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Division of Federal Employees' Compensation (DFEC)

Field Nurse Handbook

Part 8


Part 8 - Authorizations for Medical Services

Paragraph and Subject

Date

FNHB Trans. No.

Table of Contents

09/13

13-01

1. Overview

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2. The OWCP Central Bill Processing System – Provider/Vendor Authorizations

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13-01

3. Enrollment Requirement

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13-01

4. Prior Authorization

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5. FN Authorizations

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6. Establishing Prior Authorization - Provider/Vendor

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1. Overview. The Division of Federal Employees' Compensation (DFEC) is committed to seeing that that the injured worker (IW) receives the medical care necessary to facilitate recovery from a work-related injury in a prompt and efficient manner. All requests for treatment and subsequent payment of bills flow through the Office of Workers' Compensation Programs' (OWCP) consolidated medical authorization and bill payment system, referred to herein as Central Bill Processing (CBP). This part of the Field Nurse (FN) Handbook focuses on the medical authorization aspects of the CBP system. Specific FN billing processes are discussed in Part 9 of this handbook.

As a liaison for (and contracted employee of) the OWCP, the FN has an essential role in the medical authorization process. In accordance with the OWCP's procedures, the FN is able to authorize certain non-invasive procedures, as well as expedite the authorization process on behalf of the medical provider(s) and/or vendor(s) for other services requiring additional review and authorization levels via the CBP system. In addition, the FN is able to provide outreach services to assist the medical community with understanding and navigating the OWCP medical authorization and CBP procedures, which is of significant benefit to the IW and medical provider community when addressing medical authorization requests and/or concerns.

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2. The OWCP Central Bill Processing (CBP) System – Provider/Vendor Authorizations. Through the CBP web portal, a medical provider and/or vendor is able to:

a. Determine if an injury claim is approved and, if so, the associated accepted condition(s) of the claim.

b. Determine whether or not a claim is eligible for a particular medical service as well as whether or not prior authorization is required before the rendering of such medical service.

c. Submit an electronic request for prior authorization of a medical service and check the status of the request.

d. Submit an electronic invoice via the Electronic Data Interchange (EDI) and check the status of bill payment.

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3. Enrollment Requirement. Access to, and use of, the CBP system requires that every provider and/or vendor who renders services for an approved DFEC injury claim enroll (register) their professional and billing information with the OWCP designated bill processing contracted provider. This enrollment provides for the processing of all submitted medical authorization requests, as well as the processing of the invoices associated with those approved medical services. Upon enrollment, each provider/vendor is issued a unique provider identification number (provider ID), which is linked to each medical authorization request and/or invoice submitted by that specific provider/vendor.

a. The FN should assist the IW in establishing care and services with an enrolled provider (and vendor, if appropriate).

(1) The FN should inform the provider/vendor that enrollment may be accomplished via an online application process available on the CBP web portal which may be accessed via: https://owcp.dol.acs-inc.com/portal/

(2) The FN should inform the provider/vendor about additional CBP system resources available to assist them with the processing of enrollment forms, submitting requests for medical authorizations, submitting invoices, and/or any other questions the provider/vendor may have related to the CBP system.

(a) The automated Interactive Voice Response (IVR) telephone line (866-335-8319) provides 24 hour access to information related to the status of medical authorization requests and bill payments.

(b) The CBP customer service line (850-558-1818) will connect the provider/vendor to a customer service representative.

(c) The DFEC web page provides links to the CBP system information including, but not limited to tutorials on the enrollment process and the process for submitting medical authorization requests. http://www.dol.gov/owcp/dfec/regs/compliance/CBPtools.htm

b. The FN should proceed with actions related to obtaining medical authorizations without waiting for the provider/vendor enrollment process to be completed. Lack of enrollment should not delay the delivery of medical services/care as long as the provider/vendor has initiated the enrollment process/action(s).

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4. Prior Authorization. Medical care is subject to a prior authorization system, which is driven by the accepted condition(s) of the approved injury claim. Requests for treatment are processed based on review of the submitted procedure code and its relationship to the accepted condition(s) in the case. If the procedure code requested is typically prescribed for the accepted condition(s), the medical request can be authorized. If the procedure code requested is not typically prescribed for the accepted condition(s), the medical request is routed to the Claims Examiner (CE) for further review.

The majority of medical services do require that the provider secure an authorization prior to the medical services being rendered. In certain instances, the FN may provide the authorization to the provider, or may facilitate the prior authorization process, as discussed below. Services are generally categorized by Levels.

a. Level 1 includes services that are considered common to most medical workups. These services may include, but are not limited to routine lab work, physician office visits, and most routine, non-invasive diagnostic procedures. Level 1 services do not require a prior authorization. A provider may proceed with rendering these services without submitting a request for prior authorization.

b. Level 2 services require that an authorization be secured by the provider prior to the service(s) being rendered. These services may include, but are not limited to CT scans, MRIs, cardiovascular stress tests, echocardiography, and physical therapy. These authorizations are issued by the CBP prior authorization unit or, in some circumstances, by the FN.

c. Level 3 and Level 4 services also require that prior authorization be obtained; however, due to the complexity associated with these services, they are subject to an additional level of review. Level 3 and Level 4 authorizations are reviewed by the CBP prior authorization unit, but then are sent to the CE or District Office designee for final review and authorization.

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5. FN Authorizations. In order to utilize the specialized skills and knowledge of the FN, and to expedite the IW receiving appropriate medical care or services for the accepted work-related injury/condition(s), the OWCP grants certain, limited medical service authorization permissions to the FN. A verbal authorization from the FN allows the provider to proceed with the requested service(s) without waiting for the issuance of a written prior authorization letter from the CBP.

To further assist in an expedited authorization process, OWCP has established Medical Authorization Request forms specific for FN use; a dedicated CBP nurse fax line for the submission of FN authorizations; and a dedicated CBP nurse telephone triage line. Nurse authorization request forms are given priority status when received in the CBP prior authorization unit via the dedicated nurse fax line. These forms and dedicated lines of communication are made available exclusively for FN use in coordinating medical authorization requests and are not available to other providers, the IW, or the employing agency. As such, these forms and contact numbers are not published, but provided to the FN at the time s/he is certified as an OWCP FN.

a. The FN should provide verbal authorization to the provider and advise him/her to proceed with any requested medical service(s) that fall under the Level 1 category authorizations, as well as services designated as a Level 2 that are considered to be non-invasive.

b. The FN should fax a completed nurse authorization form to the designated CBP nurse medical authorization fax line for those Level 2 services for which s/he has provided verbal authorization.

c. The FN should assist the provider in expediting the medical service authorization request process for those services not eligible for FN authorization (those designated as Level 2 (invasive) services and those designated as Level 3 or Level 4 services) by faxing a completed Medical Authorization Request form along with any supporting medical documentation to the dedicated CBP nurse authorization fax line.

d. The FN should monitor the status of all prior authorization medical requests via the Medical Authorization link on the web portal. The CBP prior authorization unit will issue written notification of the approval status to the provider or IW. The FN, however, does not receive a copy of this written notification.

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6. Establishing Prior Authorization – Provider/Vendor. The FN can further assist the medical authorization process by being familiar with the steps required of providers for submitting medical authorization requests and obtaining prior authorizations for those services that require them.

The FN should offer the medical provider/vendor a copy of the Provider Medical Authorization Request form during the first interaction/meeting, as well as the web portal address that contains access to the form and online submission instructions. S/he can provide reinforcement of instructions and answer common questions associated with the provider's/vendor's use of the CBP system and its processes.

a. The Provider Request for Medical Authorization forms may be accessed via: https://owcp.dol.acs-inc.com/portal/

There are three (3) forms (each designated for a specific service): requests for General Medical Authorizations (which includes, but is not limited to surgery and invasive procedures); requests for Durable Medical Equipment; and requests specifically for Physical and/or Occupational Therapy services.

b. The provider/vendor may complete and submit any of the Medical Authorization Request forms electronically via the web portal or s/he may print and fax the forms to the dedicated CBP provider fax line: 1-800-215-4901.

c. All Medical Authorization Request forms should reflect the provider ID number assigned to the provider/vendor who will actually be providing and billing for the service being requested (or equipment/supply being provided). This is essential in that the CBP is structured in such a way that the authorization on file is directly linked to a specific provider and procedure code.

(1) If the provider/vendor is in the process of enrolling with the CBP system, this should be noted on the Medical Authorization Request form. In this situation, the provider/vendor should include on the form the tax ID associated with the provider/vendor performing (or providing) and billing for the service/product.

d. The provider/vendor or the IW will receive written notification of the approval status from the CBP prior authorization unit. This information is also available to the provider/vendor by accessing the Medical Authorization link on the web portal.

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