EEOICPA BULLETIN NO. 03-29
Issue Date: June 30, 2003
Effective Date: June 30, 2003
Expiration Date: June 30, 2004
Subject: Interim procedures for processing claims for new medical conditions on existing EEOICP claims.
Background: New guidelines have been established for the filing of additional medical conditions after initial filing of a claim. If a new medical condition is claimed after a Final Decision, the new condition is considered a new claim. However, ECMS is not equipped currently to accept a new claim for an already existing claimant. ECMS will be reconfigured to accept new claims for existing claimants, but until that time, this bulletin addresses the temporary procedures set up to accommodate new medical conditions for adjudicated claims.
References: Policy teleconference, dated 3-6-03; ECMS FAQ’s.
Purpose: To provide interim procedures to the District Offices and FAB on how to process new claims for existing claimants.
Applicability: All staff.
When a case has a Final Decision, and a current claimant on the case submits a subsequent claim form for a new covered medical condition, the new claim filing is recorded in ECMS by entry of claim status code ‘RD’. (Specific data entry instructions are contained in Action items 2-11, below.) A new claim form for new covered medical conditions is required once a Final Decision is issued. Please note: this does not apply to consequential conditions. New covered conditions, including all cancers, CBD, Beryllium Sensitivity, and Chronic Silicosis, would only be considered new medical conditions if they were not previously addressed in a Final Decision. If the claimant only submits new medical evidence for a covered condition, e.g., medical test results indicating the presence of a covered condition, then the District Office or FAB will send a letter requesting that the claimant submit a new claim form. The DO or FAB will only request a claim form and develop the evidence further if it is apparent that coverage is likely. The letter will address the receipt of the new evidence and explain the need for an EE-1 or EE-2 claim form in order to establish the new claim. If, however, the claimant submits new medical evidence only for a non-covered medical condition, a claim form would not be requested. If a claimant does submit a new claim form for a new non-covered condition, or states that he/she wants the medical condition to be considered, the CE must develop and adjudicate the new claim.
If the case file is at the District Office, and a new claim form is received after a Final Decision has been issued, the CE enters the new claim in ECMS by entering an ‘RD’- Development Resumed - in the claim status history screen of ECMS. The status effective date of the ‘RD’ code will be the date stamp of receipt in a DOL Office (either district office or FAB office) on the claim form or the date stamp of receipt on the initial piece of evidence that instigated the claim, whichever is earliest. Once the ‘RD’ code and effective date are entered in ECMS, the CE enters the newly claimed medical condition on the Medical Condition screen in ECMS. The CE reviews the new condition and begins development of the new medical evidence.
Development of the case will continue through new Recommended and Final Decisions. All of the previously entered ECMS claim status codes in the claim status history are all still relevant for the case, and will apply to the new claim. They do not need to be re-entered following the ‘RD’ code. However, all new development for the claim is now required to be entered in ECMS, including all further development claim status history codes.
If the new medical condition becomes an accepted condition, and the CE enters an "A" in the cond status field, then the med status effective date is determined by the following:
·If the original claim was for Beryllium Sensitivity, and was Accepted, and the new claim is for CBD, the med status effective date of the CBD is the same as the acceptance date of the Beryllium Sensitivity.
·For all other medical conditions, if the diagnosis date is prior to the new claim filing date, the med status effective date would be the new claim filing date.
5. If the case file is at FAB and a new claim form or medical evidence for a new covered medical condition is received prior to a Final Decision, and the case is in posture for Acceptance of benefits, FAB will enter the new claim in ECMS by entering an ‘RD’- Development Resumed - in the claim status history screen of ECMS. The status effective date of the ‘RD’ code will be the date stamp of receipt (in DOL or the Resource Center) on the claim form or the date stamp on the initial piece of evidence that instigated the claim, or the postmark, whichever is earliest. Once the ‘RD’ code and effective date are entered in ECMS, the FAB sends out a letter to the claimant, addressing the receipt of the new claim form, and instructing the claimant that the District Office will further develop the new condition when the case is returned to the DO. The FAB CE enters the ‘DO’ - Developing Other - claim status code in ECMS on the claim status history screen, using the status effective date of the letter. The FAB CE then enters the newly claimed medical condition on the Medical Condition screen in ECMS. The FAB CE will not begin development of the new medical condition. This will be done by the DO CE upon return in the District Office (see Action item 3).
6. FAB will then issue a Final Decision based exclusively on the Recommended Decision as quickly as possible so that any lump sum payments and/or medical benefits can be awarded, and return the case file to the District Office for development of the new medical condition. The new medical condition will neither be addressed in the Final Decision, nor will it be considered a Remand. When returning the case file to the District Office, the new claim form is attached to the front cover, with a memo alerting the DO of the new claim form.
7. There is, however, one exception to Action item 6: if the newly claimed medical condition can be accepted without any further development by the FAB, the accepted condition will also be addressed in the Final Decision. For example, if the District Office’s recommendation is to accept benefits for an SEC cancer, and prior to the Final Decision the claimant submits all the evidence necessary to show s/he has another primary SEC cancer, the newly claimed condition would also be part of the Final Decision. Only accepted new medical conditions can be included in the Final Decision, having not been addressed in the Recommended Decision. This would not be allowable for a new claimed condition that is for denial of benefits. All denied elements of a Final Decision must have been addressed in the Recommended Decision.
8. If the case file is at FAB, prior to a Final Decision, and the case is in posture for Denial of benefits, and a new claim form is submitted (for a covered or non-covered condition), or medical evidence for a new medical condition is received, the case will be Remanded back to the District Office.
9. When a case is at FAB and a Final Decision has already been issued, and a new claim form for a new medical condition is received, the new claim form will be entered in ECMS by FAB upon receipt(see Action item 5). The case file will then be returned to the District Office, with a memo alerting the DO of the new claim form.
10. At any time during the development process, prior to the District Office’s rendering of a Recommended Decision, any new claimed medical conditions will be added to the existing claim and developed. Regardless of how the new medical condition is claimed, either by a new EE-1 or EE-2 form, or by medical evidence submitted, the new condition is still part of the original claim. In this situation, the ‘RD’ - Development Resumed - claim status code would not be entered in ECMS. This code is only for claims in which a Recommended Decision has already been issued.
If a case has a Final Decision, and the claimant sends in additional medical evidence for the original medical condition(s) or a new claim form for the same medical condition(s) already adjudicated, this is not considered a new claim. For either of these occurrences, the ‘RD’ - Development Resumed - claim status code would not be entered in ECMS. Development cannot be resumed for any claims after a Final Decision without either a new claimed medical condition or a Modification Order. [Guidance is forthcoming regarding reopening claims.] New evidence for previously adjudicated medical conditions must be reviewed by either FAB or National Office.
12. All of the above Action items are temporary procedures for the handling of new claims for new medical conditions. When ECMS is reconfigured to accept new claims for existing claimants, ECMS will be updated with the specific claim information, and further instructions will be provided at that time.
Disposition: Retain until permanent procedures are distributed.
PETER M. TURCIC
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution: Distribution List No. 1: (Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, Operation Chiefs, District Directors, FAB District Managers, Hearing Representatives, District Office Mail & File Sections.)