Attention: This bulletin has been superseded and is inactive.
EEOICPA BULLETIN NO. 14-06
Issue Date: August 4, 2014
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Effective Date: August 4, 2014
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Expiration Date: August 4, 2014
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Subject: Authorization Adjustments for Home Health Care.
Background: The Energy Employees Occupational Illness Compensation Program Act (EEOICPA), specifies at 42 U.S.C § 7384t that 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.
Under this section of the Act, the the Division of Energy Employees Occupational Illness Compensation (DEEOIC) grants six-month authorizations for in-home health care when prescribed by a qualified physician and which the DEEOIC considers medically necessary because of an employee’s accepted work-related illness or injury. In certain claim situations, the DEEOIC may obtain new medical evidence that requires adjustment to a previously granted six-month home health care authorization. As a result, this guidance is necessary to ensure that claims examiners (CE) adjust existing home health care authorizations in a consistent and uniform manner.
References: 42 U.S.C 7384t; Federal (EEOICPA) Procedure Manual (PM) Chapters 2-0800 Developing and Weighing Medical Evidence, 2-1600 Recommended Decisions, 3-0300 Ancillary Medical Services and Related Expenses.
Purpose: To provide guidance to DEEOIC claims staff on processing adjustments to home health care authorizations.
Applicability: All staff.
Actions:
1. In those cases for which the DEEOIC has granted a six-month authorization for home health care, the CE may obtain new medical evidence that warrants an adjustment to the existing authorization. The medical evidence the CE receives may originate from sources such as the employee’s treating physician, a second opinion or referee medical examiner, or other qualified physician associated with the case record.
2. The medical evidence received after an existing period of authorization may require adjustments to the existing home health care authorization, including:
· Required skill level, i.e., Registered Nurse/Licensed Nurse Practitioner or Personal Care Attendant/Certified Nurse Assistant
· Service hours per day, days per week
· Specified service requirements
· Addition or removal of ancillary service personnel (hospice personnel, social workers, physical therapists etc.)
· Transfer to residential nursing or assisted living facility
Authorization adjustments may involve both home health care service level increases and decreases. Adjustments to an existing home health care authorization may only occur in situations where the CE assigns the weight of the medical evidence to the new evidence. This requires the CE to carefully evaluate and consider the totality of all evidence present in the case record relating to the employee’s medical need for home health care. Additional guidance regarding assessing the weight of the medical evidence can be found by referring to PM Chapter 2-0800, Developing and Weighing Medical Evidence.
3. Once an adjustment to an existing authorization is established based on the weight of the medical evidence, the CE is to mail a new written authorization to the claimant, and his or her home health care service provider. The written authorization is to include notification to the recipients that the existing authorization will change, effective 15 days from the date of the letter. The CE is to specify the effective date of the adjustment in the correspondence. The CE may authorize a six-month authorization at the new level of authorized home health care from the effective date of the adjustment.
4. With any adjustment that reduces the level or amount of home health care that the DEEOIC has previously authorized, the CE is to provide the claimant notice of his or her right to request a formal recommended decision should they object to the adjustment. The CE may refer to additional guidance regarding letter decisions that is contained in PM Chapter 2-1600, Recommended Decisions.
Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.
RACHEL P. LEITON
Director, Division of Energy Employees
Occupational Illness Compensation
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