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The Oregon Administrative Rules contain OARs filed through July 15, 2014
 
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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,
WORKERS' COMPENSATION DIVISION

 

GENERAL PROVISIONS

Electronic Data Interchange; Medical Bill Data

436-160-0001

Authority, Applicability, Purpose, and Administration of these Rules

(1) These rules are promulgated under the director's authority contained in ORS 656.726(4).

(2) These rules apply to workers’ compensation related transactions filed with the director by electronic data interchange (EDI) on or after Oct. 1, 2014.

(3) The purpose of these rules is to require workers’ compensation medical bill data reporting by electronic data interchange.

(4) Orders issued by the division in carrying out the director's authority to enforce ORS chapter 656 are considered orders of the director.

(5) The director may waive procedural rules as justice requires, unless otherwise obligated by statute.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS Ch. 84 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

Electronic Data Interchange

436-160-0004

Adoption of Standards

(1)(a) The director adopts, by reference, IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb 1, 2014.

(b) The director adopts, by reference, the ASC X12 Implementation Acknowledgment for Health Care Insurance (999), dated February 2011.

(2) The form, format, and delivery of data elements reported and definitions will conform to the standards adopted under section (1), unless otherwise provided in these rules.

(3) Copies of the guides in section (1) are available for review during regular business hours at the Workers’ Compensation Division, Operations Section, 350 Winter Street NE, Salem OR 97301, 503-947-7717.

(a) IAIABC members may view a copy of the Release 2.0 guide, or non-members may purchase a copy at the IAIABC website: http://www.iaiabc.org.

(b) The ASC X12 999 guide is available for purchase at the X12 online store: http://store.x12.org/store/healthcare-5010-consolidated-guides.

Stat. Auth.: ORS 656.264
Stats. Implemented: ORS 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0005

General Definitions

For the purpose of these rules, unless it conflicts with statute or rule:

(1) “ANSI” means the American National Standards Institute.

(2) "Conditional data element" means an element that becomes mandatory under certain conditions. Once mandatory, a conditional data element will cause a rejection of the transaction if the data element is omitted or submitted in a format not capable of being processed by the division’s information processing system.

(3) "Director" means the Director of the Department of Consumer and Business Services or the director's designee for the matter.

(4) "Division" means the Workers' Compensation Division of the Department of Consumer and Business Services.

(5) "Electronic Data Interchange" or "EDI" means a computer to computer exchange of information in a standardized electronic format.

(6) "Electronic Record" means information created, generated, sent, communicated, received, or stored by electronic means.

(7) "FEIN" means the federal employer identification number or other federal reporting number used by the insurer, insured, or employer for federal tax reporting purposes.

(8) "Header record" means the record that precedes each transmission for the purpose of identifying a sender, the date and time of the transmission, and the transaction set within the transmission.

(9) "IAIABC" means the International Association of Industrial Accident Boards and Commissions, a professional trade association comprised of state workers' compensation regulators and insurance representatives (www.iaiabc.org).

(10) "Information" means data, text, images, sounds, codes, computer programs, software, databases, or the like.

(11) "Insurer" means the State Accident Insurance Fund Corporation, an insurer authorized under ORS Chapter 731 to transact workers' compensation insurance in Oregon, or a self-insured employer.

(12) "Mandatory data element" means an element that will cause a rejection of a transaction if the data element is omitted or submitted in a format not capable of being processed by the division's information processing system.

(13) "Optional data element" means an element that an insurer should report to the director if the information is available to the insurer. Optional data elements will not cause a rejection if missing or invalid.

(14) "Record" means electronic record.

(15) “Reprocessed transaction” means a rejected transaction that, at the discretion of the director, has been reprocessed and accepted by the division.

(16) "Sender" means the person or entity reporting electronic data interchange transactions to the division. Sender may include vendors or insurers.

(17) "Trading partner agreement" means the agreement entered into under OAR 436-160-0020 between the director and an insurer to conduct transactions via EDI.

(18) "Trailer record" means the record that designates the end of a transmission and provides a count of transactions contained within the transmission, not including the header and trailer records.

(19) "Transaction" means a set of EDI records, defined according to standards in OAR 436-160-0004.

(20) "Transmission" means a defined set of transactions, including both header and trailer records to be sent to the division or sender via EDI.

(21) "Vendor" means an agent identified by the insurer to submit transmissions to the division on behalf of an insurer. Vendors may include service companies, third party administrators, and managing general agents.

Stat. Auth.: ORS 656.264, 656.726(4)
Stats. Implemented: ORS 84.004 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0011

Purpose (formerly 436-160-0002)

The director’s purpose is to require workers’ compensation medical data reporting via electronic data interchange.

Stat. Authority: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0012

Applicability of Rules (formerly 436-160-0003)

(1) These rules apply to workers’ compensation related transactions filed with the director via electronic data interchange on or after the effective date of these rules.

(2) The director may, unless otherwise obligated by statute, waive any procedural rules in this rule division as justice so requires.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.726(4)
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0013

Administration of Rules (formerly 436-160-0006)

Orders issued by the division in carrying out the director's authority to enforce ORS Chapter 656 are considered orders of the director.

Stat. Auth.: ORS 656.704 & 656.726(4);
Stats. Implemented: ORS 656.704 & 656.726(4)
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0014

Security (formerly 436-160-0010)

(1) The sender will verify that an electronic signature, record, or performance is that of a specific person.

(2) The sender will utilize anti-virus software to eliminate any viruses on all electronic transmissions. The sender will maintain the anti-virus software with the most recent anti-virus update files from the software provider. The sender will notify the director immediately if a virus is detected.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0015

Trading Partner Agreement (formerly 436-160-0020)

(1) If the director so requires, an insurer must enter into a trading partner agreement with the director before the division will begin testing with or accept production electronic transmissions from the insurer or from a vendor on behalf of that insurer.

(2) The trading partner agreement will include:

(a) A statement that the insurer will remain responsible and liable for all electronic records transmitted to the director;

(b) Transmission protocol between sender and director;

(c) A specific description of the form, format, and delivery of electronic transmissions under OAR 436-160-0004 and 436-160-0050;

(d) Specific identifying information for insurer, third party administrator, if any, and vendor, if any;

(e) Cost allocation of transactions, if any;

(f) The time frame for the director to submit acknowledgements of transmissions; and

(g) Any other necessary statements, conditions, or requirements to facilitate EDI.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 84.013 & 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0016

Retention of Electronic Records (formerly 436-160-0030)

Insurers and self-insured employers must retain workers' compensation records under OAR 436-050-0120, 436-050-0220, and 436-009-0030. Records may be retained in electronic format if the records can be reproduced.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.455 & 731.475
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0017

Form, Format, and Delivery for Electronic Data Reporting (formerly 436-160-0050)

The form, format, and delivery of data elements and definitions will conform to the standards specified in OAR 436-160-0004, or as otherwise identified in the trading partner agreement.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 84.013 & 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0018

Electronic signature (formerly 436-160-0070)

The sender’s federal employer identification number (FEIN) plus its postal code as reported in the header record and stated in the trading partner agreement, if such an agreement is required, is the unique identifier that is the electronic signature for electronic data interchange.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 84.001-84.061 & 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0019

Address Reporting (formerly 436-160-0090)

The sender will follow the standard United States Postal Service guidelines in reporting all addresses.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0040

Recognized Filing Date

(1) Unless otherwise stated in the trading partner agreement, an electronic record is sent when it:

(a) Is addressed or directed properly to an information processing system designated or used by the division to receive electronic records or information;

(b) Is in a form and format capable of being processed by that system; and

(c) Enters an information processing system outside the control of the sender or enters a region of the information processing system designated or used by the division and that is under control of the division.

(2) Unless otherwise stated in the trading partner agreement an electronic record is received when it:

(a) Enters an information processing system designated or used by the division to receive electronic records or information of the type sent and from which the division is able to retrieve the electronic record; and

(b) Is in a form and format capable of being processed by the division's information processing system.

(3) For the purpose of these rules, an electronic transaction is capable of being processed by the division's information processing system when all the required data elements are in the form and format specified in these rules, in the proper sequence, and in accordance with the terms of the trading partner agreement.

(4) A reprocessed transaction retains the filing date of the original transaction.

Stat. Auth.: ORS 656.264 & 656.726(4)
Stats. Implemented: ORS 84.043 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0060

Testing Procedures and Requirements

Testing and transition to production:

(1) To initiate a test for EDI, the sender must contact the director.

(2) Each transmission for test purposes must conform to the standards specified in OAR 436-160-0004, or as otherwise identified in the trading partner agreement. Test files will be evaluated in terms of whether the data was sent in the correct, standardized format.

(3) To be approved to send production transmissions, the sender must:

(a) Transmit records via EDI; and

(b) Accomplish secure file transfer protocol (SFTP) uploads and downloads.

(4) The sender must demonstrate the ability to send transmissions to the director that are readable, in the correct format, and can be processed through the division's information processing system. An EDI FTP test is successful if the sender is able to resolve any consistently recurring fatal technical errors identified by the division so that:

(a) Transmissions are sent to the director without structural errors;

(b) Transmissions are sent to the director without transaction level technical errors; and

(c) The sender can receive and process the automated EDI acknowledgement transactions.

(5) To move from test to production, 80 percent of the sender’s transactions must have been accepted by the division by the end of the testing period, including corrected and resubmitted transactions. The director will consider the sender's anticipated volume of production transactions to determine the number of transactions per test transmission required.

(6) Test periods will last a maximum of 120 days. Test periods begin the day the division processes the sender’s first test file. If the sender has not met the minimum requirements to move from test to production within 120 days of the start of testing, the sender may request a testing extension period of 60 days.

(7) Senders that fail to successfully transition from test into production within 180 days must wait an additional 180 days before requesting a new test period of 120 days.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 84.013 & 656.264
Hist.: WCD 3-2003, f. 3-18-03, cert. ef. 4-1-03; WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

Insurers’ Obligation to Report Medical Bill Data

436-160-0405

Insurers’ Reporting Responsibilities

(1) Insurers with an average of at least 100 accepted disabling claims per year are required to electronically submit detailed medical bill payment data to the Department of Consumer and Business Services under OAR 436-160-0415. The number of accepted disabling claims is determined by the director based on an average accepted disabling claim volume for the previous three calendar years.

(2) Once the director has determined that an insurer’s average accepted disabling claim count is 100 or higher the insurer must report medical bill payment data in subsequent years. If the insurer’s claim count drops below an average of 50 accepted disabling claims, the insurer may apply to the director for exemption from the reporting requirement.

(3) The director will publish the list of insurers required to report medical bill data in Bulletin 359.

(4) Insurers that were required to report medical bill payment data under OAR 436-009-0030(12) before Jan. 1, 2011, must successfully complete EDI testing and begin reporting production data before Jan. 1, 2011.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0410

Electronic Medical Bill Data Transmission and Format Requirements

(1) The transmission data and format requirements are included in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0 (Feb 1, 2014), and Appendices A and B of these rules. Oregon-specific information can be found on the division’s Electronic Data EDI webpage: http://www.cbs.state.or.us/wcd/operations/edi/ediindex.html.

(2) Data elements are listed in Appendices A and B:

(a) Appendix A shows all medical bill data elements accepted by EDI in Oregon, and whether the data element is “Fatal Technical” (F), “Mandatory” (M), “Mandatory Conditional” (MC), “If Applicable/Available with Item Reject if Invalid” (AR), or “If Applicable/Available with Item Accept if Invalid” (AA) for each transaction type.

(b) Appendix B lists mandatory conditional data elements that are mandatory under specific conditions.

(3) Unless otherwise provided in these rules, the data elements must have the meaning provided in the IAIABC EDI Implementation Guide for Medical Bill Payment Records, Release 2.0, dated Feb. 1, 2014, Section 2; Health Care Claim (837).

(4) Transactions will be rejected if “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements are omitted, or include invalid values.

(5) Transactions will be rejected if “If Applicable/Available with Item Reject if Invalid” data elements include invalid values.

(6) Invalid “If Applicable/Available with Item Accept if Invalid” data elements will be ignored if they are included in a transaction.

[ED. NOTE: Appendices referenced are not included in rule text. Click here for PDF copy of appendicies.]

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 4-2008, f. 9-17-08, cert. ef. 7-1-09; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 1-2014, f. 2-14-14, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0415

Oregon ASC X12 837 Medical Bill Data Reporting Requirements

(1) Event reporting requirements:

(a) Medical bills, including interpreter bills under OAR 436-009, must be reported within 60 days of the date paid.

(b) Denied medical bills for accepted claims must be reported within 60 days of date of denial. Denied bills are defined as any bills in which there is a non-zero charge and a zero payment.

(c) Transactions must be received and accepted by the division within 60 days of either the date paid or the date denied to be considered timely reported. If a transaction is initially rejected it must be corrected, resubmitted, and accepted within the original 60 day time period to be considered timely reported.

(d) Cancellations must be reported as soon as the payer knows that a medical bill was sent in error.

(e) Corrections/Replacements must be reported within 60 days of changes to any of the “Fatal Technical,” “Mandatory,” or “Mandatory Conditional” data elements in Appendices A and B.

(f) Bills received by the insurer before Oct. 1, 2014, may be reported to the Division using the IAIABC reporting standard version 1.1.

(2) Data reporting requirements are described in Appendices A and B.

(3) Technical requirements are described on the division’s Electronic Data EDI webpage for specifications on the Secure File Transfer Protocol (SFTP) requirements.

(4) Data Quality: The director will conduct electronic edits for blank or invalid data. Affected insurers are responsible for pre-screening the data they submit to check that all the required information is reported and is formatted correctly. OAR 436-160-0420 describes the acceptance or rejection protocol for all reported medical bills. The insurer is responsible for timely correcting and resubmitting all rejected transactions for which law or rule require filing, reporting, or notice to the director.

(5) An insurer must request and receive authorization from the director to stop submitting a previously rejected transaction when the division determines the transaction is uncorrectable.

(6) The director will periodically review reported bill data to monitor insurer performance. If the director finds repeated or egregious violations of the reporting requirements of these rules the director may issue civil penalties under OAR 436-160-0445 and ORS 656.745.

(a) Medical bills must be reported timely. “Timely” means that an insurer reports medical bills as required by OAR 436-160-0415(1).

(b) Medical bills must be reported accurately. “Accurately” means that the reported medical bill data accepted by the division conforms to the reporting requirements of the Appendices A and B.

(c) The insurer may be subject to penalties for any reported medical bills that have not been accepted by the division or designated as uncorrectable under OAR 436-160-0415(5) within 180 days of the date of bill payment or denial.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0420

Medical Bill Acknowledgement

(1)(a) The sender is expected to retrieve both TA1 and 999 interchange and functional acknowledgements (as defined by ASC X12) for each medical bill file submitted, unless technical errors in the file prevent 999 processing. In addition, the sender is expected to retrieve the 824 detailed acknowledgement, as defined by IAIABC Release 2.0 (Feb.1, 2014) for each medical bill file submitted, if at least one transaction has successfully passed the 999 edits.

(b) The detailed acknowledgement will indicate either an item accepted (IA) or an item rejected (IR) acknowledgement for each individual transaction.

(2) A TA1, 999 or 824 acknowledgement will be available for all transactions the division is unable to process, including but not limited to:

(a) An omitted mandatory data element;

(b) An improperly populated data element field, e.g., numeric data element field is populated with alpha or alphanumeric data, or is not a valid value according to the standards adopted in 436-160-0004;

(c) Transactions or electronic records within the transaction that require matching, and cannot be matched to the division's database, e.g., cancellation of an original bill that does not match the Unique Bill ID;

(d) Illogical data in mandatory or required conditional field, e.g., payment date is after reporting date;

(e) Duplicate transmission or duplicate transaction within the transmission;

(f) Invalid bill submission reason code; or

(g) Illogical event sequence relationship between transactions, e.g., cancellation transaction submitted before an original bill is accepted.

(3) A transaction accepted acknowledgement will be available for all transactions that are in a format capable of being processed by the division's information processing system and that are not rejected under section (2) of this rule.

(4) An insurer’s obligation to report medical bill data for the purposes of this rule is not satisfied unless the division acknowledges acceptance of the transaction.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 2-2009, f. 10-5-09 cert. ef. 1-1-10; WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; WCD 8-2014, f. 7-10-14, cert. ef. 10-1-14

436-160-0430

Medical Bill Data Changes or Corrections

(1) Changes or corrections to medical bill information must be submitted according to the standards referenced in OAR 436-160-0004.

(2) The Unique Bill ID will be used to match cancellations and replacements to the original bill. Failure to match on this data element will result in a rejected transaction.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.264
Hist.: WCD 10-2007, f. 11-1-07, cert. ef. 1-1-08; WCD 1-2008, f. 6-13-08, cert. ef. 7-1-08; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0440

Monitoring and Auditing Insurers

(1) The department may monitor and conduct periodic audits of medical bill data to ensure compliance with ORS Chapter 656 and these rules.

(2) All records maintained or required to be maintained must be disclosed upon request by the director.

Stat. Auth.: ORS 656.726(4)
Stats. Implemented: ORS 656.252, 656.254, 656.264, 656.455, 656.726
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

436-160-0445

Assessment of Civil Penalties

(1) Under ORS 656.745, the director may assess a civil penalty against an insurer who fails to comply with ORS Chapter 656 or the director’s rules and orders.

(2) The insurer is responsible for its own actions as well as the actions of others acting on the insurer’s behalf. If an insurer or someone acting on the insurer’s behalf violates any provisions of these rules, the director may impose a civil penalty against the insurer.

Stat. Auth. ORS 656.726(4)
Stats. Implemented: ORS 656.254, 656.745
Hist.: WCD 7-2010, f. 10-1-10, cert. ef. 1-1-11; WCD 6-2013, f. 10-10-13, cert. ef. 7-1-14; WCD 5-2014(Temp), f. 6-5-14, cert. ef. 7-1-14 thru 12-27-14; Temporary suspended by WCD 7-2014(Temp), f. 7-10-14, cert. ef. 10-1-14 thru 12-27-14

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