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    Jim Van Ness   
503-947-7753   


Appellate Review Unit

 
Appellate Review Specialists

Purpose

Provide an administrative review process for parties who disagree with a claim closure completed by the self-insured employer or an insurer.

 

Responsibilities

Reconsideration orders: Affirm or change claim closures under dispute for:
  • Improper/premature closure: Rescind closures if the worker is not medically stationary, if there is insufficient information to determine permanent disability or the criteria for statutory closure is not met.
  • Temporary disability: Resolve disagreements regarding appropriateness of temporary disability granted in relation to authorized releases from work.
  • Permanent disability: Resolve disagreements about permanent disability ratings resulting from disputed impairment findings or unclear or incomplete medical or vocational information.
Temporary standards: Issue temporary standards specific to individual claims when the permanent impairment is not addressed by the rating standards.

Claim settlements: Approve and sign Stipulated Agreements during the reconsideration process to resolve issues.

Medical arbiter referral: Ensure an impartial medical examination or review is performed to settle disagreements by the parties regarding impairment findings.
 

Functions

When a worker or worker representative requests a reconsideration of the claim closure, the appellate review specialist reviews the claim file and all information the involved parties submitted. The specialists will request additional information if necessary, clarify issues, research case law and medical and vocational rules, and develop the record. If necessary, they will consult with all parties either by phone or in writing. When there is a disagreement with impairment findings or the medical record is incomplete, they will refer the worker for a medical arbiter examination, directing the arbiter to answer specific questions regarding the medical findings in order for the specialist to rate the compensable disability.

After analyzing the information, the review specialist will apply statutes, administrative rules, appropriate case law, and reasoning in order to provide an objective conclusion to the disputed claim closure. The specialist must provide a written analysis and rationale for each decision in the reconsideration order.

If the disability rating standards do not address the worker's disability, the claim is further analyzed and researched to determine the necessity of a temporary standard. The Appellate Review Unit will issue a temporary standard for that specific claim if appropriate.
 

Primary governing rules

OAR 436-010: Medical Services
OAR 436-030: Claims Evaluation, Determination, and Reconsideration
OAR 436-035: Disability Rating Standards
OAR 436-060: Claims Administration
 

 
Appellate Service Team

Purpose

Support the claim closure reconsideration process by scheduling impartial medical examinations to settle disagreements over impairment findings.
 

Responsibilities

Medical arbiter examinations: Schedule examinations for workers as part of the reconsideration process when there is a question about the impairment findings used at the time of the claim closure. When a worker fails to attend a medical arbiter examination, the service team investigates to determine if there was good cause for missing the examination.

Medical arbiter recruitment: Recruit physicians to participate in the medical arbiter process.
 

Functions

The Appellate Service Team coordinates and schedules medical arbiter examinations and resolves related medical billing problems. They investigate and document workers who fail to show for medical arbiter examinations to determine if there was good cause for missing the appointment or if there is justification for suspension of benefits. When medical arbiter reports are received the service team reviews for completeness and compliance with administrative rules. They communicate by letter and phone with workers, insurers, legal representatives, and medical offices. They develop and update the resource manual and other related brochures sent to parties involved in the medical arbiter process. They also recruit physicians to serve as medical arbiters.
 

Primary governing rules

OAR 436-009: Oregon Medical Fee and Relative Value Schedule
OAR 436-030: Claims Evaluation, Determination, and Reconsideration
OAR 436-010: Medical Services
 
For more information contact:
Resolution Section: 503-947-7816
FAX: 503-947-7794

If you have questions about this webpage, please contact Jim Van Ness, 503-947-7753.