expenses?
(a) If an employee has paid bills for medical, surgical or dental
services, supplies or appliances due to an injury sustained in the
performance of duty, he or she may submit an itemized bill on the Health
Insurance Claim Form, HCFA 1500 or OWCP 1500, together with a medical
report as provided in Sec. 10.800, to OWCP for consideration.
(1) The provider of such service shall state each diagnosed
condition and furnish the applicable ICD-9-CM code and identify each
service performed using the applicable HCPCS/CPT code, with a brief
narrative description of the service performed, or, where no code is
applicable, a detailed description of that service.
(2) The bill must be accompanied by evidence that the provider
received payment for the service from the employee and a statement of
the amount paid. Acceptable evidence that payment was received includes,
but is not limited to, a signed statement by the provider, a mechanical
stamp or other device showing receipt of payment, a copy of the
employee's canceled check (both front and back) or a copy of the
employee's credit card receipt.
(b) If services were provided by a hospital, pharmacy or nursing
home, the employee should submit the bill in accordance with the
provisions of Sec. 10.801(a). Any request for reimbursement must be
accompanied by evidence, as described in paragraph (a) of this section,
that the provider received payment for the service from the employee and
a statement of the amount paid.
(c) OWCP may waive the requirements of paragraphs (a) and (b) of
this section if extensive delays in the filing or the adjudication of a
claim make it unusually difficult for the employee to obtain the
required information.
(d) OWCP will not accept copies of bills for reimbursement unless
they bear the original signature of the provider, with evidence of
payment. Payment for medical and surgical treatment, appliances or
supplies shall in general be no greater than the maximum allowable
charge for such service determined by the Director, as set forth in
Sec. 10.805.
(e) An employee will be only partially reimbursed for a medical
expense if the amount he or she paid to a provider for the service
exceeds the maximum allowable charge set by the Director's schedule. If
this happens, OWCP shall advise the employee of the maximum allowable
charge for the service in question and of his or her responsibility to
ask the provider to refund to the employee, or credit to the employee's
account, the amount he or she paid which exceeds the maximum allowable
charge. The provider may request reconsideration of the fee
determination as set forth in Sec. 10.812.
(f) If the provider fails to make appropriate refund to the
employee, or to credit the employee's account, within 60 days after the
employee requests a refund of any excess amount, or the date of a
subsequent reconsideration decision which continues to disallow all or a
portion of the appealed amount, OWCP shall initiate exclusion procedures
as provided by Sec. 10.815.
(g) If the provider does not refund to the employee or credit to his
or her account the amount of money paid in excess of the charge which
OWCP allows, the employee should submit documentation of the attempt to
obtain such refund or credit to OWCP. OWCP may make reasonable
reimbursement to the employee after reviewing the facts and
circumstances of the case.
