Or. Admin. R. 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.
Notes
Stat. Auth.: ORS 656.726, 656.780
Stats. Implemented: ORS 656.780
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