(a) A physician or other provider whose charge for service is only
partially paid because it exceeds a maximum allowable amount set by
OWCP may, within 30 days, request reconsideration of the fee
determination.
(1) The provider should make such a request to the district office
with jurisdiction over the employee's claim. The request must be
accompanied by documentary evidence that the procedure performed was
incorrectly identified by the original code, that the presence of a
severe or concomitant medical condition made treatment especially
difficult, or that the provider possessed unusual qualifications. In
itself, board certification in a specialty is not sufficient evidence
of unusual qualifications to justify an exception. These are the only
three circumstances that will justify reevaluation of the paid amount.
(2) A list of district offices and their respective areas of
jurisdiction is available upon request from the U.S. Department of
Labor, Office of Workers' Compensation Programs, Washington, DC 20210,
or from OWCP's home page on the Internet at http://www.dol.gov/esa/owcp_org.htm. Within 30 days of receiving the request for
reconsideration, the district office shall respond in writing stating
whether or not an additional amount will be allowed as reasonable,
considering the evidence submitted.
(b) If the district office issues a decision that continues to
disallow a contested amount, the provider may apply to the Regional
Director of the region with jurisdiction over the district office. The
application must be filed within 30 days of the date of such decision,
and it may be accompanied by additional evidence. Within 60 days of
receipt of such application, the Regional Director shall issue a
decision in writing stating whether or not an additional amount will be
allowed as reasonable, considering the evidence submitted.
