Or. Admin. Code § 436-110-0330 - Claim Cost Reimbursement
(1)
General provisions. Claim cost reimbursement provides reimbursement to the
insurer for claim costs when a preferred worker files a claim for injury or
occupational disease while employed under premium exemption as follows:
(a) Reimbursements will be made for the life
of the claim;
(b) Reimbursable
claim costs include disability benefits, medical benefits, vocational costs
under OAR 436-120-0720, claim disposition
agreements under ORS 656.236, disputed claim
settlements under ORS
656.289, stipulations, attorney
fees awarded the worker or the worker's beneficiaries, and administrative
costs;
(c) Reimbursable claim
costs for denied claims include costs incurred up to the date of denial, but
are limited to benefits the insurer is obligated to pay under ORS chapter 656
and diagnostic tests, including independent medical examinations necessary to
determine compensability of the claim;
(d) The administrative cost factor that will
apply to claim costs is published in Bulletin 316; and
(e) The claim may not be used for ratemaking,
individual employer rating, dividend calculations, or in any manner that would
affect the employer's insurance premiums or premium assessments with the
present or a future insurer. The insurer must be able to document that claim
data will not affect the employer's rates or dividend.
(2) Reimbursement request process. The
insurer must request claim cost reimbursement as follows:
(a) A request for reimbursement must be
submitted to the division within 15 months of the date on which payment was
made;
(b) The insurer must use
Form 3014, "Preferred Worker Program Quarterly Cost Reimbursement Request"; and
(c) Reimbursement documentation
must include, but is not limited to:
(A) Net
amounts paid. "Net amounts" means the total compensation paid less any
recoveries, including, but not limited to, third-party recovery or
reimbursement from the Retroactive Program, Reopened Claims Program, or the
fund; and
(B) Any other
information required by the director.
(3) Costs not reimbursable. Requests for
reimbursement may not include:
(a) Claim
costs for any injury that did not occur while the worker was employed with
premium exemption;
(b) Costs
incurred for conditions completely unrelated to the compensable claim;
(c) Costs incurred due to
inaccurate, untimely, unreasonable, or improper processing of the claim;
(d) Penalties, fines, or filing
fees;
(e) Disposition amounts in
accordance with ORS 656.236 or
656.289 not previously approved
by the director;
(f) Costs
reimbursed or outstanding requests for reimbursement from the Reopened Claims
Program, Retroactive Program, or the fund; or
(g) Reimbursable Employer-at-Injury Program
costs.
(4) Audit,
disallowed amounts. Periodically, the director will audit the insurer's file to
validate the amount reimbursed. Reimbursed amounts must be refunded to the
division and, as applicable, future reimbursements will be denied if, upon
audit, any of the following is found to apply:
(a) Reimbursement has been made for any of
the items specified in section (3) of this rule;
(b) If claim acceptance as a new injury
rather than an aggravation is questionable and the rationale for acceptance has
not been reasonably documented;
(c) The separate payments of compensation
have not been documented;
(d) The
insurer included claim costs in any dividend or retrospective rating or
experience rating calculations; or
(e) The insurer is unable to provide
applicable records relating to experience rating, retrospective rating, or
dividend calculations at the time of audit or within 14 working days
thereafter.
(5)
Reinstatement of reimbursement. If the conditions described in subsections
(4)(a) through (e) of this rule are corrected and all other criteria of the
rules are met, eligibility for reimbursement may be reinstated. If
reimbursement eligibility is reinstated, any monies previously reimbursed and
then recovered will be reimbursed again according to these rules.
(6) Reimbursement of settlement amounts. A
claim disposition agreement under ORS
656.236, a disputed claim
settlement under ORS 656.289, or any stipulation or
agreement of a claim subject to claim cost reimbursement from the fund must
meet the following requirements for reimbursement:
(a) The insurer must obtain prior written
approval of the agreement from the director. The proposed agreement must be
submitted to the division before being submitted to the Workers' Compensation
Board or administrative law judge for approval;
(b) A claim's future liability and the
proposed contribution from the fund must be a reasonable projection, as
determined by the director, in order to be approved for reimbursement from the
fund; and
(c) A request for
approval of the proposed agreement must include:
(A) A copy of the proposed agreement,
containing appropriate signatures and a signature line for director approval,
that specifies the proposed assistance from the fund;
(B) A written explanation of how the
calculations for the amount of assistance from the fund were made; and
(C) Other information as required
by the director.
Notes
Forms referenced are available from the agency.
Stat. Auth.: ORS 656.726(4) & 656.622
Stats. Implemented: ORS 656.622
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