|
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 rules:
Issue temporary rules 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 disagreement 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 submitted by the
parties involved. 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 rule. The Appellate Review Unit
will issue a temporary rule 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
|
| Supports
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 resolve
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 |
