1996 FECA Bulletins Archive

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-01

Issue Date: October 5, 1995

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Expiration Date: October 4, 1996

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Subject: Codes--Nature of Injury Codes in Cases for Occupational Illness

Background: Until now, the Office of Workers' Compensation Programs (OWCP) has had one set of time frames for adjudicating claims for occupational illness. After some study, it has become clear that certain kinds of occupational illness cases can be adjudicated in much less time than is currently allowed.

Therefore, a second standard for occupational illness cases has been developed. Some groups of cases should now be routinely adjudicated within 90 days, whereas other groups should continue to be adjudicated within 180 days.

So that claims examiners will know which cases are to be adjudicated within 90 days and which cases are to be adjudicated within 180 days, each case must now have a Nature of Injury code which shows exactly what kind of injury is involved. For this reason, code "D9" can no longer be used.

Also, new codes were needed since certain diseases, such as eye strain, inguinal hernia, Lyme disease, and dental problems were not included in the previous list of codes. Such codes have been developed, and a list of all codes to be used effective the date of this bulletin is attached.

Purpose: To instruct Case Create Clerks in proper coding of nature of injury in occupational illness claims

Applicability: All Supervisors, Mail and File Personnel

Action:

1. When coding incoming cases, Case Create Clerks should use the attached list to identify the nature of injury. The code "D9" should no longer be used.

2. If the nature of injury does not appear on the list, or if it is not clear what code should be used, the Case Create Clerk should consult the claims staff member designated by district office management for guidance.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Attachment

Distribution:List No. 5--Folioviews Groups C and D
(All Supervisors, Index and Files Personnel, Systems Managers, and Technical Assistants)

Attachment to FECA Bulletin 96-01

 

NATURE OF INJURY CODES

CODE	DEFINITION
TA	Amputation
TB	Back strain
TC	Contusion; bruise; abrasion
TD	Dislocation
TE	Exposure (including frostbite, heat stroke/exhaustion)
TF	Fracture
TH	Hernia (inguinal)
TJ	Crush injury
TK	Concussion
TL	Laceration; cut
TP	Puncture (not insect bite)
TS	Strain (not back)
TT	Tooth injury
TU	Burn, scald, sunburn
TV	Foreign body in eye
TY	Insect bite
TI	Traumatic skin diseases/conditions, including dermatitis
TR	Traumatic respiratory disease
TQ	Traumatic food poisoning
TW	Traumatic tuberculosis
TX	Traumatic virological/infective/parasitic diseases
T1	Traumatic cerebral vascular condition; stroke
T2	Traumatic hearing loss
T3	Traumatic heart condition
T4	Traumatic mental disorder; stress; nervous condition
T8	Traumatic injury - unclass. (except disease, illness)
(G )	Gastrointestinal
GH	Hiatal, umbilical or ventral hernia
GU	Ulcer
G9	Gastrointestinal, not otherwise classified
(S )	Skin Disease or Condition
SB	Biological (including poison ivy, poison oak)
SC	Chemical
SL	Skin lesion (including blister, bunion, callus and corn)
S9	Dermatitis, not otherwise classified
(M )	Musculoskeletal and Connective Tissue
MA	Arthritis
MB	Back or neck strain, sprain
MC	Carpal Tunnel Syndrome
MD	Degenerative Disc Disease; spondylosis; spondylitis
MI	Inflammatory Disease (including bursitis, tendinitis)
MK	Chondromalacia
M9	Musculoskeletal condition, not otherwise classified
* Injury or condition must be caused by a specific incident or event which occurred during a single work day or shift.
CODE	DEFINITION
(R )	Respiratory Disease
RA	Asbestosis
RB	Bronchitis, asthma
RE	Emphysema
RP	Pneumoconiosis (Black Lung)
RR	Reaction to smoke, fumes, chemicals
RS	Silicosis
R9	Respiratory disease, not otherwise classified
(V )	Virological, Infective and Parasitic Diseases
VA	Acquired Immune Deficiency Syndrome (AIDS) and HIV
VB	Brucellosis
VC	Valley Fever (Coccidioidomycosis)
VH	Hepatitis
VL	Lyme Disease
VM	Malaria
VP	Parasitic Diseases
VR	Rocky Mountain Spotted Fever
VS	Staphylococcus
VT	Tuberculosis
V9	Virological/Infective/Parasitic, not otherwise classified
(C )	Cardiovascular/Circulatory
CA	Angina
CB	Blood Disorder
CH	Hypertension
CM	Myocardial Infarction (Heart Attack)
CP	Phlebitis; varicose veins
CS	Stroke; cerebral vascular condition
C9	Cardiovascular/circulatory, not otherwise classified
(O )	Occupational disease, non-complex
OF	Food poisoning
OG	Tooth and gum-related problems
OL	Inguinal Hernia
OP	Pregnancy (Peace Corps only)
(D )	Other Disability, Occupational
DH	Hearing loss
DI	Vision/sight loss
DM	Mental disorder; emotional condition; nervous condition
DN	Nerve injury, incl. paralysis, after exposure to toxins
DR	Radiation
DT	Tumors and other cancer-related conditions

 

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-02

Issue Date: November 5, 1995

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Expiration Date: November 4, 1996

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Subject: Dual Benefits--Severance and Separation Pay

Background: Employing agencies may grant severance pay to employees who are involuntarily separated as part of a reduction in force (RIF). Severance pay represents a certain number of weeks worth of salary or wages, and it is usually computed as a lump sum.

Employing agencies may also offer separation pay ("buyouts") to encourage employees to leave Federal employment voluntarily. For example, the U.S. Postal Service offered a six-month lump-sum payment as part of its Special Retirement Option, as described in FECA Bulletin No. 93-1.

We have received many questions about entitlement to compensation during periods covered by severance or separation pay. The purpose of this bulletin is to explain which payments constitute dual benefits under the FECA and the actions which district office staff should take when a claimant receives one of these forms of payment. (Determining loss of wage-earning capacity (LWEC) under these circumstances is addressed in FECA Procedure Manual Chapter 2-1500.9.)

Severance pay was first authorized by the Federal Employees' Salary Act of 1965 (Pub. Law 89-301, since codified at 5 U.S.C. 5595). Under this statute, severance pay could not be paid "concurrently with salary or on account of the death of another person." FECA Program Memorandum 55, dated January 24, 1968, interpreted the phrase "concurrently with salary" to allow payment of severance pay to claimants receiving benefits for LWEC, since the severance pay is calculated on the basis of the salary only, and does not take claimants' LWEC payments into consideration. Also, a schedule award may be paid concurrently.

Health benefits and optional life insurance coverage may continue during the period of severance pay as long as the OWCP eventually makes appropriate payments for the time period covered by the severance pay to the Office of Personnel Management (OPM).

Separation pay is offered in different forms by different agencies. Sometimes it is defined as a number of weeks of pay, and other times as a specific amount of money. How separation pay is defined is determined by the law governing the operations of the agency in question. For example, in 1992 the Postal Service calculated its payments as six months of the employee's base pay, while the Department of Defense, beginning in 1993, used the amount of severance pay to which the individual would have been entitled, or $25,000, whichever was less. The method of offset differs somewhat according to how the separation pay is defined (see below).

Reference: 5 U.S.C. 8116; FECA Program Memorandum 55

Purpose: To provide instructions for payment of compensation, deductions for health benefits and optional life insurance, and later claims for compensation in cases involving severance and separation pay.

Applicability: Claims Examiners, Senior Claims Examiners, All Supervisors, Technical Assistants, Staff Nurses, Rehabilitation Specialists, and Fiscal Officers in the district offices; and Hearing Representatives

Action:

1. Nature of Payment. Before attempting to address entitlement to benefits, it will be necessary to determine whether severance pay or separation pay is at issue. The employing agency should provide this information. If there is any doubt, request a copy of the pertinent law (or at least a citation to it). If the nature of the payment remains unclear after correspondence or discussion with the employing agency, the Supervisory Claims Examiner or higher-level manager should contact the National Office for further guidance.

The employing agency should also submit a copy of the claimant's acceptance of the offer of separation pay and severance pay (if applicable) and the separation or retirement papers themselves.

Some employees may be entitled to both severance and separation pay. If the separation pay is based on a specific sum of money, address separation pay first (see item 3 below). Otherwise, the two types of payment may be addressed in either order.

2. Severance Pay.

a. Section 5 U.S.C. 5595(c), which governs severance pay, states as follows:

(c) Severance pay consists of--

(1) a basic severance allowance computed on the basis of 1 week's basic pay at the rate received immediately before separation for each year of civilian service up to and including 10 years for which severance pay has not been received under this or any other authority and 2 weeks' basic pay at that rate for each year of civilian service beyond 10 years for which severance pay has not been received under this or any other authority; and

(2) an age adjustment allowance computed on the basis of 10 percent of the total basic severance allowance for each year by which the age of the recipient exceeds 40 years at the time of separation.

Total severance pay under this section may not exceed 1 year's pay at the rate received immediately before separation. For the purpose of this subsection, "basic pay" includes premium pay under section 5545(c)(1) of this title.

b. Claimants are not entitled to compensation payments for temporary total disability (TTD) during the period covered by the severance pay. For example, if a claimant receives 13 weeks worth of severance pay, compensation is not payable until the fourteenth week.

The employing agency will need to advise the OWCP of the total dollar amount of severance pay and the date of separation or retirement.

c. Compensation payments should be suspended for the period in question, effective the date of separation or retirement, by 100% offset for the number of weeks (not the amount of money) which the severance pay represents. The total amount of the severance pay should be divided by the salary used to compute it to determine the number of weeks for which compensation payments should be suspended. The employee will not be entitled to compensation payments at least through the end of that period.

d. Where the OWCP finds out after the fact that severance payments were made to a claimant for the same period that compensation was paid, an overpayment must be declared and the usual due process rights provided.

e. Compensation for a schedule award may be paid concurrently with severance pay. Also, medical benefits continue to be payable.

f. Severance pay may also be paid concurrently with compensation for LWEC. The basis for allowing concurrent payment for LWEC is that the amount of severance pay is based on the employee's reduced salary, not OWCP's payments for LWEC. If an employee who is receiving compensation for LWEC receives severance pay and then retires, an election of benefits will be required at the time of retirement.

3. Separation Pay Based on Period of Time.

a. The entitlement to benefits is as described for those entitled to severance pay (items 1a-1c above). That is, the claimant may not receive compensation for TTD, but may receive compensation for a schedule award or LWEC based on a given number of weeks of compensation at the current rate of salary (i.e., the salary as reduced to reflect the claimant's LWEC) concurrently with separation pay.

b. Provisions for offset and overpayments are also as noted above for severance pay. A claimant who was receiving compensation for TTD should be advised that payment of these benefits will cease immediately because he or she has elected to receive separation pay and severance pay (if applicable).

4. Separation Pay Based on Amount of Money.

a. The entitlement to benefits is as follows: a claimant may not concurrently receive payment for TTD or LWEC, but may receive payment for a schedule award. The reason for the difference in policy with respect to payments for LWEC is that, under 5 U.S.C. 8116 (a), lump-sum separation payments are not included in the categories of payments which may be made concurrently with compensation payments (except, of course, for schedule awards). As with other kinds of severance and separation payments, medical benefits continue to be payable.

b. The employing agency should advise the OWCP of the total dollar amount of separation pay and the date of separation or retirement. This amount should be applied to the amount of compensation for wage loss on a dollar-for-dollar basis. The claimant should be advised of the approximate time the offset will end; the estimate may be affected by application of cost-of-living increases, etc.

5. Health Benefits and Optional Life Insurance.

a. For claimants with health benefits and/or optional life insurance coverage, compensation should be suspended at the net rather than the gross amount to allow OWCP to collect the appropriate deduction(s) and forward them to OPM. Form CA-25 should be completed so that only the amounts of deductions for health benefits and/or optional life insurance are payable. The amounts are payable to OPM. If compensation payments are suspended at the gross rate, it will be necessary to contact the claimant to arrange for payment of the premiums for the period in question.

b. The agency will transfer the health benefits enrollment to OWCP effective the date that employment ceases. The claimant is responsible only for his or her own share of the premiums.

c. Claims and Fiscal personnel may receive inquiries concerning entitlement to continuation of health benefits coverage under the Temporary Continuation of Coverage (TCC) program. This program allows employees who have been involuntarily separated to continue their coverage for a short period of time. The TCC program will not allow the enrollment of an individual who is entitled to compensation, and it will terminate any existing enrollment of a person entitled to either of these benefits.

6. Claims for Additional Compensation.

a. If a schedule award ends during the period covered by the separation or severance payment, the employee may claim additional compensation for disability (see subparagraph b below). If the claimant was not receiving compensation for disability before the schedule award, he or she would not be entitled to receive compensation afterwards unless it could be shown that the medical condition had worsened to the point that it disabled him or her from the regular or limited duty job performed before separation. Should entitlement to additional compensation be established, the employee will need to elect between OWCP and retirement benefits (if eligible).

b. A separated employee who was not receiving compensation at the time of separation because of placement in a modified job with no loss of pay will not be entitled to further compensation at the end of the period covered by separation or severance pay solely because the modified job is no longer available. A claimant who has returned to duty, whether regular or light, has the burden of proof to show that injury-related disability had worsened to the point that he or she is now disabled for the limited duty position (see Terry L. Hedman, 38 ECAB 222).

c. Benefits will not necessarily be reinstated in cases where the employee shows that the condition has worsened, since he or she might have been able to continue performing the modified job even if the condition worsened. Therefore, where a formal LWEC decision has not been issued, the employing agency should be asked to submit a description of the employee's job duties, including the physical requirements, at the time of separation. With this evidence, it will be possible to determine if the employee has any further entitlement to compensation.

d. An employee who establishes that his or her accepted condition worsened to the point of being unable to perform a modified job will be required to make an election of benefits, if eligible for retirement, since he or she has been formally separated. An employee who elects OWCP benefits should receive compensation for TTD and be considered for referral for vocational rehabilitation services to explore reemployment in another job.

e. Employees working part time, or working full time but at lower rates of pay, will be entitled to continue receiving compensation at the end of the period covered by separation or severance pay at the LWEC rate, if injury-related disability continues and they elect OWCP benefits in favor of retirement benefits. Should a recurrence be claimed, it will be their burden to show that injury-related disability has worsened (see question 6 above).

f. An employee who was performing regular duty at the time of separation would be entitled to receive compensation only if a true recurrence of disability were established (see subparagraph b above).

g. An employee who accepts separation pay and then changes his or her mind may not receive compensation for the duration of entitlement to separation pay or severance pay (if applicable). After that time, a claimant who remains entitled to benefits on the basis of total disability or LWEC when separated, and who contacts OWCP seeking compensation, will be offered an election of benefits.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2 --Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-03

Issue Date: November 30, 1995

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Expiration Date: November 29, 1996

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Subject: Excluded Provider Changes

Background: The National Office has in the past maintained a data file of medical providers which were excluded under the FECA program. The source of most of these exclusions was the Department of Health and Human Services, Office of the Inspector General (HHS OIG). These exclusions make up most of the so-called automatic exclusions. In addition, district offices have regulatory authority to exclude medical providers for a variety of reasons. These inhouse exclusions comprise most of the so-called non-automatic exclusions.

Formerly, all updates to the National Office excluded provider file were made manually. Periodically, updated reports of excluded providers were sent to district offices and were also made available to Federal employers for their use in authorizing medical treatment. When updates were made to the National Office data file, the geographically appropriate district offices were also informed, so that the provider payment flag on the local Sequent provider file (v46) could be set to N for "no".

Major changes have been made to the ADP systems portion of the excluded provider process. A new excluded provider data file has been created at National Office (m41). This file has a different format from the previous data files. The m41 file will be updated automatically from data provided by the HHS OIG. The m41 file can also be updated manually, to allow for exclusions from other sources, including the inhouse non-automatic exclusions.

A new data file at the district office Sequents (v41) is an extract of the m41 file. The v41 file will be updated periodically. Whenever the v41 file is updated, the records in that file will be compared to the records on the office's existing v46 file (provider file), using the tax identification numbers. If a match is found, the v46 file record will be flagged as an excluded provider (the excluded provider flag will be Y for "yes"). In addition, whenever a new provider is added to the provider file, the provider update program checks tax identification number against the v41 file to determine whether that provider has been excluded, and if a match is found, the v46 exclusion flag is set to Y. A message concerning the exclusion status of the provider appears at the top of the provider update screen.

The new excluded provider flag is in addition to and does not replace the existing v46 payment flag, which is set by the district office, and is Y for "yes" if the provider is payable. District offices also have the ability to query the v41 (excluded provider) file, using either a tax identification number or a last name. Within a short time, district offices will also be able to run reports of the records in the v41 file.

A new edit has been added to the BILL552 process which is based on the provider exclusion flag in v46.

Reference: 20 C.F.R. Chapter 10, Subpart F; Federal (FECA) Procedure Manual Chapter 3-800, Exclusion of Medical Providers.

Purpose: To inform offices of changes to the excluded provider process, and provide revised procedures.

Applicability: Regional Directors, District Directors, Systems Managers, District Medical Advisors, Claims and Bill Resolution staff, and individuals responsible for secure provider file updates in the district offices.

Action:

1. Updates to the v41 file (excluded providers) will be performed promptly by the operations staff. Whenever v41 updates are done, a new excluded provider report (BILL610) will be run and be made available to district office staff. (Note that the report is not yet available, but will be shortly.)

2. When providers are added to the provider file (v46) by the authorized individual(s) responsible for security input, a check against the v41 file (using the tax identification number) will be made automatically by the system. A message appears on the BILL005 (provider master file update) screen stating whether the provider is excluded or not, based upon the v41 data. In addition to the automated check, an on-line excluded provider query must be performed, using the provider's last name, to determine whether the provider is excluded. Excluded provider query is option 19 on the FECS001 bill payment menu and option 24 under the FECS001 query menu. A copy of the screen is shown as Attachment 1. This action is necessary because providers may use different tax identification numbers, and the information from the HHS OIG contains Social Security Numbers, rather than Employer Identification Numbers. For organizations, the first word of the organization should be used to query. A flow may be set up between FECS001 bill payment menu options 19 (excluded provider query) and 5 (provider update). In place of the on-line query, once it is available, the latest excluded provider report may be checked to determine whether the name of the provider appears on the report, and has been excluded. If the provider is present in the on-line query or on the excluded provider report, but was not identified as an excluded provider in the provider update screen, the district office payment flag should be set to N for "no" when the provider is added to v46 (provider file), and the National Office notified.

3. Offices will continue to flag a v46 provider record for non-payment when an inhouse or non-automatic exclusion is made. The Director for FEC will also be informed, preferably by memorandum. The National Office will then add the provider to the m41 table, and the local v41 exclusion flag should be set to Y automatically the next time a v41 update is done. After the v41 flag has been set to Y, the district office may change the v46 payment flag to Y.

4. A new bill processing system edit 201 is based upon the new v46 exclusion flag. If the exclusion flag is Y for a provider, and a bill from that provider is data entered and edited by the BILL552 process, edit 201 will fail. Edit 201 failure results in suspension of the bill for manual review. The resolver should check the excluded provider query (or report) to ensure that the excluded provider's name matches the name on the bill. Complete instructions for resolving edit 201 failures are contained in Attachment 2. This attachment should be inserted in the thick BPS edit by edit resolution job aid.

5. The description and resolution instructions for BPS edit 202 have been modified slightly to reflect the differences between edits 201 and 202. The modified information is contained in Attachment 3. This modified sheet should be substituted for the existing edit 202 sheet in the thick BPS edit by edit resolution job aid.

6. E-mail containing Attachments 2 and 3, as well as an updated condensed edit listing, and EOB listing has been sent to each office.

7. Each office should continue to keep a written file of actions taken with respect to non-automatic exclusion of providers.

8. Any problems or inaccuracies noted with respect to the v46 exclusion flags or v41 records should be brought to the attention of the Director for FEC. An example of such a problem would be if a provider was shown as excluded on the system, but provided documentation that the exclusion had been rescinded or was in error.

9. It should be noted that the excluded provider file includes a large number of providers for whom no tax identification number was provided. These providers, which include organizations as well as individuals, are being placed on the excluded provider file and may be viewed through a name query. Because of variances in name formats, the entire name for these providers is placed in the last name field.

10. Excluded provider information is also used by Federal agencies when they authorize medical treatment for injuries covered under the FECA. The excluded provider report should be made available to employing agencies upon request. The National Office also provides excluded provider information to employing agencies on a periodic basis, either by report or diskette.

Training for all personnel affected by these changes should be conducted no later than November 30, 1995.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

 

EXCLUDED PROVIDER QUERY SCREEN
PAYEE NO: 123456789	LAST NAME: JONES
PAYEE NAME: LAST: JONES	FIRST: JOHN	MI: J
ADDR: 123 MAIN STREET
CITY: ANYWHERE	ST: DC	ZIP: 20210
SANCTION DATE: 09/21/1995	NOTIFY DATE: 09/01/1995│
SOURCE OF EXCLUSION: H - HHS
NEXT RECORD [Y/N]

 

This is what the screen would look like if a query were performed using the last name of Jones. The user is able to view all of the records which contain "JONES" in the last name field by responding "Y" for "yes" to the NEXT RECORD prompt.

FECA Bulletin 96-3

Attachment 1

 

Back to Top of FECA Bulletin No. 96-03

 

MEDICAL BILL SYSTEM
EDITS

 

EDIT NO. 201H

 

ERROR DESCRIPTION: PROVIDER EXCLUDED UNDER FECA

 

EDIT DESCRIPTION:BILL TIN MATCHES THAT OF A RECORD ON THE PROVIDER FILE WITH V46_EXCLUDE_FLAG OF Y (FOR YES).

 

SUSPEND/DENY: S

 

OVERRIDE: Y

 

EOB: Payments to this provider are excluded under Federal Regulations 20 C.F.R. Part 10, Subpart F.

 

PRIORITY: 1

 

BILL RESOLUTION:

1. Verify that the TIN (tax identification number) was keyed correctly. Correct any errors.

2. If the TIN was keyed correctly, verify that this particular provider has been excluded by querying provider exclusions, preferably on-line, and matching the name of the provider. This flag is activated by the national office. The flag is set to Y when the provider has been excluded automatically from participation in FECA. These flags are updated periodically.

3. If the provider has been formally excluded from participation in FECA, deny bill with EOB 201 (above), unless a CA-16 authorization was issued to the excluded provider. If a CA-16 authorization was issued, the bill should be paid by overriding the edit. The CE is responsible for rescinding the CA-16 authorization. If this particular provider has not been excluded, but shares a tax identification number with an excluded provider, the edit failure may be overridden.

4. If it appears that the exclusion flag is in error, national office should be contacted.

FECA Bulletin 96-3

Attachment 2

 

Back to Top of FECA Bulletin No. 96-03

 

MEDICAL BILL SYSTEM
EDITS

 

EDIT NO. 202H

 

ERROR DESCRIPTION: PROVIDER SUSPENDED OR UNDER REVIEW

 

EDIT DESCRIPTION:BILL TIN MATCHES THAT OF A RECORD ON THE PROVIDER FILE WITH V46_PAYMENT_FLAG OF N (FOR NO).

 

SUSPEND/DENY: S

 

OVERRIDE: Y

 

EOB: Payments to this provider are excluded under Federal Regulations 20 C.F.R. Part 10, Subpart F.

 

PRIORITY: 1

 

BILL RESOLUTION:

1. Verify that the TIN (tax identification number) was keyed correctly. Correct any errors.

2. If the TIN was keyed correctly, determine why the provider file payment flag has been set to no. This flag is activated by the district office. The flag may have been set because of a non-automatic exclusion, or a need to review all of this provider's bills. The systems manager or other office manager should maintain information on these providers.

3. If the provider has been formally excluded from participation in FECA, deny bill with EOB 202 (above), unless a CA-16 authorization was issued to the excluded provider. If a CA-16 authorization was issued, the bill should be paid by overriding the edit. The CE is responsible for rescinding the CA-16 authorization.

4. If the flag has been activated with the purpose of reviewing services rendered by the particular provider, the bills should be reviewed by the CE. If the services are approved for payment the edit is overridden. Non-reimbursable services are denied with an appropriate EOB.

FECA Bulletin 96-3

Attachment 3

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-04

Issue Date: January 25, 1996

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Expiration Date: January 24, 1997

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Subject: September 1995 DFEC/OPM Computer Match

Background: Another DFEC/OPM computer match, designed to identify possible occurrences of prohibited concurrent dual benefit payment, was completed in September using the data for the August 19, 1995 periodic roll cycle. The data shared with OPM again included the death roll, and excluded schedule award cases. 55 cases survived the manual and automated screening processes employed by OPM.

With its advance copy of this bulletin, each District Office will receive a computer printout of the cases under its jurisdiction which should be screened, followed and reported on in accordance with the procedures described in FECA Bulletin 95-22 and again specified below. The presence of a case on the list should indicate that benefits were being paid by both DFEC and OPM on August 19, 1995, in apparent violation of the dual benefit prohibitions. (Note: The Boston, Philadelphia and Kansas City District Offices had no "hits" from this match.)

For this, and future matches, we will continue the procedures used for the past few years; that is, OPM and the responsible District Offices will directly converse and correspond in order to resolve the hits. The District Offices will continue to have National Office reporting requirements, as detailed below. However, any problems that arise with OPM, or with any other aspect of processing the match hits, should be raised with Alex Senecal (202) 219-8461 for resolution. Telephone inquiries to OPM should be directed to Jim Najjar at (202) 606-0235 (or 0232). Written inquiries or other correspondence should be directed to the Office of Personnel Management, Program Integrity Section, P.O. Box 7174, Room 2309, Washington, D.C. 20044, Attention: Jim Najjar.

Purpose: To inform District Offices of the procedures for follow-up review and reporting requirements concerning the "hits" identified in the September 1995 DFEC/OPM match, and to reiterate continuing reporting requirements for the previous OPM matches.

Applicability: District Directors, Assistant District Directors.

Action: Each District Office with one or more cases appearing as hits from this match will receive a copy of a computer printout detailing the information on those cases, in a combined listing of disability and death cases. (On this printout the OPM Claim Number begins with "A" for disability cases and begins with "F" for death cases. Also, if the first digit of the OPM Claim Number is 7 or 8 then benefits are being paid under FERS rather than CSRS.) In addition, "hit sheets" completed by OPM should have already been mailed directly to the District Offices by OPM. Please note that the field identified on the printouts as "OWCP Gross" is actually the FECA 28 day payment amount converted to a 30 day equivalent for easy comparison purposes. The "OWCP Net" field is the actual 28-day gross compensation amount paid.

FB 96-04 September 1995 DFEC/OPM Computer Match
1. Immediately pull and review each disability (OPM "A" prefix) case listed in which the OPM gross payment amount exceeds the FECA gross payment amount. (For these cases the OPM amount is underlined on the printout.) If a review of the case confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.

2. Review the remaining disability cases (those where FECA benefits exceed OPM benefits), and the death (OPM "F" prefix) cases (as detailed below). In the disability cases where FECA benefits are greater, OPM will seek the election and return a copy of the election along with a completed OPM "hit sheet" to DFEC.

3. In death/survivor cases (OPM "F" prefix), an informed election must be made before either benefit is terminated. Please remember that split elections can be made. In fact, several de facto split elections were discovered during previous matches; that is, there appeared to be dual benefits situations when in fact different beneficiaries were receiving OPM and FECA benefits. In other cases split elections have been made as a result of the matches. It is important that truly informed elections are made in these cases. During the 3rd match you were advised of our revised policy regarding the revocability of elections in death cases. That change was formalized by revision to the regulations. However, OPM maintains that survivor elections are irrevocable; that is, that once an election of FECA benefits is made, the beneficiary may not subsequently elect OPM benefits, unless the FECA entitlement is later determined to have been mistaken, or there is a third-party credit absorption.

Therefore, included in the information provided to a beneficiary in order for him/her to make an informed election should be a statement that an election of OPM benefits can later be changed to elect FECA benefits, but that the reverse is not possible. In addition, an informed election should be based on a comparison of each beneficiary's benefits. Where the total converted gross FECA benefit is greater than the total OPM benefit, OPM will obtain the election of benefits and return a copy of the election along with a copy of the OPM "hit sheet" to DFEC.

Where the total OPM benefit exceeds the total converted gross FECA benefit and the review of the file confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.

4. In any case which results in a DFEC overpayment, the District Office should take immediate action in accordance with the overpayment procedures specified in Part 6 of the Procedure Manual.

5. Each DFEC overpayment case should be reviewed in order to determine whether the usual notifications concerning the prohibition against receiving concurrent retirement and compensation payments have been made. If so, the assumption must be made that the claimant is not without fault when such an overpayment occurs. Thus, except where this assumption is overcome by the evidence in the case file, a CA-2201 should be released immediately. Examiners are reminded that the supporting memorandum should explicitly detail the notification made.

6. When the appropriate overpayment letter is released, a 30-day call-up should be placed in the file. As soon as possible after a final decision has been released, administrative offset should be requested from OPM.

7. Initial review of all the listed cases should be completed and a report submitted by January 15, 1995, and quarterly thereafter until each "hit" is resolved. This review should confirm or refute the information supplied, the receipt of dual benefits and, where receipt of dual benefits is confirmed, determine whether or not there is an election of benefits on file. Each report must include, as appropriate:

a. The FECA case number and beneficiary name for each listing.

b. For death cases, the name, date of birth and relationship to the decedent should be listed for each eligible beneficiary.

c. Periods for which FECA benefits have been paid (specify schedule award periods).

d. Was the payment of dual benefits discovered through this match? (yes/no)

e. Is there an election on file? (yes/no) If yes, a copy of the election letter should be attached.

f. Have compensation payments been terminated? If so, effective on what date?

g. Is there an overpayment of compensation? (yes/no)

h. Is DFEC responsible for recovery?

i. What is the amount of the OPM overpayment?

j. What is the amount of the FECA overpayment transferred to the Accounts Receivable ledger?

k. Dates of subsequent due process and collection actions, including issuance of overpayment letters, final decision, release of SF-2805 to OPM requesting offset, etc. (Note: The current version of the SF-2805, Revised October 1988, should be used.)

Follow-up reporting for this match and for unresolved cases from prior matches should continue quarterly (by the 15th day of the first month of each quarter, i.e., 4/15, 7/15, 10/15, 1/15) until final resolution of the matter, until, for example, either the debt has been collected in full, a repayment schedule has been established and met at least once, or the account is otherwise closed. The final report should describe the repayment plan and/or date of payment. For example, the final report should show that a CA-2201 was issued on March 6, 1996; a final decision was issued on April 10, 1996 finding an overpayment of $2000; an SF-2805 was issued on May 20, 1996; the first payment of $200 was received from OPM on August 1, 1996; the debt will be recovered by June 1997. (Note: For OPM debts, reporting may cease once the OPM overpayment amount has been reported. You no longer need to report any actions on OPM debts beyond this point.)

Disposition: This Bulletin should be retained until all actions have been completed.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 6
(Regional Directors, District Directors, Assistant District Directors, Systems Managers, Technical Assistants and National Office Staff)

Back to Top of FECA Bulletin No. 96-04

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Back to Table of Contents

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-05

Issue Date: December 15, 1995

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Expiration Date: January 4, 1997

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SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1996.

PURPOSE: To provide the 1996 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1996.

APPLICABILITY: All appropriate personnel are to be made aware of the periods and "cut-off" dates for the ACPS periodic disability, death, and daily payrolls.

The production schedule for the DMS periodic reports is made available for the appropriate personnel. IT IS IMPERATIVE that this schedule be closely followed.

DISPOSITION: This bulletin should be retained in front of Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Attachments

Distribution: List No. 2--Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)

AUTOMATED COMPENSATION PAYMENTS SYSTEM (ACPS) - 1996

FECA DISABILITY PAYROLL - EACH 28 DAYS
FECA DEATH PAYROLL - EACH 28 DAYS

CHECK CYCLE	PERIOD ENTITLEMENT FROM    TO*	BI-WEEKLY PAY PERIODS FOR HEALTH AND LIFE iNSURANCE PURPOSES	DISTRICT OFFICE CUT-OFF DATE TO ENTER ROLL DATA	N.O. CHK OF TAPE TO TREASURY
1	01/07/96-02/03/96	01/07/96 - 01/20/96 01/21/96 - 02/03/96	01/24/96	01/26/96
2	02/04/96-03/02/96	02/04/96 - 02/17/96 02/18/96 - 03/02/96	02/21/96	02/23/95
3	03/03/96-03/30/96	03/03/96 - 03/16/96 03/17/96 - 03/30/96	03/20/96	03/22/96
4	03/31/96-04/27/96	03/31/96 - 04/13/96 04/14/96 - 04/27/96	04/17/96	04/19/96
5	04/28/96-05/25/96	04/28/96 - 05/11/96 05/12/96 - 05/25/96	05/15/96	05/17/96
6	05/26/96-06/22/96	O5/26/96 - 06/08/96 06/09/96 - 06/22/96	06/12/96	06/14/96
7	06/23/96-07/20/96	06/23/96 - 07/06/96 07/07/96 - 07/20/96	07/10/96	07/12/96
8	07/21/96-08/17/96	07/21/96 - 08/03/96 08/04/96 - 08/17/96	08/07/96	08/09/96
9	08/18/96-09/14/96	08/18/96 - 08/31/96 09/01/96 - 09/14/96	09/04/96	09/06/96
10	09/15/96-10/12/96	09/15/96 - 09/28/96 09/29/96 - 10/12/96	10/02/96	10/04/96
11	10/13/96-11/09/96	10/13/96 - 10/26/96 10/27/96 - 11/09/96	10/30/96	11/01/96
12	11/10/96-12/07/96	11/10/96 - 11/23/96 11/24/96 - 12/07/96	11/27/96	11/29/96
13	12/08/96-01/04/97	12/08/96 - 12/21/96 12/22/96 - 01/04/97	12/24/96	12/27/96
*ENDING PERIOD IS THE CHECK DATE FOR EFT PAYMENTS, THE DAY BEFORE

****FECA DAILY ROLL SCHEDULE (ONCE WEEKLY)****

DATE OF CHECK	DISTRICT OFFICE CUT-OFF DATE TO ENTER DATA INTO ACPS	N.O. CHECK TAPE TO TREASURY
EACH FRIDAY**	PREVIOUS TUESDAY	PREVIOUS WEDNESDAY
**FOR EFT PAYMENTS, EACH FRIDAY

DEBT MANAGEMENT REPORT SCHEDULE 1996

Date	Report
12/22/1995	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/16/1995 -12/22/1995)
12/29/1995	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/23/1995 -12/29/1995)
01/02/1996	MONTH END PROCESSING (12/31/1995)
O1/05/1996	ACPS/DMS DEBT NUMBER MATCH
01/08/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/30/1995 -01/05/1996)
01/16/1996	WEERLY CASH RECEIPTS/INTEREST REPORT (01/06/1996 -01/12/1996)
01/22/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/13/1996 -01/19/1996)
01/29/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/20/1996 -01/26/1996)
01/31/1996	MONTH END PROCESSING (01/31/1996)
02/05/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/27/1996 -02/02/1996)
02/05/1996	ACPS/DMS DEBT NUMBER MATCH
02/12/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/03/1996 -02/09/1996)
02/20/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/10/1996 -02/16/1996)
02/26/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/17/1996 -02/23/1996)
02/29/1996	MONTH END PROCESSING (02/29/1996)
03/04/1996	ACPS/DMS DEBT NUMBER MATCH
03/04/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/24/1996 -03/01/1996)
03/11/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/02/1996 -03/08/1996)
03/18/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/09/1996 -03/15/1996)
03/25/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/16/1996 -03/22/1996)
03/27/1996****	SPECIAL ACPS/DMS DEBT NUMBER MATCH****
03/31/1996	MONTH END PROCESSING (03/31/1996)
04/01/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/23/1996 -03/29/1996)
04/08/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/30/1996 -04/05/1996)
04/15/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/06/1996 -04/12/1996)
04/22/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/13/1996 -04/19/1996)
04/26/1996	ACPS/DMS DEBT NUMBER MATCH
04/29/1996	WEERLY CASH RECEIPTS/INTEREST REPORT (04/20/1996 -04/26/1996)
04/30/1996	MONTH END PROCESSING (04/30/1996)
05/06/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/27/1996 -05/03/1996)
05/13/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/04/1996 -05/10/1996)
05/20/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/11/1996 -05/17/1996)
05/24/1996	ACPS/DMS DEBT NUMBER MATCH
05/28/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/18/1996 -05/24/1996)
05/31/1996	MONTH END PROCESSING (05/31/1996)
06/03/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/25/1996 -05/31/1996)
06/10/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/01/1996 -06/07/1996)
06/17/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/08/1996 -06/14/1996)
06/21/1996	ACPS/DMS DEBT NUMBER MATCH
06/24/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/15/1996 -06/21/1996)
06/28/1996	MONTH END PROCESSING (06/30/1996)
07/01/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/22/1995 -06/28/1996)
07/08/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/29/1996 -07/05/1996)
07/15/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/06/1996 -07/12/1996)
07/19/1996	ACPS/DMS DEBT NUMBER MATCH
07/22/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/13/1996 -07/19/1996)
07/29/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/20/1996 -07/26/1996)
07/31/1996	MONTH END PROCESSING (07/31/1996)
08/05/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/27/1996 -08/02/1996)
08/12/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/03/1996 -08/09/1996)
08/16/1996	ACPS/DMS DEBT NUMBER MATCH
08/19/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/10/1996 -08/16/1996)
08/26/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/17/1996 -08/23/1996)
08/30/1996	MONTH END PROCESSING (08/31/1996)
09/03/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/24/1996 -08/30/1996)
09/09/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/31/1996 -09/06/1996)
09/13/1996	ACPS/DMS DEBT NUMBER MATCH
09/16/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/07/1996 -09/13/1996)
09/23/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/14/1996 -09/20/1996)
09/30/1996	MONTH END PROCESSING (09/30/1995)
10/01/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/21/1996 -09/27/1996)
10/07/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/28/1996 -10/04/1996)
10/11/1996	ACPS/DMS DEBT NUMBER MATCH
10/15/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/05/1996 -10/11/1996)
10/21/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/12/1996 -10/18/1996)
10/28/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/19/1996 -10/25/1996)
10/31/1996	MONTH END PROCESSING (10/31/1996)
11/04/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/26/1996 -11/01/1996)
11/08/1996	ACPS/DMS DEBT NUMBER MATCH
11/12/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/02/1996 -11/08/1996)
11/18/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/09/1996 -11/15/1996)
11/25/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/16/1996 -11/22/1996)
11/29/1996	MONTH END PROCESSING (11/30/1996)
12/02/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/23/1996 -11/29/1996)
12/06/1996	ACPS/DMS DEBT NUMBER MATCH
12/09/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/30/1996 -12/06/1996)
12/16/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/07/1996 -12/13/1996)
12/23/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/14/1996 -12/20/1996)
12/30/1996	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/21/1996 -12/27/1996)
12/31/1996	MONTH END PROCESSING (12/31/1996)
01/03/1997	ACPS/DMS DEBT NUMBER MATCH
01/06/1997	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/28/1996 -01/03/1997)
01/13/1997	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/04/1997 -01/10/1997)
01/21/1997	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/11/1997 -01/17/1997)
01/27/1997	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/18/1997 -01/24/1997)
01/31/1997	MONTH END PROCESSING (01/31/1997)
02/03/1997	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/25/1996 -01/31/1997)

 

Back to Top of FECA Bulletin No. 96-05

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Back to Table of Contents

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-06

Issue Date: January 29, 1996

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Expiration Date: January 27, 1997

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Subject: Case Management--Role of Registered Nurses in QCM Cases

Background: The Federal Employees' Compensation program has had two years of experience in using the services of registered nurses to assist in medical management of disability claims and help claimants return to work. Staff Nurses and Field Nurses have identified several policies which affect their ability to bring claimants back to work at their fullest potential. Also, district office and national office staff have been discussing the nurses' role during the 60-day period after the claimants' return to work, especially in light of the downsizing of the Federal government. Among the foremost issues raised are follow-up by the nurse after return to light duty, the effects of surgery, and other kinds of medical situations which may develop.

Until now, the focus of the 60-day return-to-work period has been to ensure that the claimant remains on the job. Where the job is other than full-time full duty, we have not emphasized the need to increase the number of hours of work, or to help the claimant progress from light to full duty. In the period just after return to work, the nurse should remain involved to help the claimant reach higher levels of physical capacity, resulting wherever possible in return to full-time full duty. Toward this end, Claims Examiners (CEs) will now be able to extend the nurses' time beyond the usual 60-day follow up when return to full(er) duty is imminent.

At the same time, it is also clear that delays in returning to work or problems in remaining at work may be caused by other medical conditions, either work-related or not. Nurses sometimes continue working on such cases, but by the time the claimant has recovered from the concurrent condition or surgery and return to work has again become a viable goal, the nurses have often exceeded their allotted 120 days. To remedy this situation, we are instituting an interrupted status for nurse services.

References: FECA PM Chapters 2-600 and 3-201; OWCP Bulletin Nos. 91-2 and 93-6; MEDGUIDE Chapter 1

Purpose: To describe when extensions and interruptions of the Field Nurse's time may be warranted, and the actions which Staff Nurses, Field Nurses and Claims Examiners should take

Applicability: All Claims Examiners, Supervisors, Staff Nurses, Rehabilitation Specialists, and Technical Assistants

Action: Nurse intervention can result in various outcomes. If the intervention progresses along the normal course, the expected result is that the claimant returns to work within 120-180 days. Action items have been grouped by topic for ease of reference.

LIGHT/PART-TIME DUTY

1. Field Nurses (FNs) should stress to claimants the need to return to maximum functioning and work potential. Return to light duty should be considered just the first step in helping claimants reach their maximum abilities. After the claimant has returned to work, the FN should continue to pursue increases in work tolerance limitations and obtain descriptions of them on Form OWCP-5 at periodic intervals if the claimant does not return to full-time full duty. These attempts should be made at approximately two to three week intervals unless the facts of the case suggest a different plan.

2. After the 60-day follow-up period ends, the FN may continue to work toward full-time full duty if the medical evidence shows that such an outcome is likely. The FN and the Staff Nurse (SN) should recommend additional time in increments of no more than 30 days each, up to a total of 60 days. The Claims Examiner (CE) must authorize each increment.

3. In authorizing the extension, the CE must note on the Form CA-110 (or other form; see Attachment 1 for a sample) the goals of continued intervention, the steps the CE has directed the FN to take, and the time frame for performing the work. The goals should be consistent with the medical evidence of record, and they must be specific, i.e., framed as a stated number of hours within a stated time frame. The CE should also advise the SN of the extension. See Attachment 2 for a sample tracking sheet, which should be maintained in the case file.

SURGERY AND OTHER MEDICAL ISSUES

4. Return to work may be delayed by the need to obtain a second opinion evaluation. The FN may help the CE or Medical Management Assistant to identify physicians who can perform such examinations on an expedited basis.

5. Return to work may be delayed or interrupted by other medical conditions (work-related or not), by pregnancy, or by surgery. The chart below lists some common surgical procedures and their usual recovery times. As with the medical matrices contained in MEDGUIDE, this information is meant to serve as guidance, not the last word in determining a return to work date.

FB 96-06 Case Management--Role of Registered Nurses in QCM Cases
TTT	TYPE OF SURGERY	PROCEDURE	EXTENSION
A. Simple, uncomplicated		Endoscopies, diagnostic arthroscopy, herniorrhaphy	30 day extension, for a maximum of 150 days
B. Moderately complex		Discectomies	60 day extension, for a maximum of 180 days
C. Very complex surgery or surgery with serious complications		Multiple fusions, open heart surgery, amputa- tion of limb	Work with claimant until stable, then refer for rehabili- tation services

In general, the simple procedures should require no more than 8-10 hours of professional nurse services within the 30-day period. The moderately complex procedures will require about 12-16 hours of services within the 60-day period. Since the complex procedures will typically result in work limitations which may warrant referral for vocational rehabilitation services, the FN should work toward stabilizing the claimant's condition and obtaining Form OWCP-5 in these cases.

6. For a concurrent non-work-related condition, or surgery (whether work-related or not), the SN should determine whether continued FN services will likely be needed within six months.

If so, and the CE concurs, the SN should place the case in interrupted status until the time of expected recovery. (Interrupted status, rather than an extension, is appropriate since the claimant would require little or no active involvement by the FN during this time.)

The FN may not unilaterally interrupt services, and the CE's approval is necessary because any interruption will affect the one-year time frame for resolving the case. Interrupted status should not continue longer than six months. The status code "NIN" (Nurse Interrupt) has been added to the QCM tracking system and is available for immediate use. The Nurse/Rehabilitation Tracking System (N/RTS) will also be modified to accommodate entry of an interrupt status code.

7. During the interruption, the FN should stay in touch with the claimant to monitor medical issues and maintain a focus on return to work. If surgery is involved, the FN will typically review the attending physician's orders with the claimant after surgery and monitor the claimant's course at home. Also, the FN may discuss the post-operative plan with the physician by telephone and monitor the claimant's compliance with these orders. The RN may perform these services up to five hours per month.

MANAGEMENT BY CLAIMS EXAMINERS

8. The CE must assess the medical evidence carefully and use judgment to determine the continuing benefit of the FN's services. For instance, if the medical evidence states that the claimant will be able to work eight hours per day within a month, the situation is straightforward, and the CE may authorize another 30 days of FN services. However, if the claimant has reached a plateau and is unlikely to improve, nurse services should be terminated.

9. Timely responses to telephone calls from FNs are crucial to successful case management. Interventions, whether by telephone or in writing, do not necessarily need to be long and involved. Brief but timely inquiries and reminders to physicians, employing agencies, and RNs are often very effective.

10. The claimant may progress from light to full duty or from four to six or eight hours of work a day, then claim a recurrence of total disability or a relapse which returns the claimant to light duty status or fewer hours of work per day. In addition to developing the claim for recurrence, the CE will need to decide whether the FN should continue to work with the claimant, or whether referral for vocational rehabilitation services is needed. This decision should be based on whether return to work with the Federal employing agency remains feasible, the length of time since the original injury, and the degree of disability.

REFERRAL FOR VOCATIONAL REHABILITATION SERVICES

11. In cases where at 120 days (or sooner) the FN cannot identify any potential for return to the previous employment, the FN must obtain a good description of work tolerance limitations using Form OWCP-5 and then recommend referral for vocational rehabilitation services if there is any ability to work. The FN may also recommend a second opinion examination. The SN may complete Form OWCP-14 to refer the case for vocational rehabilitation services, but may not sign the form. The actual referral remains the CE's responsibility.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

 

REQUEST FOR EXTENSION OF FIELD RN SERVICES

CLAIMANT NAME:__________________________________

FILE NUMBER:_____________________

NO. OF DAYS REQUESTED:___________

REASON FOR EXTENSION:____________

Change of attending physician
Released to light duty
Monitor RTW full time full duty

 

 

 

FIELD RN INTENDS TO ACCOMPLISH:

 

 

 

 

 

CE AUTHORIZATION:________________________________

DATE:__________________________

 

FIELD RN:_________________________________________

TELEPHONE NO:__________________

FAX NO:________________________

Attachment 1

Back to Top of FECA Bulletin No. 96-06

PLANNING CHART FOR QCM CASES

Claimant Name	DOB	DOI	File Number
Accepted Condition(s)			ICD-9 Codes
Date Wage Loss Began	10 Month Letter/ VR Referral Due		Reinstatement Rights Expire
Date RN Assigned	Status at 120 Days
RN Services	Date/How Long		Reason	| Interrupted
	Date/How Long		Reason
	Date/How Long		Reason
RN Services Extended	Date/How Long		Reason
	Date/How Long		Reason
	Date/How Long		Reason

For interruptions and extensions which will exceed the date of the 10 month letter, the SCE must initial concurrence with the time frame

Attachment 2

Back to Top of FECA Bulletin No. 96-06

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-07

Issue Date: January 7, 1996

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Expiration Date: January 4, 1997

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Subject: Compensation Pay: Compensation Rate Changes Effective January 1996.

Background: In December 1995, the President signed an Executive Order implementing a salary increase of two percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the two percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 1996.

Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.

The new rates will be effective with the first compensation payroll period beginning on or after January 1, 1996. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $90,090 per annum.

The minimum increase specified in this Bulletin is applicable to Postal employees.

The effect on 5 U.S.C. 8112 is as follows:

Minimum/maximum Compensation Rates

Effective January 7, 1996	Minimum	Maximum
Monthly	$1,160.25	$5,630.63
Weekly	200.81	1,299.38
Daily (5-day week)	40.16	259.88

 

The basis for the minimum compensation rates is the salary of $13,923 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $90,090 per annum (GS-15, Step 10). The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,160.25, effective January 7, 1996. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $5,630.63 per month.

Applicability: Appropriate National and District Office personnel.

Reference: Memorandum For Directors of Personnel (CPM 95-10), dated December 29, 1995; and the attachment for the 1996 General Schedule.

Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.

1. Adjustments Dates.

a. As the effective date of the adjustment is January 7, 1996, there will be no supplemental payroll necessary for the periodic disability and death payrolls.

b. The new minimum/maximum compensation rates will be available in ACPS on or about January 26, 1996.

2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 1996. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.

3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows (later this year these forms will be reproduced):

CA-842
1/07/96	40.16-60.24 40.16-53.55	200.81-301.22 200.81-267.75	40.16	200.81	1,160.25
CA-843
1/07/96	259.88	1,299.38	(5,197.52)	5,630.63

4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose. Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.

Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)

Back to Top of FECA Bulletin No. 96-07

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-08

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Issue Date: March 1, 1996

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Expiration Date: February 28, 1997

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Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1996.

Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1996.

1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 2.5 percent.

2. The increase is effective March 1, 1996, and is applicable where disability or death occurred before March 1, 1995.

3. The new base month is December 1995.

4. The maximum compensation rates which must not be exceeded are the following:

$ 5,630.63 per month
1,299.38 per week
5,197.52 each four weeks
259.88 per day (for a 5-day week)

Applicability: Appropriate National Office and District Office personnel.

Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.

Action: On or about February 23, 1996, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.

1. Adjustment Dates.

a. The periodic disability and death supplemental payrolls for CPI adjustments will cover the period March 1 through March 2, 1996, with the new cycle effective March 3, 1996.

b. The supplemental check date for the periodic disability and death payrolls will be March 19, 1996.

2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 23, 1996, daily roll payment cases requiring the new CPI should be held for data entry until that date.

3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information.

4. Forms.

a. Form CA-837, Notice to Payee, will be sent to the payees on the periodic disability and death payrolls. The notice will be sent to the payees from the National Office. The CA-837 will be addressed using the ACPS Correspondence Address File. PLEASE be sure to maintain the address file as you do with the Payee Address File and the CMF. PLEASE remember that an address change to the CMF DOES NOT automatically change the ACPS check address or correspondence address. ACPS must be accessed and the enter key must be depressed through the address areas. Be watchful for those payments being sent via Direct Deposit.

b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.

c. CP-140 will be printed for each case adjusted. These should be drop filed in the case file.

Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)

Back to Top of FECA Bulletin No. 96-08

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-09

Issue Date: June 17, 1996

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Expiration Date: June 17, 1997

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Subject: Occupational Rehabilitation Programs (ORPs)

Background: There are a great variety of rehabilitation services available to help the injured worker return to work, and to expedite that process through the use of abbreviated workdays or altered job duties. As a group, these services, which were previously known as work hardening or work conditioning, are now defined as Occupational Rehabilitation Programs (ORPs). Although some report significant successes, professionals in rehabilitation concur that the lack of standards in this area make it difficult to identify programs with positive outcomes and reasonable cost.

The substantial increase in the length and cost of such services over the past year has prompted inquiry about their quality, appropriateness, and outcomes. Moreover, these services constitute a workload for district offices. The lack of a coding scheme often results in inappropriate denials, suspensions and fee reductions. Conversely, the lack of codes prevents the application of cost controls. To encourage the use of effective services and to prevent abuse, OWCP has developed guidelines for the authorization and reimbursement of occupational rehabilitation services. These guidelines are intended to aid as a resource for: (1) the selection of claimants who would benefit from these services, (2) the identification of programs that are effective and cost efficient, (3) setting limitations on the length and cost of ORPs, (4) providing methods for monitoring ORPs, and (5) establishing a means to measure program outcomes.

Purpose: To transmit guidelines for the authorization and reimbursement of Occupational Rehabilitation Programs (ORPs).

Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives, Supervisors, Technical Assistants, Rehabilitation Specialists, Staff Nurses, Bill Resolution Staff.

Action:

1. Identification of cases which could benefit from these services may arise from various sources:

(a) CEs refer the following cases to the Rehabilitation Specialist for an ORP assessment:

i. cases in which a health care provider has recommended rehabilitation, unless the claimant has already returned to full regular duty,

ii. QCM cases in which the Field Nurse (FN) period has been exhausted but the claimant has not returned to work, and has been determined to have moderate to high physical limitations/deconditioning, or has not had an assessment of physical limitations.

(b) The RS initiates an ORP placement and notifies the responsible CE in any case already open for vocational rehabilitation which, in his or her opinion, may benefit from this type of service.

2. The RS reviews these cases and verifies that they meet the criteria detailed in Chapters 1-2 of the attached Guidelines.

3. Cases referred by the CE that meet the basic criteria are opened for rehabilitation. To open these cases, the RS introduces the appropriate case information in the RTS, using status M (medical rehabilitation), assigns a Rehabilitation Counselor (RC), and selects an ORP facility that meets the provider criteria and is as close as possible tot he claimant's residence. If the case is already in an open rehabilitation status, the RS changes the status to M.

4. The RS refers the case to a RC for a screening interview and the scheduling of a Functional Capacity Evaluation (FCE) to determine the type and character of the ORP most suited to the claimant's needs. As usual, the RS forwards pertinent claim documentation, and a completed Form OWCP-35A to the RC. A Form OWCP-3 with detailed instructions relating to the ORP is also forwarded, accompanied by a completed authorization form for a Functional Capacity Evaluation with an Occupational Rehabilitation Plan (Table I). A maximum of three (3) months and twelve (12) professional hours are allowed for this status.

5. The RC assigned to the case previews the pertinent documentation and performs the claimant interview and categorizes the claimant as a potential candidate for a Return to Work (RTW) or a Work Readiness (WR) ORP in keeping with the criteria set forth in Chapters 2 and 3. The RC schedules a Functional Capacity Evaluation (FCE) in the selected facility and:

(a) Transmits all available information regarding job availability job description(s), the current work tolerance of the claimant and other relevant work site considerations,

(b) advises the facility of the purpose of the FCE, report requirements, and the necessity for a detailed description of any recommended ORP, including treatment schedules and cost,

(c) communicates timeliness requirements and instructions for billing, and sends a copy of the ORP-FCE authorization form (Table I).

6. Once the FCE is completed, the RC forwards the facility report with his or her own brief report, which should contain recommendations for actions. Based on these documents, and using the criteria detailed in Chapter 3, the RS selects and authorizes the appropriate ORP "class" for the claimant. He or she advises the facility and the RC of the types and number of services authorized. Tables II or III should be used for this purpose. Additionally, the RS or RC provides instructions on billing procedures and requirements, and informs the facility about the applicable price maxima.

7. The RS or another DO staff enters the authorization for the ORP in the "notes" section of the Claimant Management File (CMF). To ensure the accurate processing of facility bills, the following information must be included: the approved ORP category (RTW vs. WR) and class, the date range for the approved services. If additional services, such as work-site visits, or the use of modifiers are approved, a notation to this effect must be also included (See Guidelines, Chapter 4).

8. Once the particular program has been authorized and the claimant is enrolled in the ORP, the treating physician, employer (when available), the RC and the CE are notified using a Form OWCP-3.

9. The RC continues to act as a liaison with the ORP facility and he or she works with the claimant to ensure attendance and to resolve issues that arise during the ORP which may interfere with the completion of the program. Medical or other issues which could delay or terminate the ORP, such as the appearance of non-work related conditions, recurrences, complaints of high levels of pain, etc. have to be reported immediately to the RS and CE.

10. The RC provides reports as established in the district office, including a brief summary of the ORP activities, the progress of the claimant, problems awaiting resolution, and expected completion date. All request for extension of services or the provision of additional services such as work-site visits, follow-up treatments and the use of modifiers, should be reviewed and decisioned by the RS.

11. The RC must notify the RS immediately when an ORP is completed and he or she forwards the ORP final report to the RS as soon as this document is available. As a response, the RS changes the status to W, Placement Previous Employer with Services, to P, Placement New Employer, or to T, Training, as warranted in the particular case. The RS transmits this change and further instructions to the RC using a Form OWCP-3.

12. In instances where the results of the ORP indicate that the claimant is not able to perform the duties of the previous employment or the targeted jobs, the RS may place the case in D, Plan Development, with the concurrence of the CE to consider other rehabilitation solutions. In instances where the result of the ORP indicate that the claimant is able to perform the duties of the date of injury job, the RS should notify the CE immediately. Alternatively, the RS may select other options (eg. recommend the application of sanctions or the performance of a second opinion) and forwards the case to the CE.

13. When the ORP is interrupted before completion, the RC notifies the RS immediately, carefully detailing the reason(s) for the interruption. The RS communicates this fact to the CE and recommends an appropriate course of action based on the circumstances of the case. He or she also includes mention of this event in the CMF "NOTES", and change the approved last date of service to coincide with the date of the interruption.

14. Processing of ORP Facility Bills.

(a) Bills from an ORP facility that is providing authorized services are "prompt pay" bills.

(b) Facilities should submit a single global bill at the end of the ORP on a Form HCFA-1500 or UB-92. The bill should contain all the data elements required to process bills through the automated bill processing system, including: the claimant's name, address, and claim file number; and the provider's name, address, and EIN. In addition, the provider must include the pertinent OWCP ORP codes, with the corresponding units (hours), the amount billed code, and the total amount of the bill.

(c) Because these bills will contain unique alphanumeric codes, they can be identified and batched together prior to data entry. Once data entered, the bill lines will fail Error Code 302, and manual resolution will be required to process them to completion. To resolve these suspensions, the designated district office staff should access the CMF "Notes" and verify whether an ORP has been authorized. If so, the codes on the bill are matched against the ORP category (RTW vs. WR) and "class", and the dates of services on the bill are matched against the authorization period present in the "Notes". If a line meets the above conditions, the edit failure is overridden.

(d) If a line does not meet the above condition, the bill resolver forwards the bill to the district office staff responsible for the resolution of problematic rehabilitation bills. This other staff consult with the RS and the facility as necessary and take appropriate action.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 1
(Claims Examiners, All Supervisors, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

Attachment

Back to Top of FECA Bulletin No. 96-09

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-10

Issue Date: May 9, 1996

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Expiration Date: May 8, 1997

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Subject: Adjudication of Claims: Use of Incorrect Form

Background: In examining cases received in the Branch of Hearings and Review, National Office staff have increasingly noticed that claims are sometimes denied because they are filed on the incorrect form, without substantive development. For example, Form CA-1 may be submitted to claim a recurrence, or Form CA-2a may be submitted for another episode of a condition for which a Form CA-2 is already on file. (With respect to the latter instance, see FECA PM Chapter 1500.3b(2)(e), which states that a new claim need not be filed.)

Submission of an incorrect form is only a technical error, and it is improper to deny a case simply because the claimant has not submitted the correct form. The case should be developed and adjudicated on the basis of the evidence submitted. Moreover, to the extent possible, the same Claims Examiner should handle all claims involving the same part of the body for a given claimant.

Reference: FECA PM Chapters 2-400.8, 2-800.4 and 2-1500.3

Purpose: To describe actions to be taken when an injury, illness or recurrence of disability is claimed using an incorrect form

Applicability: All Claims Examiners, Supervisors, and Technical Assistants

Action:

1. As indicated in FECA PM 2-800.4, if a Form CA-1, Form CA-2 or Form CA-2a is incorrectly submitted in place of another form, the Claims Examiner (CE) should develop the claim based on the facts at hand. The development letter should include a request that the claimant complete the proper form, and the CE should include a blank copy of the proper form with the current claim number written in large letters on the top of the form.

2. The CE should not deny the case on the basis of the form filed, even if the case is technically in posture for denial. For instance, if Form CA-1 is received and Form CA-2 is actually required, the CE should not deny the case on the basis that fact of injury is not established.

3. However, if Form CA-1 has been submitted in error, it may be necessary to deny payment of continuation of pay. This action may be taken in conjunction with the development letter. 4. When the requested Form CA-1 or CA-2 has been received, the Case Management Record should be changed to reflect the correct form, so that the adjudication time frame for the case will be accurate. A case previously entered into the Disability Tracking System in error should be removed. Similarly, if Form CA-2a was requested and received, the case should be entered into the Disability Tracking System.

5. The CE should evaluate the evidence as a whole as it pertains to a given part of the body. To do so, case doubling may be necessary. FECA PM 2-400.8 describes the current criteria for doubling cases, which are being modified to include the following situations:

a. A new injury is reported for an employee who has filed a previous injury claim for a similar condition;

b. Two or more separate injuries (not recurrences) occurred on the same date.

c. Adjudication or other processing of a case will require frequent reference to an earlier case for a dissimilar condition. Cases of this nature include those where problems arise with bill pay and/or mail placement, such as when the same physician is treating the claimant for more than one injury; and those with overlapping periods of disability.

Cases should be doubled as soon as they are identified as proper to double. Changes of responsible CE should be avoided if possible.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

Back to Top of FECA Bulletin No. 96-10

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-11

Issue Date: July 9, 1996

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Expiration Date: July 8, 1997

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Subject: Compensation - Revised Leave Buy-Back Procedures

Background: In February 1995, a team of OWCP employees met in Washington D.C. to reinvent the current leave buy back (LBB) procedures.

Surveys of OWCP employees indicated that the existing LBB process was cumbersome and time-consuming for claims examiners, and often confusing for both injured workers and federal employing agency staff. In addition, data shows that only about one-half of claimants elect to repurchase their leave after the CA-1207 is issued and they become aware of the additional payment the agency requires beyond the amount of their FECA entitlement.

A decision was made to simplify the current procedures from a two step process to a one step process, with the CE issuing an immediate payment (instead of a CA-1207) where possible.

Two new forms, a Time Analysis Form (CA-7a) and a Worksheet/ Certification and Election Form (CA-7b), have been developed to be filed with Form CA-7 in LBB claims. The new form CA-7a is to be used when leave dates are intermittent or when more than one continuous period of leave is claimed. The CA-7b fully explains the process to the claimant and allows an estimate of the FECA entitlement. It requires the employing agency to advise the employee of the amount required by the agency to reinstate the leave in question and to agree to the process in advance of submission of the form. Based on past experience with non-returned EN-1207s, many claimants will decide at this point not to file the claim when they become aware of the balance they must pay to have their leave restored.

The revised CA-7 claim form refers the claimant to new forms CA-7a if time was lost for intermittent hours or days and CA-7b for leave repurchase. These forms are supplements to the CA-7 and a CA-7 must be submitted as part of the claim. If the claim is incomplete, it may be returned to the employer for completion and tracking is not required, as with current practice.

Unless there is a significant variance between the agency estimate of FECA entitlement and the actual entitlement, the LBB claim can be paid immediately upon receipt of the completed claim providing the medical evidence supports injury related time loss for each date claimed. A significant variance exists where the estimated entitlement is more than 10% above the actual entitlement. If there is a significant variance between the agency estimate and the CE's calculation and supporting medical evidence has been provided for all hours claimed, the CE advises the claimant of this via CA-1207 and requires return of a signed EN-1207 election before the claim is paid. If there is a 10% variance and medical evidence has not been provided for some or all of the hours claimed, the CE will develop the medical status before proceeding further. Please see item 7 under "Action" for a more detailed explanation.

If the estimated entitlement was calculated accurately but there is insufficient medical evidence to support all hours claimed, the CE will process the claim for the verified hours.

ACPS will be updated to include a relationship code "LB" which will automatically generate the correct agency payee address for leave buy back. The claims examiner will have the option of automatic or manual generation of a revised Form Letter CA-1208. If the claim is payable as presented, the automatically generated CA-1208 will be used. If only a portion of the claim is payable, the CE will generate a manual version of the CA-1208 (designated CA-1208a) and enter text concerning the unpaid periods.

The CA-7b instructions request the claimant to submit the LBB claim within one year of the date the leave was used or the claim was accepted, whichever is later. While the CA-7b instructions are designed to encourage more timely submission, claims older than one year cannot be denied on that basis.

The CA-7b instructions also request that claims be submitted for a minimum of ten hours of leave unless no further claims are anticipated. This is intended to reduce the frequency of claims and time required for processing by both the agency and OWCP.

This revised LBB process enables the examiner to resolve most LBB claims to conclusion upon initial submission, even where payment is not made for all dates claimed.

Copies of the new CA-7a, CA-7b, CA-1207, CA-1208, and CA-1208a form letters are attached.

Purpose: To provide instructions for implementing streamlined leave buy-back processing.

Applicability: Claims examiners, Supervisors, Systems Managers, Technical assistants, Fiscal Personnel, and other appropriate staff of the National and District Offices, and the Branch of Hearings and Review.

Reference: 20 CFR 10.310, Buy back of annual or sick leave Federal (FECA) Procedure Manual, Chap 2-901 (13) Comptroller General decision B-112786, January 26, 1953

Action: Each office Systems Manager or other designated staff will enter specific agency addresses for LBB payments into a new LBB address maintenance table.

Effective August 1, 1996, except as noted in paragraph 8 (below), LBB claims will be processed as follows:

1. On receipt of the agency certified LBB claim (CA-7, CA-7a, CA-7b) mailroom staff will key it into the TPCUP system and deliver it to the office designated location.

2. The CE will review the claim to insure it is complete. If the claim is incomplete or unsigned, the CE will return the claim for completion. The CE will advise the claimant by letter as to what was missing and document the case file with a copy of the letter. Returned claims do not have to be tracked and can be deleted from TPCUP as with current practice.

3. When the FECA District Office receives the package, the CE will first review the estimate of FECA entitlement on the CA-7b. If the estimate of entitlement is within 10% of the amount determined to be accurate by the CE, the CE proceeds to review the supporting medical evidence.

For example, let us assume that the agency has estimated FECA entitlement to be $1500 for 100 hours of leave use. The CE, using the correct pay rate and compensation rate, determines the correct amount to be $1470 for those hours. Since the agency's estimate is less than 10% above the correct amount, the CE will proceed to evaluate the medical evidence.

4. If the claim is payable for all hours claimed, the CE will round the total number of hours payable to the nearest whole hour, key the payment using relationship code "LB", and obtain payment certification. Entry of the relationship code "LB" will cause the payment to be made to the agency address designated for LBB payments (this may be the same as the agency correspondence address). Answer "yes" to the system prompt for automatic generation of the CA-1208. This action will automatically generate the revised form letter CA-1208 to the claimant and agency showing that the claim was accepted in full with the inclusive dates and amount of the payment made. The CA-1208 will not have to be signed by the CE and can be mailed by other staff.

In rare situations, the total FECA entitlement will exceed the amount owed by the claimant to the employing agency. In these instances, the employing agency will pay the claimant any balance due.

5. Where there is medical support for some but not all of the hours claimed, the CE will key a payment for the approved hours.

Using the example in 3 (above), if medical evidence only supports 80 of the 100 hours claimed, the CE will key the payment for the 80 approved hours, and will manually generate Form Letter CA-1208a. Even though we are not paying all of the hours claimed, payment can be made because the amount actually paid will be proportionately the exact same percentage of the agency estimate of FECA benefits.

The Letter CA-1208a will show the total number of hours approved and the inclusive dates, with a freeflow entry explaining any additional hours not approved for payment. The CE will enter a TPCUP "D1" code. This will close out OWCP processing of that particular leave buy back claim. If the claimant is able to obtain medical support for the unpaid hours, he/she may initiate a new leave buy back claim specifically for those hours.

6. If medical evidence received is insufficient to support payment of the hours claimed, the CE will defer a decision on the claim. The claimant will be advised in writing of the deficiency of the claim and given 30 days to provide the supporting evidence.

If medical evidence is received in response to the request, the CE will evaluate it and proceed as outlined in paragraph 4 or 5 above.

If no medical evidence is received or if the evidence is not sufficient to establish entitlement for any of the hours, the CE will deny the leave buy back claim by formal decision.

7. If the employing agency's estimate of FECA entitlement differs from the CE's calculation of the correct amount by more than 10%, the CE will review the medical evidence before proceeding further.

Using the example in 3 with the agency estimate of $1500, let us assume that the CE determines the correct amount of FECA entitlement to be $1250 for the hours claimed. Since this is a variance of more than 10%, the CE will proceed as shown below after evaluating the medical evidence.

If there is medical evidence for all hours claimed, the CE will issue a letter CA-1207 showing the correct entitlement amount. If the claimant still wishes to pursue leave repurchase, he/she will then complete his/her portion of the enclosure EN-1207 and return it to the employing agency. If the parties reach an agreement on restoration of leave, the agency will complete its portion of the EN-1207 and forward the completed form to OWCP. The CE will then issue a compensation payment to the agency and release letter CA-1208 to the claimant, with a copy to the agency.

Where the medical evidence is insufficient to support all of the hours claimed, the CE will defer payment of the claim and send the claimant a narrative letter requesting additional medical documentation. The CE may also contact the employer if there is a question as to the correct pay rate to be used.

If there is no medical evidence to support any of the hours claimed, the CE will deny the leave buy back claim by formal decision.

8. District offices will use the old procedures to process LBB claims filed with the employing agency in the old format prior to 10/1/96, and will not require these to be resubmitted in the new format. The old form CA-1207 has been modified to advise parties of the new process and has been renumbered as CA-1206, and will be used to process these old claims.

9. All District Offices will conduct training on this bulletin prior to August 1, 1996. Please address any questions on any of this material to Cecile Moran (202) 219-8461 or email cmf@fenix2.

Disposition: Retain until incorporated in Federal (FECA) Procedure Manual.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)

 

DRAFT////////////////////////DRAFT/////////////////DRAFT

Month 9, 1999
	File Number: 99999999 Date of Injury: 99/99/1999 Employee: FIRSTNAME M. LASTNAME SSN:
claimant name/address 000000000000000000000 000000000000000000000

Dear FIRSTNAME M. LASTNAME:

Your claim for compensation to repurchase leave for the period indicated below has been approved in full.

This payment is based on your weekly salary of ($ ENTERED BY SEQUENT), as of (effective date of payrate used, ENTERED BY SEQUENT). This is paid at the rate of (the without dependents rate of 66 2/3rds, OR 75%, as you have one or more dependents - ENTERED BY SEQUENT).

The amount of compensation paid and the period covered are shown below. The full FECA payment has been made directly to your employing agency at the address below. If you have not already done so, you must make arrangements with your employing agency to pay any balance due for the repurchase of your leave. If your FECA entitlement exceeds the total amount required by your agency, your agency will pay you any balance due.

FECA compensation paid: $ (ENTERED BY SEQUENT)

Period covered by payment: 00/00/0000 to 00/00/0000 (ENTERED BY SEQUENT)

 

Sincerely,

 

Fname M. Lname
Claims Examiner

COPY ONE TO ?????????????????? 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000

COPY TWO TO ??????????????? 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000

 

Back to Top of FECA Bulletin No. 96-11

 

C11
CA12-08-0896

Month 9, 1999
	File Number: 99999999 Date of Injury: 99/99/1999 Employee: FIRSTNAME M. LASTNAME SSN:
claimant name/address 000000000000000000000 000000000000000000000

Dear FIRSTNAME M. LASTNAME:

Your claim for compensation to repurchase leave for the period indicated below has been approved in part.

This partial payment is based on your weekly salary of ($ entered by CE), as of (effective date of payrate used, entered by CE). This is paid at the rate of (the without dependents rate of 66 2/3rds, OR 75%, as you have one or more dependents - entered by CE).

The amount of compensation paid and the period covered are shown below. The FECA payment has been made directly to your employing agency at the address below. If you have not already done so, you must make arrangements with your employing agency to pay any balance due for the approved period. If your FECA entitlement exceeds the total amount required by your agency for the approved period, your agency will pay you any balance due.

FECA compensation paid: $ (entered by CE)

Period covered by payment: 00/00/0000 to 00/00/0000 (entered by CE)

We are unable to approve payment for the following dates and/or number of hours for the reasons stated:
FREEFLOW TEXT UP TO 10 LINES
2
3
4
5
6
7
8
9
10

If you wish to pursue a claim for the unpaid time, please submit a new claim for the balance along with medical or other evidence relating to the reason for non payment.

Sincerely,

 

Fname M. Lname
Claims Examiner

 

COPY ONE NAME AND ADDRESS 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000

COPY TWO NAME AND ADDRESS 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000

 

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C11

CA1208a-0896

Month 9, 1999
	File Number: 99999999 Date of Injury: 99/99/1999 Employee: FIRSTNAME M. LASTNAME SSN:
claimant name/address 000000000000000000000 000000000000000000000

Dear FIRSTNAME M. LASTNAME:

This refers to your claim for compensation for leave buyback for the period (to/from dates manually entered by CE).

Your agency's estimate of your FECA entitlement exceeded your actual entitlement by more than 10% Therefore, we must advise you of your actual entitlement, and require your election as whether you desire to pursue your claim since you must pay a greater amount to your employing agency than originally estimated.

Your actual entitlement is calculated as follows:

a. Weekly pay rate as of (DOI, DDB, DOR as entered manually by CE)	$_____
b. Above weekly pay times either 2/3 (if no dependents) or 3/4 (with dependents)	$______
c. Number of leave hours approved for buyback	____hrs
d. Total hours worked per week (see CA 7b, item F)	____hrs
e. TOTAL actual FECA entitlement (B above times C above divided by D)	$______
Calculation for payment due to employing agency by employee
1. Total amount required by your agency to recredit leave	$______
2. Actual FECA entitlement in (e) above	$______
3. Amount you owe your agency Item (1) LESS item (2)	$______

If you desire to proceed with you claim, please complete the staement below, give a copy to your agency, and return the original to us. We will assume you do not desire to pursue your claim if your signed statement is not returned to us.

Sincerely,

 

Fname M. Lname
Claims Examiner

TO OWCP: I desire to proceed with my claim, and have made arangements to refund all leave pay received.

Signed_______________________________ Date___________________

COPY ONE NAME AND ADDRESS 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000 000000000000000000000000000000

COPY TWO NAME AND ADDRESS 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000 000000000000000000000000000

 

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C11

CA1207-0896

FB 96-11 Compensation - Revised Leave Buy-Back Procedures TIME ANALYSIS FORM
EMPLOYEE STATEMENT - Please carefully read instructions on reverse
1. Name of Employee Last		First Middle			2. SSN	3. OWCP File Number
4. Period covered by this form		5. Total Hours Claimed
From ___/___/___ To ___/___/___		for LWOP _________________
		for leave buyback __________

6. In "Type Leave" column use codes "S"=sick, "A"=annual, "O"=other If compensation is claimed for date, indicate "Yes" in "COMP claimed" column.

DATES	COMP CLAIMED?	NUMBER OF HOURS				TYPE LEAVE	Reason For Leave Use/Remarks (e.g.,DR visit, therapy)
		LWOP	Worked	Ho1	LVE
TOTALS

 

Signature of Claimant	Date Signed
__________________________________________________________________________________ 7. AGENCY STATEMENT/CERTIFICATION: I certify the above is accurate, except as follows:
__________________________________ Signature Agency Official	__________________________________ Date Signed

CA-7a

 

INSTRUCTIONS FOR COMPLETING FORM CA-7A
LEAVE ANALYSIS

 

GENERAL: This form is used when claiming FECA compensation, including for repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.

INSTRUCTIONS FOR EMPLOYEE:

Blocks 1, 2 and 3 are self-explanatory.

Block 4:indicate beginning and ending dates covered by this form. These must be the same as on forms CA-7 and CA-7b.

Block 5:if claiming compensation for any dates detailed in block 5, state total number of hours claimed for leave without pay and total number of hours of leave. This should be at least 10 hours unless this is your final claim.

Block 6:

1st Column: Show full date

2nd Column: For each date noted in column 1, state Y if you are claiming compensation for that date and N of you are not.

3rd, 4th, 5th and 6th columns: Show the number of hours of LWOP, number of hours worked, paid holiday hours, and number of hours of paid leave.

7th Column: Using the legend provided, indicate the type of leave used.

8th Column: State the reason you were off work. For each date for which compensation is claimed, there must be medical evidence supporting entitlement.

SIGN AND DATE FORM AND SUBMIT TO THE APPROPRIATE AGENCY OFFICIAL.

INSTRUCTIONS FOR EMPLOYING AGENCY

Block 7: Verify accuracy of hours and status for each date listed. If challenging entitlement for any date, attempt to resolve discrepancies prior to submitting the claim to OWCP. If discrepancy cannot be resolved, indicate the specific basis for the challenge in the space provided.

 

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LBB WORKSHEET/CERTIFICATION AND ELECTION FORM
A. Name of Employee:		Last	First	Middle	B. OWCP File No.
C. Social Sec. No.
D. Period for which compensation is claimed to repurchase leave From ___/___/___ To____/____/____
--------------------------------------------------------------- I. AGENCY ESTIMATE OF FECA ENTITLEMENT:
A. WEEKLY BASE PAYRATE (excluding overtime)
o Date of Injury			___/___/___	$_____
o Date Stopped Work			___/___/___	$_____
o Date of Recurrence			___/___/___	$_____
Enter the greatest amount & the effective date of that amount on line 1.					1. __________   __________
					___ /___/___ (eff. date)
B. ADDITIONS TO BASE PAY: If employee works a regular schedule, state the amount earned weekly. If irregular schedule, state amount earned 1 year prior to date entered on line 1 ö by 52.
o Night Differential					2. _________
o Sunday Premium					3. _________
o Subsistence/Quarters					4. _________
o Other (specify)					5. _________
C. TOTAL WEEKLY PAYRATE (Add lines 1 thru 5)					6. _________
D. COMPENSATION RATE (Circle either 2/3 or 3/4)					7. 2/3 3/4
E. TOTAL HOURS CLAIMED ON CA-7a					8. _________
F. TOTAL HOURS WORKED PER WEEK					9. _________
G. FORMULA (FOR FECA ENTITLEMENT)
$__________ X (Wkly Payrate - see line 6)	__________ X (Comp Rate - see line 7)	_________-- (Hrs - see line 8)	__________ = (Hrs Wkd/wk - see line 9)		10. $ _______
II. AGENCY CERTIFICATION:
H. Total amount due agency to repurchase leave					11. $ _________
I. Estimate of FECA entitlement (See Line 10)					12. $ _________
J. Balance due Agency from Employee (Line H minus Line I)					13. $ _________
I hereby certify that the above is consistent with agency payroll records.
The employing agency agrees to allow the employee to repurchase his/her leave. Leave records will be, or have been, changed from "Leave With Pay" to "Leave Without Pay" for the period shown on the leave analysis.
I further certify that if this claim is signed by the employee, the employee has made arrangements to pay the agency the balance between the total amount the agency requires to recredit leave and the amount of the FECA entitlement.
___________________________________ (Signature of Agency Official)			_________________________ (Title/Position)
Phone No:_________________________			Date Signed______________
Employing Agency Address for Check			_______________________________ _______________________________ _______________________________
III. EMPLOYEE CLAIM
____ K. I hereby elect NOT to repurchase the leave used at this time.
____ L. I hereby elect FECA compensation to repurchase leave used for medical care or disability resulting from my job-related injury or condition. I understand that I am responsible for paying my agency the difference between the FECA entitlement and the amount my agency requires to restore my leave, and have done or made arrangements for this. I understand that if my actual entitlement to FECA compensation is within 10% of the amount estimated above, OWCP will process the leave buy back. If the payrate used in the worksheet above is within 10% of the payrate determined by FECA, and less than the full period claimed is approved, OWCP will process payment for the approved period.
____________________________________________ (Signature of Claimant)				_______________________ (Date Signed)

 

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INSTRUCTIONS FOR FORM CA-7B, LEAVE BUY BACK WORKSHEET

This form is intended to accompany Form CA-7, Claim for Compensation, when the employee is claiming leave buy back.

THINGS TO KNOW ABOUT LEAVE BUY BACK: When an employee uses their sick or annual leave to cover an injury-related absence from work, they may elect to receive compensation instead. Compensation is paid at 2/3 of the employee's base pay if there are no eligible dependents, or at 3/4 with 1 or more dependents. The agency pays leave at 100% of salary. In order for leave to be reinstated, the employee must refund to the agency the difference between the compensation entitlement and the total amount of leave paid by the agency.

The employee's pay status must be changed to LWOP in order for compensation to be paid. Leave is not earned while in LWOP. Also, contributions to the Thrift Savings Plan (TSP) are not made during LWOP. Therefore, the repurchase of leave may result in a reduction in an employee's leave and/or TSP balance. Consult your personnel office to learn how the change to LWOP would effect you.

When a Leave Buy Back (LBB) payment is made during the same year that leave is used, the employee's earnings are reduced by the amount repaid, and tax is not paid for the compensation received. Where leave repurchase is not completed during the same year in which leave is used, the employee may not adjust their prior year tax form. They may only claim the amount of leave paid as an employee expense, if they itemize deductions. Further questions regarding tax implications of LBB should be addressed to the IRS.

A claimant may not repurchase leave used during a period they were eligible for COP.

When disability does not exceed 14 days beyond the COP period, 3 day LWOP must be charged before compensation can be paid. If leave was used for this period, compensation can not be paid for the 3 days, but the claimant will have to pay back leave paid during the 3 days to repurchase the leave.

INSTRUCTIONS TO THE EMPLOYEE:

Please submit a claim for a minimum of 10 hours unless no further claim is anticipated. Medical documentation must be provided for all dates claimed.

1. Complete the Form Ca-7 for the dates claimed. Where more than one continuous period of leave is claimed, complete From CA-7a following the instructions for completing that form.

2. Submit the completed CA-7, CA-7a, if appropriate, and medical documentation for all dates claimed, to your agency official. If there are discrepancies, try to reconcile the difference with your agency official prior to submission of the claim.

3. The agency official will provide you with an estimate of worker's compensation benefits due, the total amount owed the agency in order for the leave to be restored, and the amount you must pay the agency. Using this information, determine whether you wish to repurchase your leave, and check the appropriate block. If you choose to repurchase the leave, you will be required to pay to the agency the difference between the compensation due and the amount owed to the agency.

a) If the total amount of FECA benefits estimated by the agency is not more than 10% above the amount determined by OWCP to be accurate, OWCP will process a payment for all hours supported by medical evidence. If medical evidence supports some, but not all of the hours claimed, payment will be made for the approved hours. You may submit a new claim with medical support for the additional hours.

c) If the total amount of FECA benefits estimated by the agency is more than 10% above the correct amount, OWCP will not process the payment. Instead, the Office will offer you a new election with the correct amount of FECA benefits payable.

INSTRUCTIONS TO THE AGENCY:

Items A through D (top of form) are self-explanatory.

Section I (Agency Estimate of FECA Entitlement):

Item A: Enter all three pay rate types and effective dates if applicable. Choose the greatest amount of the three and enter the amount and effective date in Line 1. A recurrent pay rate should only be used if: (1) the employee stops work more than 6 months following their first return to regular, full time duty and (2) the loss of time is due to disability rather than medical examinations or treatment.

For unusual situations, please refer to Payrate Desk Aid.

Item B: If the employee works a regular schedule, enter the differentials earned weekly. If an irregular schedule, give the total amount earned for the year prior to the date in Line 1 divided by the number of weeks worked in that year.

Please refer to Payrate Desk Aid for guidance on inclusions and exclusions. If in doubt, consult a Claims Examiner.

Item C: Add lines 1 through 5 and enter the total in Line 6.

Item D: Circle the appropriate rate: 2/3 for employees without dependents; 3/4 with dependents. Dependents include: spouse; children under 18 living with or supported by the employee; children under 23 in school full time; children over 18 incapable of self support; and parents wholly supported by the employee.

Item E: Enter the total hours claimed, from Form CA-7a.

Item F: Enter the total hours in the employee's normal work week.

Item G. Formula For FECA Entitlement: Use this formula to calculate estimate of FECA entitlement and enter the result in Line 10.

Example of computation: The weekly pay from line 6 is $574.00. The employee is married, works 40 hours a week, and is claiming 82 hours of leave. FECA entitlement is calculated as follows:

$574.00 x 3/4 x 82 hrs -- 40 hrs = $882.52

II. Agency Certification

Item H & I are self explanatory. For Line J, subtract Line I from Line H.

Sign and date and advise the employee of the amount they owe to the agency.

III. Employee Claim: If the employee elects not to repurchase the leave, retain the form in the agency files. If the employee elects to repurchase the leave, submit all claim documents (CA-7, CA-7a & CA-7b) plus any medical documentation too OWCP for processing.

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-12

Issue Date: June 30, 1996

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Expiration Date: June 29, 1997

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Subject: OWCP Guidelines for General Purpose Functional Capacity Evaluations

Background: District offices report significant variability in the content, cost and quality of the Functional Capacity Evaluations (FCE's) provided to injured Federal workers. In addition, because there are no well-structured codes for these various services, processing of FCE bills often involves edit failures, manual resolutions, inappropriate fee schedule reductions, as well as telephone calls and letters from providers. To ensure the quality of these services, control their cost, and simplify the processing of bills, OWCP has developed guidelines for the authorization, evaluation, and payment of FCE's.

Under these guidelines, FCE's can be classified in two primary types according to their purpose, duration and content: (1) a general purpose GP-FCE, and (2) an FCE for placement into an Occupational Rehabilitation Program (ORP-FCE) such as Return to Work or Work Readiness (commonly called work-hardening, work conditioning, etc.). This bulletin discusses the General Purpose FCE (GP-FCE) while the FCE's associated with rehabilitation services are described in Bulletin No. 96-9.

Purpose: To transmit procedures and guidelines for the authorization and reimbursement of General Purpose Functional Capacity Evaluations (GP-FCE's).

Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives, Technical Assistants, Rehabilitation Specialists, Staff Nurses, and Bill Resolution staff.

Action:

1. A CE or Staff Nurse (SN) may authorize a GP-FCE in the following instances:

a. QCM cases undergoing nurse intervention where the treating physician recommends a FCE;

b. cases where management of disability call for clarification of job tolerances, job modifications, etc. and the treating physician, or the second opinion or referee specialist recommend or require this service.

2. Before authorizing the FCE, the CE or SN reviews the case and verifies that: the injury is greater than 3 months old, the functional impairment is of moderate to high complexity, and the services recommended by the physician exceed routine physical performance tests and measurements (e.g. CPT 97750).

3. The CE or SN authorizes the FCE and communicates the approval to the recommending physician, who in turn, makes the referral after requesting the name of a FCE facility. Based on the severity of the case, and the presence or absence of complicating factors, the CE or SN can approve up to eight hours for the GP-FCE.

4. The CE or SN completes the authorization form (Table A) and enters the authorization in the "Notes" section of the Case Management File (CMF). To ensure the accurate processing of facility bills, the following information must be included: the approved service code, the number of hours approved, the name of the provider, and, as necessary, the use of modifiers. He or she notifies the Field Nurse (FN) assigned to the case of the authorization of the FCE and provides the FN with a copy of the authorization.

5. After the FCE referral has been made, the FN conducts a brief telephone interview with the claimant to explain the purpose and expected content of the FCE, and to discuss any concerns the claimant has voiced regarding the FCE, expectations pending the outcome of the FCE, and related issues such as return to work. The claimant is to be made aware of his or her responsibilities regarding attendance, effort and cooperation.

6. The FN schedules the FCE in the selected facility and:

(a) transmits medical and work site information as necessary to the facility,

(b) advises the facility of the purpose of the FCE, the program's requirements regarding the content and timeliness of the facility's report,

(c) provides instructions for billing, and sends copy of the FCE authorization form.

(d) continues to be available to the claimant and the facility to resolve issues that may arise during the performance of the FCE.

7. It is expected that the GP-FCE report will be submitted to the CE or SN within three working days after completion of the evaluation and that it will meet OWCP guidelines (see Table B). Recommendations detailed in the GP-FCE report are evaluated by the CE in light of the nature of the case and the status of other case management procedures. If recommendations are made for a Return to Work or a Work Readiness Occupational Rehabilitation Program, the case is referred to the RS as described in Bulletin No. 96-9.

8. Processing of GP-FCE bills.

(a) Bills from a facility that is providing authorized services are "prompt pay" bills.

(b) The facility should submit a single global bill for the GP-FCE on a Form HCFA-1500 or UB-92. It should contain all the data elements required to process bills through the automated bill processing system, including: the claimant's name, address, and claim file number; and the provider's name address and EIN. In addition, the provider must include the pertinent OWCP service code with the corresponding units (hours) and amount billed.

(c) Because these bills will contain unique alphanumeric codes, they can be identified and batched together prior to data entry. Once data entered, the procedure code will fail Error Code 302, and manual resolution will be required to process the bill to completion. To resolve these suspensions, the designated district office staff should access the CMF "Notes" and verify whether the service has been previously authorized. If so, the date(s) of service on the bill is matched against the authorized date(s) in the "Notes". If a line meets these conditions, the edit failure is overriden.

(d) If a line does not meet the above condition, the bill resolver forwards the bill to the district office staff responsible for the resolution of problematic prompt pay bills. This other staff will consult with the CE, SN and/or facility as necessary and take appropriate action.

Disposition: This bulletin is to be retained in the OWCP (FECA) Procedure Manual until further notice or the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

TABLE B
DEFINITIONS AND GUIDELINES FOR GENERAL PURPOSE FUNCTIONAL
CAPACITY EVALUATIONS (GP-FCEs)

A GP-FCE consists of a series of physical and behavioral tests, measurements, and evaluations.
A GP-FCE includes the following evaluations and measurements:

*	Functional work capacity
*	Musculoskeletal status/strength measurements
*	Cardiovascular status
*	Cognitive status
*	Behavioral/attitudinal status, and psychologic-readiness/ barriers to return to work, routinely conducted under FCE's
*	Work tolerance assessments for a specific job and/or vocational options
*	Other assessments as specified by the requesting claim manager

The GP-FCE Report includes the following information:

*	Description of evaluation performed
*	Test, and measurement results, both raw and tabulated data
*	Normative values where available
*	Work capacity assessment findings
*	Activity restrictions when applicable
*	Attitudinal status, psychologic/behavior work-readiness evaluation results
*	Vocational status of claimant related to targeted jobs, including accommodation or safety issues, and other factors as relevant
*	Recommendations regarding therapy needs when indicated and/or requested, such as enrollment in an occupational rehabilitation program, physical conditioning exercises, pain management techniques, or other restorative services with comments on expectations for outcomes.

 

When a claimant is being evaluated for an Occupational Rehabilitation Program (ORP), the FCE is specifically tailored to help identify the health care and rehabilitation needs of the claimant who is transitioning back to work. A description of FCE's for ORP's is found in FECA Bulletin No. 96-9.

Back to Top of FECA Bulletin No. 96-12

 

TABLE C
GENERAL PURPOSE FUNCTIONAL CAPACITY EVALUATION (GP-FCE)
PROCEDURE CODES, MODIFIERS AND MAXIMA ALLOWABLES

Type	Code	RVU Work	RVU Overhead	RVU Mal-practice
Type of Service:	GP-FCE
Procedure Code:	RE100	46.73	41.68	5.04
Conversion Factor:	1.00
Units:	Hour
Modifier Code: (RE10010)	10	Allows for a 20% differential of the total allowable amount after geographic adjustment

Services authorized: The purpose and the established goals for the GP-FCE, and the claimant's physical limitations and deconditioning influence the duration and the complexity of the evaluation required to complete a FCE of high quality. Four to eight hours may be authorized for the GP-FCE. The authorization is recorded as indicated on Table A.

Modifiers:

On rare occasion, a claimant's condition requires professional assistance beyond the usual scope, or other circumstances are present that require special care and attention. When such claimants require a functional capacity evaluation, fee schedule adjustments for the additional professional time required may be made through the use of the OWCP modifier code "10". This modifier code must be added to the primary code by the FCE provider when services are billed. Also, "10" must be added to the authorization codes entered into the "Notes" area by the claims manager. In most cases, however, the use of modifiers will not be necessary, and the required FCE can be provided within the scope of the OWCP guidelines.

Reimbursement Rates:

Fee schedule rates are established to set maximum amounts for services prior-authorized by OWCP. They are not to be considered expected amounts. Providers are required to bill OWCP at their usual and customary rates; rates greater than those allowed under the OWCP fee schedule are reduced according to the schedule. Maxima are adjusted for geographic variance by multiplying the base rate relative value units times the fee schedule Geographic Adjustment Factor (GAF) values for the appropriate Metropolitan Statistical Area (MSA). Providers should have a clear understanding at the time an FCE is authorized that both time and dollar limitations will apply; related reimbursement issues should be resolved at the time authorization occurs. The provider should always be given a copy of Table A - OWCP FCE Guidelines and Authorized Procedure Code with the approved number of hours indicated.

Coding Conventions: FCE's are included under the general group of services called Occupational Rehabilitation. The first letter (R) of the procedure code indicates Rehabilitation, the second letter (E) indicates evaluation.

Note: Routine psychometric testing performed as a portion of the GP-FCE are included in the FCE reimbursement rate. Comprehensive evaluation services by a psychologist or psychiatrist are not usually anticipated. In those instances where it is believed necessary to treat the work-related injury, justification is to be provided and the services are to be prior authorized by the claims examiner. They are billed under CPT.

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TABLE D
PROVIDER DIRECTORY
OCCUPATIONAL REHABILITATION PROVIDERS

A GP-FCE is conducted by trained and licensed medical professionals who are knowledgeable about work-related disorders and occupational rehabilitation services. To ensure the quality of the facilities providing this service, OWCP has developed a Provider Directory based on those facilities that have been certified by the Commission on Accreditation of Rehabilitation Facilities (CARF). The directory contains type of service identifiers and includes those that provide FCE's and ORP services. District offices can add to the directory as more facilities are found that meet OWCP's requirements and provide FCE's of high quality. The directory provides space for comments and the listing of claimants referred; guidelines for additions to the directory at the level of the district office are detailed in FECA Bulletin 96-9. The National Office will also provide periodic updates to the Directory.

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-13

Issue Date: June 24, 1996

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Expiration Date: June 23, 1997

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Subject: BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.

Background: Effective June 7, 1996, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles was increased to 31 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.

Applicability: Appropriate National Office and District Office personnel.

Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual; Instruction CA-77, Instructions for Submitting Travel Vouchers; and 5 USC 8103.

Action: Instruction CA-77, Instructions for Submitting Travel Vouchers, has been revised to reflect the indicated rate change. A copy of the revised instructions is attached to this bulletin and may be reproduced at local levels. It will not be necessary to search and locate vouchers processed subsequent to June 7, 1996; however, if inquiry is received, appropriate adjustment should be made.

Disposition: This Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

 

Attachment

Distribution: List No. 2 -- Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)

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FECA BULLETIN NO. 96-14

Issue Date: July 15, 1996

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Expiration Date: Indefinite

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Subject: Employees' Compensation Appeals Board--New Address

Background: Effective July 29, 1996, the Employees' Compensation Appeals Board (ECAB) is moving to the Frances Perkins Building. The new address is:

Employees' Compensation Appeals Board
U. S. Department of Labor
200 Constitution Avenue, N.W., Room N-2609
Washington, D. C. 20210

Purpose: To provide the ECAB's new address to employees of the Division of Federal Employees' Compensation

Applicability: All FECA employees

Action: All form letters in the WP letters system which include appeal rights, and thus contain the ECAB's address, will shortly be modified to show the new address. Managers of each district office must ensure that all macros used locally reflect the new address.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-15

Issue Date: July 28, 1996

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Expiration Date: July 27, 1997

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Subject: Forms--Distribution of FECA Customer Service Brochure

Background: A customer service brochure has been developed to advise disability claimants of basic information about the Federal employees' compensation program. A customized version has been developed for each district office so that information specific to individual district offices can be conveyed along with generic text which applies program-wide. This brochure, which is designated Form CA-14, is to be sent shortly after case creation to all disability claimants whose cases are in UD status (i.e., not closed C1 or C4).

Purpose: To describe how Form CA-14 is to be distributed

Applicability: All FECA personnel

Action:

1. Although the printing order included the request that the brochures be sealed during printing, so that they would be ready to mail on delivery, this was not done. Therefore, it will be necessary for each district office to order enough wafer seals for the current printing (or, in the alternative, the brochures may be stapled together). Future printings will be wafer-sealed.

2. Address labels are to be obtained by running CASE624 during case create. The case create clerk should use these labels to send the brochures to the claimants. Brochures are not to be sent in death cases and in cases closed at the time of case create.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-16

Issue Date: August 12, 1996

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Expiration Date: August 11, 1997

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Subject: Bill Payment/BPS - Physical Therapy Authorizations

Background: FECA Bulletin 90-22, dated August 1, 1990, issued new procedures for authorizing physical therapy services (PT). To summarize briefly, for orthopedic or neurological cases accepted on or after September 1, 1990, an initial 90-day period of PT was to be authorized via the initial acceptance letter. Additional periods of PT authorization were to be specifically requested and authorized. Indefinite PT was to be authorized for brain and spinal cord injuries, extensive second and third degree burns, and other conditions which rendered the claimant bedridden. For cases accepted prior to September 1, 1990, PT services were to continue to be paid, without prior authorization.

When the bill processing system (BPS) was enhanced during FY 1993, physical therapy edits were put in place which essentially mimicked the existing procedures (now found in the Federal [FECA] Procedure Manual, Chapter 2-0810.16). Because of the inconsistencies which could arise from using the date of adjudication as a starting point for authorizing services, the date of injury was used instead, and the period of initial authorization which did not require pre-approval was 120 days instead of 90. A physical therapy authorization function was placed on the system, so that the BPS edits could automatically check the authorization for services after 120 days from the date of injury. These edits (710, 720, 721) were potentially applicable to cases in which the date of injury was on or after August 1, 1990 (to mirror the September 1, 1990 adjudication date in the original procedures). If the date of injury was prior to August 1, 1990, and the accepted conditions were orthopedic or neurological in nature, PT services usually were paid automatically by the BPS without a PT authorization on the system. If the accepted conditions in a case were such that PT would never be appropriate, or would be questionable, the bills would either be denied automatically or suspend for review.

DFEC has continued to pay for a substantial amount of PT on cases with a date of injury prior to August 1, 1990. The enhanced BPS has now been in place in excess of three years. A number of offices have expressed concern about continuing to pay for unauthorized PT in the older cases. Therefore, effective October 1, 1996, the BPS edit program will be modified to apply the physical therapy edits uniformly to all cases, whether the date of injury is before or after August 1, 1990. The effect of this change is that PT bills which have previously been paid on older cases regardless of (or without) PT authorization will now require specific PT authorization on the system.

The National Office is in the process of mailing letters to claimants who have received PT during the past six months, and whose date of injury predates August 1, 1990. Letters are also being sent to the providers of the PT. The letter informs them that effective October 1, 1996, PT performed more than 120 days after the date of injury must be authorized in advance by OWCP. The requirements for the medical evidence required to authorize PT are also outlined. As a result of these letters being sent out, offices may expect to receive an increase in the number of requests for PT authorization.

In addition, each district office has been provided with a report showing cases with date of injury prior to August 1, 1990, in which PT has been paid during the past six months.

References: FECA Bulletin 90-22, dated August 1, 1990; FECA Bulletin 93-9, dated May 12, 1993; Federal (FECA) Procedure Manual, Chapter 2-0810.16.

Purpose: To outline revised PT authorization requirements.

Applicability: All supervisors, claims examiners, bill resolution personnel, and mail room personnel.

Action:

1. Prompt action should be taken on requests for authorization of physical therapy.

2. Cases which appear on the list provided by National Office should be reviewed prior to October 1, 1996 to determine whether there is sufficient information in the case file to authorize PT. If PT is authorized, the provider and claimant should be notified in writing, and the dates of the authorization should be placed on the system under "PT authorization", case management menu item 34.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 96-17

Issue Date: September 20, 1996

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Expiration Date: September 19, 1997

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Subject: Impairment/Schedule Awards: Further Issues in Computing Awards Using the Fourth Edition of the AMA Guides

Background: FECA Bulletin No. 95-17 described various differences between the fourth edition of the AMA Guides to the Evaluation of Permanent Impairment and previous editions of this volume. Since that bulletin was released, several medical and administrative questions have arisen from various district offices and the Branch of Hearings and Review concerning the calculation of schedule awards.

Several comments addressed reports from examining physicians, which sometimes lack complete (or any) citations to tables and figures used and which do not always show clearly how the physician performed his or her calculations. Not surprisingly, examining physicians are usually more aware of the requirements of their respective state systems than those of the Federal Employees' Compensation Act. However, the differences in interpretation result in the need for OWCP staff to make time-consuming clarifications of medical reports.

Several other comments concerned the reviews performed by District Medical Advisors (DMAs) and District Medical Directors (DMDs). Here, too, incomplete or absent citations to tables and figures used in calculating awards and lack of clarity in calculations were noted, as well as illegibility of reports.

It was also indicated that disputes often arise over small differences in calculations as performed by the examining physician and by the DMA or DMD. Such disputes often result in lengthy and time-consuming appeals, and it was suggested that a range be established within which differences between evaluations would be administratively disregarded.

Reference: FECA PM Chapters 2-808 and 3-700; FECA Bulletin No. 95-17

Purpose: To address various issues pertaining to calculation of schedule awards

Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives and Examiners, All Supervisors, District Medical Directors and Advisers, Technical Assistants, and Rehabilitation Specialists

Action:

1. Claims Examiners are reminded that where a claim has been accepted for temporary aggravation of a condition, consideration for a schedule award is not appropriate.

2. The attachment to FECA Bulletin No. 95-17 contained lists of tables which should not be used together, because doing so will result in inflated percentages of impairment. This list may be sent to examining physicians, along with a statement that it represents OWCP policy in determining impairment. (As the attachment contains information which is not customized to the individual case, it is not being added to Form CA-1303.)

3. Schedule award evaluations prepared by DMAs and DMDs should include the following information: the part of the body involved, the particular motion(s) affected, and the range of each pertinent motion in degrees; the percentage of impairment; the number of the figure or table used to reach the percentage stated; and the page number of each figure or table used. The DMA or DMD should also indicate how he or she arrived at the total percentage of impairment, i.e, whether by simple addition or use of the combined values table.

The attached form, which is adapted from a form developed in the New York District Office, may be used for this purpose. It is analogous to Form CA-51, which is used to calculate awards for hearing loss. The DMA or DMD's evaluation should be legible (i.e., printed or typed).

4. To address the problems noted in the second paragraph of the Background section above, we will no longer ask the examining physician to calculate a percentage of impairment. Rather, the DMA or DMD will be responsible for taking the calculations provided by the examining physician and arriving at an overall percentage rating. Form CA-1303 will be revised to remove the last question on each attachment, which asks the physician for a percentage of impairment. Also, the form appended to this bulletin may be sent to examining physicians.

5. In some instances, examining physicians may still provide summary ratings. The DMA or DMD will still need to compute the percentage of the award, and his or her assessment will be used as the basis of the award issued.

6. Where more than one method of calculation may be used, the DMA or DMD should use the same one as the examining physician did. Where more than one physician in the case has performed a schedule award evaluation, each using a different method, the DMA or DMD should calculate the award using both methods, and the percentage awarded should be the higher of the two. If the examining physician's calculations are in error, the DMA or DMD's calculations may be used without further medical evaluation.

7. After a schedule award is issued, additional medical evidence showing a different percentage of impairment may be submitted. If there is less than a five percent difference between the DMA or DMD's review and the examining physician's review, no change to the rating will be considered unless the supporting measurements have changed.

8. With respect to particular tables and issues of medical evaluation, the following points are offered (references are all to Chapter 3 of the AMA Guides):

a. Table 16, which addresses upper extremity impairment due to entrapment neuropathy, is used to evaluate impairment due to carpal tunnel syndrome. In ambiguous cases, the choice between mild and moderate impairment may depend on EMG results and/or an assessment of the effect of the impairment on activities of daily living, which in turn depends on the availability of clinical information. The most significant difference between Table 16 and its predecessors is in the calculation of severe impairment.

b. Table 62, which addresses impairment due to arthritis, may be used only if no other abnormality is present, with the exception of joint fractures. The last two paragraphs on p. 82 describes the x-rays needed to support a rating derived from this table. Specifically, a "sunrise view" x-ray is required. Neither an MRI nor any other test may be used instead of the sunrise view x-ray.

c. Pain which is neurological in origin may be included in evaluations for schedule awards, but pain which has other sources (e.g., that which accompanies sprains and strains), must be excluded from evaluation. It is therefore essential to distinguish between these types of pain in evaluating claims for schedule award.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)

 

Attachment to FECA Bulletin 96-17

OWCP SCHEDULE AWARD (SA) WORKSHEET
Resource: AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition
Claimant Name:____________________________		Case#_____________
Date of Maximum Medical Improvement:_______________		CE:_______
CALCULATION
Body Part/Data/ROM (degrees)	Percent of Impairment	Page #	Figure/ Table
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
____________________________	__________	______	_______
Comments______________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
__________________________________________ Reviewer Signature		________________ Date

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