider" who provides
medical services subject to the terms and conditions of the governing
MCO.
(b) Notwithstanding
subsection (a) of this section, if a worker is unable to find three providers
that are willing to treat the worker in a category of providers listed in OAR
436-015-0030(6)(a) and
(b) in the worker's geographic service area
(GSA), the worker may contact the MCO for a list of three providers who are
willing to treat the worker. If the MCO, within 14 days, is unable to provide a
list of three providers who are willing to treat the worker within a reasonable
period of time, the worker may choose a non-panel provider in that
category.
(c) Notwithstanding
subsection (a) of this section, if the MCO has fewer than three providers in a
category of providers listed in OAR
436-015-0030(6)(a) and
(b) in the worker's GSA, the worker may
choose a non-panel provider in that category.
Notes
Forms & Appendices referenced are available from the agency.
Statutory/Other Authority: ORS 656.726(4)
Statutes/Other Implemented: ORS 656.245, ORS 656.252 & ORS 656.260
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