TABLE OF CONTENTS
Paragraph and Subject Page Date Trans. No.
Chapter 3-0200 Medical Bill Process
Table of Contents. . . . . . . . i 01/10 10-07
1 Purpose and Scope. . . . . . . . 1 01/10 10-07
2 Roles and Responsibilities . . . 1 01/10 10-07
3 Parameters for Payment . . . . . 4 01/10 10-07
4 Mailbox for Medical Bill
Inquiries . . . . . . . . . . . 4 01/10 10-07
5 DMC Reviews. . . . . . . . . . . 9 01/10 10-07
6 Medical Records Procurement. . . 9 01/10 10-07
7 Psychiatric Treatment. . . . . . 10 01/10 10-07
8 Hearing Aids (above $5000) . . . 10 01/10 10-07
9 Chiropractic Services. . . . . . 11 01/10 10-07
10 Acupuncture Treatments . . . . . 11 01/10 10-07
11 Organ Transplants (Including
Stem Cell). . . . . . . . . . . 11 01/10 10-07
12 Experimental Treatment and
Clinical Research . . . . . . . 13 01/10 10-07
13 Treatment Suites . . . . . . . . 14 01/10 10-07
14 Eligibility Files. . . . . . . . 14 01/10 10-07
15 ICD-9-CM . . . . . . . . . . . . 14 01/10 10-07
16 Coding Software. . . . . . . . . 16 01/10 10-07
17 Prompt Pay . . . . . . . . . . . 16 01/10 10-07
18 Time Limitations for
Submission of Medical Bills . . 16 01/10 10-07
19 Fee Schedule . . . . . . . . . . 17 01/10 10-07
20 Fee Schedule Appeal Process. . . 17 01/10 10-07
1. Purpose and Scope. This chapter describes the roles of the Claims Examiner, Fiscal Officer, and District Medical Scheduler, in the medical bill process; and outlines the procedures for evaluating and approving requests from employees and their families who are in need of medical services, supplies, or reimbursement of expenses related to medical care.
2. Roles and Responsibilities. Upon issuance of a final decision approving a specific medical condition, the Claims Examiner (CE), the Bill Processing Agent (BPA), the Fiscal Officer (FO), and the Medical Scheduler (MS) must ensure that the basic medical needs of the claimant, as they relate to his or her accepted medical condition, are reasonably provided for.
a. Medical Bill Processing Agent (BPA). The use of a contractor for processing medical bills allows the DEEOIC to provide a high level of service to eligible claimants and their providers. Once a claimant has been accepted for a covered condition under the EEOICPA, an eligibility file is automatically generated in ECMS and sent to the BPA electronically.
(1) When the BPA receives the eligibility file, the BPA sends a medical bill identification card (MBIC) and general information about the medical bill process to the claimant.
(2) DEEOIC sends all medical bills, treatment notes, and requests for claimant reimbursement directly to the contractor for scanning and keying into their system.
(3) The BPA maintains a customer call center, medical staff, and bill resolution units.
b. Point of Contact Claims Examiner. The Point of Contact Claims Examiner (POC CE) is a specialized claims examiner responsible for reviewing, developing, and approving or denying requests for in-home health care. Each District Director is to appoint one to three CEs (as appropriate) to serve in this role.
c. Claims Examiner. The Claims Examiner (CE) considers for approval those Level 4 services (see Para. 3), appliances, supplies, modifications, or travel expenses that are recommended or prescribed by a licensed physician, and necessary to cure, give relief, or aid in reducing the overall cost of services required by the employee for an accepted condition. (Refer to EEOICPA PM 3-0300 for detailed information on approval of durable medical equipment, hospice services, in-home health care, gym memberships, extended medical travel, and other ancillary medical services.)
(1) The CE considers the level of care prescribed by the treating physician as it relates to the accepted medical condition and the facts of the case. The CE must then make an informed judgment based on the level of care prescribed by the doctor.
(2) This decision must take into account the overall desires and needs of the patient, as well as those of the family. DEEOIC will not dictate or demand what option an employee must accept, nor will decisions be made based solely upon cost.
The CE must also consider what level of care or services satisfy the patient’s needs.
(3) The CE is responsible for communicating all decisions (approval/denial) to the requestor.
(a) If a request for services or payment originates from the BPA, the fiscal officer notifies the CE via e-mail. These requests may come to the CE as a prior authorization request, or may come after submission of a charge to the BPA.
The CE’s determination are communicated via e-mail to the fiscal officer, input into ECMS notes, and communicated to the BPA via letter explaining the decision.
(b) If the request originates from a claimant or provider, the CE immediately sends a copy via facsimile to the BPA, and concurrently begins development for approval or denial of the request. All approvals or denials are communicated to the requestor as outlined above.
d. Fiscal Officer. The Fiscal Officer (FO) acts as liaison between the CE and the Medical BPA, serves as coordinator for medical bill issues between the District Offices and the National Office, and maintains a District Office record of persons authorized to access the BPA website. The FO does not determine eligibility or authorize payments.
e. Medical Scheduler. The Medical Scheduler (MS) coordinates all requests for both internal and external District Medical Consultant reviews. The Medical Scheduler serves as the primary assistant to District Medical Consultants who are assigned to the District Office on a part-time basis.
f. District Medical Consultant (DMC). The DMC reviews and evaluates the medical evidence of record and provides medical opinions about various aspects of cases, such as:
(1) Causation: The DMC determines medical causation by reviewing medical, employment and exposure evidence to determine if the medical history is indicative of toxicity (arising out of exposure to a toxic substance) or of an organic/other nature (arising out of a natural medical occurrence, such as hereditary factors, or a lifestyle illness). The DMC may also be called upon to determine the likely role of an accepted condition as it relates to a cause of death, or the appearance of secondary or consequential illnesses or diseases.
(2) Explanation of treatment modalities, the interpretation of clinical test results, and the clarification of other physician’s reports.
(3) Determining the level of impairment in a given case in accordance with the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, subject to DEEOIC’s guidance.
3. Parameters for Payment. OWCP procedures employ four levels of review in the medical bill process, only two of which DEEOIC currently uses. The BPA automatically processes charges for Level 1 services and the CE is not required to approve. Any higher level of service (i.e. two, three or four) is treated as a Level 4 service in our program and requires that the CE review the proposed procedures or service(s), the proposed charges if applicable, and the supporting medical documentation, prior to approving or denying the request. All of the following services (Paragraphs 4 through 11) are Level 4 services.
4. Mailbox for Medical Bill Inquiries. The Policy, Regulations and Procedures Unit (PRPU) of the DEEOIC Policy Branch, located in the National Office (NO), has created an electronic mailbox (email) for use in resolving medical bill questions. This mailbox is to be used when submitting inquiries concerning medical bills, travel reimbursement, treatment suites, provider outreach, or policy questions regarding medical bill processing.
The Fiscal Officers (FO) in each respective district office serve as liaison for Claims Examiners (CE) with questions that require review by the PRPU, at the NO. CE2 staff submit questions to the mailbox through the CE2 Unit Manager. The Fiscal Officers and CE2 Unit Managers act as the District Office Point of Contact (DO POC) for purposes of communicating medical bill issues to the PRPU. A Medical Bill Processing POC at the National Office (Medical Bill POC) is responsible for routing email inquiries to the proper party at the NO.
Use of this mailbox provides for expedited resolution of medical bill issues as they arise, and provides a more uniform process for responding to these questions and issues, program wide. The email address is DEEOICbillpay@dol.gov, and is to be used exclusively by the DO POCs, upon completion of the following steps:
a. When a CE receives an inquiry regarding reimbursement of a medical bill, for an accepted condition, the CE first reviews the bill in the Achieve medical bill inquiry system, and/or the Stored Image Retrieval(SIR)system, available at: http://owcp.dol.acs-inc.com/portal/main.do) in order to verify that the supporting medical documentation is on file. If, after reviewing the supporting documentation in the ACS web portal and in the case file, the CE still has questions related to medical bill processing, travel reimbursement, treatment suites, provider outreach, or a policy question regarding medical bill processing, additional assistance may be requested through the medical bill inquiries mailbox.
b. The CE prepares an email to the DO POC, or the CE2 prepares an email to the CE2 Unit Manager. In order to maintain consistency and to provide clarity in the communication process, it is imperative that the CEs provide sufficient information in the email, clearly defining the nature of the question, so that it can routed to the proper entity at the NO. Inquiries to the mailbox should be categorized using the subject headings below, and the subject line of the email must contain one of the following four subject headings:
(1) Policy Questions. Questions regarding policy interpretation or implementation are answered by the Medical Bill POC.
(2) Treatment Suites. The treatment suites and ICD-9 codes utilized by the DEEOIC are contained within a database, administered by medical professionals within the OWCP. This database compares an ICD-9 coded diagnosis, and associated services being billed by a provider, with a group (or suite) of acceptable, allowable treatments or services for that accepted condition. The use of treatment suites allows bills to be paid automatically when the treatment being billed is reasonable and customary for the accepted condition. Often, issues arise when a claimant is trying to obtain payment for a consequential illness and the medical bills are being denied because the consequential illness is not being recognized within the treatment suite(s) for the accepted condition. Inquiries of this nature will be directed to the Medical Bill POC, for a response.
(3) Provider Outreach. Questions from medical providers regarding assistance with enrollment, submission of bill(s), or understanding DEEOIC’s medical billing process, must be forwarded to the Medical Bill POC, who will then coordinate with the Resource Center (RC) Manager on these issues. Provider outreach issues must be coordinated through the Medical Bill POC.
(4) Bill Payment Processing. Questions regarding reimbursement of medical bills should use this subject heading, and will be routed to Payment Systems Manager for a response.
The body of the email itself must contain the following information (as applicable):
§ District Office Location;
§ CE Name;
§ Employee’s Name;
§ DOL File Number(not to be used in the subject line);
§ Accepted Condition(s) with ICD-9 code(s);
§ Billed Amount(s);
§ Date(s) of Service(s)or Travel day(s);
§ Medical Provider Name(s);
§ Type of Service(s) (i.e., Pharmacy, In-Home Health);
§ Question(s) or issue(s) to be resolved.
c. Upon receipt of an email question being posed, the DO POC reviews the email carefully and determines whether the issue warrants review by the NO. If the question does warrant such review, the POC forwards the inquiry to DEEOICbillpay@dol.gov.
d. The Medical Bill POC reviews all submissions received in the medical bill inquiries email box and determines the proper course of action. As noted above, all policy, treatment suite, and medical provider outreach questions will be evaluated and answered directly by the Medical Bill POC. Issues related to medical bill payments will be forwarded to the NO Payment Systems Manager, who is responsible for evaluating each inquiry and providing a response. Some referrals to the mailbox may have elements related to several topics in the inquiry, and the Medical Bill POC ensures that the question is evaluated by the proper individual(s), and coordinates the response to the DO.
e. In the case of a policy or treatment suite issue, the Medical Bill POC researches the inquiry and provides an answer to the requesting DO within five (5) business days. If a policy question requires additional research, a reasonable extension of time is granted by one of the PRPU Policy Unit Chiefs. Complex policy issues might require the involvement of the Policy Branch Chief before a response can be generated, and the Medical Bill POC must monitor such issues to ensure that they are resolved in a timely manner.
f. The Medical Bill POC forwards all medical bill payment inquiries directly to the Payment Systems Manager, who assesses each question and provides an answer directly to the inquiring DO within five (5) business days of receipt of inquiry.
g. The Medical Bill POC refers all medical inquires to the RC Manager for response. The RCs serve as the primary point of contact for DEEOIC’s provider enrollment inquiries. The RC Manager will provide a response to the Medical Bill POC within three (3) business days of receipt detailing the planned response to these types of inquiries. The Medical Bill POC will relay the proposed response(s) to the inquiring DO so the DO is aware that resolution is being sought.
h. Upon receipt of inquiry responses, the DO POC forwards the response to appropriate CE/CE2 via e-mail. The CE/CE2 is responsible for notifying the employee, claimant, authorized representative and or provider (if applicable), via telephone or in writing, of appropriate response to the issue at hand. All telephone activity is documented in the Energy Case Management System (ECMS) Telephone Management System (TMS) and a copy of the email response from the Medical Bill POC or Payment Systems Manager is placed in the case file.
i. Policy decisions rendered through this process, which have the potential for program-wide impact, are treated like policy teleconference notes, and are placed on the shared drive for use by all DEEOIC staff. It is the responsibility of the Medical Bill POC to ensure that such issues, as identified by the PRPU Unit Chiefs/Policy Branch Chief, are added to the policy teleconference answers, on the shared drive.
5. District Medical Consultant Reviews. For detailed information on the DMC referral process, refer to DEEOIC procedures on weighing medical evidence.
6. Medical Records Procurement. DEEOIC pays cost associated with obtaining medical records regardless of whether a claim has been approved for benefits. This reimbursement is payable only to a hospital, physician’s office, or other medical facility that charges a fee to produce records. The maximum allowable reimbursement is $100 per employee.
a. Form of Request. The provider provides the CE with the written fee request on official letterhead or billing statement. The request includes the tax identification number of the facility, total amount charged for the record request, and the provider enrollment number. If the provider is not enrolled, the CE forwards an enrollment package to the provider with a letter requesting that the provider enroll, and after completion of the enrollment process, the provider informs the CE of their new provider number.
b. Approval of Payment. Upon receipt of the required information, the CE approves the payment of the bill by completing a Form OWCP-1500, sending an approval letter to the requestor, and completing ECMS coding as required in DEEOIC procedures. The CE then forwards the completed Form OWCP-1500, approval letter, and invoice to the Fiscal Officer for payment processing.
7. Psychiatric Treatment. Prior to approval of psychiatric treatment, the CE must conduct the necessary medical development to substantiate a psychiatric condition as a consequential condition of an accepted illness; and the consequential condition must be accepted.
a. Expense of support groups that meet on a periodic basis, for individuals with a similar covered illness, are acceptable for reimbursement under the EEOICPA.
b. For ongoing therapy or for personalized care for a psychiatric condition, the CE obtains medical records and reports that support the need for these specific services as treatment for a consequential condition of the covered illness.
c. A narrative medical report from a licensed psychologist or psychiatrist must be submitted which includes:
(1) Diagnosis (with correct code);
(2) Medical rationale in support of how the psychiatric condition is related to the approved illness.
d. After appropriate development the CE decides whether to approve a psychiatric condition as a consequential illness. The CE advises the claimant of the decision to accept (via letter) or deny (via a Recommended Decision followed by a Final Decision), and updates ECMS as appropriate.
8. Hearing Aids (above $5000). The CE approves hearing aids in excess of $5,000 when hearing loss has resulted from an accepted illness, if the treating physician so recommends. DEEOIC may authorize maintenance of hearing aids, including batteries, repairs, and replacement as needed. For hearing aids under $5,000, see DEEOIC procedures regarding durable medical equipment.
9. Chiropractic Services. Chiropractic services may be authorized, but are limited to treatment for correction of a spinal subluxation, along with the tests performed or required by a chiropractor to diagnose such subluxation. A diagnosis of spinal subluxation must be documented with an x-ray in the chiropractor’s report prior to the CE considering payment.
10. Acupuncture Treatments. Acupuncture treatments may be authorized when recommended by the treating physician to provide relief. Such treatment shall be supervised by the treating physician, who shall submit periodic reports to show progress or any relief of the symptoms. If the treatment continues beyond six months and/or the results are questionable, the case should be referred to the DEEOIC Medical Director.
11. Organ Transplants (including Stem Cell). Treating physicians send all requests for organ transplants to DEEOIC’s bill processing agent (BPA) via fax, mail, or electronically, to begin the authorization process. The BPA creates an electronic record of all such requests, and initiates a thread to the district office FO, advising of a new, pending organ transplant request. The FO alerts the CE of the request for a transplant, and the CE ensures that the case file contains the necessary documentation, including a letter describing the necessity of the transplant from the treating physician, laboratory and diagnostic test results, CT or MRI scan results, and a transplant protocol. Once the CE has verified that this information is on file, and is contained in the thread, the CE forwards the information to the Medical Bill POC. The Medical Bill POC forwards all pertinent information to the DEEOIC Medical Director, who prepares a memorandum approving or denying the transplant for signature by the DEEOIC Director. The signed memorandum is returned to the DO following signature by the DEEOIC Director. All approved requests for organ transplants must be performed at a CMS (Center for Medicare and Medicaid Services) approved facility. See http://www.cms.hhs.gov/ApprovedTransplantCenters/
An organ donor is not considered an “employee” or “claimant” within the meaning of DEEOIC and is not entitled to compensation for wage-loss or permanent impairment, nor is a donor entitled to benefits for any complications resulting from the transplant. Only those medical and related expenses of the donor which are necessary to secure treatment for the employee are allowable.
a. In-Patient or Out-Patient. Depending upon the transplant center, the condition of the patient, and geographic limitations, transplant procedures may be performed on an in-patient or out-patient basis. Once a treating physician has requested approval for an organ transplant of any type, the CE forwards a letter to the transplant center requesting a detailed schedule of the procedures to be performed, and whether the procedure(s) require in-patient stay.
(1) Autologous transplants may be performed on either an in-patient or out-patient basis, depending upon the transplant center. This type of transplant requires stem cells that have been gathered and stored, coming directly from the patient. No unrelated donor, related donor, or cord blood search needs to be authorized.
(2) Allogenic transplants may also be performed on either an in-patient or out-patient basis. Allogenic transplants require that donor-blood stem cells be drawn, stored, and then transplanted into the patient.
b. Choice of Donors.
(1) The first choice of a donor is generally a family member or relative. If the transplant facility approves a related donor, transportation expenses and the cost of required medical procedures for obtaining the organ(s) or blood stem cells are reimbursable. The transplant facility bills DEEOIC, referencing the employee’s (recipient) SSN, in addition to pertinent information pertaining to the donor. Travel is reimbursed following the same guidelines established for companion medical travel, and is paid to the employee.
(2) If no suitable match is available through a relative, an unrelated donor search must be authorized. The transplant center coordinates with the National Donor Program for the testing of each potential donor. The transplant center bills for all such tests and procedures. The average time waiting for an unrelated donor is four months. Unrelated donors are not paid for their donation; the only coverage is for the medical expenses related to the organ donor procedure. These procedures are billed by the transplant facility, the same as with related donors, referencing the covered employee’s social security number on all bills.
c. Long-Term Living Expenses. In many cases, transplants involve prolonged out-patient procedures requiring the patient to remain within a short distance of the transplant center. If the transplant procedure is authorized, and if it requires extended residency near the facility, lodging, per diem, companion, and other travel-related expenses may have to be authorized on a long-term basis. (Refer to Chapter 3-0300 for additional guidance on reimbursement for extended medical travel.)
12. Experimental Treatment and Clinical Research. Experimental treatments, or those which are generally not accepted, will be considered if: the accepted condition is life-threatening; established therapy has been tried to no avail; and a significant body of data supports the view that the experimental procedure is indeed beneficial.
All such requests are forwarded to the DEEOIC Medical Director for concurrence using the same procedures for organ transplants as outlined above, with the exception of the documents needed to approve the treatment. To request experimental treatment, the treating physician must send the treatment protocol, medical rationale, and peer reviewed documents supporting the treatment to the CE, to be forwarded to the NO for review.
13. Treatment Suites. At the core of the medical bill reimbursement process is the use of treatment suites. The treatment suites used by the DEEOIC are contained in a database maintained by medical professionals within the OWCP. They compare an accepted (ICD-9 coded) diagnosis for which a provider has billed, with acceptable, allowable treatments for that condition. The use of treatment suites allows automatic payment of bills, for authorized services, when the amount billed is reasonable and customary for an accepted condition.
14. Eligibility Files. In order for a claimant’s bills to be paid, an eligibility file is automatically generated in ECMS and sent to the bill processing agent once a condition has been accepted. This eligibility file contains the accepted condition for which a claimant is entitled to medical treatment. When the accepted condition(s) are coded and billed with the correct ICD-9 Code, the volume of suspended and denied bills is significantly reduced. Consequently, accurate code selection expedites provider reimbursement for all approved medical services rendered to the claimant.
15. ICD-9-CM. The International Classification of Diseases, 9th Revision, and Clinical Modification, (referred to simply as ICD-9 codes), is a statistical classification and coding system used to assign appropriate codes for signs, symptoms, injuries, diseases, and other medical conditions.
These codes are assigned, based on the claimants’ medical documentation (records), including, but not limited to physician notes, diagnostic tests, and surgical reports. ICD-9 codes are composed of numbers with 3, 4, or 5 digits. Three-digit category codes are generally subdivided by adding a fourth and/or fifth digit to further specify and clarify the nature of the disease or medical condition. The CE entering an ICD-9 code must identify and enter the code that references the disease, illness or medical condition that was reported, and should identify the organ(s) or portion of the body affected by the condition.
In general, three-digit codes identify a category of illness, while codes with fourth digits are called subcategory codes, and those with fifth digits are referred to as sub-classifications.
When a specific condition, illness, etc., contains a 4th or 5th digit, the CE uses all available digits to identify the condition. In addition to providing further specificity of the anatomical site, the 4th and 5th digits also provide additional pertinent clinical information related to the injury or medical condition. Therefore, when selecting ICD-9 codes, the CE should always use the code that most specifically describes the medical condition reported.
a. Examples of valid 3-digit codes:
(1) 496- Chronic Obstructive Pulmonary Disease (COPD).
(2) 501- Asbestosis.
b. Examples of 4-digit and 5-digit codes:
(1) 162.5- malignant neoplasm, lower lobe, bronchus or lung (requires a 4th digit).
(2) 508.0- Acute pulmonary manifestation due to radiation (requires 4th digit).
(3) 205.10- Myeloid leukemia, chronic, in remission (requires a 5th digit).
(4) If an employee was diagnosed with diabetes mellitus, it would be incorrect to assign code 250, since all codes in the diabetes series (250) have five digits.
16. Coding Software. Claims examiners are to utilize the coding software which is available at https://www.medicalcodeexpert.com/expert/. This is an online tool that helps to identify the appropriate ICD-9-CM code. These guidelines are to be used as a supplement to the ICD-9-CM Coding books.
17. Prompt Pay. The Prompt Payment Act requires federal agencies to pay vendors in a timely manner. The Act requires assessment of late interest penalties against agencies that pay vendors after a payment due date. The DEEOIC has identified three classes of bills that fall under the Prompt Pay Act: Reviews by a District Medical Consultant, Second Opinion/Referee Medical Examinations, and Impairment Rating Examinations. These bills must be processed within seven calendar days from date of receipt in the District Office. (Refer to PM 2-800 for the specific actions to be taken by the CE and the Medical Scheduler in the processing of DMC bills.)
18. Time Limits for Submission of Medical Bills. DEEOIC pays providers and reimburses employees promptly for all bills that are properly submitted on an approved form and which are submitted in a timely manner. No such bill is paid for expenses incurred if the bill is submitted more than one year beyond the end of the calendar year in which the expense was incurred, or the service or supply was provided; or, more than one year beyond the end of the calendar year in which DEEOIC first accepted the claim, whichever is later.
19. Fee Schedule. For professional medical services, OWCP maintains a schedule of maximum allowable fees for procedures performed in a given locality.
The schedule consists of:
a. An assignment of a value to procedures identified by HCPCS/CPT code which represents the relative skill, effort, risk and time required to perform the procedure, as compared to other procedures of the same general class.
b. An index based on a relative value scale that considers skill, labor, overhead, malpractice insurance and other related costs.
c. A monetary value assignment (conversion factor) for one unit of value in each of the categories of service.
Generally, bills submitted using HCPCS/CPT codes can not exceed the fee schedule. If the time, effort and skill required to perform a particular procedure varies widely from one occasion to the next, DEEOIC may choose not to assign a fee schedule limitation. In these cases, the allowable charge is set individually based on consideration of a detailed medical report and other evidence. At its discretion, DEEOIC may set fees without regard to schedule limits for specially authorized consultant examinations, and for other specially authorized services.
20. Fee Schedule Appeal Process. As part of the medical bill review process, the EEOICPA regulations provide for the appeal of fee schedule reductions (charges by a provider that have been reduced in accordance with the OWCP fee schedule for that specific service.) In order to maintain consistency, record responses, and track fee schedule appeals, the following procedures have been developed to further delineate this process.
a. When the BPA receives a fee appeal request letter, the BPA stores an electronic copy of the appeal letter in the Stored Image Retrieval system (SIR), linked to the remittance voucher, and sends a printed copy of the letter to DEEOIC Central Bill Processing, through the NO Payment Systems Manager (PSM).
b. For each fee schedule appeal letter received, the PSM creates a record, and maintains them in a tracking system (spreadsheet or database) created for this purpose.
c. The PSM reviews the fee appeal request to determine if the provider has met any of the conditions below which justify a reevaluation of the amount paid. These three conditions, as found in 20 C.F.R. 30.712, are:
(1) The service or procedure was incorrectly identified by the original code; or
(2) The presence of a severe or concomitant medical condition made treatment especially difficult; or
(3) The provider possesses unusual qualifications (i.e. possesses additional qualifications beyond board-certification in a medical specialty, such as professional rank or published articles.)
d. Within 30 days of receiving the request for reconsideration, the PSM prepares a response to the medical provider outlining DEEOIC’s decision to either:
(1) Approve an additional payment amount: In this instance, the PSM generates a draft letter for the District Director’s (DD) signature, informing the provider of the approval for additional payment. [Where an additional amount is found to be payable based on unusual provider qualifications, the DD determines whether future bills for the same or similar service from that provider should be exempt from the fee schedule.] The PSM also prepares a memorandum for the case file stating the findings and the basis for the approval of the additional amount, or;
(2) Deny any additional payment: In this instance the PSM prepares a draft letter-decision for the DD’s signature, advising that additional payment is denied, based upon the provider’s failure to establish one of the conditions listed above, in Item c above(1,2,3). Where additional payment is denied, the letter decision must contain a notice of the provider’s right to further review, similar to the following:
If you disagree with this decision, you may, within 30 days of the date of this decision, apply for additional review. The application may be accompanied by additional evidence and should be addressed to the Regional Director, District _________, Office of Workers’ Compensation Programs, U.S. Department of Labor, [Insert appropriate Regional Office address and Zip Code.]
e. The draft approval or denial letters are prepared by the PSM, for the signature of the District Director (DD) whose office has control of the claim file(s) being addressed in the decision(s). The PSM sends the draft letter (via email) to the District Director for review, signature, and mailing. The DD places a copy of the signed letter in the case file and also returns (via email) a scanned copy of the signed letter, to be retained by the PSM.
f. The PSM continues to track the status of any fee schedule appeal case, and maintains an electronic copy of all correspondence. This includes a copy of the draft letter and a scanned copy of the signed letter mailed by the DD.
g. If a denial is subsequently appealed to the Regional Director (RD), the RD must consult with the PSM to obtain copies of relevant bills and documents, and to discuss the appeal. The PSM also provides the RD with a copy of the denial letter signed by the DD. This can be handled via email.
h. After consultation with the PSM, the RD prepares a written response to the provider within 60 days of receipt of the request for review. Where additional payment is denied at the regional level, the letter decision from the RD advises the provider that the decision is final and is not subject to further administrative review. The RD forwards a scanned copy of the signed letter decision to the PSM. The PSM also retains that response as part of the appeal record.
i. The final outcome of each appeal letter is recorded in the PSM tracking system to indicate:
(1) Additional payment made.
(2) DD Denial letter.
(3) RD Appeal letter.
(4) Time limit (30 days) has expired for appeal to RD.
(5) The final disposition date for each appeal letter.