Or. Admin. Code § 436-015-0070

Current through Register Vol. 63, No. 10, October 1, 2024

Section 436-015-0070 - Come-along Providers

(1) The MCO must authorize a physician, physician associate, or nurse practitioner who is not an MCO panel provider to provide medical services to an enrolled worker if:

(a) The nurse practitioner is an authorized nurse practitioner under ORS 656.245, the chiropractic physician or physician associate has certified to the director that the chiropractic physician or physician associate has reviewed required materials under ORS 656.799, or the physician is a primary care physician under ORS 656.260(4)(g);

(b) The physician, physician associate, or authorized nurse practitioner agrees to comply with MCO treatment standards, protocols, utilization review, peer review, dispute resolution, billing and reporting procedures, and fees for services under OAR 436-015-0090; and

(c) The physician, physician associate, or authorized nurse practitioner agrees to refer the worker to the MCO for specialized care that the worker may require, including physical therapy.

(2) The physician, physician associate, or authorized nurse practitioner who is not an MCO panel provider will be deemed to have maintained the worker's medical records and established a documented history of treatment, if the physician's, physician associate's, or nurse practitioner's medical records show treatment has been provided to the worker prior to the date of injury. Additionally, if a worker has selected a physician, physician associate, or authorized nurse practitioner through a private health plan, prior to the date of injury, that selected provider will be deemed to have maintained the worker's medical records and established a documented history of treatment prior to the date of injury.

(3) The MCO may not limit the length of treatment authority of a come-along provider unless such limits are stated in ORS chapter 656.

(4) Notwithstanding section (1), for those workers receiving their medical services from a facility that maintains a single medical record on the worker, but provides treatment by multiple primary care or chiropractic physicians, physician associates, or authorized nurse practitioners who are not MCO panel providers, the requirements of sections (1) and (2) will be deemed to be met. In this situation, the worker must select one primary care or chiropractic physician, physician associate, or authorized nurse practitioner to treat the compensable injury.

(5) Any questions or disputes relating to the worker's selection of a physician, physician associate, or authorized nurse practitioner who is not an MCO panel provider must be resolved under OAR 436-015-0110.

(6) Any disputes relating to a come-along provider's or other non-MCO provider's compliance with MCO standards and protocols must be resolved under OAR 436-015-0110.

Or. Admin. Code § 436-015-0070

WCD 11-1990(Temp), f. 6-19-90, cert. ef. 7-1-90; WCD 33-1990, f. 12-12-90, cert. ef. 12-26-90; WCD 2-1992, f. 1-10-92, cert. ef. 2-1-92; WCD 14-1994, f. 12-20-94, cert. ef. 2-1-95; WCD 13-1996, f. 5-6-96, cert. ef. 6-1-96; WCD 3-2002, f. 2-25-02 cert. ef. 4-1-02; WCD 14-2003(Temp), f. 12-15-03, cert. ef. 1-1-04 thru 6-28-03; WCD 6-2004, f. 6-14-04, cert. ef. 6-29-04; WCD 8-2005, f. 12-6-05, cert. ef. 1-1-06; WCD 7-2013, f. 11-12-13, cert. ef. 1-1-14; WCD 5-2018, amend filed 03/15/2018, effective 4/1/2018; WCD 4-2022, amend filed 06/13/2022, effective 7/1/2022; WCD 4-2023, amend filed 11/22/2023, effective 1/1/2024; WCD 13-2024, minor correction filed 06/06/2024, effective 6/6/2024

Statutory/Other Authority: ORS 656.726(4) & ORS 656.260

Statutes/Other Implemented: ORS 656.260