MEDICAL BENEFITS PLAN 1
Administrative Rule Adopted by FPD&R Board Pursuant to Rule-Making Authority
5.13.01 – DEFINITIONS
“Attending Physician.” The term “Attending Physician” means:
(A) A medical doctor or doctor of osteopathy licensed under ORS 677.100 to 677.228 by the Board of Medical Examiners for the State of Oregon or a similarly licensed doctor in any country or in any state, territory or possession of the United States, or
(B) For a period of 30 days from the first visit on the initial claim or for 12 visits, whichever first occurs, a doctor or physician licensed by the State Board of Chiropractic Examiners for the State ofOregonor a similarly licensed doctor or physician in any country or in any state, territory, or possession of the United States.
“Claim.” The term “Claim” means a written request to FPDR for a retirement, disability or death benefit and may be filed by an active member, his/her representative or legal beneficiary, or surviving spouse or other legal representative of a deceased member. This term may be used synonymously with the term “application.”
“Compulsory Retirement Age:” The term “Compulsory Retirement Age” means any Member who has reached his or her sixty-fourth (64th) birthday anniversary shall be retired by the Board.
“Director.” The term “Director” where used in these Administrative Rules shall mean the Fund Director and/or Fund Administrator or his or her designee.
"Medically Stationary." The term "Medically Stationary" means that no further material improvement can reasonably be expected from medical treatment or the passage of time.
“Recurrence.” An Aggravation of a service-connected injury/illness or occupational disability that requires claim re-opening for additional disability benefits and/or medical benefits.
“Specialty Physician.” The term “Specialty Physician” means a licensed physician who qualifies as an Attending Physician who provides evaluation, diagnosis or temporary specialized treatment at the request of the Member’s “Attending Physician” on an approved claim.
5.13.02 – MEDICAL SERVICES
(A) Reimbursement for actual, reasonable and necessary expenses, as determined by the Director, incurred by a Member as a result of a service-connected or occupational injury or illness shall be paid as provided below:
(1) Members shall be reimbursed for the actual, reasonable and necessary medical expenses they have incurred. Payment directly to the medical care provider shall be deemed to be reimbursement of the Member.
(2) Actual, reasonable and necessary costs for travel, prescriptions and other necessary expenses paid by the Member will be reimbursed upon request by the Member.
(3) All requests for reimbursement shall be made on forms provided by the Director and accompanied by itemized documentation which supports the request. For example, requests for reimbursement for prescriptions must be accompanied by a receipt from the provider identifying the prescription and its price and requests for mileage reimbursement must be accompanied by a statement reflecting the actual mileage traveled.
(4) Reimbursement for the cost of meals, lodging, public transportation or use of a private vehicle shall be at the rate of reimbursement paid to City employees when incurring such expenses.
(5) Reimbursement for the cost of meals, lodging, or travel exceeding 50 miles will be paid only if such expenses are pre-approved by the Director
(6) Expenses incurred for public transportation or the use of a private automobile will be reimbursed based on the most direct route between the Member's home and the facility where the service is to be performed.
(7) All requests for reimbursement for expenses paid by the Member must be submitted to and received by the Director within 60 days of incurring the expense for which reimbursement is sought.
(8) Initial determinations regarding actual, reasonable and necessary medical and other expenses shall be made by the Director. Members shall be advised, in writing, of any denials. In the event that a denial is issued by the Director, the Member may appeal such determination by filing with the Director a written notice of appeal requesting reconsideration before a hearings officer. However, the reconsideration shall not be granted unless the notice of appeal is received by the Director within 60 days after the mailing of the determination, unless the Member can establish good cause why the notice of appeal was not received within the required 60 days.
(B) Medical treatment and services provided by approved health care providers must be consistent with the nature of the approved injury or disease, and care that is reasonable and necessary to promote recovery.
(C) The Director reserves the right to request of the Member’s Attending or Specialty Physician, evidence of the frequency, extent and efficacy of treatment and services.
(D) Ancillary Services provided by a health care provider other than the Member’s Attending Physician will not be reimbursed unless prescribed by the Member’s Attending or Specialty Physician. These services must be according to a treatment plan that has been provided to the Member’s Attending or Specialty Physician within a reasonable time of when the ancillary treatment begins. The treatment plan must include the following:
(1) Objectives of planned treatment;
(2) Description of modalities to be provided;
(3) Frequency of treatments; and
(4) Duration of treatments.
The Member’s Attending or Specialty Physician shall sign off on the ancillary treatment plan and send a copy to the Director.
5.13.03 – MEDICAL SERVICES GUIDELINES
Medical Services provided to the injured Member must not be more than is reasonable and necessary to treat the approved injury/illness or occupational disease. The Director may deny services that are shown to be more than the nature of the approved injury/illness or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.
(A) The utilization and treatment standard for physical therapy included in any fee arrangement agreement with a medical or hospital service provider will be followed. If none exists, the number and duration of therapy visits covered will not exceed what is medically reasonable and necessary under accepted professional standards. The Member’s Attending or Specialty Physician will be required to provide the Director with a written explanation for visits exceeding this standard.
(B) Attending Physicians may prescribe treatment or services to be carried out by persons not licensed to provide a Medical Service or treat independently only when such services or treatment is rendered under the physician’s direction.
(C) Massage therapy not administered under the direct oversight of a physician must comply with the requirements for “Ancillary Services” in these rules.
(D) Prescription Drugs may be purchased by the Member at apharmacy of the Member’s choice. The Director may ask that the Member access the services of providers that the Director has made fee arrangements with. Except in an emergency, drugs and medicine for oral consumption supplied by a physician must not exceed that which is medically necessary to treat the Member.
(E) Post-Medically Stationary medical care may fall into one of the following categories:
Curative Care – Medical care necessary to stabilize a temporary and acute flare up of symptoms of the Member’s condition; or
Palliative Care - Medical care that is reasonable and necessary to reduce or temporarily moderate the intensity of an otherwise stable condition and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program.
In both cases, the Member’s Attending Physician will be required to submit to the Director a written request that provides the following:
(1) A description of the objective findings;
(2) The diagnosed medical condition for which the care is being requested, to include the appropriate ICD-9-CM diagnosis code;
(3) Provide an explanation of how and why requested care is reasonable and necessary and will improve the Member’s condition; and/or is reasonable and necessary to enable the Member to continue current employment or a vocational training program.
(4) A description of how the care is medically reasonable and necessary to treat the approved Claim.
5.13.04 – NON-COVERED SERVICES
(A) Medical treatment that is excessive, unscientific, unproven as to its effectiveness, outmoded, inappropriate or experimental in nature is not reimbursable. Accepted professional standards will be relied upon in making these determinations.
(B) Dietary supplements, unless prescribed by the Member’s Attending or Specialty Physician specifically as medical treatment for an approved dietary deficient condition are not reimbursable.
(C) Articles including but not limited to beds, hot tubs, chairs, Jacuzzis, and gravity traction devices are not covered unless a need is clearly justified by a report which establishes that the “nature of the injury or the process of recovery requires” the item be furnished. The report must specifically set forth why the Member requires an item not usually considered necessary in the great majority of workers with similar impairments.
(D) Trips to spas, to resorts or retreats, whether prescribed or in association with a holistic medicine regimen, are not reimbursable unless special medical circumstances are shown to exist that render such treatment medically reasonable and necessary.
(E) Physical Restorative Services may include but are not limited to a regular exercise program, gym membership or swim therapy. Such services are not compensable unless the nature of the Member’s limitations requires specialized services to allow the worker a reasonable level of social and/or functional activity. The Attending Physician must justify by report why the Member requires services not usually considered necessary for the majority of injured workers.
(F) The Director may deny services that are shown to be more than the nature of the approved injury/illness or the process of recovery requires. Accepted professional standards will be relied upon in making these determinations.
5.13.05 – INDEPENDENT MEDICAL EXAMINATIONS
(A) If requested by the Director, any Member eligible to receive benefits under this program is required to undergo a medical examination by one or more licensed physicians or psychologists. Should the Member fail to submit to the examination, or obstructs the same, the Member’s rights to benefits may be suspended or reduced by the Director until the examination has taken place.
(B) The Director is not required to schedule an IME appointment during a Member’s work hours. Members will be required to attend an IME during off work hours, as well as work hours, if so scheduled, and unless there is good cause for not attending the IME. An IME scheduled during a Member’s off work hours is not considered good cause, of and by itself, for not attending an IME.
(C) FPDR will mail a written notice to the Member by certified and regular mail at least 14 calendar days prior to the IME appointment date. If the Member has an attorney, the Member’s attorney shall be simultaneously notified in writing of a scheduled medical examination under these Administrative Rules.
FPDR may provide fewer than 14 days notice if the Member agrees. The Member’s notification of the medical examination shall include the following information:.
(1) The name of the examiner or facility;
(2) A statement of the specific purpose for the examination and, identification of the medical specialties of the examiners;
(3) The date, time and place of the examination; and
(4) The first and last name of the Member’s attending physician and verification that the Member’s attending physician was informed of the examination.
(D) The Member may request a change in the appointment date, time or place for good cause.
(E) The Member must cooperate with a scheduled IME by arriving at the date and time of the scheduled appointment and cooperating with the examination unless the Member can show good cause for non-cooperation.
(1) Suspension or reduction of benefits may result from non-cooperation in participation with an IME.
(F) When Elective Surgery is recommended by the Member’s Attending or Specialty Physician the Member may be required to attend an IME with an independent consultant prior to approval of the surgery.
(1) The Director will notify the physician within 7 days of receiving a request to approve surgery that an IME will be required prior to approval of the surgery.
(2) The Director will arrange the IME as soon as possible, but no later than 30 days following the request for surgery by the Member’s Attending Physician or Specialty Physician.
(3) The Director will issue a decision to approve or deny the request for surgery as soon as possible, but no later than 21 days, following the date of the IME.
5.13.06 – MEDICAL MANAGEMENT PROGRAMS
(A) Clinical Case Management – the use of a combination of medical professionals (nurses and physicians) to manage or assist in managing the medical and disability aspects of service-connected and occupational disability Claims.
(1) Typical clinical case management providers and services may include telephonic and field nurse case management services, utilization management, and physician advisor.
(2) A Nurse Case Manager may be assigned to monitor and track recovery of a Member’s approved injury Claim when deemed appropriate by the Director.
(a) Members are required to cooperate with the Nurse Case Manager assigned to their injury Claim. Cooperation includes submitting to personal and/or phone contact and answering relevant medical and vocational questions posed to them by the Nurse Case Manager.
(b) Members may decline to allow the Nurse Case Manager to accompany them to their medical appointments.
(c) Members may request achange of Nurse Case Manager. However, it is at the discretion of the Director to assign a new nurse case manager.
(B) Utilization Review - FPDR may require the use of utilization review services to provide pre-certification of surgical and specialty care prior to approval of the Medical Service.
5.13.07 – MEDICAL FEES AND PAYMENTS
(A) The Director may contract with medical or hospital service providers or groups of providers for medical or hospital services and enter into fee arrangement agreements with such to reimburse medical fees of approved Claims under these rules.
(B) Health care providers will submit their fees for services rendered pursuant to current Charter and administrative rules. Billingsmust be itemized and include Chart Notes, and must be submitted directly to FPDR no later than 90 days from the date of service. A health care provider must establish good cause if billing is submitted later than 90 days from the date of service or in accordance with the terms of their provider panel agreement with whom FPDR is contracted. Failure to show good cause may result in a reduction or non-payment of allowable charges.
(C) Medical fees will be reimbursed according to the fee arrangement agreements made between the medical providers and FPDR.
(D) If no fee arrangement agreement has been made with the medical provider, and the service complies with these administrative rules in all other respects, FPDR will reimburse at the “usual and Customary Fee” for the Medical Service.
(E) FPDR payment shall be considered payment in full. Members will be “held harmless” by the medical provider for any costs above the usual and customary fee schedule or an agreed upon fee arrangement amount payable by FPDR on an otherwise approved billing.
(F) FPDR will date stamp each medical bill received. Bills for services rendered on approved Claims will be adjudicated within 30 days of receipt. Payments will be in accordance with adopted fee schedules.
(G) If there is a dispute concerning the amount of a bill, the appropriateness of the service rendered, or the relationship of the services to the approved Claim, FPDR must pay any undisputed portion of the bill and notify the provider of the specific reasons for non-payment or reduction of the remainder of the bill.
5.13.08 – MEDICAL PAYMENT LIMITATIONS
(A) Member shall not pay for any Medical Service that is related to an approved service- connected or occupational disability or any amount that has been reduced by the FPDR in accordance with these administrative rules. A medical provider shall not attempt to collect payment for any Medical Service from a Member, except as follows:
(1) When the Member seeks treatment for conditions not related to the approved Claim;
(2) When the Member seeks treatment that has not been prescribed by the Attending Physician, or a Specialty Physician upon referral of the Attending Physician.
(3) When the Member seeks treatment outside the provider panels which FPDR has contracted with, and said treatment was not pre-authorized by FPDR.
(4) When the Member seeks treatment after being notified that such treatment has been determined to be unscientific, unproven, outmoded, or experimental, or has been notified that the treatment is not approved or outside of these Administrative Rules.
5.13.09 – POST-RETIREMENT MEDICAL BENEFITS
(A) Service-connected Disability – Medical and hospital expenses arising from an approved service-connected disability claim shall be reimbursable, if the Member’s disability benefits continued until the Member reached Compulsory Retirement Age.
(B) Occupational Disability – Medical and hospital expenses arising from an approved occupational disability claim shall be reimbursable, until the expiration of one (1) year from the Member’s retirement, if the Member’s disability benefits continued until the Member reached Compulsory Retirement Age.
Adopted November 12, 1991.
Effective February 1, 1992.
Revision filed in PPD December 28, 2005.
As Amended by: Resolution No. 287 on August 8, 1995, Resolution No. 288 on September 12, 1995, Resolution No. 298 on October 14, 1997, Resolution No. 320 on December 14, 1999, Resolution No. 323 on April 11, 2000, Resolution No.332 on April 17, 2001, Resolution No. 335 on August 14, 2001, Resolution No. 338 on December 11, 2001, Resolution No. 340 on January 15, 2002, Resolution No. 345 on April 9, 2002, Resolution No. 349 on August 13, 2002, Resolution No. 350 on August 13, 2002, Resolution No. 351 on September 10, 2002, Resolution No. 352 on October 8, 2002, Resolution No. 365 on August 12, 2003, Resolution No. 372 on February 10, 2004, Resolution No. 381 on August 10, 2004, Resolution Nos. 388, 389 and 390 on June 14, 2005, Resolution No. 392 on November 8, 2005, Resolution No. 393 on December 13, 2005, Resolution No. 405 on May 9, 2006, Resolution No. 419 on March 13, 2007, Resolution No. 423 on November 27, 2007, Resolution No. 442 on May 26, 2009, and Resolution No. 457 on June 28, 2011.