OAR 436-055-0100: Insurer Duties

(1) Insurer’s responsibility to employ certified or qualified examiners. An insurer may only employ Oregon certified claims examiners to process claims. An Oregon certified claims examiner must have primary responsibility for all activities related to the determination of compensability and management of a claim including, but not limited to, calculating benefits and authorizing payments to workers. (2) Claims examiner trainees and temporary claims examiners. Notwithstanding section (1), an insurer may employ a claims examiner trainee or a temporary claims examiner who is not certified to assist with claims processing activities, subject to the following: (a) A “claims examiner trainee” is an individual hired by an insurer to assist with claims processing activities who has no previous experience as an Oregon certified claims examiner, or who did not have current Oregon claims examiner certification in the 12 months before the date of hire. An individual may only work as a claims examiner trainee for up to 12 months in any five-year period; (b) A “temporary claims examiner” is an individual hired by an insurer to assist with claims processing activities who has at least two years of prior experience as an Oregon certified claims examiner. An individual may only work as a temporary claims examiner for up to 90 days in any 12-month period; (c) The claims examiner trainee or temporary claims examiner must work under the direct supervision of a certified claims examiner; and (d) The claims examiner trainee or temporary claims examiner may not represent the insurer in communications with the director or the Workers’ Compensation Board. (3) Responsibility for training. An insurer must ensure that training required under these rules, including training related to interactions with independent medical examination providers, is provided for any claims examiners it employs. No provision of these rules is intended to prevent an insurer from providing training to its employees beyond the requirements of these rules. (4) Records. An insurer must keep records sufficient to verify the certification and training of all certified claims examiners, temporary claims examiners, and claims examiner trainees it employs to process claims. (a) The records must include: (A) The names of all certified claims examiners, claims examiner trainees and temporary claims examiners, currently employed by the insurer; (B) The names of the certified claims examiners supervising any claims examiner trainee or temporary claims examiner currently employed by the insurer; (C) The date of certification and date of expiration of certification for each certified claims examiner; (D) The dates of employment of any temporary claims examiner who has been employed by the insurer within the past 24 months; (E) The dates of employment of any claims examiner trainee who has been employed by the insurer within the past five years; (F) Documentation of any qualified trainings completed by each certified claims examiner during the most recent period of certification, including: (i) The names of the instructors providing the training; (ii) The syllabi; (iii) The dates of training; and (iv) The number of training hours completed for each component under OAR 436-055-0070(3); and (G) Documentation provided to the insurer to support any acknowledgment of an initial certification or renewal issued by another insurer. (b) Upon the director’s request, the insurer must make the records available for inspection or review. (c) The insurer must provide a claims examiner with a complete copy of all records verifying the most recent certification and any subsequent training completed by the claims examiner within 14 days of the termination of the claims examiner’s employment, or upon receipt of a written request. (d) The insurer must retain records used to verify the certification and renewal of any certified claims examiner it employs for six years from the date of the most recent certification or renewal. (5) Civil penalties. An insurer that fails to comply with the requirements of this rule, or misrepresents information related to the certification of any of its employees to a worker, employer, or the director may be subject to a civil penalty under OAR 436-055-0110.