[DATE]

 

[COMPANY NAME]

[ADDRESS]

 

RE : [CLAIMANT’S NAME]

Case # : XXX-XX-XXX

 

Dear [NAME FROM LETTER],

 

You have advised the Department of Labor’s Office of Workers’ Compensation Programs (OWCP), Division of Energy Employees Occupational Illness Compensation (DEEOIC) that it may be the responsible payer for costs incurred by [COMPANY NAME] on behalf of [CLAIMANT’S NAME]. 

 

The Privacy Act covers Department of Labor records concerning claims filed under the Energy Employees Occupational Illness Compensation Programs Act (EEOICPA). However, we are authorized to release information to medical insurance or health welfare plans for the purpose of coordinating benefits.  As your inquiry relates to the coordination of benefits, we are able to inform you of the medical conditions for which we are the responsible payer.

 

[CLAIMANT’S NAME] has filed a claim under the EEOICPA, which has been accepted.  The Department of Labor is responsible for reimbursement and/or payment of authorized medical expenses incurred for the following covered medical conditions and associated ICD 9 codes:  

 

ICD-9: [ENTER ONE OR MORE APPROVED MEDICAL CONDITION]

Status Effective Date: [ENTER STATUS EFFECTIVE DATE FOR EACH]

 

To request reimbursement for medical expenses associated with the covered medical conditions, you must be an enrolled provider with OWCP. Enrollment information can be obtained by contacting our medical bill payment contractor at 1-866-272-2682 or visiting http://owcp.dol.acs-inc.com/portal/main.do. 

 

 

Once enrollment is complete, and you have been assigned a provider number, all reimbursable charges, including a copy of the original bill and proof of payment, may be submitted to the address below:

 

U.S. Dept. of Labor

OWCP/DEEOIC

P.O. Box 8304

London, KY 40742-8304

 

Reimbursement may only be sought for treatment costs relating to a condition that has been accepted under the EEOICPA.  Costs relating to the care of any other medical condition are not the responsibility of OWCP.

 

If you have any questions regarding the contents of this letter, please contact OWCP/ DEEOIC at the address listed above; or call [DISTRICT OFFICE PHONE #].

 

Sincerely, 

 

 

 

Claims Examiner

District Office