Chapter 2-1300 Impairment Ratings
Table of Contents. . . . . . . i 05/09 09-04
1 Purpose and Scope. . . . . . . 1 05/09 09-04
2 Policy . . . . . . . . . . . . 1 05/09 09-04
3 Definition of Impairment . . . 1 05/09 09-04
4 General Requirements for
Impairment Ratings . . . . . 1 05/09 09-04
5 Developing an Impairment
Claim . . . . . . . . . . . 5 05/09 09-04
6 Impairment Ratings for
Certain Conditions . . . . . 10 05/09 09-04
7 Receipt of the Impairment
Evaluation . . . . . . . . . 13 05/09 09-04
8 Pre-Recommended Decision
Challenges . . . . . . . . . 14 05/09 09-04
9 Issuance of a Recommended
Decision . . . . . . . . . . 14 05/09 09-04
10 FAB Development. . . . . . . . 15 05/09 09-04
11 Additional Filings for
Impairment Benefits. . . . . 16 05/09 09-04
12 Issues Involving Survivor
Election . . . . . . . . . . 18 05/09 09-04
13 The Resource Centers’ Role
in Developing Impairment
Claims . . . . . . . . . . . 18 05/09 09-04
1 Not at MMI Letter. . . . . . . 05/09 09-04
2 Breast Impairment Letter . . . 05/09 09-04
3 Development Letter for
Impairment with Attachments. 05/09 09-04
4 Required Medical Evidence
Specific to ICD-9 Codes. . . 05/09 09-04
5 Not Claiming Impairment
Letter . . . . . . . . . . . 05/09 09-04
6 Impairment Eligibility
Letter to Physician
with Attachments . . . . . . 05/09 09-04
7 Form EE-10 . . . . . . . . . . 05/09 09-04
1. Purpose and Scope. This chapter provides guidance on the responsibilities of the Claims Examiner (CE) in regard to awards based upon a covered Part E employee’s impairment that is attributable to a covered illness, how the District Office (DO) and the Final Adjudication Branch (FAB) will evaluate medical evidence of impairment in the case record, what is considered to be a ratable permanent impairment, and the potential eligibility for additional impairment benefits following previous award of impairment benefits.
2. Policy. The CE is responsible for processing impairment rating determinations and ensuring benefits are appropriately paid under the provisions of 42 U.S.C. 7385s, 7385s-2, 7385s-4, and 7385s-5 and as outlined in the procedures in this chapter.
3. Definition of Impairment.
a. Impairment. The American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides) 5th Edition defines impairment as “a loss, loss of use or derangement of any body part, organ system or organ function.” Furthermore, “Impairment percentages or ratings developed by medical specialists are consensus-derived estimates that reflect the severity of the medical condition and the degree to which the impairment decreases an individual’s ability to perform common Activities of Daily Living (ADL),excluding work.” (Emphasis in original).
4. General Requirements for Impairment Ratings.
a. Covered Employees. The employee must be a covered Department of Energy (DOE) contractor or subcontractor, or Radiation Exposure Compensation Act (RECA) section 5 employee found to have contracted a covered illness through exposure to a toxic substance at a DOE facility or RECA section 5 facility.
b. Claiming Impairment. The employee must claim impairment as a result of a covered illness or illnesses in writing.
c. Maximum Medical Improvement (MMI). An impairment that is the result of a covered illness will be included in the employee’s impairment rating only if the physician concludes that the condition has reached MMI, which means the condition is unlikely to improve substantially with or without medical treatment. Conditions that are progressive in nature and worsen over time, such as chronic beryllium disease (CBD), are considered to have reached MMI when the condition is not likely to improve.
(1) Terminal Employees. An exception to the MMI requirement exists for terminal employees undergoing ongoing treatment for an illness that has not reached MMI. In these situations, the terminal employee could die before the outcome of treatment is known and eligibility for an impairment award would be extinguished. Therefore, if the CE finds probative medical evidence that the employee is terminal, the impairment that results from such a covered illness is included in the impairment rating even if MMI has not been reached.
(2) MMI Has Not Been Reached. After reviewing the medical evidence, if the CE determines that the condition has not reached MMI, and the employee is not in the terminal stages, the CE does not make an impairment determination. A letter is sent to the employee informing him or her that the claim will be administratively closed and an impairment determination will not be made because MMI has not been reached. The letter should also state that the employee should contact the DO when MMI is reached. (See Exhibit 1).
(a) A treating physician may state that an employee is not at MMI and recommend treatment that could improve the condition. If the employee chooses to forgo the recommended treatment, the CE must request a written statement from the employee attesting to this choice to forgo the recommended treatment. After receipt of this written statement, the CE may proceed with an impairment determination.
(b) Once medical evidence is received in the DO indicating that the employee is at MMI, development is resumed and an RD (“Reopened – Development Resumed”) code is entered into ECMS. The status effective date is the date the evidence of MMI is received in the DO.
(3) Multiple Covered Illnesses. In a case of multiple covered illnesses where one condition is at MMI and another is not, the CE should proceed with a determination regarding impairment for the condition at MMI. If different covered illnesses affect the same organ, and one condition is not at MMI, the CE cannot proceed with an impairment rating until all conditions in that organ have reached MMI.
d. Impairment Rating. An impairment evaluation performed by a qualified physician is the basis for the CE’s determination of impairment benefit entitlement. Therefore, the physician’s impairment rating report must be clearly rationalized and grounded in sound medical opinion.
(1) Evaluation. An impairment evaluation of the employee must be based upon the 5th Edition of the AMA’s Guides.
(2) Rating Physician. An impairment evaluation must be performed by a qualified physician who satisfies the Division of Energy Employees Occupational Illness Compensation’s (DEEOIC) criteria for physicians performing impairment evaluations. In order for a physician to be deemed qualified, he/she must hold a valid medical license and Board certification/eligibility in their field of expertise (e.g., toxicology, pulmonary, neurology, occupational medicine, etc.). The physician must also meet at least one of the following criteria: certified by the American Board of Independent Medical Examiners (ABIME); certified by the American Academy of Disability Evaluating Physicians (AADEP); possess knowledge and experience in using the AMA’s Guides; or possess the requisite professional background and work experience to conduct such ratings.
(a) In order for a physician to demonstrate that he/she is qualified, there is no need to submit copies of their medical license or certificates. Qualifications may be determined by the submission of a letter or a resume which demonstrates that the physician is licensed and meets the requisite program requirements.
(b) If a physician does not possess ABIME or AADEP certification, the physician must submit a statement certifying and explaining his/her familiarity and years of experience in using the AMA’s Guides.
(3) Rating Percentage. The impairment rating is a percentage that represents the extent of a whole person impairment of the employee, based on the organ(s) or system(s) affected by a covered illness or illnesses. The rating accounts for all Part E accepted covered illnesses and includes all conditions that are present in the covered organ(s) or system(s) at the time of the impairment evaluation.
(4) Whole Person Impairment. The physician must specify the percentage points of whole person impairment that are the result of all accepted covered illness or illnesses.
(a) In some instances, there are multiple diseases or life style choices (e.g., smoking and the lungs), in addition to the covered illness, that affect an organ. DEEOIC does not apportion damage, thus the impairment rating should assess the functionality of the whole organ regardless of the multitude of other factors.
(b) If the CE finds that the employee contracted more than one covered illness, the physician should specify the total percentage points of impairment that result from each of the employee’s accepted covered illnesses. The total percentage points of impairment are determined by a combined value chart in the AMA’s Guides. Therefore, the sum of each individual impairment rating may not equal the total combined rating (i.e., 2% + 2% does not necessarily equal 4%).
(c) An impairment that is the result of any accepted covered illness that cannot be assigned a numerical impairment percentage using the 5th Edition of the AMA’s Guides will not be included in the employee’s impairment rating, and the physician performing the impairment evaluation needs to explain the rationale as to why a numerical impairment percentage cannot be assigned.
5. Developing an Impairment Claim. This section discusses the developmental steps and evidence necessary to adjudicate an impairment claim.
a. Resource Centers’ (RCs) Role: RCs assist employees with the submission of their impairment claims.
(1) When a final decision is issued to an employee with a positive causation determination, the FAB sends a copy of the final decision to the designated RC. This is done only in situations where there is no indication that a claim has already been made for impairment.
(2) Upon receipt of the final decision, the RC calls the employee to provide information about the potential impairment benefits available, explains eligibility requirements or program procedures, and responds to any questions. The RC then memorializes the telephone call in the Telephone Management System (TMS) section of ECMS and forwards a printout to the appropriate DO or Co-Located Unit (CE2) for association with the case file.
b. Initial Impairment Development Letter. In conjunction with the RCs’ outreach to the employee as mentioned in paragraph 5a above, the CE sends a development letter (Exhibit 3 with attachments) to the employee.
(1) Timeframe. This development letter is sent after issuance of a final decision accepting an employee’s claimed condition as a covered illness under Part E. This letter is only sent for employee claims. (See section 12 for survivor claims).
(2) Explanation. In the letter, the CE explains what an impairment rating is and that the employee may be eligible for an award based on permanent impairment.
(3) Request for Impairment Claim. In the letter, the CE requests that the employee advise DEEOIC in writing as to whether or not he/she would like to claim impairment for a covered illness or illnesses. The CE further explains that if the employee has more than one covered illness, he/she must also advise the DO on which covered illness he/she is claiming. However, an employee may not elect to file an impairment claim on some, but not all, covered illnesses in an effort to avoid a tort offset or coordination of state workers’ compensation benefits. The letter includes a response sheet on which the employee may claim impairment. (See Exhibit 3 and attachments)
(4) Required Medical Evidence. In the letter, the CE outlines the medical evidence that will need to be submitted, based on individual conditions as outlined in Exhibit 4, for a physician to conduct the rating. If a condition is not listed in Exhibit 4, the CE should consult with a DMC to determine what medical information is required as outlined in the AMA’s Guides.
(5) Physician Choice. In the letter the CE explains that the employee may choose to have his or her own qualified physician or a DMC perform an impairment evaluation. The employee indicates this choice on the response sheet attached to the letter. If the employee is requesting his or her own physician, the employee must provide the physician’s name and address. The response sheet provides a space for this information.
(a) If the employee does not indicate who should perform the impairment evaluation, the CE assumes that the employee wishes to have a DMC perform the evaluation. The CE sends a letter to the employee outlining the evidence needed for a DMC to perform the impairment evaluation. (See Paragraph 4, Required Medical Evidence, above, and Exhibit 3).
(6) Timeframe. The employee is allotted 60 days to respond to the initial impairment development letter, with a follow up request sent to the employee at the first 30 day interval. The CE does not develop the impairment issue until a response is received from the employee.
(a) If the employee does not respond to the development letter within 60 days, or informs the CE that he or she does not want to pursue a claim for impairment, the CE sends a letter (Exhibit 5) to the employee advising that DEEOIC will not undertake further development of the claim for impairment at this time. The CE also notifies the employee of the right to claim impairment in the future. Lastly, the CE codes ECMS with the proper code. The status effective date is the date the letter is received from the employee stating he/she does not wish to claim impairment or the date the timeframe of the letter expires.
(b) If the employee responds in writing that he/she wants to claim impairment, ECMS is coded appropriately. The status effective date is the postmark date of the letter, if available, or the date the letter is received in the DO or RC, whichever is the earliest determinable date.
c. Impairment Ratings by the Employee’s Own Physician.
(1) Letter to Selected Physician. The CE sends a letter (Exhibit 6 with attachments) to the physician selected by the employee. In the letter, the CE notifies the physician of the employee’s eligibility, and the covered illness or illnesses with respective ICD-9 code(s). The CE also explains that in order for DEEOIC to pay for an impairment evaluation, the evaluation must have been performed within one year of receipt by DEEOIC. The letter explains that the impairment evaluation must be performed in accordance with the 5th Edition of the AMA’s Guides, and that specific reference to the appropriate page numbers and tables used from the AMA’s Guides is required in the report. Lastly, the CE includes a medical bill pay agent enrollment package, which includes: an OWCP-1500, Health Insurance Claim Form (Exhibit 6 attachments), OWCP-1168, the EEOICP Provider Enrollment Form (Exhibit 6 attachments), and a form (SF Form 3381, available on the share drive at the Policies and Procedures folder, forms subfolder) to allow the medical bill pay agent to process electronic fund transfers to the provider. The OWCP-1168 explains how a physician enrolls with the medical bill pay agent. If a physician is already enrolled, there is no need to enroll again. If the employee opted to select his/her own physician to perform the impairment rating but does not know of one, the CE may direct the employee to the appropriate RC for a list of physicians who perform impairment ratings and are enrolled in the program.
(2) Scheduling an Appointment with the Selected Physician. The employee must schedule the impairment appointment within 30 days of DEEOIC receiving the employee’s written choice of physician. The appointment does not need to occur within this first 30 days, but must be scheduled for a definite date in the future.
The CE places a call up note in ECMS for 60 days from receipt of the employee’s choice of physician. If after 60 days the CE finds no evidence of an impairment evaluation or that the employee scheduled an appointment, the CE makes a phone call to determine the status of the appointment (whether it has been made or is in the process of being made, etc.). The CE advises the employee verbally of the need to schedule the appointment within the next 30 days and to provide written evidence of such to the DO. It is important that the CE record this discussion carefully in the TMS section of ECMS. The CE sends a written summary of the call and need for confirmation of an appointment within the 30 day time period to the employee.
If at the end of this 30 day period no evidence exists to show progress in obtaining the necessary impairment evidence, the CE may issue a recommended decision to deny the impairment claim.
d. Impairment Ratings by a DMC. If DEEOIC is to arrange for the impairment evaluation, the CE reviews the medical evidence received from the initial impairment development letter and in the case file to determine if the evidence is sufficient for a DMC to perform the impairment evaluation.
(1) Insufficient Evidence. If the CE determines that the medical evidence of record is not sufficient, the CE sends a follow up development letter to the employee explaining the additional evidence and/or diagnostic test(s) required in order to conduct an impairment evaluation.
(2) Unavailability of Records. If the employee is unable to provide some of the necessary medical records, whether or not an impairment evaluation can be performed is completely dependent upon what the AMA’s Guides allow for rating the covered illness. The information may be forwarded to a DMC to determine if the available records are sufficient to perform a rating. If the DMC is able to perform a rating based on partial medical evidence and states that additional testing could potentially increase the rating, the employee must be notified that the rating is based solely on the present evidence of record, and additional testing is needed to allow for the highest potential rating. The CE sends the employee a letter and gives the employee the option of getting the necessary testing, or of notifying the CE in writing that the additional testing cannot be obtained, and that a decision may proceed based on the available medical evidence. If the employee does not respond, the CE proceeds with the impairment evaluation based on the available medical evidence.
(3) Outdated Evidence. If the employee has been given the opportunity to obtain current medical evidence and supplies little or no medical evidence, the CE may use medical evidence in the file that is older than 12 months to obtain an impairment rating from a DMC. In some instances the DMC may still not be able to render an opinion with older or missing medical records.
(4) Referral and Payment to a DMC. Procedures for referring a case to a DMC and “Prompt Pay” of DMC bills can be found in EEOICPA Procedure Manual (PM) Chapter 2-300 and will be in the new EEOICPA PM Chapter 2-0800 Developing and Weighing Medical Evidence.
6. Impairment Ratings for Certain Conditions:
a. Mental Disorders.
(1) Upon receipt of a claim for a mental impairment, the CE must determine whether the claimed impairment originates from a documented physical dysfunction of the nervous system.
(2) Once it has been established that an employee’s mental impairment is related to a documented physical dysfunction of the nervous system, the employee should obtain an impairment evaluation from the physician based on Table 13-8 of Chapter 13 in the 5th Edition of the AMA’s Guides.
(3) If the mental impairment is not related to a documented physical dysfunction of the nervous system, it cannot be assigned a numerical percentage using the 5th Edition of the AMA’s Guides. The CE communicates this with the employee and provides the employee with 30 days to submit documentation from a physician if the employee believes there is a link between the exposure to a toxic substance at a covered facility and the development of a mental impairment. The report from the employee’s physician must contain rationalized medical evidence establishing that the mental impairment is related to neurological damage due to a named toxic exposure. Speculation or unequivocal statements from the physician reduce the probative value of a physician’s report, and in such cases the CE may find it necessary to refer the case to a District Medical Consultant (DMC) or a DEEIOC toxicologist to determine whether toxic exposure caused physical dysfunction of the nervous system.
(b) Breast Cancer.
(1) Upon receipt of a claim for impairment for the breast in either a male or female, the CE submits a request to the physician undertaking the evaluation explaining all the criteria that must be considered and referenced in the final report. For the purposes of considering impairment due to breast cancer in a female, child bearing age will not be a determining factor when issuing an impairment rating, as the AMA’s Guides do not define “child bearing age.”(See Exhibit 2)
(2) When the completed impairment evaluation is returned, the CE must review it to ensure that the physician has comprehensively addressed each of the factors necessary for an acceptable rating. The report must show that the physician has considered: (1) the presence or absence of the breast(s); (2) the loss of function of the upper extremity (or extremities if there is absence of both breasts due to cancer), including range of motion, neurological abnormalities and pain, lymphedema, etc.; (3) skin disfigurement; and (4) other physical impairments resulting from the breast cancer. The total percentage of permanent impairment of the whole person must be supported by medical rationale and references to the appropriate sections and tables (with page numbers) of the AMA’s Guides.
(3) If the CE determines the physician has not provided a complete rating for a claimed impairment of the breast, a follow-up letter is sent to the physician. The CE explains the noted deficiency in the assessment and that the purpose for obtaining a complete response is to ensure the employee received the maximum allowable rating provided by the AMA’s Guides.
(4) Upon receipt of an acceptable report pertaining to an assessment of permanent impairment of the breast, the CE should proceed with additional development of the claim, as necessary, and issuance of a recommended decision.
(c) Pleural Plaques/Beryllium Sensivity.
(1) While it is very unlikely that a ratable impairment will exist for the covered conditions of pleural plaques or beryllium sensitivity alone, the employee may claim impairment for these conditions. In the initial impairment development letter to these employees, the CE explains that the rating for these conditions is generally very low to 0%. (See Exhibit 3 with attachments). When sending this letter, as with any impairment development letter, send all necessary attachments.
(d) Metastatic Bone Cancer.
(1) In situations where the CE accepts a case under the SEC provision based on metastatic (secondary) bone cancer, often the primary source of the metastatic bone cancer will prove to be the prostate. If the CE does not accept the prostate cancer due to a lack of a causative link and because prostate cancer is not a SEC specified cancer, it is important that the CE ensure that the non-covered prostate cancer is not considered in the impairment rating. Only the accepted condition of SEC metastatic bone cancer is considered for the impairment rating. If a rating is received for the prostate, the report must be resubmitted and a new rating must be requested.
7. Receipt of the Impairment Evaluation. Upon completion of the impairment evaluation and receipt in the DO, the CE reviews the report to assure that all DEEOIC criteria has been met. While by no means exhaustive, the CE reviews impairment evaluations to determine the following: whether the opining physician possesses the requisite skills and requirements to provide a rating as set out under paragraph 4d(2); whether the evaluation was conducted within one year of receipt by DEEOIC; whether the report addresses the covered illness or illnesses; and whether the whole person percentage of impairment is listed with a clearly rationalized medical opinion as to its relationship to the covered illness or illnesses. The employee is entitled to an award of impairment benefits if one or more percentage points of the impairment are found to be related to a covered illness or illnesses.
a. Awards. To calculate the award, the CE multiplies the percentage points of the impairment rating of the employee’s covered illness or illnesses by $2,500. For example, if a physician assigns an impairment rating of 40% or 40 points, the CE multiplies 40 by $2,500, to equal a $100,000 impairment award.
b. Incomplete Ratings. If the impairment rating report is unclear or lacks clearly rationalized medical evidence as support, additional clarification is required. In such instances, the CE returns the impairment rating evaluation to the rating physician with a request for clarification, indicating what areas are in need of remedy. If the report was performed by the employee’s physician and no response is received or is returned without sufficient clarification, the CE notifies the physician of the need for additional justification. If no response is received, the case is sent to a DMC for a new rating. If the incomplete report was submitted by a DMC, the CE must notify the DMC of the deficiency and request a more comprehensive report.
8. Pre-Recommended Decision Challenges. The CE may provide the employee with a copy of the impairment rating report if the employee specifically requests a copy. The employee may submit written challenges to the impairment rating report and/or additional medical evidence of impairment. However, any additional impairment evaluations must meet the criteria discussed above in paragraph 7 before the CE can consider it when making impairment determinations. DEEOIC will only pay for one impairment evaluation unless DEEOIC directs the employee to undergo additional evaluations. Subsequent evaluations not directed by DEEOIC must be paid by the employee. If the additional evaluation differs from the existing rating, the CE must review the two reports in detail to determine which report has more probative value. In weighing the medical evidence, the CE must use his or her judgment in the analysis of the reports. If the reports appear to be of equal value, the CE may refer the case to a second opinion physician for additional consideration.
a. Equally Probative Reports. If the second opinion physician opines that both impairment evaluations are of the same probative value, the CE may obtain a referee medical examination.
9. Issuance of a Recommended Decision. The recommended decision must contain a thorough discussion of the impairment evidence submitted in the case. If a decision recommends denial of an impairment claim based on an insufficient evaluation, or if one evaluation is relied upon by the DO over another evaluation(s) in the file, the CE must provide a detailed discussion regarding the probative value of the evaluation(s).
The employee must be informed of the reasons why a report is insufficient, and/or why one report offers more probative value than another. This is necessary in the event the employee submits additional impairment evidence to the FAB, as any additional impairment evidence submitted must have more probative value than the evidence relied upon by the DO for the employee to have met his or her burden of proof.
a. Recommended Decision. Any claim that is coded in ECMS for impairment must be developed and adjudicated by way of recommended decision. If a claim has been filed for impairment and the necessary documentation to allow for a decision is not presented, a recommended decision to deny must be issued.
10. FAB Development. Once a recommended decision on impairment has been issued and forwarded to the FAB, the employee may submit new medical evidence and/or additional impairment evaluations to challenge the impairment determination discussed in the recommended decision.
a. Reviewing Ratings. The employee bears the burden of proving that additional impairment evidence has more probative value than the evaluation relied upon by the DO to determine the impairment benefit eligibility.
b. Probative Value Determinations. The FAB Hearing Representative (HR) must take into consideration the list of factors in paragraph 7 when weighing impairment evaluations for probative value.
In the event an employee’s file contains multiple impairment evaluations, the HR reviews each report to determine which, on the whole, provides the most probative value given the totality of the evidence. For example:
(1) The RD is based upon Dr. X’s impairment rating of the employee, finding 20% whole person due to the covered illness asbestosis. Dr. X’s opinion is clearly rationalized and provides a detailed analysis as to how the medical findings were deduced, addressing the covered illness and its relation to the rating. The employee submits an impairment rating from Dr. Y that finds a 30% whole person impairment due to asbestosis and other unrelated conditions. The report provides little analysis as to how the medical findings were reached and does not provide a rationale as to why the 30% rating is related to the covered illness of asbestosis. Both doctors possess the requisite credential and the reports were submitted timely. The HR gives credence to the impairment rating by Dr. X, as it has more probative value than the report submitted by Dr. Y. The clear medical rationale provided by Dr. X lends more explanation as to how the rating was determined compared to the rating by Dr. Y.
c. FAB Review. In addition to the impairment rating(s), the FAB reviews all the relevant evidence of impairment in the case record and bases its determination on the evidence it finds to be most probative.
d. Final Decision. The final decision must contain detailed rationale and discussion for any determination, especially decisions concerning multiple impairment evaluations. The final decision also includes analysis of all relevant evidence and argument(s) in the record.
11. Additional Filings for Impairment Benefits. An employee previously awarded impairment benefits may file a claim for additional impairment benefits for the same covered illness included in the previous award. This claim must be based on an increase in the impairment rating that formed the basis for the previous award. Such a claim must be submitted on Form EE-10. (See Exhibit 7).
a. Timeframe. The employee may not submit a Form EE-10 for an increased impairment rating earlier than two years from the date of the last award of impairment benefits (date of the final decision).
(1) New Covered Illness. An exception to the two year time period requirement exists if the DO adjudicates an additional impairment claim based upon a new covered illness not included in the previous award. A new covered illness involves a different disease, illness, or injury that was not the basis of the original impairment rating.
b. Untimely Requests for Re-evaluation. If the two year date is near, the impairment claim can be developed, but not adjudicated, until the two year mark has been reached. In circumstances in which an employee submits an untimely request for re-evaluation and it is too early to proceed with adjudication, i.e., six months prior to the two year mark, the CE should inform the employee in writing that he/she is not eligible for an impairment decision and that a decision will be deferred until such time as the employee is eligible. The CE enters a call up note in ECMS to follow-up at the two year mark, but no action is taken to administratively close out the impairment claim.
(1) ECMS Coding of Untimely Requests for Re-evaluation. If an employee claims re-evaluation of a covered illness for which an impairment final decision has been issued prior to the two year mark, the proper ECMS code for impairment claimed should be entered for the postmark date or the date received by the DO, FAB, or the RC, whichever is earliest determinable date.
(2) Follow Up. The RCs maintain a list of employees that have received impairment ratings. Upon two years of the final decision, a representative from designated RCs will contact the employee to determine if additional impairment will be claimed. If the CE had already contacted the employee regarding additional impairment filing, the RC may forgo this contact.
c. Time Requirements Not Applicable. If an employee is issued a 0% impairment rating final decision and subsequently obtains new evidence concerning the covered illness that received the 0% rating, a two year wait period does not apply and the new evidence should be evaluated for reopening.
12. Issues Involving Survivor Election. If a covered Part E employee dies after submitting an impairment claim but before compensation is paid and death is caused solely by a non-covered illness or illnesses, the survivor may elect to receive the compensation that would have been payable to the employee, including impairment and/or wage loss.
a. Instances Where Impairment is Not Available to a Survivor. If the necessary diagnostic or medical evidence will not allow for a viable rating, and there is no way to collect new information following the death of the employee, the CE should advise the survivor that he/she may only elect to receive compensation for wage loss. The DMC in this situation would advise that given the available evidence, no rating is possible in accordance with the AMA’s Guides. The specific deficiencies should be noted by the DMC, and this information should be furnished to the survivor in a letter from the CE.
13. The RCs’ Role in Developing Impairment Claims. The RCs facilitate the development of impairment claims by engaging in outreach efforts and educating covered employees on the requirements for filing and obtaining impairment benefits. This outreach effort takes place after the issuance of a Part E final decision to an employee with a positive causation determination (see paragraph 6a) and also after the two year re-filing mark for impairment claims is reached (see paragraph 11b).
In some situations, the RCs may be used when waivers and forms EN-20 need to be signed quickly due to the health of the employee and the possibility that the benefit may be extinguished due to the employee’s death. The RCs also advise the employee concerning the tests to obtain an impairment rating.