Or. Admin. Code § 461-195-0303

Current through Register Vol. 63, No. 11, November 1, 2024

Section 461-195-0303 - Personal Injury Claim

(1) The Personal Injury Liens program is designated and authorized to administer the personal injury lien program for the Oregon Heath Authority (the Authority) and the Oregon Department of Human Services (the Department) (see OAR 461-195-0301). To administer the program, the Personal Injury Liens program is also authorized to:

(a) Prepare and file liens;

(b) Assign lien authority to a CCO (see OAR 461-195-0301) or a prepaid managed care health services organization (see 461-195-0301) for medical costs paid by a CCO or prepaid managed care health services organization to or on behalf of an applicant (see 461-195-0301) or recipient (see 461-195-0301) arising from any personal injury (see 461-195-0301);

(c) Assert any rights or remedies, including filing a complaint in court, arising from an assignment of right to payment acquired by the Authority in accordance with ORS 659.830 and 743.847, from an applicant or recipient; and

(d) Assert any rights or remedies granted in ORS 416.580 or 416.610.

(e) Issue subpoenas under ORS 411.593 or 413.037.

(2) Subpoenas require approval of an Office of Payment Accuracy and Recovery manager or policy analyst.

(3) By applying for and receiving medical assistance, an applicant or recipient automatically assigns to the Authority and the Department any rights to payment from any third party liable for medical costs paid by medical assistance to or on behalf of an applicant or recipient arising from any personal injury.

(4) An applicant or recipient of assistance (see OAR 461-195-0301), except HSD medical programs (see 461-001-0000), must pursue a personal injury claim (see 461-195-0301) in accordance with 461-120-0330 (Requirement to Pursue Assets).

(5) An applicant or recipient of HSD medical programs assistance must pursue a personal injury claim in accordance with OAR 410-200-0220 (Requirement to Pursue Assets).

(6) An applicant or recipient must cooperate with the Personal Injury Liens Unit, CCO, or prepaid managed care health services organization to:

(a) Identify any third party liable or potentially liable for medical costs paid by the Department, the Authority, CCO, or prepaid managed care health services organization to or on behalf of an applicant or recipient arising from any personal injury;

(b) Provide information about liability or other insurance that may cover or pay for medical costs paid by the Department, the Authority, CCO, or prepaid managed care health services organization to or on behalf of an applicant or recipient arising from any personal injury;

(c) Complete a MSC 0451, MSC 0451NV, or similar online form as required by the Personal Injury Liens Unit, CCO, or prepaid managed care health services organization;

(d) Provide other information as required by the Personal Injury Liens Unit, CCO, or prepaid managed care health services organization to assist in pursuing payment from any third party who may be liable for medical costs paid by the Department, the Authority, CCO, or prepaid managed care health services organization to or on behalf of an applicant or recipient arising from any personal injury;

(e) Appear as a witness in court, administrative hearing, or other proceeding arising from any personal injury; and

(f) Pay to the Department any medical damages received by the recipient that are subject to the Department's lien or assignment of rights to payments.

(7) An applicant or recipient of HSD medical programs assistance who fails to comply with section (6) of this rule is ineligible for benefits until the individual meets the requirements of section (6) of this rule, or has good cause (see OAR 410-200-0220) not to comply.

(8) An applicant or recipient of assistance, other than HSD medical programs, who fails to comply with section (6) of this rule is ineligible for benefits until the individual meets the requirements of section (6) of this rule, or has good cause (see OAR 461-120-0330) not to comply.

(9) For all programs, the existence of a claim for damages for a personal injury does not make an applicant or recipient ineligible for program benefits.

Or. Admin. Code § 461-195-0303

AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 26-1993, f. 10-29-93, cert. ef. 11-1-93; Renumbered from 461-195-0300; SSP 19-2005, f. 12-30-05, cert. ef. 1-1-06; SSP 15-2015, f. 3-30-15, cert. ef. 4/1/2015; SSP 8-2019, amend filed 03/13/2019, effective 4/1/2019; SSP 18-2021, minor correction filed 02/18/2021, effective 02/18/2021; SSP 19-2021, minor correction filed 02/18/2021, effective 2/18/2021; SSP 30-2024, amend filed 03/26/2024, effective 4/1/2024

Statutory/Other Authority: ORS 409.050, 411.060, 416.510 - 416.610 & 413.085

Statutes/Other Implemented: ORS 411.630, 411.632, 411.635, 411.640, ORS 411.620, 413.085, 42 CFR 433.146(c) & 42 USC 1396k