EEOICPA BULLETIN NO. 03-06

 

Issue Date:  November 6, 2002

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Effective Date:  November 6, 2002

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Expiration Date:  November 6, 2003

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Subject:  Claims Filed for Non-Covered Condition(s) and Claims Filed with No Reported Condition(s).

 

Background:  Recent analysis of denied claims has shown that more detailed information is required to definitively capture and report in the Energy Case Management System (ECMS) medical condition types on claims that are:

         

1.              denied due to lack of claimed medical condition; or

2.              denied due to lack of a covered condition.

 

With the exception of specific cancers, most non-covered conditions currently fall into the ECMS condition type of “Other Condition – not in table.”  The use of this “Other Condition” category obscures the types of conditions that are being recommended for denials in the District Offices.  Further definition is required.  To achieve this objective, more comprehensive condition types, which fall into the category of non-covered conditions, have been added to the condition type listbox in ECMS.

 

These codes are to be used at the outset of development by the Case Create Clerk (CCC) and Claims Examiner (CE) in order to help identify those claims that do not meet the criteria to receive compensation under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

 

Reference:  ECMS Frequently Asked Questions (FAQs).

 

Purpose:  To provide guidance to District Office personnel in capturing and updating medical condition data in ECMS.  To more clearly identify claims denied because no condition was ever claimed, claims denied due to non-covered conditions, and the frequency of conditions by type that are being denied as non-covered.   

 

Applicability:  All staff.

 

Actions:

 

1.              The CCC looks at all the conditions claimed on the EE-1 (Box 8) or EE-2 (Box 14) claim form and matches each covered and non-covered condition with a code from the listbox in the Cond Type field on the Medical Condition Screen. 

 

If no condition is reported on the EE-1 or EE-2, the CCC selects NR (no condition reported) from the listbox in the Cond Type field on the Medical Condition screen.

 

The ECMS Medical Condition Type listbox has been expanded (beyond covered and consequential conditions) to include specific non-covered medical condition types.  These additional condition types are identified in the table below.  If any of these conditions are reported on the EE-1 or EE-2 claim form, they are entered by the CCC as noted above.

 

CODE

Non-Covered Medical Condition Types

99

Other Condition - not listed in table

AN

Anemia

AS

Asbestosis

BK

Back or Neck problems

BT

Benign Tumors, Polyps, Skin Spots

BU

Burns

CL

CLL (Chronic Lymphocytic Leukemia)

CT

Cataracts

DI

Diabetes

HF

Heart Failure/ Heart Attacks/Hypertension

HL

Hearing Loss

HM

Other Heavy Metal Poisoning (e.g. chromium, cadmium, arsenic,  lead, uranium, thorium, and plutonium)

MC

Multiple Chemical Sensitivity

MP

Mercury Poisoning

NE

Neurological Disorder

NR

No condition reported

OL

Other Lung Conditions:  Bronchitis; Asthma; Pulmonary Edema

(except for RECA claims)

PD

COPD (Chronic Obstructive Pulmonary Disease); Emphysema

PK

Parkinson's Disease

PL

Pre-Leukemia (note:  review attached reference for specific conditions)

PS

Psychological Conditions

RN

Renal Conditions (kidney failure, kidney stones)

TH

Thyroid Conditions (e.g. Hypothyroidism)

 

 

2.              The CCC selects from the listbox any conditions shown on the claim form.  For example, if the illness claimed is hearing loss, the CCC selects HL from the listbox in the Cond Type field on the Medical Condition screen. 

 

 

3.              The CCC selects 99 (Other Condition – not in table) from the listbox if the reported condition does not appear in the listbox.  S/he also types the reported condition in the Note Text Field as it appears on the claim form.  For example, if the condition reported on the claim form is not in the listbox (e.g. cuts/bruises), the CCC selects 99 from the listbox and in the Note section s/he types “cuts/bruises.”

 

4.              If no condition is reported on the EE-1 or EE-2, the CCC selects NR from the listbox.

 

5.              The CE verifies the accuracy of the information entered by the CCC and makes changes as needed.  For example, if the claimed illness on the EE-1 or EE-2 is asbestosis and the Medical Condition screen shows that OL (Other Lung Condition) had been incorrectly entered as the Cond Type, the CE changes the claimed illness to AS (asbestosis).

 

6.              The CE updates the Condition Type field on the Medical Condition screen as new conditions are reported during case development.  The CE enters these updates as they occur. For example, recent medical evidence submitted by the claimant shows his/her physician is also linking COPD and multiple chemical sensitivity to his/her work exposure.  (The claim was originally filed for CBD.)  The CE selects the appropriate codes for COPD and multiple chemical sensitivity from the listbox in the Condition Type field on the Medical Condition screen.  The Claim screen would then show the three claimed conditions:

 

          BD   =    CBD

          PD   =    COPD

          MC   =    Multiple Chemical Sensitivity

 

7.              When the selection is made from the listbox for non-covered conditions (e.g. COPD and multiple chemical sensitivity) or no condition reported, the Medical Condition Status Field on the Claim screen defaults to the R (reported) status code.  This status code will not be changed by the CE to A (accept) or D (deny) as the A and D codes are exclusively reserved for covered conditions.  An A or D status code would never be used in conjunction with a non-covered condition.  

 

Note:  Only when a covered condition is claimed, does the CE develop the condition and determine whether the covered condition will be A (accepted) or D (denied).  The only time this procedure would not apply is the rare situation when benefits for a condition covered under the EEOICPA are not payable because the claimed condition could not have developed at the employee’s work site.  For example, if an employee worked at Savannah River and filed a claim for silicosis, the claimed condition, silicosis, would be considered a non-covered condition and the Medical Condition Status field would remain in the R status to indicate the condition is non-covered.

 

8.              ICD-9 codes should not be entered for non-covered conditions.

 

9.              Before a recommended decision is signed by a Senior Claims Examiner (SrCE), s/he must ensure that the recommended decision accurately cites all non-covered medical conditions claimed and that correct codes from the listbox have been entered into ECMS.  The SrCE is responsible for adding any conditions that were omitted (e.g. conditions that were reported after the initial entries were made by the CCC or while the CE processed the claim) or correcting any entries that were made in error (e.g. the condition was incorrectly identified). 

 

10.         If a claim was filed, but no medical condition was ever reported by the claimant, the SrCE ensures the recommended decision reflects this and that ECMS contains the NR code.

 

11.         Backfill of medical condition types for cases denied due to lack of a claimed condition or lack of a covered condition will be mandatory in all District Offices.  This backfill project will be completed through the National Office.   

 

Disposition:  Retain until incorporated into the EEOICPA Procedure Manual.

 

 

 

 

PETER M. TURCIC

Director, Division of Energy Employees

Occupational Illness Compensation

 

Distribution List No. 1: (Claims Examiners, Supervisory Claims Examiner, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections.)