EEOICPA BULLETIN NO.04-01
Expiration Date: October 31, 2004
Subject: Instructions for Reworks of NIOSH Dose Reconstruction Reports
Background: Section 20 CFR 30.115(a) of the final regulations provides that the Office of Workers Compensation Programs (OWCP) will forward eligible claimant application packages to Health and Human Services (HHS) for dose reconstruction. When the dose reconstructions are received from the National Institute for Occupational Safety and Health (NIOSH), the Claims Examiner (CE) reviews the report in preparation for determining the probability of causation using NIOSH-IREP.
This Bulletin provides additional details on what to do when claimant information in the case file differs from information used in the dose reconstruction (DR) report. Also, details are provided for situations in which a case at NIOSH for dose reconstruction may be placed in a “pending status” while DOL develops additional information.
Reference: Final regulation 20 CFR 30.115(a) and EEOICPA Bulletin 03-03.
Purpose: Provide procedure for referring an issue back to NIOSH after a dose reconstruction has already been completed.
Applicability: All staff.
1. The CE must notify NIOSH of any changes to information submitted on the NIOSH Referral Summary Document (NRSD) while the case is at NIOSH for dose reconstruction (DR). NIOSH currently provides weekly reports to the district offices listing the cases for which the NIOSH contractor started performing dose calculations in the past week. When a CE identifies one of his/her cases on the list, the CE must review the information in the case file against the information sent to NIOSH in the NRSD. Any revisions to information contained in the original NRSD must be forwarded to NIOSH using an amended NRSD (per the guidance given in Bulletin 03-03). This will allow NIOSH to use the correct information in their development of the DR report.
2. After the DR report is received by the CE from NIOSH, the CE must review it to ensure that the information in the case file is still consistent with the information contained in the NRSD. If there are any significant discrepancies between the information in the case file and the DR report the new information must be reviewed by NIOSH and a new DR may be necessary. “Significant” discrepancies, for example, would include changed employment facilities or dates; changed cancer site; different ICD-9 code; or major change in date of diagnosis.
3. For cases found to be in error, incomplete, or for which new information was recently received, the CE sends an E-mail message, with the amended NRSD attached, and forwards the case file to the Supervisory or Senior Claims Examiner (Sr. CE) outlining the issue(s) with the DR. The amended NRSD is prepared as necessary (using the guidance given in Bulletin 03-03). The CE must ensure that a copy of the E-mail message (printed from the sent file in order to document the date of issue) is placed in the case file. The CE must not enter the PoC data into ECMS when a case is referred back to NIOSH.
There will be some situations that will not require a rework. One example is when the diagnosis date is found to be different, but is still within the same calendar year. For these cases, the results of the DR will not be significantly affected. If uncertain, contact the DEEOIC Health Physicist to discuss the issue.
Also, the CEs should remember that metastatic and consequential cancers should NOT be treated as additional primary cancers.
4. The Supervisory or Sr. CE reviews and approves the amended NRSD and forwards the information along with the amended NRSD and the case file to the district office (DO) person designated by the District Director to handle NIOSH information, i.e., the DO NIOSH liaison. The DO NIOSH liaison will review the case file and must contact the DEEOIC Health Physicist for a review prior to referral to NIOSH for a rework of the DR. The DO NIOSH liaison should create a spreadsheet to track cases sent for review and rework of the DR by NIOSH.
To expedite the process, the DO NIOSH liaison will use E-mail to send a description of the need for the rework of the DR to the DEEOIC Health Physicist. When this E-mail is sent, the DO NIOSH liaison must copy the Sr. CE, SCE, District Director and CE so they are aware that the issue has been sent to the DEEOIC Health Physicist for review. The CE must ensure that a copy of the E-mail message (printed from the sent file in order to document the date of issue) is placed in the case file.
When the E-mail is sent, the District Director enters the “WS” code in ECMS, by selecting the “WS” code on the ECMS claim status history screen. The status effective date is equal to the date of the “WS” memo to the National Office. ECMS checks the reason required table to determine if the status code entered requires that a reason code be selected. If a reason is required (e.g., entering “WS” will require selecting a reason code), then ECMS will display the reason_cd field. The user clicks on reason_cd list box. ECMS displays valid reason selections for the code entered. The District Director then selects "HP-Health Physicist Review" from the reason code list box. The "HP-Health Physicist Review” status code signifies that the additional information related to the DR is with the DEEOIC Health Physicist for a review as to whether a rework of the DR by NIOSH is necessary.
5. The DEEOIC Health Physicist serves as the central liaison between NIOSH and DOL on all dose reconstruction related issues. All requests for reworks of DR reports must be forwarded to the DEEOIC Health Physicist for review. The DEEOIC Health Physicist will review the request for rework and determine whether a rework is required. The DEEOIC Health Physicist will contact the CE if additional information is needed to make a determination, which may include requesting the case file. If the information would change the outcome of the DR or affects the accuracy of the case, the request for rework will be referred to NIOSH. If the information would not change the outcome of the DR, the DEEOIC Health Physicist will send an E-mail to the CE and the DO NIOSH liaison explaining the rationale for not continuing the review of the DR report. When the CE receives this response, he/she must proceed with the IREP calculation and enter the PoC value(s) into ECMS.
If the DEEOIC Health Physicist determines that a rework is necessary, he sends an E-mail to the designated OCAS contact person, who is currently the Technical Program Manager. The CE will be copied on the E-mail, along with the Sr. CE, SCE, District Director and the DO NIOSH liaison, so that he/she is aware that the rework will proceed. The CE must enter the “WR” status code in the Case Status screen in ECMS and use the date of the Health Physicist’s E-mail as the status effective date. The CE must ensure that a copy of the E-mail message (printed from the sent file in order to document the date of issue) is placed in the case file.
6. DOL has the responsibility to inform the claimant(s) that his/her dose reconstruction is undergoing additional review by NIOSH. When the DO is notified that the case will be referred to NIOSH for rework, the CE must complete the following within three workdays. The CE must forward the amended NRSD as an electronic attachment via E-mail to the Public Health Advisor (PHA) at NIOSH assigned to the DO. The CE must send a letter to the claimant, using Attachment 1 as a model, explaining that the case has been returned to NIOSH for a review of the dose reconstruction. The CE must include in the body of the letter the reason that the case is being returned to NIOSH. The CE must send a copy of this letter to the Public Health Advisor at NIOSH assigned to the DO along with the weekly district office submissions to NIOSH. The dates on the amended NRSD and the letter to the claimant must both be the same, since this will be the date used for the new NI entry into ECMS (discussed below).
The CE does not need to return the entire case file to NIOSH. NIOSH will generally require no more than 60 days to complete the rework of the DR. For example, where only the diagnosis date changes, NIOSH should be able to complete the rework in much less than 60 days. Alternatively, for cases where the ICD-9 code changes, it could result in a major rework of the DR. After the new draft DR report is completed, NIOSH will send it to the claimant along with another OCAS-1 form. The claimant has up to 60 days to return the signed OCAS-1 form.
7. The Sr. CE, supervisor or other approved person in the DO will enter a new NI code on the ECMS Claim Status screen to signify that a case has been returned to NIOSH for review of the DR. The status effective date is the date on the letter that is sent to the claimant. When the new dose reconstruction report is received, the Sr. CE, supervisor or other approved person in the DO must enter a new NR code on the ECMS Claim Status screen using the date the new DR report is received in the DO as the status effective date.
8. The DO NIOSH liaison must notify the DEEOIC Health Physicist by E-mail when the DR report is received in the DO. This will allow the DEEOIC Health Physicist, who tracks the progress of DR reworks, to be aware of the completion of the rework.
9. Sometimes when a case is at NIOSH, it may require additional claims development by the CE. This additional development may be requested by NIOSH or DOL. When NIOSH places a file in “pending status” it does not stop the process, but may delay the DR completion. The action of placing a case in “pending status” alerts the NIOSH staff that clarification is needed on a specific issue that may affect the case.
A supervisor, Sr. CE, and the DO NIOSH liaison are the only people that can place or remove a “pending status” for a case at NIOSH. For cases that are not prompted by NIOSH, the supervisor, Sr. CE, or the DO NIOSH liaison must send an E-mail to the DO’s PHA (with copies to the other two DO individuals) with a request that NIOSH place the case in “pending status” while DOL develops the case for additional information. The supervisor, Sr. CE, or the DO NIOSH liaison must provide a brief explanation of the specific information the DO is attempting to clarify or obtain, e.g., employment, medical, smoking or race/ethnicity questionnaire, etc.
On receipt of the development information, DOL personnel must follow the procedures for preparing and forwarding an amended NRSD, as necessary, as discussed earlier. The supervisor, Sr. CE, or the DO NIOSH liaison must notify the appropriate PHA (with copies to the other two DO individuals) by E-mail to remove the case from “pending” status.
Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.
PETER M. TURCIC
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections