TABLE OF CONTENTS

 

 

Paragraph and Subject                 Page  Date   Trans. No.

 

Chapter 1-0300 Case Creation

     

      Table of Contents. . . . . . .  i     05/15   15-01 

  1   Purpose and Scope. . . . . . .  1     05/15   15-01

  2   New Cases. . . . . . . . . . .  1     05/15   15-01 

  3   Receipt of a New Claim . . . .  1     05/15   15-01

  4   Case Assignments . . . . . . .  3     05/15   15-01

  5   Creating Cases in Energy

       Compensation System (ECS) . .  3     05/15   15-01 

  6   Claims Examiner Review . . . .  4     05/15   15-01

  7   Creating a Claim under Part B

         Vs. Part E, or Both . . . .  5     05/15   15-01

  8   New Claims in Existing Cases    7     05/15   15-01 

  9   Withdrawal of a Claim . . . .   8     05/15   15-01

 

Exhibits

 

  1   Letter of Acknowledgement . . .       05/15   15-01

  2   ECS Change Request                    05/15   15-01

 


1.   Purpose and Scope.  This chapter describes the role of the Resource Center (RC), Central Mail Room (CMR), district office, and Final Adjudication Branch (FAB) in the case creation process.  In addition, the chapter covers the process of creating an Energy Employees Occupational Illness Compensation Program Act (EEOICPA) case file electronically in the OWCP Imaging System (OIS) and Energy Compensation System (ECS). The chapter contains instructions for deciding whether a new claim is considered filed under Part B and/or Part E of the EEOICPA.  Finally, the chapter provides guidance regarding the proper handling of additional claims received during claim adjudication and the handling of withdrawn claims.

 

2.   New Cases.  A new case usually consists of a Claim for Benefits, Form EE-1 or EE‑2, with the accompanying Form EE‑3, Employment History for a Claim Under the EEOICPA. A new case is created based on a signed written communication from the claimant; a claimant’s authorized representative (AR), or a person acting on behalf of the claimant (e.g., a relative or guardian).  Any one of the following documents is considered a request for benefits:

 

a.   Form EE-1, Employee’s Claim for Benefits;

 

b.   Form EE-2, Survivor’s Claim for Benefits; or

 

c.   Any letter or document containing “words of claim” under the EEOICPA. “Words of claim” means that the individual has communicated in writing his or her intent to seek benefits under the EEOICPA.

 

3.   Receipt of a New Claim. Designated staff at the Division of Energy Employees Occupational Illness Compensation (DEEOIC) district office or RC take new claim documentation, including the postmarked enveloped used to mail a claim form, and affix an inked date stamp on all documents. The date stamp is to identify the receiving office location and received date. Once date stamped, CMR contract staff then make an electronic image of the documents and upload them into the Energy Document Portal (EDP), which goes directly into the Case Create Queue in OIS. The CMR then send a notification to the Centralized Case Create (CCC) office of their action. The EDP also allows claimants, their attorneys, Authorized Representative, family members, etc. to upload claim documentation into OIS.

 

Case create clerks at the CCC are responsible for checking the Case Create Queue daily to identify new incoming claims. The CCC records the relevant demographic data relating to the claim into ECS, such as personal, medical, employment and other component data. Upon completion, a copy of the claim form is uploaded into OIS, which automatically generates a unique ECS Case Identification Number (Case ID number).

 

a.     Terminal Claims.  In instances where a claim form is received by the DEEOIC office or a RC from, or on behalf of, a terminal claimant, the claim form and all supporting documentation is date-stamped, scanned, converted to a PDF attachment and immediately sent via e-mail to zzOWCP-DEEOIC-Centralized Case Create Group.

 

The subject line for any e-mail concerning a terminal claim should include “Terminal Case Create” followed by the name of the office sending the email, the claimant’s last name (or case  number in case of an existing case). For example, a subject line would read: Terminal Case Create DEN Smith; or Terminal Case Create JAC 50100000.

 

To comply with program procedure, district office staff prioritizes any claim with a terminal status. Should a District Director or FAB Manager determine that even a short delay in processing the forms would adversely affect the claimant, they are to contact the OIS Coordinator or Cleveland District Director by telephone.

 

(1)    If a terminal claim is received in the RC, the RC uploads all claim documentation to the EDP.

 

(2)    The District Director or designee reviews the documentation to determine whether the medical records necessitate the claim be expedited. If the claim is to be expedited, the district office follows the procedure described above. If the claim documentation does not support a designation of terminal status, the district office forwards the claim documents to the CMR for processing.

 

b.   Occupational History Development.  For Part E causation claims, RC staff completes an Occupational History Questionnaire (OHQ) by interviewing claimants about their knowledge of employee exposure to toxic substances. 

 

The RC staff completes the OHQ interview either in-person or telephonically within 14 days of assignment or receipt of claim.  If the OHQ interview cannot be completed within 14 days, the RC staff may request an extension with the jurisdictional district office.  Once the OHQ interview is complete, the RC staff scans and uploads the completed OHQ interview to the case file, via the Energy Document Portal along with the approved DEEOIC checklist. While the RC is generally the recipient of new incoming claims, occasionally the district office will receive new claim documentation.  In these situations, the district office receiving the new claim coordinates with the appropriate RC to have it conduct an OHQ. 

 

4.   Assignment of Claims to a District Office. The assignment of a claim to a particular district office occurs based on the state where the employee’s most recent location of covered employment occurred, as listed on Form EE-3. Each district office is responsible for claims originating from a state for which it has jurisdictional responsibility. Information regarding district office jurisdictional boundaries is located on the DEEOIC main webpage.  If the claimant does not submit a Form EE-3 with his claim, the CCC uses the claimant’s state of residence to make a district office assignment.  Each district office is to provide the CCC with an up to date case create digit assignment list so that upon creation, the CCC directs the claim to appropriate CE. When CE digit assignments change, the District Director or a designee is to email the updated list to zzOWCP-DEEOIC-Centralized Case Create Group.

 

5.    Creating Cases in Energy Compensation System (ECS).  The CCC enters into ECS information reported by the claimant from the incoming claim form, such as personal, medical, employment and any other relevant claim data. Important demographic information from the claim form necessary to create a claim include the employee/survivor name, Social Security Number, mailing address, phone number, date of birth, sex etc.  The CCC also enters information concerning the nature of the claim to include the medical conditions claimed as work-related, the employment history for the employee, and responses to the receipt of other award or other legal information.  Once this information is entered and saved, ECS assigns a unique Case ID# for the entire case file. 

 

In addition, each person who has filed a claim within a case is assigned a unique claimant identification number.  If the CCC is processing a claim based on the submission of correspondence that contains words of claim, he or she is to enter as much information as possible to permit ECS to assign a Case and Claimant ID#.  At a minimum, ECS requires the entry of name and mailing address of the claimant (in the case of a survivor, it is necessary to name the employee) to permit the creation of a case.  Once the CCC creates a claim under this circumstance, the matter is referred to the assigned CE to notify the claimant of the need to complete an EE-1 or 2 to allow for claim adjudication.  A claimant signature is not necessary on any form or letter with words of claim for case creation to occur; however, for claim adjudication a signed EE-1 or EE-2 is required.  Without a properly completed form, the claim is administratively closed.

 

For a systematic guide to ECS case create procedures, refer to the Claim Form Entry and Initial Review (Red Pane Review) instructions located in the ECS Procedures folder available to district office staff on the shared drive.

 

a.  Handling Alternative Filings. A non-covered spouse or child of a deceased DOE contractor employee or RECA Section 5 uranium worker may submit a written request for an informal evaluation of whether the employee contracted a covered illness as a result of employment at a covered facility. As no recommended or final decisions are issued in these instances, an EE-2 is not required. Accordingly, alternative filing requests are entered into ECS as “Words of Claim” under the form EE-2.  The alternative filing request will be processed in ECS as a survivor claim according to instructions provided in Chapter 2-1200.13.

 

6.   Claims Examiner Review.  Once a new claim is received from the CCC, but prior to initial development and adjudication, the assigned CE reviews the claim forms, any employment and/or medical evidence, the claimed employment and occupational history development conducted by the RC and ECS to ensure ECS contains accurate information. If the claim requires additional follow up action by the RC, the CE may assign additional tasks to the RC as necessary.

 

a.   Missing Information.  If a claim form or document with “words of claim” is missing vital information (e.g., a diagnosed condition, employment information), the assigned CE requests the omitted information and/or the appropriate claim form from the claimant, or the designated Authorized Representative. 

 

b.   Acknowledgement Letter. Upon receipt of a new claim, the district office is responsible for sending the claimant a letter acknowledging the receipt of a new claim and providing the claimant with a case ID number and contact information should the claimant have questions regarding his/her claim. A sample acknowledgment letter is provided as Exhibit 1.

 

c.   Corrective Action. Should the CE identify data entry error(s) in ECS based on the information supplied on the claim forms, he or she is to complete an ECS Change Form (Exhibit 2) and forwards it to the appropriate staff person for corrective action. However, in limited circumstances, the CE can make the changes to ECS (date of birth, date of death, gender, relationship type, phone numbers, Power of Attorney and Authorized Representative).

 

7.   Creating a Claim Under Part B vs. Part E, or Both. Identifying when a claim is to be adjudicated under Part B, Part E, or both, it is first necessary to identify the claimed conditions. Conditions covered under Part B include chronic beryllium disease (CBD), beryllium sensitivity, chronic silicosis and radiogenic cancers. Claims for any other illness not covered under Part B are created and adjudicated solely under Part E, which covers any illness found related to occupational toxic substance exposure.

 

a.   Consideration of Employment.  In addition to considering the claimed medical condition(s), claimed employment is also considered. Part B of the EEOICPA covers employees of the Department of Energy (DOE), its contractors and subcontractor, and eligible survivors. Part E offers benefits to DOE contractors, subcontractors and their eligible survivors.

 

For claims filed at the RC, the RC verifies employment through the Oak Ridge Institute for Science and Education (ORISE) and/or clarifies the nature of claimed employment.

 

Example 1: If a claim identifies employment as a federal employee at a DOE facility and a Part B medical condition, the claim is adjudicated under Part B only, because a DOE federal employee is not a covered DOE contractor employee, as required under Part E.

 

Example 2: If a claim identifies employment at an Atomic Weapons Employer (AWE) or a beryllium vendor and a Part B/E medical condition, the claim is adjudicated under Part B only, because working at an AWE or beryllium vendor is not covered employment under Part E. (The exception to this is if it is indicated that the employee worked at an AWE or beryllium vendor that was designated as a DOE facility for remediation.) 

 

Example 3:  If only Part B medical conditions are checked on the claim form (e.g., CBD, beryllium sensitivity, chronic silicosis, or radiogenic cancer) and DOE contractor employment is claimed, the claim will be adjudicated under both Part B and Part E.  

 

Example 4:  Some AWE and beryllium vendor facilities are designated as DOE facilities during periods of remediation.  If the claimant from Example 1 instead claims employment with an AWE or beryllium vendor during a period of remediation or identifies the AWE or beryllium vendor as a DOE facility on Form EE-3, the claim is to be adjudicated under both Part B and Part E.  In such a case, additional development to establish covered Part E employment would be required.

 

Example 5:  To establish covered employment under Part E, the employee must have been a DOE contractor employee.  If the claimant from Example 1 claims only employment as a DOE federal employee, the claim is adjudicated under only Part B.

 

Example 6:  If a non-Part B medical condition (e.g., asbestosis) and DOE contractor employment are claimed, the claim is treated as a Part E claim only.

 

Example 7:  If the claimant claims diabetes (a non-Part B medical condition) and employment with an AWE or beryllium vendor during a period in which remediation did not occur, or does not identify the AWE or beryllium vendor as a DOE facility on the Form EE-3, the claim is adjudicated under only Part B, as the employee must be a DOE contractor employee to be covered under Part E.

 

Example 8:  If an employee claims prostate cancer and DOE contractor employment, the claim is adjudicated under both Parts B and E.  If the same employee claims both prostate cancer and asbestosis, the prostate cancer is treated as a Part B and Part E condition, while asbestosis is adjudicated under Part E only.

 

Example 9:  If a claimant identifies chronic silicosis on the Form EE-2, the claim is evaluated under both Parts B and E only when the claimed employment was in underground tunnels in Nevada or Amchitka Island, Alaska.  If the claimant employment is outside of these facilities, the claim is adjudicated under only Part E.

 

Example 10:  All new Radiation Exposure Compensation Act (RECA) 5 claims are to be adjudicated under both Part B and Part E.

 

8.   New Claims in Existing Cases.  In situations where there is an existing case record, if a district office or RC receives a new claim for an additional medical condition, or new survivor, the new claim form is date-stamped and forwarded to the CMR for processing, as outlined in Item 3 above.

 

a.   Case Assignments. New claims in existing cases are assigned to the appropriate district office and CE, as outlined above in Item 4. However, if the case is found to be currently outside of the jurisdictional office (i.e. at FAB or National Office), the new claim will be assigned to the district office CE assigned to the case.

 

b.      Medical Evidence Only.  If the claimant submits medical evidence for an unclaimed condition (i.e., medical evidence indicating the presence of an illness which identified as being potentially work-related) without a claim form, or document with “words of claim” for a covered condition, the CE contacts the claimant to request the appropriate claim form. He or she can also forward the evidence to a RC for assistance in initiating a new claim.

 

c.   Survivorship Evidence Only.  If a new survivor submits survivorship evidence (e.g., birth certificate, marriage certificate, school records) without a claim form, the district office or RC contacts the claimant to request he or she complete Form EE-2.

 

d.   Wage-Loss and Impairment Claims.  In cases in which a claimant submits Form EE-10, Claim for Additional Wage-Loss and/or Impairment under the EEOICPA, the CMR does not submit the form into the Case Create Queue. Any EE-10 received in the CMR is scanned as regular mail and appears in the assigned CE’s “Unreviewed Assigned” document queue, at which time the CE is responsible for reviewing the claim form, entering the appropriate information into ECS and completing appropriate development actions. This data entry process also applies when a claimant submits “words of claim” in lieu of Form EE-10 to requesting wage-loss and/or impairment benefits.

 

9.  Withdrawal of a Claim.  A claimant is able to withdraw his or her claim for benefits for any claimed condition(s), or wage-loss or impairment, prior to the issuance of a Final Decision for the requested benefit(s).  All requests to withdraw a claim for benefits must be in writing, signed by either the claimant or his or her authorized representative, and specific in reference to what Part or Parts under the EEOICPA the claim is to be withdrawn.

 

Exhibit 1: Letter of Acknowledgement

Exhibit 2: ECS Change Request