OAR 436-055-0070: Certification of Claims Examiners

(1) Claims examiner test. To become an Oregon certified claims examiner, an individual must complete a test that demonstrates the individual’s competency in claims processing activities, subject to the following: (a) The test must include questions that demonstrate the individual’s: (A) Familiarity with ORS chapter 656; (B) Ability to navigate OAR chapter 436; (C) Ability to perform claims processing activities; and (D) Understanding of all of the components in OAR 436-055-0085(1); and (b) The individual may use a copy of ORS chapter 656 and OAR chapter 436 during the testing period. (2) Initial certification. An insurer may certify an individual as an Oregon certified claims examiner upon verification of the individual’s satisfactory completion of the test under section (1) of this rule. The certification will remain in effect for three years from the date of the test. As used in this section, “satisfactory completion” means: (a) The individual received a score of at least 80 percent on the test; and (b) The test was not completed through dishonest or fraudulent means. (3) Renewal of certification. An insurer may renew a claims examiner’s certification upon verification that the claims examiner has completed 24 hours of training within the past three years. The 24 hours of training must include: (a) At least six hours of training on ORS chapter 656, OAR chapter 436, and relevant case law; (b) At least one hour of training related to interactions with independent medical examination providers that has been approved under OAR 436-055-0085(1); and (c) Additional training that covers any of the following subjects: (A) Medical case management including, but not be limited to, medical terminology, basic human anatomy and the interpretation of medical reports; (B) Communication skills including, but not be limited to, courses in ethics, mediation, negotiation and conflict management; or (C) Claims processing skills relevant to Oregon workers’ compensation claims. (4) Expired certification. An insurer may renew a claims examiner’s certification that expired within the past 12 months if the individual meets the requirements of section (3) of this rule. An insurer may recertify a claims examiner who has not held current certification in the past 12 months under section (2) of this rule. (5) Acknowledgement of certification issued by another insurer. If an individual provides an insurer with documentation of current certification issued by another insurer, the insurer receiving the documentation may: (a) Issue an acknowledgement of the certification stating that the individual has met the requirements for initial certification or renewal, if the documentation is sufficient to verify that the individual has met the requirements for initial certification or renewal; or (b) Require the individual to recertify under section (2) of this rule, if the documentation is not sufficient to verify that the individual has met the certification requirements.