EEOICPA BULLETIN NO. 03-02

Issue Date: June 5, 2003

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Effective Date: June 5, 2003

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Expiration Date: June 5, 2004

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NOTE: This bulletin replaces Bulletin 02-26, Referrals to Dr. Lee Newman.

Subject: Referring case files to the District Medical Consultants (DMC) for review.

Background: The Division of Energy Employees Occupational Illness Compensation (DEEOIC) has negotiated contracts with several physicians to fulfill the role of District Medical Consultant (DMC) for the district offices (DO).

The DMC’s role will be two-fold: 1) evaluating medical evidence and rendering medical opinions and 2) interpreting test results.

The District Director (DD) will designate an individual in each district office (DO) who will process and track the referrals and coordinate with Computer Sciences Corporation (CSC) to ensure prompt payment of the bills. For the purposes of this bulletin, this individual is called the Medical Scheduler.

The Medical Scheduler will be provided with a list of the DMCs, their addresses, telephone numbers, specialties and points of contact.

The DMCs are located in various states across the U.S. and the Medical Scheduler will make the referral selections based upon the DMC’s specialty.

Reference: EEOICPA Procedure Manual Chapter 2-300.9.

Purpose: To provide guidance on the procedures for referring case files to the DMC’s.

Applicability: All staff.

Actions:

1. Once designated, the Medical Scheduler creates and maintains a DMC file system that contains individual file folders labeled with the names of the DMCs.

2. Each time a medical review is completed, the Medical Scheduler places a copy of the report in the DMC’s folder.

3. CEs will refer claims to a DMC for medical review if they are unable to interpret medical evidence and have no success with obtaining clarification from the treating physician and/or have a specific question(s) on the medical evidence (PM Chapter 2-300.9). Examples of situations when a referral is needed may include:

Medical tests are submitted which do not provide a clear interpretation (i.e., pathology report, LPT, X-ray, CT scan).

Pre-1993 medical evidence is submitted that includes a lung biopsy report that is inconclusive.

When a CE identifies a claim for referral to a DMC, the CE must complete the District Medical Consultant Referral Form (Attachment 1) and include it in the front of the referral package described below. All referral packages to the DMC are prepared by the CE and given to the Medical Scheduler. The package must include the following information.

The CE completes all of the information required in Attachment 1 except for the section that provides the information on the DMC. The Medical Scheduler completes this portion of the form. The section concerning required medical information, e.g., X-ray or CT scan films, lists information that may be included for the review. The CE signs the form before forwarding it to the Medical Scheduler.

A cover letter to the DMC that includes a description of the billing specifications (See Attachment 2).

The Statement of Accepted Facts (SOAF) is a narrative summary of the factual findings in a case. The SOAF must include the claimant’s name and case file number; a detailed description of the claimant’s employment history; personal information, such as date of birth, date of death, etc.; exposure data, such as radiation, beryllium, silica; accepted condition(s); and any other diagnosed medical conditions. Additional medical information is contained in the medical evidence that is sent to the DMC, and need not be reiterated in the SOAF.

The CE must limit the questions to only those that address the particular issue or problem for which clarification is required. Questions to the DMC must not be general, but specific to each statutory requirement. For example, in a pre-1993 CBD claim, a general question is, "Based upon your review of the enclosed medical evidence, do you feel that the claimant had CBD?" Specific questions are, "Is the lung pathology consistent with CBD? Does the x-ray show characteristic abnormalities? Does the record show a clinical course consistent with a respiratory disorder?" In a claim for silicosis, specific questions are, "Is the CAT scan result consistent with silicosis?" or "Is the lung biopsy result consistent with silicosis?" In a cancer claim, a specific question is, "Based upon your review of the medical evidence of record and the pathology report, is there evidence of cancer? If so, please provide the specific cancer diagnosis and the date the cancer was diagnosed."

The Form HCFA-1500. The CE completes the following portions of the HCFA-1500 that will be sent in the package to the DMC: employee’s name, address, birth date, sex, and SSN. If the employee is deceased, the CE does not need to fill in the address. The CE also completes section 21 of this form by entering the code V49.8 and by entering the procedure code FR001 in section 24D. Lastly, the CE must also enter a 1 in section 24C (Type of Service) and a 1 in 24E (Diagnosis Code). (See Attachment 3)

· For the information discussed above, one copy of each must be sent to the DMC (except for Attachment 1) and one copy of each must be placed in the case file.

5. Upon receipt of the package from the CE, the Medical Scheduler compares the list of physicians provided on the District Medical Consultant Referral Form to the list of DMCs. If a DMC has already seen the claimant, the Medical Scheduler schedules the review with an alternate DMC.

6. When the Medical Scheduler receives the package from the CE, the Medical Scheduler ensures that all of the required documents listed in action number 4 above are included. The Medical Scheduler includes an express mail envelope and airbill and fills in his/her name and mailing address so that the physician can return the completed report and bill to the proper district office.

7. If the package from the CE is incomplete, the Medical Scheduler returns the package to the CE annotating the deficiencies in a memorandum placed on the front of the case file.

8. Once the package is complete and ready to forward to the DMC, the Medical Scheduler telephones the DMC and verifies that the DMC is available to perform the review. If not, the Medical Scheduler either determines when the DMC will be available or refers the package to a different DMC.

9. Once the package is mailed to the DMC, the Medical Scheduler notifies the CE, via email, so that the CE may enter the MS status code (sent to medical consultant) into the ECMS claims status screen. The status effective date for the MS code is the date on the letter from the Medical Scheduler to the DMC. The CE also enters the name of the DMC in the comments/notes field.

10. After entering the MS code, the CE enters a call-up note in ECMS for a 30-day follow-up on the referral. If the CE does not receive the narrative report and bill within 30 days from the date the request was mailed to the DMC, the CE notifies the Medical Scheduler. The Medical Scheduler will then follow-up with the DMC, by telephone, and obtain the date(s) of completion and mailing.

11. Upon completion of the review, the DMC completes sections 24 A, F, G; 25; 28; 30; 31; and 33 of the HCFA-1500. (See Attachment 4) The DMC returns the narrative report and the completed HCFA-1500 to the Medical Scheduler within 30 days.

12. The Medical Scheduler retains the original of the Form HCFA-1500 and a copy of the medical report and forwards the original medical report and a copy of the Form HCFA-1500 to the CE. The Medical Scheduler places a copy of the narrative report in the respective DMC folder.

13. Upon receipt of the narrative report and the copy of the HCFA-1500, the CE enters the MR status code (received back from medical consultant) into the ECMS claims status screen. The status effective date for the MR code is the date the report from the DMC is stamped "received" by the DO.

14. The CE uses the copy of the HCFA-1500 to enter the code V49.8 and the date(s) on which the DMC performed and completed the review (see item number 24A on Attachment 4). In some instances a claim may have more than one V49.8 code entered into ECMS. If the V code is not entered into ECMS, CSC will be unable to process the bill. The CE may shred the copied HCFA-1500 after the V code information is entered into ECMS.

15. The CE should take the following steps to complete the process of entering the prior approval code V49.8 into ECMS.

The CE must first access the case update screen.

The CE highlights any area in the "medical condition" box and presses the insert key. The next screen should have "medical condition (insert)" written at the top.

The CE must click the down arrow in the box next to "reported ind" and change the Y to N. Tab to the next field and click on the down arrow in the "cond type" field and select "PA-Prior Approval". Tab to the ICD 9 field and enter V49.8. Tab to the note field and enter the phrase, "Medical Records Review Conducted by Dr.{Enter the DMC’s Name}". Tab to the "cond status" field and select "A-Accepted". Tab to the "status effective date" and "elig end dt" fields and enter the dates listed in item 24A of the HCFA-1500.

Save the entries and close the record.

16. The CE reviews the report for accuracy and completeness ensuring that the narrative report includes a discussion of the following:

Interpretation of test results and medical reports submitted for review; and

Answers to each question posed.

17. If the narrative report is accurate and complete the CE notifies the Medical Scheduler, via email, so that the Medical Scheduler may approve the bill and forward it to CSC for processing.

18. If the report is deficient or requires clarification, the CE prepares a memorandum to the DMC requesting a second review. The CE advises the DMC of the deficiencies or item(s) that require clarification and requests that the DMC review the claim again and provide an addendum report that includes the deficient information.

19. In preparing the request for clarification, the CE must include:

A letter to the physician describing the deficiencies and any questions to be answered;

Copies of all the medical evidence; and

The SOAF.

20. Upon completion of the addendum package, the CE forwards it to the Medical Scheduler who prepares and mails the package to the DMC. The CE enters the DM status code (developing medical) into the ECMS claims status screen. The status effective date for the DM code is the date on the letter/memo mailed to the DMC. The Medical Scheduler will not approve the bill until all of the proper information is received from the DMC.

21. When reviewing the completed Form HCFA-1500, the Medical Scheduler ensures that the:

Billing hours and charges are appropriate. The maximum amount payable for a case review is $2,000.

Claimant’s name and SSN are correct.

The Federal tax ID number is entered (may use SSN or EIN).

Date of service is entered.

Form is signed by the DMC and includes his/her name and address.

Provider number is entered in item 33

22. If all the required information is included, the Medical Scheduler approves the bill by writing "APPROVED" in the top right hand corner along with his/her signature and date. The writing must not be placed over any relevant bill information. The writing should be in black ink only, no red ink. (See Attachment 4)

23. If the Form HCFA-1500 is not approved by the Medical Scheduler, CSC will return the bill for approval. Any bills with a "V code" (i.e., V49.8), must not be mailed to CSC without the appropriate approval as described in action number 22 of this Bulletin and as shown in Attachment 4. The CE must ensure that all the information shown on Attachment 4 is entered on the bill before forwarding to CSC. In some instances, the Medical Scheduler may have to contact the DMC to obtain the required information.

24. The Medical Scheduler forwards the approved HCFA-1500 to CSC. The mailing address for CSC is:

Energy Employees Occupational Illness Compensation Program

P.O. Box 727

Lanham-Seabrook, MD 20703-0727

25. Once CSC processes the bill, the DMC usually receives the payment within 9-14 days.

26. Any problems encountered when dealing with the DMC’s or a member of their staff should be reported to Anita Brooks at: abrooks@fenix2.dol-esa.gov. The email should include the name and number of the staff member and the DMC, the nature of the problem, any resolutions attempted, and any other relevant information.

27. If the CE receives a request from the claimant for a copy of the DMC’s report, the CE must attach a cover letter to the copied report which includes a disclaimer paragraph. For example, "Attached is a copy of the medical report that you requested. Please be advised that {Enter the DMC’s name} is a medical consultant for the Department of Labor. The Department of Labor will make the final decision in this claim. Please do not contact {Enter the DMC’s name} regarding this report. If you have additional evidence to submit in support of your claim or if you have any questions or concerns regarding this report, please contact me on {Enter the DO’s toll free number}."

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

PETER M. TURCIC

Director, Division of Energy Employees

Occupational Illness Compensation

Attachments

 

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

District Medical Consultant Referral Form

Employee’s Name

Case No.

Two (2) copies of a STATEMENT OF ACCEPTED FACTS and QUESTIONS TO THE DMC are attached. One copy of each should be mailed to the second opinion physician and one copy retained in the claimant’s file.

The following physicians have been involved with this case.

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Medical Condition(s) Claimed:

Name and address of DMC:

X-rays attached?

□ Yes □ No

Comments:

 

 

 

 

Provide specialist with:

□ Copies of medical reports □ Other (Specify)____________________________

Signature

 

 

District Office

Date

 

U. S. DEPARTMENT OF LABOR EMPLOYMENT STANDARDS ADMINISTRATION

OFFICE OF WORKERS’ COMPENSATION PROGRAMS

DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL

ILLNESS COMPENSATION

{STREET ADDRESS OF DO}

{CITY, STATE AND ZIP CODE OF DO}

{TELEPHONE NUMBER OF DO}

{Date}

File Number: XXX-XX-XXXX

Employee: {Name}

{Dr.’s Name and Address}

Dear Dr. _____:

Thank you for your willingness to participate in the Energy Employees Occupational Illness Compensation Program (EEOICP) as a medical consultant. Your role as a medical consultant will be to evaluate the medical evidence, interpret test results and render your medical opinion.

You are ensured payment by the Office of Workers’ Compensation Programs for services rendered. The enclosed package includes a copy of all the pertinent medical evidence from the case file, a Statement of Accepted Facts (SOAF) which presents a broad history of the case, and a list of questions to be addressed. In addition, I have enclosed an express mail envelope and airbill that you may use to return your report and bill.

Enclosed in this package is a Form HCFA-1500 with appropriate authorization codes. This form must be used to bill for your service. You need to complete sections 24 A, F, and G; 25; 28; and 30. Please provide your signature and date in section 31. Also, provide the information for section 33, including your Provider Number. If you have any difficulties completing the form, please contact me. Please return this form to me and be aware that the OWCP can not process payment until a report is received which addresses the particular questions being raised.

 

Please note that you should not release your report to the claimant or representative, but should instead refer any request for it to the DOL claims examiner.

If there are any questions or concerns, please contact me directly at the District Office on XXX-XXX-XXXX.

Sincerely,

 

{Medical Scheduler’s name and title}