Or. Admin. Code § 436-105-0540 - Employer-at-Injury Program Reimbursement Procedures
The following provisions apply when the insurer requests reimbursement from the division under the Employer-at-Injury Program:
(1)
Reimbursable benefits.
Reimbursements may include wage subsidy, Employer-at-Injury Program purchases,
and worksite modification.
(2)
Program administrative costs. The insurer is entitled to a program
administrative cost of $120 for the first approved reimbursement request for an
Employer-at-Injury Program. Subsequent requests for reimbursement, including
amended requests, for the same Employer-at-Injury Program are not entitled to
additional program administrative costs.
(3)
Minimum reimbursement
request. The first reimbursement request for an Employer-at-Injury
Program must be for a minimum of $100. Subsequent requests, including amended
requests, may be for less than $100.
(4)
Required documentation. The
insurer must have all documentation required for reimbursement in its
possession at the time reimbursement is requested. The insurer must stamp or
display evidence of the initial date of receipt on each document as required
under OAR 436-060-0017(2).
(5)
Timeframe for submitting a
reimbursement request and required documentation.
(a) The employer must submit all required
documentation for reimbursement to the insurer within one year from the end of
the Employer-at-Injury Program.
(b)
The insurer must submit to the division within one year and 30 days from the
end of the Employer-at-Injury Program:
(A)
Form 2360, "Employer-at-Injury Program (EAIP) Reimbursement Request Form." The
form is published with Bulletin 260, both of which are available on the
division's website at wcd.oregon.gov; and
(B) For EAIP purchases and worksite
modifications:
(i) Documentation of the
transitional work that includes the start date, wage and hours, and a
description of the job duties;
(ii)
The corresponding medical release that the transitional work was based
on;
(iii) A legible copy of proof
of any purchase showing the item was ordered during the Employer-at-Injury
Program period and proof of payment for the item; and
(iv) Documentation of the insurer's approval
of any worksite modifications.
(6)
Corrected request forms. If
the reimbursement request form is incomplete or contains an error, the division
may return the form to the insurer for correction. The insurer has 60 days from
the date it receives the returned reimbursement request form from the division,
or one year and 30 days from the end of Employer-at-Injury Program eligibility,
whichever is later, to make the corrections and return the corrected form to
the division.
(7)
Amended
requests.
(a) Amended reimbursement
requests must be submitted to the division within one year and 30 days from the
end of the Employer-at-Injury Program eligibility except as otherwise permitted
in this rule.
(b) An amended
reimbursement request must clearly state that it is an amendment and clearly
state the corrected information.
(8)
Denied claims.
(a) The insurer may request reimbursement
when a claim that was initially denied is subsequently accepted after the
Employer-at-Injury Program eligibility ended and more than one year and 30 days
have passed. In that case, the insurer must submit a completed Form 2360,
"Employer-at-Injury Program (EAIP) Reimbursement Request Form," with the
documentation specified in (5)(b) of this rule to the division within 60 days
of the first litigation order or stipulation and order accepting the claim. A
copy of the order or stipulation must be attached to the reimbursement request
form.
(b) The insurer may request
reimbursement for a qualifying Employer-at-Injury Program that took place
before a claim denial even if the claim is denied at the time the insurer
submits the request to the division.
(9)
Effect on rates, dividends,
premiums, or assessments. The insurer may not use Employer-at-Injury
Program costs subject to reimbursement for rate making, individual employer
rating, dividend calculations, or in any manner that would affect the
employer's insurance premiums or premium assessments under ORS
656.612 and OAR 436-085 with the
present or a future insurer. The insurer must be able to document that
Employer-at-Injury Program costs do not affect the employer's rates or
dividend.
(10)
Claim
costs. If a preferred worker employed by an eligible employer with
active premium exemption under OAR
436-110-0325 incurs a new
injury, the claim is subject to claim costs reimbursement under OAR
436-110-0330. If the worker
subsequently begins an Employer-at-Injury Program, program costs must be
separated from claim costs and will not be reimbursed as claim costs.
Notes
Forms referenced are available from the agency.
Statutory/Other Authority: ORS 656.622 & 656.726(4)
Statutes/Other Implemented: ORS 656.622
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