| Medical
disputes
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Medical Resolution Team |
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Purpose:
Resolve medical disputes between injured workers and insurers, medical providers
or managed care organizations in a fair, just and timely manner.
Resolve
disputes for:
Medical services: provided to the worker
(Bulletin 293, Form 440-2842)
Medical fee: reduction or non-payment
(Bulletin 293, Form 440-2842, 440-2842a)
Medical treatment: determines if the
treatment is excessive, inappropriate, ineffectual or in
violation of the worker's 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)
Functions:
The medical reviewers of the Resolution Team (RT) identify and investigate
complex issues in response to disputes regarding medical services for injured
workers. RT 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 then collects an all inclusive medical and legal
record sufficient for judicial review. Finally, RT 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), and then if a party is still not satisfied, they can appeal
the WCB Order to the Oregon Court of Appeals. Also conducts medical and
legal research relevant to the disputed issues.
In reviewing a medical treatment issue, RT may schedule an impartial physician's
examination and record review. The consultation report becomes part of the
record and final decision.
Primary governing rules:
OAR 436-009: The Oregon Medical Fee
OAR 436-010: Medical Services Rules
ORS 656.245, .247, .248, .260, .327, .704, .726
Contact
the medical section:
Phone: 503-947-7816 - select option
2 and ask for the Medical Reviewer of the day
Fax: 503-947-7612
E-mail: wcd.medicalquestions@state.or.us
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