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All Contested Case Subject
MCO Issues
In General
Where new evidence develops in a treatment dispute between the administrative review and the hearing the AlJ does not have authority to take new evidence or to remand to the WCD RT, so the only remedy is to remand to the MCO for additional fact finding and review. Widmaier, Reiner K.,
16 CCHR 409 (2011).
It was error under OAR 436-015-0008 for the ALJ to approve a treatment plan that had not been presented to, reviewed by, or approved or disapproved by, the MCO. Kirkpatrick, Daren S.,
16 CCHR 219 (2011).
Payments that an insurer makes voluntarily that it is not required to make are not "compensation benefits." Carpenter, Curt G.,
16 CCHR 217 (2011).
Where medical services have been denied on the grounds they are not directed towards an accepted condition, the dispute concerns causation and the Workers' Compensation Division does not have jurisdiction over the dispute as one concerning an MCO. Daugherty, Tammy L.*,
15 CCHR 286 (2010).
Insurer not responsible for medical services where there is no evidence the provider was a member of the MCO in which claimant was enrolled. Texeria, Bill E.,
15 CCHR 138 (2010).
Insurer not required to reimburse provider for disputed services on the basis that insurer did not notify provider that claimant was enrolled in an MCO, because insurer's enrollment notice complied with the rules and it was incumbent on claimant to notify provider that he was subject to MCO rules. Texeria, Bill E.,
15 CCHR 138 (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).
Doctor entitled to payment for emergency surgery performed because he complied with the contract by requesting certification, when the MCO contract required the doctor to seek retrospective certification for surgery performed. Davis, Charles M.,
14 CCHR 180 (2009).
RT made an error of law when it found that a contract term required something more than the submission of a request for certification. Davis, Charles M.,
14 CCHR 180 (2009).
The insurer is liable for services provided by a non-MCO provider because the services were directed at conditions which were unclaimed, then denied, and then ultimately accepted. Ellis, Sandra D.,
14 CCHR 126 (2009).
No evidence existed that the doctor violated any relevant portions of the MCO contract involving retrocertification for an emergency surgery because, in the absence of a copy of the actual contract, the relevant portions of the administrative manual do not contain language specifically addressing the situation posed by this controversy, and ambiguities in an MCO contract's content are generally resolved against the drafter. Davis, Charles M.*,
14 CCHR 116 (2009).
Insurer is not liable for the work-hardening program because claimant began that program at a time when claimant was medically stationary without impairment, claimant was without approval for palliative care, and claimant was not in the workforce. Koser, Joshua,
14 CCHR 89 (2009).
Claimant is not responsible for any charges for the physical therapy provided by the non-MCO provider because no evidence exists that the claimant received the insurer's explanation of benefits. Arevallo-Orozco, Damian,
14 CCHR 73 (2009).
Insurer should not be liable for any of the charges for physical therapy provided by the non-MCO provider because substantial evidence supports the RT's and the ALJ's conclusions of no liability. Arevallo-Orozco, Damian,
14 CCHR 73 (2009).
A medical services dispute is not ripe for WCD adjudication because OAR 436-009-0010 requires that medical providers submit bills on the HCFA form accompanied by chart notes in order to receive payment, and the self-insured employer has not yet received that documentation. Wofford, Shannon,
13 CCHR 505 (2008).
The MRU did not err in concluding that the insurer was not liable for the physical therapy because the worker continued to receive the physical therapy from the unauthorized provider, even though the worker's nurse practitioner, an MCO provider, had referred the worker to the unauthorized MCO provider. Arevallo-Orozco, Damian*,
13 CCHR 92 (2008).
A worker may be liable for medical services when the worker is notified that he is enrolled in an MCO and continues to receive services from a non-MCO provider. Arevallo-Orozco, Damian*,
13 CCHR 92 (2008).
The statute and rules require insurers to pay "vendors" and "providers" of medical services, not third parties which do not fit the definition of "medical provider" or "medical service provider." Yekel, Stuart C,
12 CCHR 319 (2007).
If when the doctor's services were provided the evidence shows that he was not on the MCO panel, insurer does not have an obligation to pay for services and it does not matter that the doctor is currently on the MCO panel. Yekel, Stuart C,
12 CCHR 319 (2007).
When a CDA maintains rights to medical services benefits under ORS 656.245, which requires claimants enrolled in an MCO to obtain medical services from the MCO panel, it is not an error of law for MRU to apply the MCO provisions of ORS 656.245 to claimant's request for benefits. McKay, Dan L,
12 CCHR 296 (2007).
For claims in an MCO, OAR 436-009-0008 requires that an aggrieved party be given 90 days to request review by the director from when the party knows there is a dispute over the provision of medical services. Larson, Tony M,
12 CCHR 250 (2007).
An injured worker is not liable to pay for medical services for an accepted compensable injury, except when a worker seeks treatment outside an MCO contract after being notified of the MCO contract. Orender, Pamela,
12 CCHR 166 (2007).
When an MCO fails to respond to a request for review within 60 days, the MCO's initial decision is deemed affirmed and the parties may proceed as though the MCO issued an order affirming the their initial decision. Orender, Pamela,
12 CCHR 166 (2007).
The fact that the medical provider may not have known of an MCO pre-certification requirement is not a persuasive basis for requiring insurer to pay for anesthesiology services. Jimenez, Tammie D,
12 CCHR 169 (2007).
When claimant is enrolled in an MCO, the insurer is only liable to pay for services received from providers on the MCO provider list. Martinez, Jose L,
12 CCHR 155 (2007).
The fact that a billing service is used for business efficiency should not insulate an insurer from its responsibility to pay for otherwise appropriate treatment when the treatment is provided before notice of insurer's pharmacy network. Yekel, Stuart C*,
12 CCHR 101 (2007).
Workers who are subject to an MCO contract receive medical services by the manner prescribed in the contract. If the contract requires pre-certification of a surgery, the surgery will not be a reimbursable medical service if it was not pre-certified even though the surgery otherwise would be reimbursable. Crippen, William R,
12 CCHR 34 (2007).
Under the terms of an MCO contract, all medical treatment must be provided by an MCO designated physician or on referral from such a physician, and care not ordered by the attending physician will not be reimbursed. Wolfe, Cheryl A,
12 CCHR 28 (2007).
An insurer is not obligated to pay for services before receiving authorization by the injured worker's attending physician or authorized nurse practitioner. Moore, Robert J,
11 CCHR 84 (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).
Claimant residence that is 'more likely than not' 100 miles form the geographic boundaries of the MCO territory can receive reimbursable treatment from non-contract providers. Benthin, Dave W.*,
10 CCHR 35 (2005).
Chiropractic care provided by a non-MCO panel member and an MCO panel member is not reimbursable because it was provided without pre-authorization and without a treatment plan. Mironchenko, Andrey,
8 CCHR 70 (2003).
Claimant was able to receive medical services from outside the MCO after insurer's denial of the aggravation claim. Curtis, Michelle*,
7 CCHR 428 (2002).
A physician that was referred to by the MCO physician was an MCO specialist. Boling, Stephen C.,
7 CCHR 258 (2002).
Claimant's enrollment in an MCO prevented reimbursement from a physician outside the MCO. Gilmore, Dianna L.,
7 CCHR 111 (2002).
Substantial evidence supported the MCO's decision to deny a proposed treatment. Wymer, Franklin,
7 CCHR 99 (2002).
Insurer is liable for surgery performed outside the MCO because claimant's aggravation claim was in denied status during the surgery. Curtis, Michelle*,
7 CCHR 52 (2002).
Claimant is not liable for medical services because the treating physician was an MCO panel member, and claimant did not seek treatment outside the MCO. Yoney, Thomas A.,
7 CCHR 29 (2002).
Burden of Proof
The party seeking review of an Administrative Order concerning actions by an MCO bears the burden of proof. Moss, David T.,
16 CCHR 23 (2011).
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