TABLE OF CONTENTS

 

Paragraph and Subject                Page  Date   Trans. No.

 

Chapter 3-0300  Ancillary Medical Services and Related Expenses

 

     Table of Contents. . . . . . .    i    01/10     10-07

  1  Purpose and Scope. . . . . . .    1    01/10     10-07

  2  In-Home Health Care  . . . . .    1    01/10     10-07

  3  Attendant Services . . . . . .    13   01/10     10-07

  4  Hospice Care . . . . . . . . .    15   01/10     10-07

  5  Extended Care Facilities . . .    16   01/10     10-07

  6  Durable Medical Equipment. . .    17   01/10     10-07

  7  Vehicle Modifications

       and Purchase . . . . . . . .    20   01/10     10-07

  8  Housing Modifications. . . . .    26   01/10     10-07

  9  Health Facility Membership

       and Spa Membership . . . . .    33   01/10     10-07

 10  Medical Alert Systems. . . . .    36   01/10     10-07

 11  Extended Medical Travel

       Expense Reimbursement. . . .    39   01/10     10-07

 

Exhibits

 

  1  Sample Initial Medical

       Development Letter . . . . .         01/10     10-07

  2  Sample Follow-up Development

       Letter . . . . . . . . . . .         01/10     10-07

  3  Sample Authorization Letter. .         01/10     10-07

  4  Billing Codes. . . . . . . . .         01/10     10-07

  5  Sample Recommended Decision to

       Deny Home Health Care. . . .         01/10     10-07

  6  Sample Travel Authorization

       Letter . . . . . . . . . . .         01/10     10-07


 

1.   Purpose and Scope.  This chapter describes the procedures for evaluating and approving requests from claimants who need ancillary medical services and supplies, and who seek reimbursement of expenses related to ancillary services. The roles and responsibilities of those who authorize such expenses are described in EEOICPA PM 3-0200.

 

2.   In-Home Health Care.  This section provides clarification with regard to the evidence needed to authorize in-home health care, as well as procedural guidance with regard to the process for review, development, and authorization of in-home health care services.

 

a.   All requests for in-home health care must be submitted 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 documents and requests, and initiates a thread to the district office Fiscal Officer (FO), advising of a new pending in-home health request. FO is the point of contact with DEEOIC’s BPA for all in-home health care requests.

 

b.   All requests for in-home health care require prior authorization from the POC Claims Examiner (expedient review occurs under certain emergency situations - see “q” below for further information), including authorization for initial nurse assessment.  If a physician requests that an initial in-home assessment be performed to determine the need for in-home health care, the request for that initial assessment must be submitted to the BPA with appropriate supporting medical documentation.

 

c.   Written requests that are received in the district office from the claimant, the authorized representative, the treating physician, or a service provider, must be faxed by the POC CE to the BPA to begin the authorization process. Concurrently, the POC CE begins development on any such request while awaiting an acknowledgement from the BPA.

 

d.   If the POC CE receives a request for an initial assessment without a physician’s signature or recommendation, the POC CE must fax it to the BPA and begin concurrent development, the same as in step “c” above. The POC CE sends a letter to the claimant advising that a request for an initial in-home assessment was received without a physician’s recommendation.  In the letter, the POC CE provides 30 days for receipt of a physician’s authorization or request for the assessment. If medical documentation is not received within 30 days, the POC CE denies the request for assessment pursuant to the instructions in “y” below.

 

e.   Telephone requests for in-home health care must be documented in ECMS. Except in cases of an emergency nature (See “r” below), the POC CE may provide information and answer questions pertaining to in-home care covered by DEEOIC, however all callers should be advised that they must submit their requests in writing before the authorization process can begin. Written requests must include a medical rationale and a detailed explanation of the type and level of service the patient requires.

 

f.   Valid requests do not always have to be initiated by a claimant to be considered valid requests.  Requests for an in-home assessment of a patient’s needs, and/or requests for in-home care can be initiated by an authorized representative, or any licensed doctor or medical provider.

 

g.   Upon receipt of an authorization request for in-home health care from the BPA, the FO forwards the information to the appropriate POC CE for review and adjudication.

 

h.   Upon receipt of such request, the POC CE must determine the particular in-home health services or care being requested. Generally, the types of requests that are submitted include:  a physician’s request for authorization of an initial in-home assessment; discharge summary from a hospital requesting specific in-home health care services; or requests from a physician for continuing in-home health care services (following expiration of a previous authorization).

 

i.   Upon receipt of a request, the POC CE reviews the medical evidence to determine if the initial assessment or in-home health care was requested by the treating physician.  If the request comes from the treating physician, or another appropriate doctor, the POC CE approves the initial assessment only (if applicable).  When an initial assessment request precedes a request for in-home health care, the POC CE may not approve in-home health care until after the initial assessment has been completed and a plan of care has been submitted.  Once the POC CE approves the initial assessment, the POC CE sends an email to the FO, who sends a thread to the BPA authorizing the request (see “p” for more information concerning approvals).

 

j.   Upon receipt of a plan of care, discharge summary, or physician’s recommendation delineating a specific request for in-home health care services, the CE must conduct a complete review of the case file to determine if there is any recent medical documentation from the primary care physician (or treating specialist for the accepted condition), describing the need for in-home medical care as it relates to the covered medical condition.  The primary information that the treating physician must provide (often contained in the plan of care signed by a physician) should include:

 

(1)  Description of the in-home medical needs of the patient arising from the covered medical condition.  This includes a narrative of the patient’s medical need for assistance while in the home and how this is linked to the covered medical condition.  The physician must describe the findings upon physical examination, and provide a complete list of all medical conditions (those accepted by DEEOIC and those not accepted by DEEOIC). If a claimant has one or more non-covered conditions, medical evidence must demonstrate how the requirement for in-home health care is related to the accepted conditions.  The physician should also describe laboratory or other findings that substantiate a causal relationship between the accepted condition(s) and the need for assistance or skilled nursing care in the home.  Generally, approved in-home services include:  administration of medication, medical monitoring, bathing and personal hygiene, meal preparation and feeding, wound dressing changes, and medical equipment checks.

 

(2)  Level of care required, i.e. Registered Nurse (RN), Licensed Practical Nurse (LPN), Home Health Aide (HHA), etc.  The doctor must specify the appropriate type of professional who will attend to the patient.  Services requiring specialized skills such as administration of medication and medical monitoring generally require a RN or LPN, while services of a general nature (typically referred to as activities of daily living), such as bathing, personal hygiene, and feeding are generally performed by home health aides and attendants.

 

(3)  Extent of care required (months, days, hours, etc).  A written medical narrative must describe the extent of care to be provided in allotments of time. (Example: RN to administer medication and check vitals once a day, every three days, with a home health aide to assist with bathing, personal hygiene, and feeding, eight hours a day, seven days a week for three months.)

 

k.   If upon review the POC CE finds that the medical evidence is incomplete and the file does not contain an adequate description of the in-home health care needs of the patient, the POC CE prepares a letter to the claimant advising that the DEEOIC has received a request for in-home health care.  In the letter to the claimant, the POC CE advises that additional medical evidence is required before services can be authorized.  Additionally, the POC CE forwards a copy of the claimant letter to the treating physician, requesting a narrative medical report that includes all of the information described in “j” (above).  In addition, the physician is asked to estimate the length of time for which the patient will ultimately require in-home health care assistance.  The POC CE advises in the letter that the medical report is required within 30 days. (see Exhibit 1 for sample letter)  The POC CE also faxes a copy of the letter to the treating physician’s office. 

 

l.   Upon mailing the request to the claimant (copy to the treating physician) the POC CE enters an ECMS note describing the action and inserting a 15-day call-up.  If on the fifteenth day the physician has not responded, the CE contacts the physician’s office to inquire if the letter was received, and to ask if there are any questions regarding the request for information. The call is documented in TMS and another 15-day call-up inserted in ECMS.

 

m.   After 30 days has passed with no satisfactory response from the treating physician, or no response from the claimant, the POC CE prepares a second letter to the claimant (accompanied by a copy of the initial letter), advising that following the previous letter, no additional information has been received from the treating physician.  The POC CE advises that an additional period of 30 days will be granted for the submission of necessary evidence, and if the information is not received in that time, the request for in-home care may be denied by the DEEOIC (see Exhibit 2 for a sample letter).

 

n.   If the claimant or the physician does not provide a response to the second request for information within the 30-day period allowed, the POC CE issues a letter decision to the claimant denying the claim for in-home health care. (See “y” below for more details.) The POC CE further sends an email to the FO, who sends a thread to the BPA advising that the service has been denied.

 

o.   If the claimant calls and states that he/she does not require in-home health care, the POC CE requests that the claimant put this in writing.  Upon receipt of any written statement from the claimant stating that he/she is not requesting in-home health care, the POC CE writes a letter to the claimant with a copy to the treating physician advising that the claimant is not requesting in-home health care and thus the matter is closed. In this situation, the POC CE sends an email to the FO, who sends a thread to the BPA advising that this service is denied.

 

p.   If medical evidence is received, the POC CE must determine if it is of sufficient probative value to authorize in-home health care. It is absolutely critical that the POC CE undertake appropriate analysis of any documentation pertaining to in-home services before authorizing such care.

 

The underlying function of the POC CE is to ensure that the covered employee receives the necessary medical care for the accepted medical condition and that any such request for care reasonably corresponds with the medical evidence in the case file.  If the physician does not provide sufficient details concerning the claimant’s physical condition, relationship to accepted conditions, or specific reasons for in-home health care, the POC CE must refer the case to a District Medical Consultant (DMC) for review. Upon receipt of a DMC’s opinion, the CE weighs the medical evidence in the file.  If the DMC opinion is clearly in conflict with the recommendations of the treating physician, and the POC CE attempts to resolve the situation by communicating with the treating physician have not been successful, the POC CE is to arrange for a second medical opinion or referee evaluation, depending on the circumstances.  In evaluating the medical evidence, the POC CE must base any determination solely on the weight of medical evidence in the case file.  The POC CE must not under any circumstances deny or reduce in-home health care services without a medical basis for such denial.

 

q.   In certain emergency claim situations (see “r” for a full discussion of the types of emergencies), the CE may authorize in-home health care for a preliminary 30-day period while additional development is undertaken.

 

(1)  Under these circumstances, the physician or hospital staff contacts DEEOIC’s BPA for immediate attention.  The physician or hospital employee must notify the BPA that the situation is of an emergency nature (e.g., the claimant is being released from the hospital and requires immediate in-home care).  The BPA obtains any pertinent documentation and assesses the emergency nature of the request.  Once the medical evidence is obtained, the BPA contacts the FO immediately, advising of the situation and providing electronic copies of documentation obtained. The BPA does not make a decision regarding the request, but simply obtains the pertinent documentation and advises the FO of the emergency request.

 

(2)  Upon receipt of the documentation, the FO forwards the information to the POC CE for review.  If discharge information from a treating physician supports the need for immediate authorization, the CE provides approval for 30 days pending additional development.  The POC CE concurrently sends an email to the FO advising of this approval.  The FO sends a thread to the BPA with the approval information and places a telephone call to the BPA, alerting them of an impending emergency request.

 

(3)  After the initial approval for 30-day emergency care, the POC CE sends a letter to the treating physician with a copy to the claimant requesting necessary evidence to fully substantiate that the care being provided is medically necessary to give relief for the accepted medical condition. This should occur within the preliminary 30-day authorization period.  Extensions may be granted in increments of 30 days, but should generally never exceed a total of 120 days without the collection of the necessary evidence to fully document that the care being provided is medically warranted and necessitated by the accepted medical condition.

 

(4)  In some situations the request for emergency home health care may not be accompanied by evidence supporting the emergency nature of the request.  For example, the claimant’s condition may be stable, or he/she is not being discharged from a hospital.  In these situations, the POC CE sends a letter to the claimant, with a faxed copy to the requestor if other than the claimant.  The letter advises that no evidence was submitted to support the request for emergency care, and that additional medical evidence is required. In addition, the POC CE sends an email to the FO advising that the request for emergency care is under development.  The FO sends a thread to the BPA advising of this determination and places a telephone call to the BPA, alerting them of an impending emergency request.

 

r.   Emergency situations warranting short-term preliminary authorization for in-home health care include:

 

(1)  Requests for in-home health care for terminal patients with six months or less to live.  Terminal status must be based on the opinion of a physician.

 

(2)  Patients discharged from in-patient hospital care with need for assistance.  The CE must carefully evaluate these situations to ensure the medical documentation clearly indicates that the patient’s care and well-being is dependent on the assignment of a medical professional in the home, (normally following a hospital stay).  If the BPA has not already obtained this, the POC CE requests the attending physician discharge summary and discharge planning summary, which is normally available within 72 hours of discharge.

 

When pre-authorization of emergency in-home care is to be granted, the POC CE prepares a memorandum for the case file documenting the rationale applied in authorizing care. For each subsequent 30-day pre-authorization granted, a new memo is prepared outlining the basis for such authorization. In addition, the POC CE notifies the claimant and provider in writing of additional periods of authorization.  The POC CE sends an email to the FO advising of any authorizations, and the FO forwards the information to the BPA in the form of a thread.

 

s.   For all requests, if upon review of the medical evidence the POC CE decides that in-home health care is required, authorization is to be granted.  The POC CE prepares a letter notifying the claimant and the home health care provider of the decision, and delineating the following information (see Exhibit 3 for a sample authorization letter):

 

(1)  Covered medical condition(s) for which care is being authorized.

 

(2)  A specific narrative description of the service approved (e.g. in-home assistance in administering medicine, monitoring accepted conditions, assistance in/out of bed, preparing meals and feeding, and medical equipment checks).

 

(3)  Level and duration of the specialized care to be provided, i.e. RN 1 hour per day and Home Health Aide 8 hours per day, 7 days a week for a period of 3 months.

 

(4)  Authorized billing codes relevant to the level of authorization (see Exhibit 4 for a description of the pertinent codes).

 

(5)  Period of authorization with specific start and end dates.

 

t.   The authorization must be limited to in-home medical services that are reasonably necessary for the treatment or care of the patient’s covered medical condition. These services generally include: Home Health Aide or attendant for mobility, food preparation, feeding and dressing; skilled nursing should be limited to the scope of practice of an RN or LPN, as long as there is medical evidence of such.  The POC CE may not authorize a lower level of care than that requested by the physician unless the weight of medical evidence supports a lower level of care and the claimant has been provided the right to a recommended decision.

 

u.   Once the responsible POC CE sends the letter of authorization to the claimant and the provider, the POC CE prepares an email to the fiscal officer (FO).

 

In the email, the POC CE advises the FO of the precise level of care, billing codes, and time period of authorization.  The POC CE is not required to advise the FO of the number of correlating units per billing codes.  In assigning billing codes, the POC CE references Exhibit 4.

 

v.   Once the email authorizing the services has been sent, the POC CE enters a note into ECMS detailing the level of service and time period of authorization.  In addition, the POC CE enters a call-up note into ECMS for 30 days prior to the expiration date for which services have been authorized.

 

w.   If no request for additional authorization for in-home health care is received prior to the date of the call-up, the POC CE sends a letter to the provider, with a copy to the claimant.  In the letter, the provider is notified of the expiration date of the in-home health care services.  The provider is further advised of the medical evidence required if additional services are necessary.  If the POC CE does not receive an additional request, further action is unnecessary.  However, if the provider or the claimant submits an additional request for ongoing services, the POC CE evaluates the evidence as above.

 

x.   Upon receipt of the email authorization from the POC CE, the FO prepares a thread to the BPA authorizing the specific level of care, billing codes (with units), and period of authorization.  The FO calculates the authorized number of units based upon the POC CEs description of the level of care, weekly authorized amount for each level of care, and the time period of authorization.

 

y.   If upon review of the medical evidence in the file, and if after appropriate development as outlined above, the POC CE determines that there is insufficient evidence to warrant authorization of in-home health care, the POC CE sends a detailed letter-decision to the claimant (with a copy to the in-home provider).  The letter-decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

z.   In the event that the claimant does request a Recommended Decision, the POC CE prepares a Recommended Decision (see Exhibit 5 for a sample decision).

 

aa.  At any time after a period of authorized services and after the POC CE has undertaken any medical development (i.e. letter to the claimant requesting additional documentation, referral to DMC or second opinion) the POC CE may receive new medical evidence that warrants a change in the level of in-home care currently authorized.  If this occurs, the POC CE must review that evidence, employing the same decision-making process described in “p.”  If the new medical evidence supports a denial of services, or reduction in the level of services currently being authorized, that reduction or denial must be communicated to the claimant in a detailed letter as discussed in “y”, (with a copy to the in-home care provider) explaining the change.

 

bb.  Letters that advise of a reduction or termination of services must be copied to the in-home care provider and must specifically advise the claimant that:

 

(1)  Any reduction in the current level of service being provided will occur 15 days from the date of the letter. This letter must also contain information describing the new level of care being authorized; or,

 

(2)  Any termination of services will occur 30 days from the date of the letter.

 

cc.  After the expiration of the 15 or 30 day periods, the POC CE sends a letter-decision to the claimant advising as to the final action taken on the request for in-home health care services.  In this letter the POC CE advises the claimant of his/her rights of action as delineated in action item “y” above.

 

In addition, the POC CE sends an email to the FO advising of the new level of care or the termination of current level of services.  The FO then sends a thread to the BPA advising of the determination.  It is very important for the POC CE to note that only a single authorization can exist at any one time.  If the POC CE has authorized a certain level of care that subsequently changes, it is essential that this information be clearly communicated in an email to the FO. The FO sends a thread to the BPA advising of any change in the level of care being authorized, or of any additional period of authorization beyond the existing expiration date.  The POC CE must also document the information in the notes section of ECMS when a thread is sent to the BPA.

 

dd.         If the claimant requests a recommended decision on a termination of services, the POC CE proceeds with a recommended decision.  If the claimant requests a recommended decision on a reduction in the level of care, the POC CE proceeds with a recommended decision.

 

ee.  If, after initial approval of services, the claimant’s treating physician sends in medical documentation (without prior POC CE development) recommending a lower level of care, the POC CE authorizes the new level of care via letter to the claimant (with a copy to the provider).  Since the new level of care is requested by the treating physician without development by the POC CE, the POC CE does not need to provide the claimant with a right to a recommended decision.  The POC CE concurrently sends an email to the FO advising of the new level of care.  The FO sends a thread to the BPA advising of this change.

 

(1)  Period of Service.  In-home health care may be authorized for a period of up to six months. Recertification is required for any period of time beyond six months.  Recertification should be completed before the current authorization expires, to allow for care to continue uninterrupted.

    

3.   Attendant Services.  This section provides clarification with regard to the evidence needed to authorize attendant services. Refer to item 2 of this chapter for guidance regarding development of attendant services.

a.   Section 7384t of the EEOICPA authorizes payment for personal care services whether or not such care includes medical services, as long as the personal care services have been determined to be medically necessary and are provided by a home health aide, licensed practical nurse, or similarly trained individual.

(1)  Attendant services are non-skilled services routinely provided in an in-home setting. These services assist claimants with activities of daily living (i.e. bathing, feeding, dressing, etc). Attendant services must be provided by a trained individual.

(2)  The POC CE may authorize attendant services to a claimant when a treating physician determines that these services are required for an accepted condition. The physician must provide a written statement, prescription or plan of care to that effect.

 

b.   A claimant’s relative may provide attendant care (if properly trained), but may not be reimbursed for care that falls within the scope of household duties and other services normally provided by a relative. Duties such as maintaining a household, washing clothes, or running errands are not considered attendant services, and will not be authorized. A claimant’s relative who provides attendant care services to a claimant can be authorized for reimbursement up to 12 hours per day.

 

c.   All requests for attendant services must be submitted to DEEOIC’s BPA via fax, mail, or electronically, to begin the authorization process.  The BPA creates an electronic record of all such documents and requests, and initiates a thread to the district office FO, advising of new, and pending attendant service requests. Upon receipt of an authorization request for attendant services from the BPA, the FO forwards the information to the appropriate POC CE for review and adjudication.

 

(1)  Period of Service.  Attendant services may be authorized up to six months. Recertification is required for any period of time beyond six months.  Recertification should be completed before the current authorization expires, to allow for care to continue uninterrupted.

 

(2)  Billing.  Attendant care services should be billed weekly or monthly.  Supporting documentation (i.e., weekly or monthly notes) must be submitted with the bill to the DEEOIC’s BPA. The DEEOIC’s BPA then forwards weekly/monthly notes to the district office for review. In assigning billing codes, the POC CE references Exhibit 4.

 

4.   Hospice Care.  This section provides clarification with regard to the evidence needed to authorize hospice care services. Refer to item 2 for guidance regarding the development of hospice care.

 

a.   Hospice care is generally requested and authorized when a claimant is determined to be terminally ill and has no more than six months to one year of life remaining.

 

(1)  When a treating physician determines that hospice care is required for an accepted condition and provides a written statement, prescription or plan of care to that effect, the CE may authorize the services.

 

(2)  Hospice, once authorized, is responsible for assessing the claimant’s needs and providing all levels of care to the claimant.

 

b.   All requests for hospice care in the home must be submitted to DEEOIC’s BPA via fax, mail, or electronically, to begin the authorization process.  The BPA creates an electronic record of all such documents and requests, and initiates a thread to the district office FO, advising of a new, pending hospice request. All requests for hospice care require prior authorization from the CE.  Upon receipt of an authorization request for hospice care from the BPA, the FO forwards the information to the appropriate CE for review and adjudication.

 

(1)  Period of Service.  Hospice services may be authorized for up to six months. Recertification is required for any period of time beyond six months.  Recertification should be completed before the current authorization expires, to allow for care to continue uninterrupted.

 

(2)  Billing.  Supporting documentation (i.e., medical notes) must be submitted with the bill to the DEEOIC’s BPA.  The DEEOIC’s BPA then forwards monthly notes to the district office for review. In assigning billing codes, the CE references Exhibit 4.

 

5.   Extended Care Facilities.  This section provides clarification with regard to the evidence needed to authorize placement in an extended care facility.

 

a.   Care in a nursing home, skilled nursing facility and assisted living facility may be authorized when the claimant does not need acute care but does require medical services and assistance with daily activities of living.

 

b.   All requests for extended care must be submitted to DEEOIC’s BPA via fax, mail, or electronically, to begin the authorization process.  The BPA creates an electronic record of all such documents and requests, and initiates a thread to the district office FO, advising of a new, pending extended care facility request. All requests for extended care require prior authorization from the CE.  Upon receipt of an authorization request for extended care from the BPA, the FO forwards the information to the appropriate CE for review and adjudication.

 

When a treating physician determines that extended care is required for an accepted condition, and provides a written statement to that effect, the CE may authorize the services. The claimant should remain under continuing medical supervision of a physician while residing in an extended care facility.

 

(1)  Period of Service.  Extended Care facilities may be authorized up to six months. Recertification is required for any period of time beyond six months.  Recertification should be completed before the current authorization expires, to allow for care to continue uninterrupted.

 

(2)  Billing.  Supporting documentation (i.e., medical notes and itemization of charges,) must be submitted with the bill to the DEEOIC’s BPA.  The DEEOIC’s BPA then forwards supporting documentation to the district office for review. DEEOIC will reimburse the rates for standard accommodations according to the requirements of the medical condition. In assigning billing codes, the CE references the Current Procedural Terminology (CPT) manual.

 

6.   Durable Medical Equipment.  This section describes procedures to be followed when a claimant requests authorization for durable medical equipment (DME), appliances and supplies. All DME, appliances, and or supplies must be purchased from a DME supplier.

 

a.   DME is primarily and customarily used to serve a medical purpose only. DME can withstand repeated use, and is appropriate for use in the home. Some examples of DME include hospital beds, walkers, wheel chairs, and oxygen tents.

 

b.   The District Office has broad discretion in approving DME, appliances, or supplies provided under the EEOICPA.

 

(1)  Most appliances, supplies and or DME purchases under $5,000.00 do not need CE approval and are automatically paid by the DEEOIC’s BPA in accordance with the OWCP fee schedule.

 

(2)  Requests for DME, appliances and or supplies equal to or over $5,000 (excluding mobility devices) must be approved by the CE, and that approval must be communicated to DEEOIC’s BPA through the FO.

 

(3)  Requests for mobility devices, such as a scooter or a motorized wheelchair, including its components and accessories, which are medically necessary to provide basic mobility, under $10,000, do not need approval and are paid automatically by DEEOIC’s BPA.

 

(4)  Requests for mobility devices equal to or over $10,000 must be approved by the CE, and that approval must be communicated to DEEOIC’s BPA through the FO.

 

c.   When authorizing purchase requests for DME equipment equal to or over $5,000 and mobility devices equal to or over $ 10,000, the CE must obtain the following information:

 

(1)  From the treating physician:

 

(a)  The treating physician must provide either a detailed letter of medical necessity or another means of justification for the medical equipment required, relating the need to the accepted condition.

 

(b)  A full, specific description of the basic equipment.

 

(c)  The anticipated duration of the need for the item (to determine whether rental or purchase is appropriate).

 

(d)  The full name and address of two suppliers.

 

(2)         Claimant:

 

(a)  Claimant must submit two estimates from two different DME suppliers. These estimates must be for exactly the same type of DME appliances and or supplies.

 

(3)  From the Supplier:

 

(a)  From each potential supplier, a signed statement describing in detail the DME equipment item, a breakdown of all costs including delivery and installation, and the current Healthcare Common Procedure System (HCPCS) code for each DME item needed.

 

e.   Estimates. The CE must authorize the lowest estimate provided that no exceptional circumstances warrant the higher estimate, (e.g., inability to provide the equipment in a timely fashion).

 

f.   Repair/Maintenance Cost: Cost for repairs and maintenance to DME equipment is covered.

 

g.   DME add-ons or Upgrades: Add-ons or upgrades are not covered; when they are intended primarily for the claimant’s convenience, and do not significantly enhance DME functionality.

 

h.   Communicating the decision.  Upon receiving a request for DME, appliances or supplies, the CE takes one of the actions below:

 

(1)  Approval:  If the CE approves the request, he/she writes a letter to the claimant advising him/her of the decision.  The letter includes the following: the date DO received the request; the type of service or appliance being approved; and a statement that the reimbursement amount will be based on the OWCP fee schedule.  The CE also communicates this decision to the DEEOIC’s BPA, through the fiscal officer. The claimant should be instructed to submit a copy of this approval letter, along with the request for reimbursement or payment, to the DEEOIC’s BPA.

 

(2)  Additional Information: If upon review the CE determines that additional information is necessary, he/she writes to the claimant requesting specific documentation that is necessary to continue the processing of the payment.

 

(3) Follow-up. If the provider and/or claimant do not respond to the development letter, or if he/she fails to provide sufficient documentation to support their request, the CE has the discretion to either take additional steps to develop the evidence, or to deny the request.  The CE must review the evidence in accordance with the guidance in this chapter, properly weighing the medical rationale provided.

 

     (4)  Denials.  If the CE denies the request he/she writes a detailed letter decision to the claimant detailing the reason(s) for the denial. The letter-decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

     (5)  Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

7.   Vehicle Modifications and Purchases.  This section provides clarification with regard to the evidence needed to approve vehicle modifications and purchases; as well as procedural guidance with regard to the process for review, development, and authorization of vehicle modifications and purchases.

 

a.   When it becomes necessary to provide the claimant with some form of private transportation, other than taxis or hired services, modification to, or replacement of the claimant’s privately owned vehicle can be approved. Upon receipt of a letter of medical necessity from the treating physician, detailing the physical limitations involved, and the specific transportations needs of the claimant as related to the accepted medical condition. The CE must gather two estimates from certified or licensed dealers for the cost of vehicle modifications recommended by the claimant’s treating physician. The CE has the latitude to approve an estimate that the claimant favors, if the estimates are reasonably similar in scope and cost.

 

(1)  Criteria for Modifications.  If the claimant’s transportation needs can be met by modifying or adding accessories and equipment to the claimant’s present vehicle, the CE explores this option first, before consideration is given to replacing the existing vehicle.  When considering modifications to an existing vehicle, the CE takes into consideration the type of vehicle currently owned, its age, and condition. Modifications must be consistent with the claimant’s pre-injury standard of living and should approximate that standard insofar as is practical.

 

(2)  Proposals.  If the CE determines that the claimant’s needs warrant vehicle modification, the CE advises the claimant in writing to submit a detailed written proposal containing the following information:

 

(a)  The year, make, model, and body style of the vehicle to be modified, as well as current mileage, description of general mechanical condition, and any repairs currently needed or anticipated.  The same applies regardless of whether the vehicle to be modified is new or used.

 

(b)  An itemization of all vehicle modifications proposed, to include parts, labor and their respective costs.  The itemization should also specify the amount of time required for the modifications.

 

(3)  After considering the proposal for modification to an existing vehicle, the CE accepts or rejects the proposal, in writing, within a reasonable time frame.

 

(4)  Approval.  If upon review of the evidence the CE approves the request, the CE writes a detailed letter decision to the claimant advising of the approval.

 

(5)  Notifying the BPA.  Once the CE sends the letter of approval to the claimant, the CE prepares an email to the FO. In the email, the CE advises the FO of the approval, citing the appropriate homegrown code (e.g. VHMDF, VHPUM) for a vehicle modification or purchase and the amount approved.  The fiscal officer communicates this approval to DEEOIC’s BPA.

 

(6)  Additional Information.  If the CE determines that additional information is necessary, the CE sends a letter to the claimant requesting additional documentation that is necessary to continue with the review process.

 

(7)  Follow-up.  If the claimant does not respond to the development letter, or if he or she fails to provide sufficient documentation to support the request, after considering all relevant evidence, the CE issues a detailed letter decision informing the claimant of the denial. The CE also informs DEEOIC’s BPA through the FO of this denial.  The letter-decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

(8)  Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

(9)  Purchase.  If it is established that the claimant’s currently owned vehicle is no longer acceptable for his or her transportation needs, and if modifications to that vehicle are not possible or practical, then the CE reviews the case with a supervisor and may authorize the purchase of a suitable replacement vehicle, taking credit (see (e) below) for the value of the claimant’s existing vehicle. Purchase options include the following:

 

(a)  Purchase of a used vehicle, similar in quality to the claimant’s existing vehicle, which is already equipped to accommodate the claimant’s disability and transportation needs.

 

(b)  Purchase of a used vehicle that is suitable for modification as described above.

 

(c)  Purchase of a new vehicle, modified, or suitable for modification, to meet the transportation needs of the claimant, arising from an accepted condition.

 

(d)  Whether a new or used vehicle is purchased, it must be a vehicle of similar quality as the vehicle that the claimant already owns (i.e. a vehicle in a price range that closely approximates the level of income and/or standard of living of the claimant).

 

For example if the claimant owns a mid-priced Chevrolet, Ford, Honda or Toyota, purchase of a Cadillac or Lincoln SUV, to be modified for their needs, would not be of comparable value. A vehicle of comparable value would have to be selected. Once the baseline cost of a comparable quality vehicle has been established, the claimant may (at his or her option) choose to upgrade the baseline model, by adding additional equipment, with the difference in cost being paid for by the claimant.

 

(e)  After determining the baseline cost of a comparable vehicle, the CE must take credit for (deduct) the wholesale value of the claimant’s existing car, when determining the allowance to be paid for a replacement vehicle. The wholesale value of the existing vehicle can be determined through a number of internet websites that make this information available free-of-charge. The CE should advise the claimant of the source of their information, once the wholesale value of the claimant’s current vehicle has been determined.

 

(f)  Sales Tax: State sales tax should be included in the cost of obtaining a replacement vehicle.

 

(g)  Equipment that is medically necessary for the accepted condition should be factory-installed whenever possible.

 

(10) Maintenance Costs.  The CE authorizes necessary maintenance on the specialized equipment in a modified vehicle, whether installed in a new or used vehicle.

 

a)   Replacement cost of the specialized equipment, due to normal wear and tear, may be considered as well.  Other parts of the vehicle will be maintained at the owner’s expense, even if the vehicle purchase was reimbursed by DEEOIC.

 

(b)  Replacement of the vehicle, and all authorized equipment, can be considered if the claimant can establish that the age, mileage, and condition of the vehicle warrant such replacement.  Any residual value remaining in the vehicle to be replaced would be applied as a credit toward the cost of a replacement vehicle.

 

(11) Proof of Insurance.  The claimant is required to obtain adequate insurance and to maintain current registration of the vehicle in the state of residence.  Claimants are required to carry comprehensive (fire, theft, vandalism, etc.) and collision insurance on any vehicle for which DEEOIC has authorized reimbursement, unless the fair market value of the vehicle and its equipment is less than $2,500.  The claimant may select the deductible of the insurance policy but will be responsible for any such deductible should an accident occur.

 

(12) Vehicle No Longer Needed.  When the claimant no longer needs the vehicle, DEEOIC is entitled to recover the fair market value of the modified vehicle, less any percentage contribution the claimant made to the overall purchase price of the vehicle and its modifications.  If the fair market value of the modified vehicle is less than $5,000, no reimbursement will be due DEEOIC.

 

(a)  Example 1.  The claimant owns a $10,000 vehicle that is not­ suitable for modification.  The purchase price of a suitable replacement vehicle is $30,000. The claimant contributes $10,000 toward the purchase of the new $30,000 vehicle, as this represents the value of the vehicle he or she owned, which is being replaced. DEEOIC then pays an additional $20,000 in reimbursement toward the purchase price of the modified vehicle.

 

(b)  Example 2.  The claimant has a $30,000 vehicle, for which he or she has contributed one-third of the purchase price. At the time of sale, the claimant would be entitled to one-third of the proceeds and DEEOIC would recover two-thirds. However, if at the time of sale, the fair market value was determined to be $4,995 (less than $5000); the DEEOIC would recover zero dollars.

 

8.   Housing Modifications.  This section provides clarification with regard to the evidence needed to approve housing modifications, as well as procedural guidance with regard to the process for review, development, and authorization of housing modifications.

 

a.   Modifications must be prescribed by a treating physician whose medical specialty qualifies him or her to offer a medical opinion on the specific architectural needs of a medically disabled person.  Modifications must be in conformity with applicable building codes and must conform to the standard of décor that existed prior to the disability.

 

(1)  Modifications to Owned Property.  Modifications to a house must be consistent with the claimant’s pre-injury standard of living and should approximate that standard insofar as practical, with respect to the quality of construction materials and workmanship.

 

(a)  Modifications may include certain additions where warranted.  For example, if a ground-floor recreation room is converted to a bedroom, to accommodate a wheelchair-bound individual, and if no ground-floor bathroom facilities exist, then the addition of a bathroom on the ground floor could be approved. Similarly, if there is no suitable space for conversion to a bedroom on the ground floor, then the addition of a bedroom on the ground floor could be approved, if no other reasonable alternative exists.

 

(b)  Modifications may include certain accessories.  The addition of appliances such as air conditioning or air filtration equipment can be considered, if found to be medically necessary for the relief of certain accepted medical conditions.

 

For example, if the claimant suffers from respiratory or cardiac conditions that have been accepted, his or her physician may order that the claimant  be kept in an air conditioned environment, in which case the expense for these modifications would be allowed.

 

(c)  Maintenance expenses. The CE approves maintenance expenses for equipment furnished to the claimant, as well as replacement costs after normal wear and tear.

 

(d)  The Government is entitled to reimbursement for the value of any special equipment that can be removed and sold separately, when no longer needed by the claimant.  Reimbursement shall also be owed for any increase in overall value of the property resulting from permanently installed special equipment, or for any architectural modifications of a permanent nature, that improve the value of the property.

 

The value of such permanent equipment or modifications may be determined in any reasonable, equitable manner, such as written estimates from real estate sources, or by comparing the recent sales prices of similar houses without the special equipment.  No reimbursement to the claimant should be considered for any reduction in the value of the property resulting from modifications which may inconvenience prospective purchasers.

 

(2)  Modifications to Non-Owned Property.  Any modifications to property not owned by the claimant and his or her family are subject to approval by the landlord or owner.  This is in addition to the preceding guidelines established for owned property.  When presented with a request for modifications to non-owned property, the CE considers the following points:

 

(a)  Rental property may be subject to federal (Americans with Disabilities Act), state or local statutes that mandate barrier-free accessibility for persons with disabilities.  The claimant should discuss any change in housing needs with his or her landlord, who may be able to offer modifications or alternative accommodations better suited to the needs of the individual.

 

(b)  If the landlord is unable or unwilling to pay for modifications, or offer other suitable accommodations, approval must still be obtained from the landlord prior to making any changes or alternations to the non-owned property.  Any such changes must be made at the claimant’s expense, and are subject to review and approval by DEEOIC, prior to any reimbursement.

 

(c)  If the landlord/owner will not permit modifications, or if the costs are excessive, and if suitable housing arrangements are available elsewhere, it may be more cost-effective to consider paying relocation expenses rather than paying for modifications at the current location.  If changing locations is the most cost-effective alternative, the CE may authorize a subsidy for any increase in rent, if warranted, in addition to the relocation expense. For example, if the claimant lives in an apartment with stairs, and is no longer able to climb stairs due to his or her accepted condition(s), DEEOIC would reimburse the claimant for the most nearly comparable apartment available that offers an elevator and any other accommodations required to fulfill the claimant’s medical needs arising from the claimant’s accepted condition(s).

 

(d)  The Government is entitled to reimbursement only for the value of special equipment that can be removed and sold separately, once the claimant no longer needs that equipment.  Improvements or modifications, and any increase in property value resulting from such changes, accrue to the benefit of the owner.

 

(3)  Proposals.  If the CE determines that the claimant is eligible for housing modifications, the CE asks the claimant to submit a detailed written proposal for review and consideration.

 

The CE advises the claimant that the proposed housing modifications should be of a quality and finish consistent with his or her present residence, not superior to it.  Further, the claimant should be cautioned that structural modifications must not compromise the integrity of the existing structure.

 

While the choice of modifications remains with the claimant, the CE does not authorize payment for any modifications that are structurally unsound.

 

Modifications will be no more expensive than necessary to accomplish the required purpose. For example, when remodeling a bathroom, it may be feasible to re-install an existing sink at wheelchair height, for less than the cost of discarding the sink and buying a new one.

 

Conversely, modifications must be in keeping with the standard of the décor of the current or pre-illness accommodations. For example, if the claimant’s dwelling (owned or rented) requires that a sink or commode be changed for handicap accessibility, and if it is necessary to tear out and replace tile, then the tile in the entire bathroom or kitchen may have to be replaced with similar quality tile in order to maintain the architectural décor of the room.

 

Proposals must include the following information:

 

(a)  A medical report detailing the physical limitations for which the requested modifications are necessary.  This report should be prepared by a physician who is a recognized authority in the appropriate medical specialty.  Reports from physical or occupational therapists may also be helpful in determining the nature of the modifications required.

 

(b)  An itemization of all modifications proposed.  Where substantial modifications are required, the detailed changes should be recommended by a medical or rehabilitation professional familiar with the needs of the disabled.

 

(c)  If the claimant lives in a rented or non-owned premise, a written statement from the landlord/owner must be obtained, approving and authorizing the specific plans and proposed modifications.

 

(d)  The CE reviews the itemized proposal and determines if the specified modifications are warranted.  If the CE identifies technical issues regarding implementation, the CE develops the issue further to identify alternate solutions.

 

b.   Fees and Bids.

 

(1)  Reasonable fees may be paid for the medical or rehabilitation professional’s visit to the site, and for the preparation of the detailed report.  The same applies to any architectural drawings that are required for significant structural changes.

 

(2)  No fee will be paid for attorneys or similar representatives engaged by the claimant to assist with the proposal.  Any fee charged by an Approved Representative remains the claimant’s obligation.

 

(3)  Two or more bids must be obtained by the CE for the proposed changes from licensed and/or certified contractors.  These bids must be for exactly the same modifications so that a true comparison of the competitive bids can be obtained.

 

(a)  If construction work is required, the bids obtained must be for binding estimates of the cost.  No fees will be paid for the bids or estimates.

 

(b)  If special accessories or devices are required, the CE stipulates that the price quoted by the vendor includes any necessary installation.

 

(4)  The CE reviews the bids and selects the one which combines any acceptable alternative means of achieving the desired results with the lowest cost, unless there is a sound reason for a higher-cost alternative, such as increased durability.

 

(5)  Approval.  If upon review of the evidence the CE approves the request, the CE writes a detailed letter decision to the claimant advising of the approval.

 

(6)  Notifying the BPA.  Once the CE sends the letter of approval to the claimant, the CE prepares an email to the FO. In the email, the CE advises the FO of the approval, citing the homegrown code (e.g. HSMDF) for housing modifications and the amount approved.  The fiscal officer communicates this approval to DEEOIC’s BPA.

 

(7)  Additional Information.  If the CE determines that additional information is necessary, the CE sends a letter to the claimant requesting additional documentation that is necessary to continue with the review process.

 

(8)  Follow-up.  If the claimant does not respond to the development letter, or if he or she fails to provide sufficient documentation to support the request, after considering all relevant evidence, the CE issues a detailed letter decision informing the claimant of the denial. The CE also informs DEEOIC’s BPA through the FO of this denial.  The letter-decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

(10) Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

9.   Health Facility Membership/Spa Membership.  This section describes procedures to be followed when a claimant requests authorization for reimbursement of fees to join a commercial health club or spa.

 

a.   Authorization.  Membership in a health club or exercise facility, or treatment at a spa, may be authorized when recommended by the treating physician as likely to treat the effects, cure or give relief from a covered illness. All requests for reimbursement of health facility and spa fees require prior authorization from the CE.

 

In all cases where such membership is requested, the CE determines whether the membership is likely to be effective and cost-efficient.

 

b.   Payment.  Whenever a request for payment of health club/spa membership is received, the CE obtains the following information:

 

(1)  Information from Physician.  The CE obtains the following information from the treating physician:

 

(a)  A description of the specific therapy and or exercise routine needed to address the effects of the covered illness, including the frequency with which the exercises should be performed.

 

(b)  The anticipated duration of the recommended regimen (i.e. weeks, months, etc.).

 

(c)  An opinion as to the actual/anticipated effectiveness of the regimen, treatment, goals attained/sought, and frequency of examinations to assess the continuing need for the regimen.

 

(d)  A description/list of the specific equipment and or facilities needed to safely perform the regimen.

 

(e)  The nature and extent of supervision, if any, required for the safety of the claimant while performing the exercises.

 

(f)  An opinion stating whether exercise can be performed at home, as part of a home exercise program, or a recommendation as to what kind of public or commercial facility could provide the prescribed exercise routine.

 

(2)  Information from Claimant.  In addition, the CE obtains the following information from the claimant:

 

(a)  The full name, address, and distance from the claimant’s home or work location, of any public facilities (no membership required) and those commercial facilities (membership required) able to accommodate the prescribed regimen.

 

(b)  If applicable, the specific reason(s) membership in a commercial health club/spa is required when public facilities are available, and or where the doctor indicates the regimen can be performed at home.

 

(c)  A signed statement from the health club/spa manager stating that the club/spa can fully provide the exercise regimen prescribed by the treating physician, and a breakdown of the fees and charges for various membership options and terms.  The statement should describe all facilities, services, and special charges not included in the membership fee.

 

c.   Approval.

 

(1)  For all requests, if upon review of the evidence the CE approves the request, CE must write a letter to the claimant advising of the approval.  The letter must include the following:

 

(a)  The date the DO received the request.

 

(b)  The period of time which the approval will cover.

 

(c)  The amount approved (i.e. monthly or annual fee, etc.).

 

(d)  The type of membership approved.

 

(e)  Two copies of a blank OWCP-957 

 

(2)  Notifying the BPA.  Once the CE sends the letter of approval to the claimant, the CE prepares an email to the FO. In the email, the CE advises the FO of the specific services being approved, citing the homegrown code (i.e. GYMME) and the amount to be reimbursed.  The FO  communicates this approval to DEEOIC’s BPA.

 

d.   Additional Information.  If the CE determines that additional information is necessary, the CE sends a letter to the claimant (with a copy to the treating physician) requesting additional documentation that is necessary to continue with the review process. In the letter, the CE provides 30 days for receipt of the requested information.

 

e.   Follow-up.  If the claimant does not respond to the development letter, or if he or she fails to provide sufficient documentation to support the request, after considering all relevant evidence, the CE issues a detailed letter decision informing the claimant of the denial. The CE also informs DEEOIC’s BPA through the FO of this denial.  The letter-decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

f.   Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

g.   Reimbursement Request.  If a request for reimbursement of a health facility membership or spa membership, not previously approved, is submitted for payment to DEEOIC’s BPA, the DEEOIC’s BPA communicates this to the DO through the FO, and waits for approval from the CE.

 

h.   Period of Service.  Health facility membership may be authorized for up to twelve months. Recertification is required for any period of time beyond twelve months.

 

10.  Medical Alert Systems.  This section describes procedures to be followed when a claimant requests authorization for medical alert system.

 

a.   Definition.  A Medical Alert system is an electronic device connected to a telephone line. In an emergency, the system can be activated by either pushing a small button on a pendant or pressing the help button on the console unit. When the device is activated, a person from the 24 hour central monitoring station answers the call, speaks to the claimant via the console unit, assesses the need for help, and takes appropriate action. A medical communication system qualifies as a Medical Alert system if it includes the following requirements:

 

(1)  An in-home medical communications transceiver;

 

(2)  A remote, portable activator (Personal Pendant, etc.);

 

(3)  A central monitoring station staffed by trained attendants 24 hours a day, seven days a week (optional).

 

b.   Authorization.  All requests for medical alert systems require prior authorization from the CE. A request for a medical alert system must be documented with a letter of medical necessity from the treating physician, linked to the accepted condition, which includes a statement that the claimant has an acute or chronic condition which can require urgent or emergency care.

 

(1)  Period of Service.  The CE may authorize the medical alert system for up to twelve months at a time. The need for such equipment should be recertified by the prescribing physician prior to the expiration of the authorization period.

 

(2)  Billing.  Systems that require a one-time connection fee and monthly monitoring fee may be approved, based on the claimant’s needs and the medical justification.  The equipment provided is leased and must be returned when no longer needed to avoid further charges.  DEEOIC is not responsible for any additional charges incurred for failure to return equipment or failure to timely return the equipment in a timely manner.

 

c.   Approval.

 

(1)  For all requests, if upon review of the evidence the CE approves the request, the CE writes a letter to the claimant advising of the approval. The letter includes the following:

 

(a)  The date the DO received the request;

 

(b)  The period of time which the approval will cover;

 

(c)  The amount approved.

 

(2)  Notifying the BPA.  Once the CE sends the letter of approval to the claimant, the CE prepares an email to the FO. In the email, the CE advises the FO of the approval, citing the HCPS code for a medical alert system and the amount approved.  The fiscal officer communicates this approval to DEEOIC’s BPA.

 

d.   Additional Information.  If the CE determines that additional information is necessary, the CE sends a letter to the claimant (with a copy to the treating physician) requesting specific documentation that is necessary to continue with the approval process. In the letter, the CE provides 30 days for receipt of the requested information.

 

e.   Follow-up.  If the claimant does not respond to the development letter, or if he or she fails to provide sufficient medical documentation to support the request, the POC CE sends a detailed letter decision to the claimant. The CE also informs DEEOIC’s BPA through the FO of this denial.  The letter decision must include a sentence at the end with language as follows:

 

If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.

 

f.   Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

g.   Reimbursement Request.  If a request for reimbursement of a medical alert system not previously approved is submitted for payment to DEEOIC’s BPA, the DEEOIC BPA communicates this to the DO through the FO, and awaits approval from the CE.

 

11.  Medical Expense Reimbursement for Extended Travel.  This section describes procedures to be followed for authorizing medical travel requests over 200 miles round trip, and the process for approving claims for reimbursement, regardless of whether the claimant obtained prior approval for the trip.

 

a.   Travel Claims.  All claims for travel reimbursement must be sent to DEEOIC’s BPA.  Should the CE receive a reimbursement request directly from the claimant for an authorized trip, the CE forwards it immediately to DEEOIC’s BPA to begin the reimbursement process. In the event the CE receives a claim for travel reimbursement that was not approved in advance, the CE immediately forwards the claim to the DEEOIC’s BPA, and concurrently begins the process of approving or denying the trip.  This ensures that all claims are adjudicated promptly and are properly recorded and tracked by DEEOIC’s BPA, throughout the reimbursement process.

 

b.   Authorization.  DEEOIC requires pre-authorization for reimbursement of transportation, lodging, meals, and incidental expenses incurred when a claimant travels in excess of 200 miles round trip for medical care of an approved condition.  DEEOIC’s BPA processes reimbursement claims for claimant travel without pre-authorization when travel is less than 200 miles round trip.

 

c.   Processing.  DEEOIC’s BPA processes reimbursement claims in accordance with GSA travel guidelines. Per diem rates for overnight stay and mileage reimbursement rates are published on GSA’s website, and air fare reimbursement is based on actual ticket cost up to the amount of a refundable coach ticket (Y-Class airfare).

 

d.   Approval.  Upon acceptance of a medical condition, the claimant receives a medical benefits package from the DEEOIC that includes instructions on how to submit a written request for prior approval of medical travel when such extended travel (over 200 miles round trip) is required. Despite these instructions, it is not uncommon for claimants to submit their request for reimbursement after a trip has been completed, and without having obtained prior approval.

 

e.   Travel Exceeding 200 Miles.  Medical expense reimbursement for travel exceeding 200 miles round trip must be authorized by the CE.  Claims that are submitted to DEEOIC’s BPA, for reimbursement of travel expenses arising from medical travel in excess of 200 miles roundtrip, will not be processed for payment unless authorization has been provided by the district office.

 

(1)  Requests.  Upon receipt of a travel authorization request from the claimant, the claims examiner (CE) takes immediate action to ensure that the request meets one basic requirement: that the medical treatment or service is for the claimant’s approved medical condition(s).  The medical provider’s enrollment in the DEEOIC program is not a prerequisite to approving medical travel if the claimant chooses to receive medical services from a non-enrolled provider.

 

(2)  Companion.  If the travel request involves authorization for a companion to accompany the claimant, the claimant must provide medical justification from a physician. That justification must be in written form, relating the treatment to the accepted condition and rationalizing the need for the companion.  If the doctor confirms that a companion is medically necessary, and provides satisfactory rationale, then the CE may approve companion travel. In the alternative, the CE can authorize the claimant to stay overnight in a hospital or medical facility, and can approve payment for a nurse or home health aide if a companion is not available. The CE must use discretion when authorizing such requests and may approve one of the above alternatives when there is a definite medical need, accompanied by written justification from the physician.

 

(3)  Mode of Travel.  The claimant is allowed to specify his/her desired mode of travel.  It is the CE’s role to authorize the desired mode of travel for the time period(s) requested.  When a request is received from the claimant that does not identify the mode of transportation, the CE contacts the claimant by telephone and assists in determining the desired mode of travel.  (Resource Center staff may be assist in this process.)

 

f.   Approval.  Once the basic requirements for travel over 200 miles are met, as outlined above, the CE prepares and sends the claimant a travel authorization letter following the guidelines below. The CE may approve an individual trip, or any number of trips within a specified date range, all in one letter to the claimant. Once an initial authorization letter has been sent, future visits to the same doctor or facility may be approved by telephone, and confirmed by a follow-up letter.

 

g.   Authorization Letter.  The authorization letter delineates the specifics of the trip being authorized, based upon the mode of travel the claimant has selected. In the travel authorization letter, the CE advises the claimant that travel costs are reimbursable only to the extent that the travel is related to obtaining medical treatment. In the letter CE also invites the claimant to contact the nearest Resource Center for assistance prior to or upon completing any trip and to complete Form OWCP-957, Request for Reimbursement, in accordance with the information and conditions as outlined in Exhibit 6. 

 

h.   Adjudication.  When adjudicating claims submitted after the trip has been completed, but for which prior approval was not obtained, the CE follows the same steps as for pre-authorized trips, to the point of sending an authorization package. At that point the CE sends only the authorization (or denial) letter to the claimant, not an entire authorization package.

 

i.   Denials.  If a travel request is denied (either before or after a trip), the CE notifies the claimant in writing, detailing the reason(s) for the denial.  The CE’s unit supervisor must provide sign-off for all denials of claimant travel before the denial letter is sent to the claimant.  The following wording is included in the denial letter: “This is the final Program decision on your request for approval of travel expense reimbursement. If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.”

 

j.   Recommended Decision.  If the claimant requests a recommended decision, the CE proceeds with a recommended decision.

 

k.   Notifying the BPA.  In conjunction with sending the claimant an approval or denial of a travel request, the CE conveys his/her decision to DEEOIC’s BPA via the office’s Fiscal Officer (FO), who is the point of contact with DEEOIC’s BPA for such issues.  The CE prepares an email to the FO, who in turn generates an electronic thread to the BPA.  In the email the CE provides the information specified below.  The CE must also enter this information into the case notes field of ECMS (Select the note type of “T” for Travel Authorization):

 

(1)  Approved dates for a single trip or in the alternative, a date range and number of trips authorized within that time frame.

 

(2)  Approved mode of transportation

 

(3)  Starting point and destination, e.g., claimant address and provider address (city & state at a minimum).

 

(4)  Authorization for rental car reimbursement, if appropriate.

 

(5)  Companion travel if approved.

 

l.   Approval Package.  The approval package must include the following:

                    

(1)  Two copies of the detailed authorization letter.

 

(2)  Two copies of a blank OWCP-957.

 

(3)  A prepaid express mail envelope, addressed to DEEOIC’s BPA, for the claimant’s use.

 

m.   Prompt Pay.  DEEOIC’s BPA promptly pays any approved claims directly to the claimant, not to any other party. However, if the claimant completes the form in error or neglects to submit the proper information, DEEOIC’s BPA attempts to resolve the issue by accessing the authorization letter or the pre-approval notification (thread) from the FO. If DEEOIC’s BPA is unable to issue payment based on information provided in one of these two sources, DEEOIC’s BPA contacts the FO, requesting clarification and/or assistance.

 

n.   DO Review.  The FO and responsible CE take immediate action to review the claim as submitted, contact the claimant when appropriate, make a determination as to the correct amount of reimbursement or denial, and send an authorization notification or correction (electronic thread) back to DEEOIC’s BPA.

 

o.   District office CEs and FOs responsible for travel authorization processing must keep management apprised of issues impacting prompt and accurate processing of travel authorizations and reimbursements.  Claims staff should be especially vigilant to identify any real or perceived problems with the processing interfaces between and among the district office, the Resource Center and DEEOIC’s BPA.

 

Problems must be elevated (reported via email) immediately to the National Office to the attention of the Branch Chief for Policy, with a copy of the notification to the Branch Chief for the Branch of ADP Systems (responsible for oversight of DEEOIC’s BPA).

 

 

Exhibit 1: Sample Initial Medical Development Letter

Exhibit 2: Sample Follow-up Development Letter

Exhibit 3: Sample Authorization Letter

Exhibit 4: Billing Codes

Exhibit 5: Sample Recommended Decision to Deny Home Health Care

Exhibit 6: Sample Travel Authorization Letter