Or. Admin. Code § 436-030-0034 - Administrative Claim Closure
(1) The
insurer must close a claim when the worker is not medically stationary and the
worker fails to seek treatment for more than 30 days without the instruction or
approval of the attending physician or authorized nurse practitioner and for
reasons within the worker's control. In order to close a claim under this
section, the insurer must:
(a) Wait for the
30-day lack of treatment period to expire or any additional time period
recommended by the attending physician or authorized nurse practitioner before
sending the worker written notification by certified and regular mail, with a
copy sent to the worker's attorney if the worker is represented, informing the
worker of the following:
(A) The worker's
responsibility to seek medical treatment in a timely manner;
(B) The consequences for failing to seek
treatment in a timely manner which include, but are not limited to, claim
closure and possible loss or reduction of a disability award; and
(C) The claim will be closed unless the
worker establishes within 14 days from the date the letter was sent certified
mail that:
(i) Treatment has resumed by
attending an existing appointment or scheduling a new appointment; or
(ii) The reasons for not treating were
outside the worker's control.
(b) Wait the 14-day period given in the
notification letter to allow the worker to provide evidence that the lack of
treatment was either authorized by the attending physician or authorized nurse
practitioner or beyond the worker's control.
(c) Determine whether claim closure is
appropriate based on the information received.
(d) Rate all permanent disability apparent in
the record at the time of claim closure. This includes, but is not limited to,
any irreversible findings.
(e) Use
30 days from the last treatment provided or any additional time period
authorized by the attending physician or authorized nurse practitioner as the
date the claim qualifies for closure on the Notice of Closure.
(2) Regardless of whether the
worker is medically stationary, the insurer must close a claim when a worker
has not sought treatment for more than 30 days with a health care provider
authorized under ORS 656.005 and ORS
656.245 (e.g., a worker enrolled
in a managed care organization (MCO) who treats with a physician outside the
MCO is not treating with an authorized health care provider). To close a claim
under this section, the insurer must follow the requirements in section (1) of
this rule and inform the worker that the reason for the impending closure is
because the worker failed to treat with an authorized health care
provider.
(3) A claim must be
closed, regardless of whether the worker is medically stationary, when the
worker fails to attend a mandatory closing examination for reasons within the
worker's control. To close a claim under this section, the insurer must:
(a) Inform the worker in writing sent by
certified and regular mail, with a copy sent to the worker's attorney if the
worker is represented, at least 10 days prior to the mandatory closing
examination of:
(A) The date, time, and place
of the examination;
(B) The
worker's responsibility to attend the examination;
(C) The consequences for failing to attend,
which include, but are not limited to, claim closure and the possible loss or
reduction of a disability award; and
(D) The worker's responsibility to provide,
within seven days from the date of the scheduled examination, information to
the insurer regarding why the examination was not attended, if the reason was
beyond the worker's control.
(b) Wait seven days from the date of the
missed examination to allow the worker to demonstrate good cause for failing to
attend before closing the claim.
(c) Rate all permanent disability apparent in
the record at the time of claim closure. This includes, but is not limited, to
any irreversible findings.
(d) Use
the date of the failed mandatory closing examination as the date the claim
qualifies for closure on the Notice of Closure.
(4) The insurer may close the claim under
section (1) of this rule, regardless of whether the worker is medically
stationary, when a closing examination has been scheduled between a worker and
attending physician directly and the worker fails to attend the
examination.
(5) A claim may be
closed when the worker's otherwise compensable injury is not medically
stationary and a major contributing cause denial has been issued on an accepted
combined condition.
(a) The major contributing
cause denial must inform the worker that claim closure may result from the
issuance of the denial and provide all other information required by these
rules.
(b) When a major
contributing cause denial has been issued following the acceptance of a
combined condition, the date the claim qualifies for closure is the date the
insurer receives sufficient information to determine the extent of any
permanent disability under OAR
436-030-0020(2)
or the date of the denial, whichever is later.
(6) When two or more of the above events
occur concurrently, the earliest date the claim qualifies for closure is used
to close the claim.
(7) The
attending physician or authorized nurse practitioner, if the worker has one,
must be copied on all notification and denial letters applicable to this
rule.
(8) When the director has
issued a suspension order under OAR
436-060-0095 or OAR
436-060-0105, the date the claim
qualifies for closure is the date of the suspension order.
Notes
Statutory/Other Authority: ORS 656.262, ORS 656.268 & 656.726
Statutes/Other Implemented: ORS 656.268 & 656.726
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