EEOICPA BULLETIN NO: 13-03

 

Issue Date:        June 5, 2013

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Effective Date:    October 1, 2013

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Expiration Date:   October 1, 2014

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Subject:  Authorizing Durable Medical Equipment

 

Background:  The Energy Employees Occupational Illness Compensation Program Act (EEOICPA or Act) provides for medical benefits to covered employees.  Specifically, 42 U.S.C. §7384s(b) and §7385s-8 provide that a covered Part B or Part E employee shall receive medical benefits under §7384t of the EEOICPA.  Section 7384t(a) states: “The United States shall furnish, to an individual receiving medical benefits under this section for an illness, the services, appliances, and supplies prescribed or recommended by a qualified physician for that illness, which the President considers likely to cure, give relief, or reduce the degree or the period of that illness.”

 

Durable Medical Equipment (DME) is primarily used to serve a medical purpose. Some examples of DME include hospital beds, walkers, wheel chairs, and oxygen equipment.

 

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is responsible for ensuring that employees with an accepted illness under the EEOICPA receive the necessary medical care, including DME as appropriate for that illness.  This bulletin provides the procedures for authorizing DME and and replaces any previous guidance given in PM Chapter 3-0300, Ancillary Medical Services and Related Expenses. 

 

References:  42 U.S.C. §7384s, §7384t, §7385s-8

 

Purpose:  To provide procedures for authorizing DME and converting rental DME items to purchases.

 

Applicability:  All staff.

 

Actions:

 

1.  All requests for the rental and/or purchase of DME must be reviewed for medical necessity and require pre-authorization by the Claims Examiner (CE) assigned to the case file.  The claimant, the authorized representative, the treating physician, or a DME supplier may submit requests for the approval of DME to the DEEOIC bill processing agent (BPA) via fax, mail, or electronically for the authorization process to begin.  If any requests are received in the District Office (DO), the CE forwards the request for approval of DME to the DEEOIC BPA.  The CE is to document telephone requests for approval of DME in the phone call section of the Energy Compensation System (ECS).  The CE advises any such callers that their request must be in writing, and that the request must be submitted to the DEEOIC BPA via fax, mail, or electronically for the authorization process to begin.  Moreover, the CE provides the caller with a verbal description of the medical evidence the DEEOIC requires with the request.

 

2.  The BPA creates an electronic record of the request and initiates an electronic communication (referred to as a “thread”) to the fiscal officer (FO) at the district office where the claimant’s case file resides.  The thread from the BPA advises the FO of a pending request for the rental/purchase of DME. Upon receipt of the thread from the BPA, the FO forwards the information to the appropriate CE for review and adjudication.

 

3.  The treating physician is to prescribe and clearly identify the need for the DME.  Along with the signed prescription from the treating physician, the requestor must submit a letter of medical necessity (LMN).  The LMN is the written explanation from the treating physician describing the medical need for the DME to assist the claimant with regard to the treatment, care, or relief of the accepted work related illness or illnesses.  The narrative of the LMN must clearly identify the type of equipment that is being requested; it must demonstrate why the equipment is medically necessary for the accepted condition; and it must clearly state the duration of use for the DME.  Additionally, the requestor is to submit any supporting documentation substantiating the medical need for the requested service (i.e. medical reports, prescriptions, therapy reports, diagnostic reports, etc.).

 

Finally, to fully process the request for authorization, the requestor is to provide the following:

 

·        Claimant information such as name, case file number, date of birth, and telephone number.

·        Provider or vendor information such as name, provider address, ACS provider number, tax id number, national provider identification number, telephone number, and fax number.

·        Treating physician contact information such as name, address, telephone number, and fax number.

·        DME information such as HCPCS/CPT, modifier, quantity, purchase price and rental price, total cost, begin date, end date, and duration of use.

·        Diagnosis code for the accepted condition for which the DME is being prescribed.

 

Note: The DEEOIC will not reimburse for any customizations to the standard DME that the physician has not prescribed, and for which there is no clear and convincing medical rationale supporting the request.

   

4. The CE reviewing a DME request is to first consider the authorization for rental rather than purchase.  In most situations, the DME rental is the preferred choice for supplying the requestor with equipment necessary to treat an accepted illness or illnesses.  The assigned CE may authorize the rental of DME for up to 6 months if supported by medical evidence. Refer to Item #10 for the process on considering DME purchases.  

 

5. When the CE receives a request for authorization of DME that is accompanied by a signed prescription, LMN, and any other appropriate medical evidence, the CE prepares a decision letter to the claimant authorizing the DME (Attachment 1). The CE sends a copy of the approval letter to the supplier designated by the claimant. The approval letter is to include the following information:

 

a.  Covered medical condition for which the DME is approved.

b.  Authorized billing code(s) relevant to the approval.

c.  Time period (dates) during which the DME rental is authorized.

d.  Statement advising that fees are subject to the OWCP fee schedule.

e.  Statement advising that if the rental is converted to a purchase, the purchase reimbursement price will be less the paid rental price.

 

Upon completion of the approval, the CE sends an email to the FO, who prepares and sends a thread to the BPA, authorizing the DME. 

 

The CE also creates a correspondence entry in the Correspondence screen of ECS, documenting the issuance of the decision letter approving the DME. Refer to the Correspondence procedures in the ECS folder found on the shared drive for instructions on documenting the approval (i.e., Z:\Policies and Procedures\ECS\ECS Procedures).

 

Finally, since reauthorization for rentals is required every 6 months, the CE is to enter a reminder in ECS that reauthorization may be needed. The reminder should be set for 30 days prior to the expiration date for which services have been authorized. If additional authorization of the DME rental is not needed, the CE sends a letter to the DME supplier, with a copy to the claimant, notifying the supplier of the expiration date of the rental for DME.  However, if an additional request for the ongoing rental of the DME is received, the CE evaluates the request as outlined in this bulletin. Refer to the DO ECS Users Manual found in the ECS Training folder on the shared drive for instruction on setting reminders in ECS (i.e., Z:\Policies and Procedures\ECS\Training). 

 

6. When the CE receives a request for authorization of DME that is unaccompanied by a signed prescription, LMN, or any other required supporting documentation, the CE begins development.  The CE sends a letter to the claimant advising that the district office has received a request for DME, but without the required supporting documentation.  The development letter to the claimant clearly describes the medical documentation needed to support the request, or any other information as listed in Item #3 above, and grants the claimant 30 calendar days to provide the requested information.  The CE also notifies the claimant that a lack of response or submission of insufficient evidence will result in a denial of the request.  The CE documents this request through correspondence in ECS. The Correspondence procedures in the ECS folder on the shared drive provide instructions on recording the development of requests for authorization of DME (i.e., Z:\Policies and Procedures\ECS\ECS Procedures). A sample development letter can be found in Attachment 2.

 

7.  If the CE receives the appropriate medical evidence within the 30-day development period, the CE prepares a decision letter to the claimant authorizing the DME. Refer to Item #5 for the process on approving DME.

 

8. If, after 30 days of development, and upon review of the evidence, the CE determines there is insufficient evidence to warrant either initial authorization or reauthorization for the rental of DME, the CE sends a letter-decision to the claimant.  The letter-decision is to include a narrative explanation as to why the evidence is insufficient to warrant authorization.  The CE is to send a copy of the letter-decision to the provider, if applicable.  The letter-decision must include the following language:

 

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.

 

Upon issuance of the denial letter, the CE creates correspondence in ECS documenting the issuance of the decision letter denying the rental/purchase of DME.  The Correspondence procedures in the ECS folder found on the shared drive provide instruction on documenting the denial of DME (i.e., Z:\Policies and Procedures\ECS\ECS Procedures).

 

Upon completion and mailing of the letter, the CE sends an email to the FO denying the request for the rental/purchase of DME. The FO then transmits this information via thread to the BPA.

 

9. Should the claimant request a recommended decision (RD) regarding denial of either the initial authorization or reauthorization of the rental/purchase of DME, the CE completes the RD process in accordance with existing DEEOIC procedures found at PM Chapter 2-1600, Recommended Decisions.  In particular, the CE is to explain the basis for denial of any request for DME authorization.  Likewise, the Final Adjudication Branch (FAB) issues a final decision following the issuance of the RD.

 

10. The DEEOIC will authorize the purchase of DME in situations where the equipment or item cannot be rented. Items that should not be rented but considered for purchase instead include medical/surgical supplies (i.e. ostomy, injection, incontinence, dialysis, wound care, etc), canes, crutches, and commodes. 

 

The DEEOIC will also authorize the purchase of DME when the price to purchase that equipment or item is more cost effective than the rental price.  For example, if the price of renting a wheelchair is more than the cost to purchase it, the CE should approve the purchase of the wheelchair rather than renting it for the duration that it is needed.

 

However, if the DME purchase price is greater than $2000, the CE should obtain the following additional evidence:

 

a.  From the claimant. The claimant must submit two estimates from two different DME suppliers. These estimates must be for the exact same type of DME appliance.

 

b.  From the Supplier. From each potential supplier, a signed statement describing in detail the DME equipment item, a breakdown of all costs (including delivery and installation), and the current Healthcare Common Procedure System (HCPCS) code for each DME item.

 

When considering the purchase of DME, the CE is to use discretion to ensure that any authorization granted for the purchase of any DME satisfies the basic medical needs of the claimant.  Any request for DME that is driven by convenience, comfort, or other non-medical reason is not sufficient to grant authorization. 

 

Furthermore, situations may arise where the CE previously authorized the rental of a DME, then subsequently receives a request for authorization to purchase that same item. Under these circumstances, it may become necessary to convert the rental to a purchase.  If the CE receives a request for a purchase, and rental charges were paid for the same DME with no break in service between the rental period and the approved purchase period, and the provider who billed for the rental is the same as the provider requesting the purchase, the CE will need to contact the provider and request that the provider deduct the rental charges previously paid from the bill to be submitted for the item being purchased.

 

All post-purchase requests for reimbursement of DME will be reimbursed in accordance with the OWCP fee schedule.

 

11. If, at the end of (or any time during) the initial rental period, the CE receives a new request for the rental of DME, the CE must conduct a new evaluation of the request for medical necessity.  If the request is appropriate (prescription for the extended use of the DME and submission of updated letter of medical necessity), the CE is to consider the most cost effective approach when making the decision to reauthorize the extended rental of any equipment.  The CE must consider whether the cost to purchase the equipment minus the rental amount paid thus far is less than the total cost to authorize another 6 months of rental. If it is, then the CE should authorize the purchase of such equipment.

 

12. All DME must be rented and/or purchased from a DME supplier.  To be reimbursed, all suppliers/vendors must be enrolled as a licensed provider with the Bill Processing Agent.

 

13.  All bills for payment of DME must be submitted to the Bill Processing Agent. The OWCP fee schedule sets the reimbursement amount for the rental and purchase of DME.

 

14. The repair and maintenance of DME is reimbursable. Add-ons and/or upgrades to DME will be considered for approval in those cases where the evidence substantiates the medical need for the enhancement.  However, add-ons and/or upgrades to DME are not covered when they are intended primarily for the claimant’s convenience and do not significantly enhance DME functionality.

 

15. In emergency situations, the CE may authorize the rental of DME for a preliminary 30-day period while additional development is undertaken.  Under these circumstances, the claimant, the Authorized Representative, or the treating physician contacts the DEEOIC’s BPA for immediate attention.  The BPA obtains any pertinent documentation, as outlined in Item #3 above, and assesses the emergency nature of the request.  Once the BPA receives the medical evidence, 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.

 

a.  Upon receipt of the documentation, the FO forwards the information to the CE for review.  If medical documentation from the treating physician supports the need for immediate authorization, the CE provides approval for 30 days pending additional development.  The 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 him/her of an impending emergency request.

 

b.  After the initial approval for the 30-day rental period, the CE sends a letter to the treating physician (with a copy to the claimant) requesting necessary evidence to substantiate that the DME is medically necessary.  This should occur within the preliminary 30-day authorization period.  The CE may grant extensions in increments of 30 days, not to exceed a total of 6 months unless medical evidence establishes that the DME is medically warranted and necessitated by the accepted medical condition.

 

c.  In some situations, the request for authorization for the rental of DME may not be accompanied by evidence supporting the emergency nature of the request.  In these situations, the CE sends a letter to the claimant, with a faxed copy to the requestor if other than the claimant.  The letter is to contain information advising the recipient that no evidence was submitted to support the request for the rental of DME, and that additional medical evidence is required. In addition, the CE sends an email to the FO advising that the request for authorization of rental is under development.  The FO sends a thread to the BPA advising of this determination, and places a telephone call to the BPA, alerting him/her of an impending emergency request.

 

Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.

 

 

 

 

RACHEL P. LEITON

Director, Division of Energy Employees

Occupational Illness Compensation

 

Attachment 1

Attachment 2

 

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