Issue
Date:
Effective
Date:
________________________________________________________________
Expiration
Date:
________________________________________________________________
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
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:
Payment Systems Manager
DEEOIC
Room, C 4511
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:
Payment Systems Manager
DEEOIC
Room, C 4511
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