U.S. Department of Labor - Office of Workers' Compensation Programs (OWCP) - Division of Energy Employees Occupational Illness Compensation (DEEOIC)

7. Requests need not come directly from the claimant to be considered a valid request. Requests for an in-home evaluation of a patient’s needs, and/or requests for in-home care can be initiated by an authorized representative, or any licensed doctor or medical provider.

8. Upon receipt of an authorization request for home health care from the BPA, the FO forwards the information to the appropriate POC CE for review and adjudication.

9. Upon receipt of such request, the POC CE must determine the particular home health services or care being requested. Generally, the types of requests that are submitted include: a physician’s request for authorization of an initial in-home assessment; discharge summary from a hospital requesting specific home health care services; or requests from a physician for continuing home health care services (following expiration of a previous authorization).

10. Upon receipt of a request, the POC CE reviews the medical evidence to determine if the initial assessment or home health care was requested by the treating physician. If the request comes from the treating physician, or another appropriate doctor, the POC CE approves the initial assessment only (if applicable). When an initial assessment request precedes a request for home health care, the POC CE may not approve home health care until after the initial assessment has been completed and a plan of care has been submitted. Once the POC CE approves the initial assessment, the POC CE sends an email to the FO, who sends a thread to the BPA authorizing the request (see action item 17 for more information concerning approvals).

11. Upon receipt of a plan of care, discharge summary, or physician’s recommendation delineating a specific request for home health care services, the CE must conduct a complete review of the case file to determine if there is any recent medical documentation from the primary care physician (or treating specialist for the accepted condition), describing the need for in-home medical care as it relates to the covered medical condition. The primary information that the treating physician must provide (often contained in the plan of care signed by a physician) should include:

(a) Description of the in-home medical needs of the patient arising from the covered medical condition. This includes a narrative of the patient’s medical need for assistance while in the home and how this is linked to the covered medical condition. The physician must describe the findings upon physical examination, and provide a complete list of all medical conditions (those accepted by DEEOIC and those not accepted by DEEOIC). If a claimant has one or more non-covered conditions, medical evidence must demonstrate how the requirement for home health care is related to the accepted conditions. The physician should also describe laboratory or other findings that substantiate a causal relationship between the accepted condition(s) and the need for assistance or skilled nursing care in the home. Generally, approved in-home services include: administration of medication, medical monitoring, bathing and personal hygiene, meal preparation and feeding, wound dressing changes, and medical equipment checks.

(b) Level of care required, i.e. Registered Nurse (RN), Licensed Practical Nurse (LPN), Home Health Aide (HHA), etc. The doctor must specify the appropriate type of professional who will attend to the patient. Services requiring specialized skills such as administration of medication and medical monitoring generally require a RN or LPN, while services of a general nature (typically referred to as activities of daily living), such as bathing, personal hygiene, and feeding are generally performed by home health aides.

(c) Extent of care required (months, days, hours, etc). A written medical narrative must describe the extent of care to be provided in allotments of time. (Example: RN to administer medication and check vitals once a day, every three days, with a home health aide to assist with bathing, personal hygiene, and feeding, eight hours a day, seven days a week for three months.)

12. If upon review the POC CE finds that the medical evidence is incomplete and the file does not contain an adequate description of the in-home health care needs of the patient, the POC CE prepares a letter to the claimant advising that the DEEOIC has received a request for in-home health care. In the letter to the claimant, the POC CE advises that additional medical evidence is required before services can be authorized. Additionally, the POC CE will direct a copy of the claimant letter to the treating physician, requesting a narrative medical report that includes all of the information described in action item 11 (above). In addition, the physician should be asked to estimate the length of time for which the patient will ultimately require home health care assistance. The POC CE advises in the letter that the medical report is required within 30 days. A sample letter to the claimant (and physician) is attached. (Attachment 1) The POC CE also faxes and mails a copy of the letter to the treating physician’s office. The POC CE enters code DM - Developing Medical into ECMS with a status effective date the date of the letter.

13. Upon mailing the request to the claimant (copy to the treating physician) the POC CE enters an ECMS note describing the action and inserting a 15-day call-up. If on the fifteenth day the physician has not responded, the CE contacts the physician’s office to inquire if the letter was received, and to ask if there are any questions regarding the request for information. The call is documented in TMS and another 15-day call-up inserted in ECMS.

14. After 30 days has passed with no satisfactory response from the treating physician, or no response from the claimant, the POC CE prepares a second letter to the claimant (accompanied by a copy of the initial letter), advising that following the previous letter, no additional information has been received from the treating physician. The POC CE advises that an additional period of 30 days will be granted for the submission of necessary evidence, and if the information is not received in that time, the request for in-home care may be denied by the DEEOIC (see Attachment 2 for a sample letter). The POC CE enters code DM – Developing Medical into ECMS with the status effective date the date of the letter.

15. If the claimant or the physician does not provide a response to the request for information within the 30-day period allowed, the POC CE issues a letter decision to the claimant denying the claim for in-home health care. (See action item 26 below for more details.) The POC CE further sends an email to the FO, who sends a thread to the BPA advising that the service has been denied.

16. If the claimant calls and states that he/she does not require in-home health care, the POC CE requests that the claimant put this in writing. Upon receipt of any written statement from the claimant stating that he/she is not requesting in-home health care, the POC CE writes a letter to the claimant with a copy to the treating physician advising that the claimant is not requesting in-home health care and thus the matter is closed. In this situation, the POC CE sends an email to the FO, who sends a thread to the BPA advising that this service is denied. The POC CE enters the code DM – Developing Medical into ECMS with the status effective date the date of the letter.

17. If medical evidence is received, the POC CE must determine if it is of sufficient probative value to authorize in-home health care. It is absolutely critical that the POC CE undertake appropriate analysis of any documentation pertaining to in-home services before authorizing such care. The underlying function of the POC CE is to ensure that the covered employee receives the necessary medical care for the accepted medical condition and that any such request for care reasonably corresponds with the medical evidence in the case file. If the physician does not provide sufficient details concerning the claimant’s physical condition, relationship to accepted conditions, or specific reasons for in-home health care, the POC CE must refer the case to a District Medical Consultant (DMC) for review. Upon receipt of a DMC’s opinion, the CE weighs the medical evidence in the file. If the DMC opinion is clearly in conflict with the recommendations of the treating physician, and the POC CE’s attempts to resolve the situation by communicating with the treating physician have not been successful, the POC CE is to arrange for a second medical opinion or referee evaluation, depending on the circumstances. (Refer to Procedure Manual 2-0300 for instructions regarding a second opinion examination or referee medical examination.) In evaluating the medical evidence, the POC CE must base any determination solely on the weight of medical evidence in the case file. The POC CE must not under any circumstances deny or reduce in-home health care services without a medical basis for such denial.

18. In certain emergency claim situations (see item 19 for a full discussion of the types of emergencies), the CE may authorize in-home health care for a preliminary 30-day period while additional development is undertaken.

(a) Under these circumstances, the physician or hospital staff will contact DEEOIC’s BPA for immediate attention. The physician or hospital employee must notify the BPA that the situation is of an emergency nature (i.e. the claimant is being released from the hospital and requires immediate in-home care). The BPA obtains any pertinent documentation and assesses the emergency nature of the request. Once the medical evidence is obtained, the BPA contacts the FO immediately, advising of the situation and providing electronic copies of documentation obtained. The BPA does not make a decision regarding the request, but simply obtains the pertinent documentation and advises the FO of the emergency request.

(b) Upon receipt of the documentation, the FO forwards the information to the POC CE for review. If discharge information from a treating physician supports the need for immediate authorization, the CE provides approval for 30 days pending additional development (see below for additional information concerning approval). The POC CE enters code DM – Developing Medical into ECMS with the status effective date being the date that a request letter is sent to the claimant. The POC CE concurrently sends an email to the FO advising of this approval. The FO sends a thread to the BPA with the approval information and places a telephone call to the BPA, alerting them of an impending emergency request.

(c) In some situations the request for emergency home health care may not be accompanied by evidence supporting the emergency nature of the request. For example, the claimant’s condition may be stable, or he/she is not being discharged from a hospital. In these situations, the POC CE sends a letter to the claimant, with a faxed copy to the requestor if other than the claimant. The letter advises that no evidence was submitted to support the request for emergency care, and that additional medical evidence is required. The POC CE enters code DM – Developing Medical into ECMS with the status effective date the date of the request letter. Further development actions are outlined below. In addition, the POC CE sends an email to the FO advising that the request for emergency care is under development. The FO sends a thread to the BPA advising of this determination and places a telephone call to the BPA, alerting them of an impending emergency request.

(d) After any initial approval for 30-day emergency care, it is very important that the POC CE undertake immediate action to obtain the necessary evidence to fully substantiate that the care being provided is medically necessary to give relief for the accepted medical condition. This should occur within the preliminary 30-day authorization period. Extensions may be granted in increments of 30 days, but should generally never exceed a total of 120 days without the collection of the necessary evidence to fully document that the care being provided is medically warranted and necessitated by the accepted medical condition.

19. Emergency situations warranting short-term preliminary authorization for in-home health care include:

· Requests for in-home health care for terminal patients with six months or less to live. Terminal status must be based on the opinion of a medical physician.

· Patients discharged from in-patient hospital care with need for assistance. The CE must carefully evaluate these situations to ensure the medical documentation clearly indicates that the patient’s care and well-being is dependent on the assignment of a medical professional in the home, (normally following a hospital stay). If the BPA has not already obtained this, the POC CE requests the attending physician discharge summary and discharge planning summary, which is normally available within 72 hours of discharge.

When pre-authorization of emergency in-home care is to be granted, the POC CE prepares a memorandum for the case file documenting the rationale applied in authorizing care. For each subsequent 30-day pre-authorization granted, a new memo should be prepared outlining the basis for such authorization. In addition, the POC CE notifies the claimant and provider in writing of additional periods of authorization. The POC CE sends an email to the FO advising of any authorizations, and the FO forwards the information to the BPA in the form of a thread.

20. For all requests, if upon review of the medical evidence the POC CE decides that in-home health care is required, authorization is to be granted. The POC CE prepares a letter notifying the claimant and the home health care provider of the decision, and delineating the following information (see Attachment 3 for a sample authorization letter):

(a) Covered medical condition(s) for which care is being authorized.

(b) A specific narrative description of the service approved (e.g. in-home assistance in administering medicine, monitoring accepted conditions, assistance in/out of bed, preparing meals and feeding, and medical equipment checks).

(c) Level and duration of the specialized care to be provided, i.e. RN 1 hour per day and Home Health Aide 8 hours per day, 7 days a week for a period of 3 months.

(d) Authorized billing codes relevant to the level of authorization (see Attachment 4 for a description of the pertinent codes).

(e) Period of authorization with specific start and end dates.

21. The authorization must be limited to in-home medical services that are reasonably necessary for the treatment or care of the patient’s covered medical condition. These services generally include: Home Health Aide for mobility, food preparation, feeding and dressing; skilled nursing should be limited to the scope of practice of an RN or LPN, as long as there is medical evidence of such. The POC CE may not authorize a lower level of care than that requested by the physician unless the weight of medical evidence supports a lower level of care and the claimant has been provided the right to a recommended decision (see below for further discussion).

22. Once the responsible POC CE sends the letter of authorization to the claimant and the provider, the POC CE prepares an email to the fiscal officer (FO). In the email, the POC CE advises the FO of the precise level of care, billing codes, and time period of authorization. The POC CE is not required to advise the FO of the number of correlating units per billing codes. In assigning billing codes, the POC CE references Attachment 4.

23. Once the email authorizing the services has been sent, the POC CE enters a note into ECMS detailing the level of service and time period of authorization. In addition, the POC CE enters a call-up note into ECMS for 30 days prior to the expiration date for which services have been authorized.

24. If no request for additional authorization for home health care is received prior to the date of the call-up, the POC CE sends a letter to the provider, with a copy to the claimant. In the letter, the provider is notified of the expiration date of the home health care services. The provider is further advised of the medical evidence required if additional services are necessary. The POC CE enters code DM – Developing Medical in ECMS with a status effective date the date of the letter. If the POC CE does not receive an additional request, further action is unnecessary. However, if the provider or the claimant submits an additional request for ongoing services, the POC CE evaluates the evidence as above.

25. Upon receipt of the email authorization from the POC CE, the FO prepares a thread to the BPA authorizing the specific level of care, billing codes (with units), and period of authorization. The FO calculates the authorized number of units based upon the POC CE’s description of the level of care, weekly authorized amount for each level of care, and the time period of authorization.

26. If upon review of the medical evidence in the file, and if after appropriate development as outlined above, the POC CE determines that there is insufficient evidence to warrant authorization of in-home health care, the POC CE sends a detailed letter-decision to the claimant (with a copy to the in-home provider). The letter-decision must include a sentence at the end with language as follows:

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

Once the letter is written, the POC CE enters code DM – Developing Medical, with a drop down code of DMB - Deny Specific Med Benefits on Accepted Conditions. The status effective date is the date of the letter.

27. In the event that the claimant does request a recommended decision, a sample decision is attached for the CE’s use (Attachment 5). Once the Recommended Decision is written, the POC CE enters code D7 – Rec Deny, Medical Insufficient to Support Claim with a drop down code of DMB – Deny Specific Med Benefits on Accepted Conditions. The status effective date is the date of the decision. If the Final Adjudication Branch (FAB) issues a final decision to deny, the FAB hearing representative enters the code F9 – Fab Affirmed – Deny – Medical Info Insufficient to Support Claim with a drop down code of DMB – Deny Specific Med Benefits on Accepted Conditions.

28. At any time after a period of authorized services, and after the POC CE has undertaken any medical development (i.e. letter to the claimant requesting additional documentation, referral to DMC or second opinion) the POC CE may receive new medical evidence that warrants a change in the level of in-home care currently authorized. If this occurs, the POC CE must review that evidence, employing the same decision-making process described in action item 17. If the new medical evidence supports a denial of services, or reduction in the level of services currently being authorized, that reduction or denial must be communicated to the claimant in a detailed letter as discussed in action item 26, (with a copy to the in-home care provider) explaining the change.

29. Letters that advise of a reduction or termination of services must be copied to the in-home care provider and must specifically advise the claimant that:

(a) Any reduction in the current level of service being provided will occur 15 days from the date of the letter. This letter must also contain the same information as is delineated in action item 20, describing the new level of care being authorized; or,

(b) Any termination of services will occur 30 days from the date of the letter.

30. After the expiration of the 15 or 30 day periods, the POC CE sends a letter-decision to the claimant advising as to the final action taken on the request for home health care services. In this letter the POC CE advises the claimant of his/her rights of action as delineated in action item 26 above. In the event of a termination of services, the POC CE enters the same codes into ECMS as described in action item 26 (corresponding with the letter decision). In the event of a reduction in benefits, the POC CE enters code DM – Developing Medical with a drop down code of RMB - Reduce Medical Benefits on Accepted Conditions. The status effective date is the date of the letter decision.

In addition, the POC CE sends an email to the FO advising of the new level of care or the termination of current level of services. The FO then sends a thread to the BPA advising of the determination. It is very important for the POC CE to note that only a single authorization can exist at any one time. If the POC CE has authorized a certain level of care that subsequently changes, it is essential that this information be clearly communicated in an email to the FO. The FO sends a thread to the BPA advising of any change in the level of care being authorized, or of any additional period of authorization beyond the existing expiration date. The POC CE must also document the information in the notes section of ECMS when a thread is sent to the BPA.

31. If the claimant requests a recommended decision on a termination of services, the POC CE proceeds with a recommended decision and codes ECMS pursuant to instructions in action item 27. If the claimant requests a recommended decision on a reduction in the level of care, the POC CE proceeds with a recommended decision. The POC CE enters code D7 – Rec Deny, Medical Insufficient to Support Claim with a drop down code of RMB - Reduce Medical Benefits on Accepted Conditions. The status effective date is the date of the recommended decision. If the final decision of the FAB is to reduce the medical benefits, consistent with the recommended decision, the hearing representative enters code F9 – FAB Affirmed – Deny – Medical Info Insufficient to Support Claim with a drop down code of RMB - Reduce Medical Benefits on Accepted Conditions. The status effective date is the date of the final decision.

32. If, after initial approval of services, the claimant’s treating physician sends in medical documentation (without prior POC CE development) recommending a lower level of care, the POC CE authorizes the new level of care via letter to the claimant (with a copy to the provider). Since the new level of care is requested by the treating physician without development by the POC CE, the POC CE does not need to provide the claimant with a right to a recommended decision. The POC CE concurrently sends an email to the FO advising of the new level of care. The FO sends a thread to the BPA advising of this change.

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, and District Office Mail & File Sections