EEOICPA BULLETIN NO. 04-05

 

Issue Date:   November 13, 2003

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Effective Date: November 7, 2003

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Expiration Date:  November 13, 2004

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Subject: Medical documents received from the medical bill pay contractor.

 

Background: The Division of Energy Employees Occupational Illness Compensation’s medical bill processing contractor, currently Computer Sciences Corporation (CSC), is responsible for educating and enrolling providers in the Energy Employees Occupational Illness Compensation Program (EEOICP) and processing medical bills for services related to the accepted condition(s). Please consider future references to CSC in this Bulletin to be generic references to DEEOIC’s medical bill pay contractor. CSC’s responsibilities include processing all routine medical bills, consequential conditions, and prior approvals (i.e. fees related to copies of medical records required prior to acceptance of the claim, bills from District Medical Consultants or second opinion physicians, costs related to special medical devices or services, and travel reimbursements). Many times medical documents accompany the bills that are sent to CSC which need to be incorporated into the beneficiaries’ case files.

 

CSC has been authorized to pay for services related to metastatic cancers.  Metastatic cancers or secondary cancers develop as a result of the natural course of the primary cancer and are not considered consequential conditions.  CSC routinely pays for most metastatic cancers and therefore until now the new accepted conditions have not been entered into the Energy Case Management System (ECMS).  In addition, beneficiaries have not been advised that the metastatic cancers have been accepted.

 

As of November 12, 2003, CSC will begin forwarding copies of all medical documents (i.e. lab reports, pathology reports, hospital discharge summaries, physician summaries) to the office where the file is located, for integration into the case file.  A cover memo from CSC outlining the required actions for the DO/FAB/NO, along with supporting medical documentation, will be submitted on a weekly basis. 

 

Purpose:  To provide procedures for processing medical documents and paid metastatic cancers submitted by the medical bill processing contractor.

 

Applicability:  All Staff

 

Action:

 

1.         On a weekly basis the DO/FAB/NO will receive a package from CSC that includes a memo and corresponding medical documents for each beneficiary.  Upon receipt of the package from CSC, the mailroom staff must process the package according to procedures outlined in PM 1-200 (date stamp each memo and attached document(s) with the appropriate receipt date). The mailroom staff must review the name and case file number on the CSC memo(s) (Attachments 1 and 2) and forward the memo(s) and attached medical documents to the appropriate CE. 

 

If a package or memo for a specific employee is sent to the DO in error, the mailroom staff must identify and forward the documents to the appropriate DO/FAB/NO office. 

 

2.  One category of medical documents, (i.e. hospital discharge summaries, physician summaries, pathology reports, radiology reports) forwarded by CSC ONLY require filing into the case file. These documents will be accompanied by a memo (Attachment 1) which informs staff that the documents are informational and no action is required (other than filing the information in the case file).

 

These medical documents usually pertain to conditions that have already been adjudicated and accepted by DEEOIC. In many cases, the payment of claims by CSC is straightforward; therefore, further development is not required by the DO/FAB/NO.

 

The CE must ensure the medical information is filed in accordance with the procedures outlined in PM Chapter 1-300 and 1-400.

 

3.  The second category of medical records received by the CE pertains to the payment and acceptance of metastatic cancers by CSC.  CSC is authorized to make a determination (based on medical documents or other resources) to accept and pay for the services related to the metastatic cancer.  In these cases, CSC will forward information pertaining to the paid bill via a cover memo (Attachment 2) which includes the name of the employee, the case file number, the accepted metastatic cancer (primary and or metastatic cancer), the corresponding ICD-9 code(s), and the diagnosis date, if available.  The memo will discuss CSC’s justification for payment of the bill and include copies of the medical document(s) or bill(s) which prompted the decision.

 

If the CE receives the memo and attached medical documents that discuss CSC’s payment of a metastatic cancer, he/she accepts the metastatic cancer as an accepted condition under the Employee Medical Condition Screen in ECMS. The CE must select “MT” (Metastatic Cancer) as the Condition type and enter the ICD-9 code provided on the memo from CSC in the ICD-9 field of ECMS.  The CE must also enter the appropriate Status Effective Date in the Status Effective Date field which is the date of first manifestation of the metastatic cancer, and an “A” (Accepted) in the Condition Type Status field of ECMS.  [Note: the medical condition type “QN” (Consequential Condition, Neoplasm) must not be used for a medical condition type of metastatic or secondary cancers.]

 

The use of the date of first manifestation as the status effective date allows the DEEOIC to pay for bills related to the diagnosis of the secondary cancer, which otherwise may be denied by the medical bill processing contractor.

 

When determining the appropriate diagnosis date for the Diagnosis Date field of ECMS, the CE must use the date provided by CSC on the cover memo.  If no date is provided, the CE reviews the medical information submitted by CSC and or the medical information in the employee’s case file to determine the appropriate diagnosis date for the metastatic cancer.  If no date is provided, the CE must use the diagnosis date of the primary cancer.  In some instances, a claim may be accepted for more then one primary cancer, therefore, the CE must review CSC’s memo to determine the appropriate primary cancer.

 

If the primary cancer site is undetermined the secondary or metastatic cancer may be the cancer accepted by the program based on the medical evidence and dose reconstruction results from the National Institute for Occupational Safety and Health (NIOSH) supporting a probability of causation of 50% or greater.  In these situations, during the adjudication process or when updating ECMS based on information received by CSC, the CE must enter the appropriate ICD-9 code reflecting a secondary or metastatic cancer condition as an accepted primary cancer.  The ICD9 range for metastatic cancers is 196-199.9.  The CE must enter the acceptance code “A” as the condition status and “MT” as the condition type under the Medical Condition Screen in ECMS. If the CE fails to enter an appropriate Metastatic ICD9 code, ECMS will recognize the error and will not transmit the medical eligibility file to CSC for medical benefits.  

 

Note— The CE must ensure that DEEOIC has accepted a cancer prior to entering the acceptance of the metastatic condition “MT” in ECMS.  In addition, the CE must ensure that metastatic bills paid by CSC are indeed metastatic cancers and fall within the appropriate ICD9 range (196-199.9). If the CE determines that a cancer has not been accepted or the cancer does not fall within the appropriate range, he/she must notify the medical bill pay contractor.  The CE sends a copy of CSC’s memo, copies of accompanying documents, and a memo signed by the CE and his/her supervisor (i.e. Senior Claims Examiner or Unit Supervisor) outlining the issues and notifying CSC to suspend all payments related to this condition until the discrepancy can be resolved to:

 

              Frank James  

              Payment Systems Manager

              DEEOIC

              200 Constitution Ave, NW

              Room, C 4511

              Washington, DC  20210

 

A supervisor (i.e. Senior Claims Examiner or Unit Supervisor) must review the CSC memo, case file and issues presented by the CE in order to determine if the memo is justified. If so determined, his/her signature must be reflected on the memo.

      

4.   The CE must communicate the acceptance of the metastatic cancer to the beneficiary (Attachment 3).  The eligibility date for medical benefits related to the accepted condition is the status effective date. 

 

5.   If at anytime the CE has questions pertaining to a metastatic cancer bill paid by CSC, or disagrees with CSC’s decision to accept the cancer, the CE must send a copy of CSC’s memo, copies of accompanying documents, and a memo signed by the CE and his/her supervisor (i.e. Senior Claims Examiner or Unit Supervisor) outlining the issues to:

 

Frank James

              Payment Systems Manager

              DEEOIC

              200 Constitution Ave, NW

              Room, C 4511

              Washington, DC  20210

 

Disposition:  Retain until incorporated into 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, ADP Branch Chief and Payment Systems Manager

 

Attachment 1: Memo for CE from CSC - Informational Only

Attachment 2: Memo for CE from CSC - Metastatic

Attachment 3: Metastatic Cancer Letter