Sample Home Modification Letter

[Date]

[Claimant Name or AR Name]

[Street Address]

[City, State, Zip]

Employee:

Case ID:

[Insert Employee Name]

XXXXX

Dear [Insert Employee or AR Name]:

This letter is in reference to your claim for medical benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received an authorization request for home modifications related to your accepted medical condition(s).

Along with your request we also received a copy of your letter of medical necessity, prescribing [Insert brief description of modifications prescribed by letter of medical necessity]. Additionally, we received the two, detailed contractor estimates, describing the scope and cost of the proposed modifications.

After a careful review of your request, we have determined that the evidence submitted is sufficient to authorize your request for home modification. The request is approved subject to the following conditions:

  • The DEEOIC is approving modifications based upon the proposal submitted by: [Insert Name and Address of Contractor and Date of Proposal, for the approved bid.]
  • The total approved cost for all work, including materials, labor, profit and overhead is the amount of [Insert Approved Dollar Amount] as stated in the proposal.
  • Upon completion of the approved modifications, you must submit a signed letter to DEEOIC advising that all of the approved work has been completed, and that the work has been completed in a satisfactory manner. Along with your letter you must submit a completed OWCP Form 915 (Claim For Medical Reimbursement), a final invoice for the charges billed, and proof of payment to the contractor.
  • If you want DEEOIC to pay the contractor directly, it will be necessary for the contractor to enroll in our medical bill processing system in order to receive payment. Contractors seeking additional enrollment information can call our toll-free number (866-272-2682) for answers to billing questions. Once the approved work has been completed, it will be necessary for you to write us advising that all work has been completed in a satisfactory manner, and that you are requesting DEEOIC to make payment directly to the contractor, for the pre-approved amount.
  • Once DEEOIC has approved a written proposal for medically necessary modifications, you have the option of contracting for additional modifications, or for materials and appliances that represent an upgrade from the medically necessary standard prescribed. You may do so with the understanding that DEEOIC will only reimburse you for the cost of medically necessary modifications approved in writing. Reimbursement for the approved amount will be made to you upon completion of all work, and upon receipt of the following:
    • A letter from you stating that all work, as detailed in the approved modification proposal, has been completed to your satisfaction.
    • A final invoice from the contractor itemizing the cost of the completed work.
    • Proof of payment to the contractor for an amount no less than the amount approved for reimbursement by DEEOIC.
  • The DEEOIC neither endorses nor sponsors any entity providing services to beneficiaries of our program.

If you have any questions or concerns regarding this authorization please call me at [Insert Telephone Number].

Sincerely,

[Enter CE Name]

Claims Examiner

Copy To: Authorized Representative

Copy To: Contractor