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Medical Resolution Team
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Purpose
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Resolve medical disputes
between injured workers and insurers, medical providers, or managed care organizations
in a fair, just, and timely manner.
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Responsibilities
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Resolve disputes for:
Medical
services: Provided to the worker - Bulletin 293 - Form
440-2842
Medical fees: Bill reduction or nonpayment - Bulletin
293 - Forms 440-2842, 440-2842a
Medical treatment: Determine if the treatment is excessive,
inappropriate, ineffectual, or in violation of the workers'
compensation rules - Bulletin 293 - Form 440-2842
Managed care organizations (MCO): When an injured worker
or medical provider disagrees with an MCO decision - Bulletin
293 - Form 440-2842
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Functions
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medical reviewers of the Medical Resolution Team review issues
such as when the provider and the insurer do not agree on payment
for medical services for workers or appropriateness of a surgery.
The team resolves these disputes in a timely manner by alternative
dispute resolution (ADR) processes and education. If the dispute
cannot be resolved through ADR, the reviewer gathers additional
information from the parties and reviews it to make a decision.
In reviewing a medical treatment issue, the team may schedule
an impartial physician's examination and record review. The consultation
report becomes part of the record and final decision. Once the
review is complete, the team issues a legally binding order based
on the Oregon Revised Statutes, Oregon Administrative Rules, and
relevant case law. These orders may be appealed to the Workers'
Compensation Board (WCB). If a party is still not satisfied, it
can appeal the WCB order to the Oregon Court of Appeals. |
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Primary
governing rules
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OAR 436-009: The Oregon
Medical Fee
OAR 436-010: Medical Services Rules
ORS 656.245, .247, .248, .260, .327, .704, .726
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For
more information contact:
Phone:
503-947-7606
FAX: 503-947-7629
E-mail: wcd.medicalquestions@state.or.us
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