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All Contested Case Subject
Director’s Administrative Review
In General
An administrative order was not a nullity where the insurer complied with that order after it was issued. Horner, Camron J.,
17 CCHR 13 (2012).
The administrative reviewer applied the proper legal standard to determine whether treatment was compensable under ORS 656.327 when the reviewer found the treatment was reasonable and necessary. Reyes-Flores, Ciro,
16 CCHR 422 (2011).
Where the administrative review fails to address the issue presented to it, this constitutes error. Kirkpatrick, Daren S.,
16 CCHR 219 (2011).
An administrative law judge's order concerning the agency's decision in a claim under the reopened claims reimbursement program is subject to review by the director. Cutshall, Bruce T.,
15 CCHR 266 (2010).
The director did not err in dismissing claimant's request for administrative review without prejudice on the basis the request was premature, where the record did not show that insurer had received proper requests for reimbursement for prescriptions and mileage, or proper bills for massage services. Granville, Alton R.,
15 CCHR 165 (2010).
Dismissal of claimant's request for review of an MCO matter was in error where the division gave claimant's counsel three business days to submit information not required by form 2842, and neither 436-010-0008 nor bulletin 293 provide a 3-day time frame, nor do they mandate dismissal for noncompliance. Brown, Kory L.,
15 CCHR 100 (2010).
In a dispute regarding a proposed medical service where causation is an issue, the appropriate remedy is to defer and transfer the compensability issue to a board ALJ, rather than dismissing claimant's request for review. Vukasin, Dalice L.,
15 CCHR 102 (2010).
WCD not required to include notice of right to request reconsideration or inform parties that requesting hearing may bar admission of new medical evidence in notice of appeal rights on administrative orders. Rice, Jeremy E.,
15 CCHR 89 (2010).
In a medical service dispute, it was improper for the director to dismiss claimant's request for administrative review, where the order reasoned that claimant failed to claim a new or omitted condition, because diagnostic medical services are compensable, even if the condition discovered during the diagnostic service is itself not an accepted condition. Juarez-Vega, Isidra,
15 CCHR 74 (2010).
No error of law found from an order that lacked a statement that reconsideration was available, because no authority was cited. Rice, Jeremy E.*,
15 CCHR 41 (2010).
In medical services disputes, the Department does not abuse its discretion or exceed its authority by unilaterally enforcing its own filing deadlines, absent a statute or rule limiting the Department's authority to enforce filling deadlines. Bergmanis, Nichele*,
14 CCHR 162 (2009).
Claimant's request for review was timely even though it was past the 90 day limit, because the record does not establish that the insurer provided claimant with notice that an "aggrieved party" must request review within 90 days of the date the party knew or should have known there was a dispute of the provision of medical services. Ellis, Sandra D.,
14 CCHR 126 (2009).
Although OAR 436-009-0008 does not define "aggrieved party" it is apparent from the rule that the term refers to the one who initiated the review process. Ellis, Sandra D.,
14 CCHR 126 (2009).
WCD's dismissal is affirmed because claimant's previous request for director review of insurer's refusal to pay for a prescription medication was premature because at the time that claimant had requested the review, the insurer had not yet accepted the claim. Champion, Ranee,
14 CCHR 106 (2009).
The 'law of the case' doctrine does not apply between different sections within WCD as none are superior to the others. Faircloth, Amber,
14 CCHR 44 (2009).
The 'law of the case' doctrine does not apply in this vocational assistance matter because the facts are different in this proceeding than they were in the previous disability matter. Faircloth, Amber,
14 CCHR 44 (2009).
All issues raised have been resolved and there is nothing for the director to review when an ALJ determines the disputed medical services are not due to the accepted claim. Tran, Tin T,
12 CCHR 238 (2007).
The director has not abused its discretion by failing to address a discrimination issue because that issue is not within the purview of workers' compensation law. Reyes-Joya, Jose*,
12 CCHR 231 (2007).
A request for review is premature when the time period provided in the rules for an insurer to respond has not expired. Myers, Terry,
12 CCHR 193 (2007).
To be sufficient for review, a director's Review and Order must show what the director found as fact and why the director believed its findings led to the conclusion it reached. Chick, Richard D,
11 CCHR 280 (2006).
A director's order is insufficient when it does not consider whether a diagnostic service was reimbursable, did not determine whether a diagnostic service is reimbursable when performed at a later date, and did not determine if the employer was estopped from denying payment because of the language of the partial denial. Chick, Richard D,
11 CCHR 280 (2006).
MRU is not required to give notice when the factual and legal issues considered for review are implicit in the medical record. Dalhaug, Shanda M,
11 CCHR 60 (2006).
The case was remanded to WCD to assess the question of responsibility between two insurers. Dugger, Larry,
9 CCHR 304 (2004).
An issue prematurely raised cannot be reviewed by the director. Turner, Ray C.,
9 CCHR 267 (2004).
Based on the insurer's conduct, MRU should have waived an application of the rule requiring that a copy of the treatment plan is signed by the attending physician and is provided to insurer within 30 days from the beginning of treatment. Glenn, Julie A.*,
8 CCHR 220 (2003).
The action by the Hearing Officer Panel is stayed pending answers from WCD regarding issues in the case. Watts, Eric,
7 CCHR 425 (2002).
The law of the case doctrine does not bind RRU to the findings of ARU. The director has authority to reconsider or withdraw any order that is not final. Vandervort, Kurt E.,
7 CCHR 41 (2002).
Procedure
WCD erred in dismissing a worker's dispute as untimely where the worker had timely requested review of an MCO treatment issue and that issue had never been withdrawn, resolved, or dismissed when the matter was transferred to the WCB to resolve causal relation issues. Steinbach, Diana M.,
16 CCHR 356 (2011).
Under OAR 436-009-0008(2), a claimant must have notice or reasons to believe that bills have not been paid before the time to request review of a fee payment dispute begins running.Under OAR 436-009-0008(2), a claimant must have notice or reasons to believe that bills have not been paid before the time to request review of a fee payment dispute begins running.Under OAR 436-009-0008(2), a claimant must have notice or reasons to believe that bills have not been paid before the time to request review of a fee payment dispute begins running. Phillips, Roger W.,
16 CCHR 317 (2011).
A claimant did not have notice sufficient that he should have known there was a dispute about the nonpayment of medical bills where neither the insurer nor the provider informed the claimant payment had been denied. Phillips, Roger W.,
16 CCHR 317 (2011).
A claimant did not have reason to know there were unpaid medical bills when he executed a DCS settling the claim that stated there were no unpaid medical bills even though his private insurer had incorrectly paid the disputed bills. Phillips, Roger W.,
16 CCHR 317 (2011).
Under OAR 436-009-0008, an insurer should provide notice to a claimant and their attorney if the insurer denies payment of a medical bill before the time to request administrative review begins running. Phillips, Roger W.,
16 CCHR 317 (2011).
It was proper for the WCD to dismiss a dispute brought by a medical provider where the dispute concerned the compensability of medical services. Wilkins, Lloyd R.,
16 CCHR 296 (2011).
The division should not have dismissed as previously decided a dispute about whether a provider could demand payment from a worker when the division's previous order was only advisory on that question as no actual dispute on this question had existed when the previous administrative order was issued. Gonzalez, Juvenal,
16 CCHR 278 (2011).
An administrative review that renders an opinion or a decision on an issue that is not yet actually the subject of a genuine dispute is only advisory because there is no jusiticable controversy and the first order is not binding on that issue. Gonzalez, Juvenal,
16 CCHR 278 (2011).
An administrative order issued in a medical dispute that found a worker might be liable for medical fees under OAR 436-009-0015(1)(c) was a non-binding advisory opinion because the provider had not yet asked for payment from the worker and there was no justiciable controversy. Gonzalez, Juvenal,
16 CCHR 278 (2011).
Under OAR 436-009-0008(2) and 436-010-0008(5), a worker must request administrative review of a medical services dispute within 90 days of when the worker knew, or should have known, or if represented by counsel, when counsel recieves written notice or has actual knowledge, that there is a dispute. Weitzman, David,
16 CCHR 257 (2011).
A party or their attorney does not know, or have reason to know, there is a medical services payment dispute until the insurer communicates that the insurer is refusing to pay a medical services bill. Weitzman, David,
16 CCHR 257 (2011).
Submission of a demand for payment alone does not establish a party knows, or should know, or has actual knowledge, that there is a medical services payment dispute. Weitzman, David,
16 CCHR 257 (2011).
Claimant was entitled to director review without first using MCO review process where the insurer's actions deprived claimant of access to the MCO review process. Keith, Brian K.,
15 CCHR 241 (2010).
Request for review was not untimly under 90 day limit of OAR 436-0010-0008(5)(b) where insurer did not provide written notice to claimant of the time limit and claimant's attorney's assertion claimant would pursue reimbursement under ORS 656.247 was not an acknowledgement of actual knowledge there was a dispute. Weitzman, David*,
15 CCHR 295 (2010).
Request for review was not untimly under 90 day limit of OAR 436-0010-0008(5)(b) where insurer did not provide written notice to claimant of the time limit and claimant's attorney's assertion claimant would pursue reimbursement under ORS 656.247 was not an acknowledgement of actual knowledge there was a dispute. Weitzman, David*,
15 CCHR 227 (2010).
Dismissal of the claimant's request for administrative review on the grounds it was untimely was error because the insurer did not provide written notice of the denial and there was not substantial evidence supporting RT's conclusion the claimant had actual knowledge of the denial. Lucas, Harry W.,
15 CCHR 221 (2010).
The director's authority in OAR 436-045-0003 to waive procedural requirements is not otherwise delegated and is permissive; the director's exercise of discretion to not waive requirements is not reviewable. Cutshall, Bruce T.*,
15 CCHR 190 (2010).
A request for administrative review was timely, following the insurer's denial of a request for authorization of palliative care, because the denial of palliative care was challenged within 90 days, per OAR 436-010-0290(1)(d), and the denial could still be appealed even though it was issued beyond the 120 day period of OAR 436-010-0290(1)(c). Bergmanis, Nichele,
14 CCHR 196 (2009).
In an administrative review request for non-payment of palliative medical services, the 90 day filing deadline under OAR 436-010-0290(1)(d) begins only after the insurer issues the written notification of disapproval required under OAR 436-010-0920(b)(1), because an alternative interpretation would conflict OAR 436-0101-0008(5)(b), whose time frame applies only if an aggrieved party is given a written notice of the 90-day filing deadline. Bergmanis, Nichele*,
14 CCHR 162 (2009).
Exceptions to a proposed and final order do not have to take any particular form or have specific content. Stevens, Bradford D,
13 CCHR 1 (2008).
The director is statutorily authorized to administer and enforce ORS 656.245(1) on a case-by-case basis in the contested case process, therefore the director may choose to interpret legislative policy already expressed in the statute in a contested case adjudication without first promulgating a rule for every potential application. Foster, Agnes K,
12 CCHR 115 (2007).
WCD may initiate director review of a proposed and final order by filing exceptions and parties are given the opportunity to respond. Rojo-Heredia, Hector,
12 CCHR 84 (2007).
To establish the date for timeliness of a request for review, MRU will consider the date postmarked, the date automatically produced by transmitting a fax, or the date a hand-delivered document is date-stamped by WCD. Wynkoop, John,
12 CCHR 37 (2007).
When the aggrieved party is a worker represented by an attorney with written notice of the representation, the 90 day time frame to request administrative review of disputed medical services begins when the attorney receives written notice or has actual knowledge of the dispute. Schmidt, Jurgen K,
11 CCHR 247 (2006).
The "aggrieved" party in OAR 436-009-0008(2)(b) is not defined, therefore the ALJ evaluated the time frame from the perspective of the medical provider and the claimant, but neither met the 90 day requirement. Schmidt, Jurgen K,
11 CCHR 247 (2006).
At the time there were no timeframes in OAR 436-009-0008(2) controlling claimant's request for review of claims enrolled in an MCO but not involving an action or decision by the MCO. Bowling, Lance L,
11 CCHR 79 (2006).
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