1999 FECA Bulletins Archive

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-01

Issue Date: September 8, 1998

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Expiration Date: September 7, 1999

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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 September 8, 1998, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles was increased to 32.5 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 September 8, 1998; however, if inquiry is received, appropriate adjustment should be made. Vouchers being processed for travel periods after September 8, 1998, may be adjusted to reflect this increase.

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)

Attachment: Form CA-77, Instructions for Submitting Travel Voucher (Link to Image)

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-02

Issue Date: May 3, 1999

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Expiration Date: May 2, 2000

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Subject: Case Management--Medical Queries by Contract Nurses

Background: OWCP nurses, both those working in the field and those working by telephone, assist claims staff in many ways: by gathering information from employing agencies and medical providers; by helping claimants to understand their medical care and limitations; and by coordinating return-to-work efforts, to name just three areas where they commonly provide assistance.

In their efforts to obtain medical information, some contract nurses take a very active role in posing questions to attending physicians. Such an approach is proper when the questions involve work limitations, expected length of recovery, and prognosis.

However, matters such as the diagnosis, the presence or absence of objective findings, and causal relationship are adjudicatory in nature, and queries addressing such matters may interfere with case management efforts by claims staff, either because they are redundant or because they inadvertently expand the scope of the claim. Therefore, only claims staff should pose such questions.

Reference: Federal (FECA) Procedure Manual Chapter 2-600, subparagraphs 3 and 5

Purpose: To clarify the kinds of information which may properly be requested by contract nurses, and the kinds of information which should be requested only by claims staff

Applicability: Claims Examiners, Staff Nurses, and Supervisors

Actions:

1. Claims Examiners remain responsible for managing claims. They may not delegate this task to OWCP nurses. While it is permissible for OWCP nurses to help claims staff compose questions to medical providers with respect to adjudicatory issues, and for second opinion medical examinations, the Claims Examiner must have the final say in wording these questions.

2. Claims supervisors and the Staff Nurse, as the manager of the contract nurses, should be alert to statements in letters from contract nurses to medical providers which indicate that contract nurses, rather than Claims Examiners, are managing claims.

In particular, contract nurses should avoid posing questions such as the following:

What is your diagnosis of Mr. X?

Are Mr. X's symptoms related to his occupational trauma on 06/06/98?

When such instances are identified, the Staff Nurse should counsel the contract nurse as to questions which may properly be asked of medical providers and questions which should be avoided.

Attached is a sample notification that can be shared with the contract nurses. The notice emphasizes the general guidelines for types of questions to be posed to physicians.

Disposition: Retain until the indicated expiration date.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Attachment

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

ATTENTION ALL OWCP CONTRACT NURSES

In reviewing monthly reports of both telephonic and field nurses' services, I have identified a need to share some general guidelines to be used when posing questions to the attending physician.

Questions regarding clarifying work limitations, expected length of recovery and prognosis are not only proper but should be posed in order to obtain a clear picture of the return to work potential. However, questions that relate to either the presence or absence of objective findings and/or causal relationships are adjudicatory in nature. Since repsonses to these questions could inadvertently expand the scope of the claim, these types of questions need to be posed only by the claims examiner.

For example, asking the physician whether "Mr. X's symptoms are related to his occupational trauma on 6/6/98" would not be appropriate. However, posing the question "Will Mr. X's cervical strain result in release to full or part time work activity" captures the real issue of what return to work capacity can be anticipated.

In some cases claims examiners will request your assistance in formulating questions to medical providers which involve adjudicatory issues. You may certainly assist them in phrasing these questions but the final wording resides with the claims examiner.

Thank you for your cooperation on this issue. Please contact me should there be any questions on this matter.

Sincerely,

 

Staff Nurse

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FECA BULLETIN NO. 99-03

CORRECTED COPY

Issue Date: January 27, 1999

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Expiration Date: January 27, 2000

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Subject: Case Management/ADP: Guidelines for Periodic Roll Management

Background: In FY 1992, the Periodic Roll Management Project (PRMP) began. The PRMP was designed to review a set universe of cases on the long-term disability rolls with an eye toward resolution of these cases. This was a four-year term project, with some district offices (Boston, Jacksonville, San Francisco, and Seattle) beginning in 1992 and completing the project in 1996. Other district offices began PRMP in either 1995 or 1997 and their teams remain active.

Owing to the success of this project, it has become a permanent initiative of the program in FY 1999. Every district office will have permanent Periodic Roll Management (PRM) staff. These examiners will continue to pursue the goals outlined for the PRMP--review and resolution of long-term disability cases.

The performance measure for resolution of periodic roll cases is defined as an entitlement decision that brings some closure to the case. Usually, the entitlement decision would be the result of a full-fledged review by the PRM claims examiner. In cases where there is no change in the entitlement level, this will include at a minimum a second-opinion examination or a directed examination by the attending physician, with specific questions regarding ongoing injury-related disability.

As part of the transition from a project to a permanent initiative, changes have been made to both the composition of the PRM universe, altering it from a set group of cases to a fluid one, and to coding under the Periodic Roll Management System (PRMS). The coding changes will better allow the tracking of program goals.

Reference: FECA Bulletin 95-15

Purpose: To inform all claims staff of updates to PRM universe composition and to the PRMS coding scheme.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel

Action:

1. The base PRM universe will be identified for each district office using all cases on the periodic roll as of the October 10, 1998 payment except those cases active in QCM (category A or B) which are less than 30 months old.

2. Cases will be added to this universe as follows:

a. Non-QCM cases placed on the periodic roll will be added to the universe immediately;

b. Any non-QCM periodic roll case transferred in to a district office will be immediately part of the new owning district office's PRM universe;

c. Any periodic roll case which is closed, removed (zeroed out) or expired (more than 30 months old) from QCM tracking will immediately become part of the PRM universe.

3. Cases will be removed from the PRM universe as follows:

a. PRM cases transferred to another district office will leave the prior owning office's PRM universe;

b. Any PRM case with a new recurrence that is approved, causing it to drop into QCM will leave the PRM universe.

c. Any case deleted from the periodic roll will be removed from the universe. These should also be tracked in PRMS as discussed below.

4. The System Manager at each District Office will be able to produce a report as frequently as needed to identify cases that have been added to or dropped from PRM per these guidelines.

5. Using the report described in item 4, district offices must manually reassign cases to the appropriate responsible claims examiner or unit on a periodic basis. The National Office is looking at the feasibility of creating new and/or modifying existing programs to automate this case reassignment process.

6. Coding in PRMS has been streamlined, to focus emphasis on the resolution of cases in the PRM universe. While codes for actions not affecting entitlement continue to be available, these codes are optional. All actions which resolve a PRM case, however, must be tracked in the PRMS. Attached is a list of all PRMS codes now available for use. Note that codes for increases in compensation are no longer being used. Additionally, election of OPM benefits is considered a resolution only when it results in termination of all compensation payments, including periodic payments for schedule award. Coding for the conclusion of a schedule award (without further loss of wage earning capacity) has been separated into codes that reflect whether intervention was taken in the case to bring about the resolution. This will assure that the ending of a schedule award, without any action on the part of claims staff, does not count as a resolution.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

Attachment

PRMS ACTION CODES

	Resolution Codes		Optional Codes
Reduction of compensation:		IR	Initial Review Done
R1	Constructed LWEC	MN	Narrative Requested
R2	RTW with LWEC	MR	Narrative Received
R3	S/A expired with LWEC	SE	SECOP scheduled
		RF	Referee scheduled
Suspension of compensation:		VR	Referred for rehab
S2	Suspension 5 USC 8123	JO	Job offer made
S3	Suspension 5 USC 8113	PR	Pre-reduction sent
		PT	Pre-term sent
		EO	Elected OPM
Termination of compensation:
T1	Terminated, no continuing IRD
T2	RTW, no LWEC
T3	S/A expired, intervention, no LWEC
T4	Refused suitable work
T5	Death of claimant
T6	Elected OPM with no periodic Schedule Award payments
Case reviewed, no change:
CR	No change in entitlement after review
Necessary code, not counted as resolution:
S1	Suspension no 1032
T0	S/A expired, no intervention, no LWEC

 

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FECA BULLETIN NO. 99-04

Issue Date: November 20, 1998

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Expiration Date: November 19, 1999

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Subject: Bill Payment/BPS--Medications Which Do Not "Match" Accepted Conditions

Background: The new procedures for processing pharmacy bills have prompted queries about handling "mismatches" between accepted conditions and medications billed. Such "mismatches" may come to OWCP's attention either because the Bill Processing System (BPS) flags the medication as questionable in the case at hand or because a bill has been denied and the claimant or the pharmacy has returned the explanation of benefits (EOB) to OWCP.

In either instance, OWCP must take further action. While some medications may prove to be payable, others will continue to be ineligible for payment or reimbursement. This bulletin describes the actions which bill resolvers and claims staff will need to take in processing bills for medications which do not "match" the accepted condition(s) in the case.

Reference: FECA Bulletin 98-11

Purpose: To describe the actions to be taken when a particular medication does not "match" the accepted condition

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Bill Processing Staff, Rehabilitation Specialists, Staff Nurses, and Technical Assistants

Actions:

1. Where OWCP has already denied a bill for a "mismatch", the edit code is likely to be one of the following: 734 (therapeutic class is not payable for the accepted condition(s); 738 (the relationship between the therapeutic class and the accepted condition(s) requires manual review); and 746 (the accepted condition is missing from the relationship table).

Edit 734 results in an automatic denial, while edits 738 and 746 result in suspension. The suspension can be overridden if the bill is payable, or set to deny if the bill is not payable.

2. When an EOB letter is returned, and the reason for denial was code 734, an NDC query should be performed. The relationship file has recently been updated, and additional changes will continue to be made periodically. As a result of these changes, a medication that was previously denied may now be payable. Also, if the accepted conditions have been updated, the medication may now be payable.

3. If the bill is now payable, it should be rekeyed. If the bill was originally denied with EOB 738 or 746, and it should have been paid, it should be rekeyed, and the edit suspension overridden. Entry of a note to indicate that the medication is payable should prevent erroneous denials in the future.

4. If the bill is not payable, but experience has shown that the medication is often used to treat the condition in question, the District Medical Advisor (DMA) should be consulted. If the DMA agrees that the medication is properly used to treat the condition, the issue should be referred to Dr. Virginia Miller, OWCP Medical Director, so that modification of the relationship table may be considered.

5. If the bill remains unpayable after these steps have been taken, the Claims Examiner (CE) will need to review the medical evidence in file and/or obtain additional medical evidence to determine whether the medication is correctly used in the case at hand. The Physicians' Desk Reference (PDR) may be consulted to determine the proper use of various medications.

As always, the CE will need to exercise judgment in deciding if a particular medication should be (or continue to be) authorized. The CE should ensure that the accepted conditions accurately reflect the scope and severity of the claimant's injury and update the ICD-9 codes if warranted.

6. If the medical evidence supports payment but is not conclusive, the CE may obtain the advice of a District Medical Adviser. It is not anticipated that second opinion or impartial referrals will be needed to adjudicate such questions.

7. In long-term cases, OWCP may have paid for a questionable medication for many months or years. (By one estimate, over a third of periodic roll cases involve at least one medication where the relevance to the accepted condition(s) is questionable.)

In such instances the CE should add "P99" as a temporarily accepted condition to allow for payment during development of the issue. (This code should also be used to indicate an adjunct condition, and instead of any "placeholder" acceptance codes.)

A note showing that the medication is payable should be placed on the system, as edit 746 will suspend the bill if it is not otherwise payable.

8. If payment is denied, the responsible CE may release a letter decision to that effect. A sample is shown as Attachment 1. It is being added to the Letter Generator system.

9. A claimant who objects to this decision, either in writing or by telephone, should be issued a formal decision with full appeal rights. However, receipt of additional bills for the medication in question will not, by itself, be considered an "objection" to the letter decision. The claimant must actually express disagreement with the letter decision. Any formal decision must be based on the medical evidence of record, not the outcome of relationship editing by the BPS.

10. At present, there is no vehicle for advising injured workers with new claims that pharmacies may bill OWCP directly using the Universal Claim Form, or that injured workers should use Form CA-915 if they are seeking reimbursement of pharmacy expenses. Form CA-1008 is being revised with this information (a copy of the revised form is shown as Attachment 2.) The information will be added to Forms CA-14 and CA-1009 as soon as the forms are revised in conjunction with the program's new regulations.

Disposition: Retain 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 Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)

Attachment 1: Form CA-1008

(999) 999-9999 File Number: 11-1111111 Date of Injury: 02/02/1900 Employee: CLAIMANT M. NAME CLAIMANT M. NAME

0000000000000000000000000000000
0000000000000000000000000000000
0000000000000000000000000000000
0000000000000000000000000000000

Dear CLAIMANT M. NAME:

I am writing in reference to your claim for injury on 02/02/1900, which you sustained while employed by the agency identified below. Your claim is accepted for:

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

If your injury results in disability for work or the need for medical treatment, you may be eligible to receive continuation of pay (COP) until you recover or return to light duty, up to a maximum of 45 calendar days. If wage loss continues after the expiration of COP, you are eligible to claim disability compensation on Form CA-7. Bills for medical expenses related to the accepted condition(s) noted above will be processed for payment by this office following proper submission of charges. This includes medications which are prescribed for the accepted condition(s) noted above.

Pharmacies may bill this office directly using the Universal Claim Form. The pharmacy should include the following information: the case file number, the nine-digit tax ID number, the NDC number, the prescription number, the quantity of medication prescribed, the name of the prescribing physician, and the date of purchase. If you request reimbursement, please complete Form CA-915, which is used in addition to the Universal Claim Form. You may obtain Form CA-915 from your employing agency or from this office.

The enclosure, which is entitled "Now That Your Claim Has Been Accepted...", provides information about payment of bills, claims for compensation, and other matters pertinent to your claim.

Sincerely,

 

NAME OF SIGNER
TITLE

CA1008-1098

Page 1

 

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Attachment 2: Sample Letter--Prescription Bill Denied

 

Dear NAME OF CLAIMANT:

I am writing in reference to prescription bills submitted in your claim for injury on 02/02/1900, which has been accepted for:

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

All claims for prescription payments must contain a National Drug Council (NDC) code for each drug billed. Each NDC code is an 11-digit number which represents a specific medication, made by a specific manufacturer, of a certain strength. The NDC coding system is used by pharmacies all over the United States.

On receipt of a bill for prescription expenses, the Office of Workers' Compensation Programs (OWCP) compares the NDC code to the medical condition(s) which OWCP has accepted as work-related. Sometimes, this comparison shows that the medication is not one which is properly used to treat the accepted condition.

In your case, OWCP received a bill from NAME OF PHARMACY on DATE OF RECEIPT for NAME OF MEDICATION. The NDC code for this medication, which is 99999999999, does not correspond to your accepted condition of ACCEPTED CONDITION. This means that the medical community does not generally recognize NAME OF MEDICATION as effective or safe to use in treating ACCEPTED CONDITION. For this reason, payment for NAME OF MEDICATION is denied.

This does not mean that your physician has prescribed NAME OF MEDICATION in error, or that you should not take this medication. Of course, NAME OF MEDICATION may be needed to treat some other, condition which is not related to your work, and you should consult your physician before changing the kind or amount of any medication you are taking. You may wish to submit bills for NAME OF MEDICATION to your health insurance carrier for consideration of payment.

If you have any questions, please do not hesitate to contact this office.

Sincerely,

 

NAME OF SIGNER
TITLE

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FECA BULLETIN NO. 99-05

Issue Date: May 17, 1999

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Expiration Date: May 17, 2000

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Subject: Case File Imaging

Background: In November of 1997, via FECA Bulletin 98-01, a pilot imaging program was implemented to facilitate the maintenance of case files where the physical file was with the Employees' Compensation Appeals Board. Prior to this pilot, all maintenance of cases before the Board was handled by the Branch of Hearings and Review, although the claims examiners in the Branch were not familiar with the cases and often did not have possession of the physical case files.

The pilot has been successful in that it has allowed maintenance of Board cases in the owning District Office, where the staff is better equipped to address the issues that arise. There have been, however, some difficulties in adapting to the imaging technology selected for the pilot. In light of these difficulties, a new prototype imaging system will be selected prior to transitioning to an imaged environment for new cases. Presentation and implementation of this system will commence in May of 1999.

Reference: FECA Bulletin 98-01

Purpose: To describe changes in imaging of cases before the Board.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel

Action:

Effective May 17, 1999, all ECAB requests are to be routed to the National Office for review prior to imaging. The new system will function as follows:

The ECAB will electronically request a docketed case.

District Office staff will transfer the case file to location code T51 (as done prior to the imaging pilot).

National Office staff will review the file to determine whether it will be imaged. This decision will be based upon the nature of decision at issue in the case and the level of maintenance expected to be needed during its tenure at the Board (the attached chart outlines some general guidelines that may be followed in making this decision, but these guidelines will be applied loosely as necessitated by the judgement of the National Office staff member).

If the case file is not to be imaged, National Office mailroom staff will number the case file and forward it to the Board.

If the case file is to be imaged, National Office staff will forward the case to the FEC Imaging Center for imaging.

Claims Examiners in the Branch of Hearings and Review will once again perform case maintenance on all non-imaged cases. This maintenance will be limited, however, due to the nature of these non-imaged cases. When these cases are returned, as paper files, to the District Office after the Board reaches a decision, they will remain non-imaged and will continue to be handled as paper files. Due to budgetary constraints, it is not foreseen that open cases, including these, will be imaged until FY 2001, when a conversion of paper files may be possible.

District Office staff will remain responsible for maintenance of any imaged case before the Board. This will include holding the case file jacket and CA-800 as outlined in FECA Bulletin 98-01, and imaging all new mail as it arrives in the District Office. National Office mailroom staff will image all documents created in relation to the appeal prior to the return of the paper file to the District Office. When the paper file is returned, it should be associated with the jacket and CA-800 as per current practice. The image file will remain the primary record, again in keeping with current practice.

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

 

SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation

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

Attachment: Basic Guidelines for Imaging of Cases Requested by the Employees' Compensation Appeals Board (Link to Image)

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FECA BULLETIN NO. 99-06

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: New Regulations: Continuation of Pay

Background: Part C of the Regulations, which includes sections 10.200 through 10.224, has been substantially revised. The revisions are as follows.

INITIAL CLAIM FOR COP:

Section 10.205(a)(3) revises the 90 days in which a person must begin losing time from work, in order to receive COP, to 45 days. Timely submission and adjudication of claims has dramatically improved since the 90-day period was adopted. Therefore, this grace period is no longer necessary to ensure that the injured worker's pay continues uninterrupted. The Program's focus on minimizing lost work time requires early intervention, which can only occur when OWCP is aware that an employee has lost time. The proposed time frame was 30 days, but upon consideration of comments received from various agencies and labor organizations, the time frame in the final rule is 45 days.

Thus, COP is payable only when disability begins, or time is lost for medical care, within 45 days of the date of injury.

While COP has always been appropriately used for medical treatment, a phrase specifying that has been included in section 10.205(a)(1).

Section 10.205(a)(2) clarifies existing practice that if Form CA-1 is not available, another form (CA-2 or CA-7, which contain words of claim) could be used to claim COP. The word "form" in this section does denote an OWCP-approved form, and a letter would not serve the purpose of timely filing.

RECURRENCE:

Consistent with Section 10.205, Section 10.207(c) allows any balance of COP remaining after the injured employee returns to duty to be used for a recurrence of disability, or for medical treatment, which begins within 45 days of the first return to work.

Section 10.207(a) clarifies that Form CA-2a is required to receive COP for a recurrence of disability.

While it does not specifically pertain to the new Regulations, the question has arisen, "When does time begin to toll for using a balance of COP in cases where there is no lost time immediately following an injury?". Various OWCP publications could be read differently on this issue. The Regulations, Procedure Manual, Publication CA-810, and the Resource Book for the Agency Workshop use the terms "work stoppage", "disability", and "lost time" variously in reference to when time begins to toll for using a balance of COP.

To clarify, time lost on the day of injury that is charged to administrative leave is considered a work stoppage, whether the time is used to obtain medical treatment or for disability. If the time away from work is so minimal that no administrative leave is charged, such as a brief visit to the health unit, this is not considered a work stoppage for the purpose of tolling time. Where administrative leave is charged on the date of injury, that constitutes a work stoppage, and the return to work after the administrative leave, whether that be on the date of injury or the following day, is considered the first return to work, and the 45 days for using any balance of COP begins to toll on that date.

MEDICAL EVIDENCE IN SUPPORT OF COP:

Section 10.210(b) reduces the time allowed for the employee to provide the employer with a medical report supporting disability from 10 working days to 10 calendar days, and includes a requirement that the medical evidence contain a statement of when the employee can return to the date of injury job. This is consistent with the emphasis on early intervention.

Section 10.506 allows an employer to contact the employee's physician in writing, for the purpose of monitoring an employee's medical progress and duty status, and specifically prohibits telephone contact and personal visits by the employer with the physician. This applies to an agency's monitoring of medical evidence during the COP period as well as later in the life of the claim. This section is discussed further in the FECA Bulletin covering an employer's responsibility in returning employees to suitable work.

INCLUSION OF SUNDAY PREMIUM IN COP:

Section 10.216 outlines the calculation of COP. Generally, the various increments of pay are included in the pay rate for COP. However, several appropriation bills recently signed into law prohibited Federal agencies funded by those bills from paying Sunday premium pay to their employees unless they actually performed work during the time period relevant to such pay. As OWCP cannot become involved in payroll functions among various agencies, section 10.216(a)(1) includes the phrase "except to the extent prohibited by law" to reflect these circumstances.

TERMINATION OF COP FOR DISCIPLINARY ACTION:

New section 10.222(b) allows an employer to terminate COP when a preliminary notice of a disciplinary action is issued before the injury, and becomes final or otherwise effective during the COP period. This revises previous section 10.201, which stated that the final written notice of termination must have been issued before the date of injury in order for the agency to terminate COP on that basis. The revision ensures that both the employee and the employer are in the same position as they would have been in but for the injury. As salary would not continue because of the disciplinary action, COP should not be paid.

Reference: 20 CFR 10.200 through 10.224, and 20 CFR 10.506

Purpose: To inform all claims staff of the revisions to the Regulations as they pertain to entitlement to COP

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Fiscal Personnel, Technical Assistants and Systems Personnel

Action:

1. The claims examiner will decide claims for COP, which are challenged by either the agency or the claimant, according to the provisions of the revised Regulations outlined above. In most cases, Form CA-1050 can be used for formal denials of COP.

2. The District Offices should conduct training on this bulletin within 30 days of the date of the bulletin.

Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

Distribution: List No. 2 – Folioviews Groups A,B, and D
(Claims Examiners, All Supervisors, District Medical Advisors, 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. 99-07

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: New Regulations - Subpart I - Information for Medical Providers

Background: On November 25, 1998, new final regulations for the FECA program were published. These regulations are effective January 4, 1999. Regulations previously found at 20 CFR 10.410 through 10.413 and 10.450 through 10.457 have been consolidated in Subpart I. Among the changes included in Subpart I are provisions for fee schedules for prescription medications, and inpatient hospital bills. In addition, National Drug Codes (NDCs) and Revenue Center Codes (RCCs) have been added to the list of codes which a provider must specify, the required form for hospitals has been changed from the UB-82 to the UB-92, and the required form for pharmacy bills is the Universal Claim Form.

The pharmacy fee schedule is based upon the average wholesale price (AWP), plus a dispensing fee equal to 20% of the AWP. The dispensing fee cannot be less than $2.50, nor greater than $15.00. A private vendor is the source of the AWP information. The data is updated monthly. The highest AWP over the prior two years is the price that will be used to calculate the allowable fee. If the amount charged for a prescription is more than the calculated fee (AWP plus dispensing fee), the calculated fee will be paid. If the amount charged is less than the calculated fee, the amount charged will be paid.

The inpatient hospital fee schedule is based on the prospective payment system (PPS) used by the Health Care Financing Administration's (HCFA's) Medicare program. Using the ICD-9 diagnosis and procedure codes that are found on the UB-92 billing form, along with other data, the hospitalization is assigned to a Diagnosis-Related Group (DRG), and is priced according to that DRG and other hospital-specific data. The HCFA PPS is based on the premise that similar medical conditions and surgeries require similar inpatient services and resources.

Certain inpatient hospital facilities (such as those that provide rehabilitation and psychiatric services) are not covered under the HCFA PPS. For those providers, OWCP will use HCFA-calculated cost to charge ratio (CCR) data to calculate the allowable fee.

Both the grouping (assigning the DRG) and pricing of inpatient hospital bills (except for non-PPS facilities, which will be calculated by National Office) will be performed by another Federal agency. The calculated allowable fee may be more or less than the billed amount. Unlike other FECA fee schedules, however, the allowable payment amount will nearly always be the calculated amount. Therefore, if the calculated fee is greater than the billed amount, the amount paid for an inpatient hospitalization may exceed the amount billed. This practice is consistent with the way Medicare processes their bills.

Notifications concerning the new fee schedules are being sent to all hospitals and pharmacies to whom payment was made during the last six months, as well as claimants who have received pharmacy reimbursements during the last year. Copies of those notices are attached (Attachments 1 - 3).

References: Federal Register, Volume 62, No. 246, published December 23, 1997; 20 CFR, Part 10, Subpart I, published November 25, 1998; FECA Bulletin 98-11; Federal (FECA) Procedure Manual Chapter 5-0206.

Purpose: To notify District Offices of changes in regulations regarding medical bills, and provide procedures for implementation of the pharmacy and inpatient hospital fee schedules.

Applicability: All staff.

Actions:

1. Bills for prescription drugs should continue to be keyed in accordance with FECA Bulletin 98-11.

2. Since pricing for prescription drugs is calculated using the number of units, accuracy of the units (quantity) is critical.

3. The allowable fees for each prescription will be calculated after the bills have been approved for payment and transmitted to the Central system. The allowable fee for a particular drug does not vary by location of the pharmacy.

4. By regulation, the only allowable bases for reconsideration of any fee schedule reductions are:

a. The procedure was incorrectly identified by original code;

b. The presence of a severe or concomitant condition made treatment especially difficult; or

c. The provider possessed unusual qualifications, beyond Board-certification in a specialty.

Requests for reconsideration must be made within 30 days of the payment, be in writing, and be accompanied by documentary evidence. Obvious errors may be corrected without going through the full appeals process as described in Federal (FECA) Procedure Manual Chapter 5-0206, but should be processed with an appeal code of 7.

The presence of a severe or concomitant medical condition which made treatment especially difficult will generally not be a relevant factor in pharmacy bills, nor will the qualifications of the pharmacy provider. Most frequently, the basis of an appeal would be:

a. Incorrect NDC code (appeal code 1 or 4);

b. Incorrect number of units (quantity)(appeal code 1 or 4); or

c. Incorrect data entry by OWCP (appeal code 7).

6. To process a request for reconsideration of a pharmacy fee schedule reduction:

a. Determine whether there is a valid basis for appeal;

b. If the basis for appeal is valid, calculate the allowable fee. The allowable fee per unit may be obtained by contacting OWCP's Branch of Medical Standards and Rehabilitation, telephone number (202) 693-0035. The per unit price should be multiplied by the quantity, and then to that amount add 20 percent of the product, no less than $2.50, no more than $15.00. The end result is rounded up to the nearest whole dollar. If the calculated fee amount is less than the amount already paid, no additional amount is payable, and the provider should be so informed at the appropriate signature level. If the calculated amount is greater than the amount already paid, a new payment should be entered on the system, with the calculated allowable amount as the bill total and the line charge amount, the prior paid amount as an ineligible amount, ineligible code C, bypass code 1, 2, or 3 as appropriate, and an appropriate appeal code.

c. If the basis for an appeal is not valid, the request should be denied at the appropriate signature level.

7. The allowable fee for inpatient hospital bills (with the exception of those keyed with a locator 4 code of 911) will be calculated after the bills have been keyed into special software and transmitted to the clearinghouse, and before the bills are loaded onto the Sequent systems in each district office. The allowable fee amount cannot be changed in bill resolution, but ineligible amounts and ineligible codes may be added.

8. New procedures for processing inpatient hospital bills are outlined in FECA Bulletin 99-21.

9. Generally, the only allowable basis for appeals of inpatient hospital bill payment amounts is coding error. The location and individual characteristics of the hospital are already factored into the price calculation. Severe or concomitant medical conditions are already part of the process for assigning the DRG, and the length of stay is factored into the pricing.

10. To process a reconsideration of an inpatient hospital fee reduction, take the following steps:

a. Determine whether the basis for the appeal is valid;

b. If the basis for the appeal is not valid, deny at the appropriate signature level;

c. If the basis for the appeal is valid, the bill should be rekeyed in the special inpatient hospital software, with the previously paid amount as a prior paid amount. The bill will then be forwarded for the usual processing (grouping and pricing). The presence of a prior paid amount will cause the bill to be loaded on the Sequent system as an indirect payment, which will cause edit 210 to suspend the bill. Upon reviewing the bill, the calculated DRG amount should be compared to the prior paid amount. If the prior paid amount is greater than the DRG amount, no additional payment is due. The bill should be internally denied, and the provider informed at the appropriate signature level. If the DRG amount is greater than the prior paid amount, an ineligible code of C should be added, and change the direct pay flag to Y (if direct pay) or override the edit 210 failure (if it is a claimant reimbursement with adequate proof of payment), enter an appropriate appeal code and bypass code, and recycle the bill.

11. The CA-91 Payment Notice is being revised to include general information concerning fee schedule appeals. A copy of the added text is shown as Attachment 4. Note that the reader is directed to contact the servicing district office for specific information on a fee reduction.

Training on these procedures should be completed as soon as possible, no later than January 15, 1999.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment 1

IMPORTANT NOTICE FOR HOSPITAL PROVIDERS

This notice applies to inpatient hospital payments made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.

FEE SCHEDULE FOR INPATIENT HOSPITAL BILLS - EFFECTIVE JANUARY 4, 1999

Charges for inpatient hospitalization will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.810, published on November 25, 1998.

The allowable amount will be calculated using formulae based on Medicare's Prospective Payment System (PPS) and Diagnosis-Related Groups (DRGs), with adjustments that reflect FECA-specific factors. These formulae always result in payments greater than Medicare's allowable per diem rate. Hospitals not subject to the PPS will be reimbursed according to formulae based on the cost-to-charge ratio.

Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The hospital provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. Non-covered items, such as television and telephone charges, are always the responsibility of the patient. There is no deductible amount.

If the provider disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.

BILLING INFORMATION

Claims for inpatient hospital services must be submitted on a completed Form UB-92. The UB-92 must contain the provider's name, address, Tax Identification Number (TIN), and Medicare Number. In addition, the injured worker's name and OWCP claim number, the type of bill (Locator 4), the period covered by the statement (Locator 6), covered days (Locator 7), birth date (Locator 14), sex (Locator 15), discharge status (Locator 22), total charges (Locator 47), and the discharge diagnoses and procedures (if any) must be present on the UB-92. Bills not submitted properly will be returned or denied.

FECA Bulletin 99-07

Attachment 1

 

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Attachment 2

IMPORTANT NOTICE FOR PHARMACY PROVIDERS

This notice applies to payments for pharmaceutical drugs made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.

FEE SCHEDULE FOR PHARMACY BILLS - EFFECTIVE JANUARY 4, 1999

All charges for medications will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.809, published on November 25, 1998. The maximum allowable amount will be calculated based on the Average Wholesale Price (AWP) for the medication, plus a calculated dispensing fee, not to exceed $15.00. Dispensing fees should not be billed separately. Payment will be the lesser of the calculated fee or the billed amount. Charges that exceed the calculated fee will be reduced to the maximum allowable.

Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The pharmacy provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. Non-covered items are always the responsibility of the patient. There is no co-pay amount.

If the provider disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.

BILLING INFORMATION

All claims for prescription payments must be coded using National Drug Codes (NDCs), and must also contain the prescription number, refill number, decimal quantity, and date filled. The pharmacy's Tax Identification Number (TIN), full name and address, and the name and OWCP case file number of the injured employee must appear on the claim. Bills not submitted properly will be returned or denied.

Bills must be submitted either in electronic format through an intermediary (preferred), or on the paper Universal Claim Form. For information about electronic billing, contact William Cole at (202) 693-0041.

FECA Bulletin 99-07

Attachment 2

 

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Attachment 3

IMPORTANT NOTICE CONCERNING PAYMENTS FOR MEDICATIONS

This notice applies to payments for pharmaceutical drugs made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.

FEE SCHEDULE FOR PHARMACY BILLS - EFFECTIVE JANUARY 4, 1999

All charges for medications will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.809, published on November 25, 1998. The maximum allowable amount will be calculated based on the Average Wholesale Price (AWP) for the medication, plus a calculated dispensing fee, not to exceed $15.00. Dispensing fees should not be billed separately. Payment will be the lesser of the calculated fee or the billed amount. Charges that exceed the calculated fee will be reduced to the maximum allowable.

Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The pharmacy provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. If the injured employee has already paid for the medication in full, and reimbursement is being made to that employee, the reimbursement amount will not exceed the OWCP allowable amount. The employee should seek reimbursement for any remaining balance from the pharmacy provider. Non-covered items are always the responsibility of the patient. There is no co-pay amount.

If the provider (or a reimbursed employee) disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.

BILLING INFORMATION

All claims for prescription payments must be coded using National Drug Codes (NDCs), and must also contain the prescription number, refill number, decimal quantity, and date filled. The pharmacy's 9-digit Federal Tax Identification Number (TIN), full name and address, and the name and OWCP case file number of the injured employee must appear on the claim. Bills not submitted properly will be returned or denied.

Bills must be submitted either in electronic format through an intermediary (preferred), or on the paper Universal Billing Form. For reimbursement to injured employees, a Form CA-915, claimant reimbursement form, is preferred. This form is used in addition to the Universal Billing Form.

Direct billings from pharmacies involve less paperwork than reimbursements to injured employees. If your pharmacy is not already billing OWCP directly for medications prescribed for your work-related conditions, you may wish to discuss this matter with them. Many pharmacies are willing to bill OWCP directly.

FECA Bulletin 99-07

Attachment 3

 

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Attachment 4

FEE SCHEDULE APPEAL RIGHTS

The accompanying card shows charged amounts, reduction amounts, and paid amounts. Unless a different explanation is shown on the accompanying card, any reduction shown was made under the schedule of maximum allowable charges used by the Office of Workers' Compensation Programs (OWCP). The fee schedule applies to professional medical services, medicinal drugs, and inpatient hospital services, in accordance with 20 CFR 10.805 through 10.813. For additional information about the reduction, contact the servicing OWCP Office shown on the accompanying card.

A provider may not seek from the patient any additional charge or fee in excess of the charge allowed by OWCP. A provider who collects or attempts to collect any additional amount from the patient may be excluded from participating in the Federal Employees' Compensation Program and other Federal programs.

By regulation, the ONLY circumstances which will justify reevaluation of the amount paid are: (1) the service was incorrectly identified by code; or (2) the presence of a severe or concomitant medical condition made treatment especially difficult; or (3) the provider possesses unusual qualifications (beyond Board certification).

PROVIDER: If you disagree with the fee schedule reduction, you may take the following action within 30 days: (1) make written request for reconsideration of the fee determination, (2) identify the service in question, (3) attach documentary evidence relevant to one of the three circumstances described above, (4) attach a copy of this notice to your request, and (5) submit to the servicing OWCP Office, ATTENTION: FEE SCHEDULE APPEAL.

REIMBURSED PATIENT: If you paid the medical provider more than the OWCP reimbursement amount, take the following actions in the order presented: (1) show this notice to the medical provider and request a refund or credit of the difference; (2) ask the medical provider to submit an appeal as described above on your behalf; (3) request in writing that the servicing OWCP Office contact the medical provider concerning the amount you paid in excess of the fe schedule.

FECA Bulletin 99-07

Attachment 4

 

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-08

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: New Regulations--Privacy Act

Background: On October 22, 1998, the Department of Labor issued new regulations codifying changes in case law involving the Privacy Act. On January 4, 1999, the new Federal Employees' Compensation Act Regulations, further referencing the Privacy Act regulatory changes, became final.

The regulatory changes involving the Privacy Act primarily serve to formalize handling of Privacy Act requests. There is a major change, however, in the delineation of which specific situations may require exemption of records from disclosure.

Reference: 29 CFR Parts 70a and 71; 20 CFR 10.10 through 10.13

Purpose: To inform OWCP staff and employing agencies of Privacy Act compliance requirements.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives

Action:

1. All records in OWCP's files and all copies of these records in the possession of the employer are considered to be OWCP records, covered by the DOL/GOVT-1 system of records. This means that although employing agencies may establish procedures for access to the records that they maintain, their decisions to grant/deny access must comply with Department of Labor rules and regulations.

2. This said, only OWCP may respond to requests for correction or amendment to any OWCP record. Employing agencies must forward such requests to OWCP without acting upon them.

If release of records is approved, the request may be read to consent to copying fees up to $25.00. The requester must be consulted before higher fees will be assessed. Fees will apply as follows:

The first copy of the requested information must be provided at no cost. Any additional/later copy should be provided at a cost of $.15 per page, but the first 100 pages will be free of charge.

OWCP may require payment in advance of fees over $250. If such a fee is anticipated, a letter should be sent to the requester, noting the amount of the fee and advising that the requester may contact a designated OWCP staff person to attempt to reformulate the request to meet his or her needs at a reduced cost.

4. Any decision on a Privacy Act request must be given in writing, whether an approval or denial. An approval should include discussion of any fees, if over $25.00, and should, whenever possible, also include the copy of the records requested. Should copying be delayed, an interim response notifying the requester of the approval, the length of the anticipated delay, and a reason for the delay, should be provided. All decisions should be issued over the signature of the designated Privacy Act officer. At the District Office level, this is the District Director or his or her designee.

5. A Privacy Act request may be denied only if the information requested is excepted from release for one of the following reasons:

a. Release of the records would allow the subject of an investigation to know he or she was the subject of an investigation, to determine the nature of the investigation, or to determine the identity of witnesses/informants, or

b. Release of the records would inform the subject of an investigation of other actual/potential violations of law that have been uncovered via investigation.

6. If access to a certain record (or records) is being denied, the denial must be formal, in writing, over the signature of the District Director, and include a statement of the reasons for denial, including the specific exemption, and a statement that appeal is possible. The appeal statement should indicate that appeal must be made within 90 days of the receipt of the denial notice, and that it must be made to the Solicitor of Labor. A sample letter for this purpose is attached.

7. If OWCP is unable to locate a record for which a Privacy Act request has been made, OWCP should notify the requester of this in writing, with the same 90-day appeal rights as outlined in item 6 above.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment: Sample Letter

DATE

File #

Dear NAME:

We have received your recent request for release of (LIST INFORMATION HERE). After full consideration of your request, it has been determined that we are unable to release this information. Our inability to release the information is because (LIST EXEMPTION HERE).

You have the right to appeal this decision. Your appeal must be dated within 90 days of your receipt of this notice. Should you wish to appeal, please state your reasons in writing to:

Solicitor of Labor
U.S. Department of Labor
Room S-4325
200 Constitution Avenue, NW
Washington, DC 20210-0002

Note that both your letter and envelope should be marked "Privacy Act Appeal." If they are not so marked, they will not be counted by the Solicitor of Labor as received until identified as a Privacy Act appeal and forwarded to the appropriate office for handling.

Sincerely,

 

DISTRICT DIRECTOR

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-09

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: New Regulations: Attendant's Allowance

Background: New section 10.314 of the regulations allows payment for the services of an attendant to be made only directly to the provider of the service, up to the maximum of $1500 per month allowed by 5 U.S.C. 8111. There will be no further payments made directly to claimants for the services of an attendant for any new claims for such services.

Where direct payments were being made to the claimant to cover the services of an attendant prior to January 4, 1999, such payments will continue until such time as the services of an attendant are no longer necessary.

In order for claims to be handled in a uniform manner in each district office, any claim for attendant services that is postmarked prior to January 4, 1999, the effective date of the new regulations, will be considered under the old regulations. Payments will be made directly to the claimant until the need for the attendant ceases. Once the services of the attendant are terminated, any new claims for attendant services will be considered under the new regulations.

OWCP will pay for attendant services as a medical service under 5 U.S.C. 8103, rather than under 5 U.S.C. 8111(a). This will allow for greater fiscal control, as bills submitted directly to OWCP will be subject to the fee schedule, and will be reviewed to ensure that charges are correct. It will also allow for quality review, ensuring that necessary services are being provided by a home health aide, licensed practical nurse or similarly trained individual.

The criteria for determining whether the services of an attendant are required have not changed. However, the method of payment has changed, and any references in the Procedure Manual to payment of an attendant allowance to the claimant is superceded by this bulletin.

The system updates required to support the payment of an attendant allowance as a medical expense are under development. Additional procedures in this regard will be issued when they are finalized. For now, use provider type code C when paying for attendant care.

References: 20 CFR 10.314

Purpose: To inform all claims, rehabilitation, and fiscal staff of the revisions to the Regulations as they pertain to the payment for the services of an attendant.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Rehabilitation Specialists, Technical Assistants, and District Medical Advisors

Action:

1. Upon receipt of a request for payment of the services of an attendant, release Form Letter CA-1090 to the claimant's physician. Form Letter CA-1086 is no longer relevant as that primarily addresses the claimant's method of paying the attendant.

2. Upon receipt of the reply from the claimant's physician, consider entitlement to an attendant allowance according to the criteria found in the Procedure Manual in Chapter 2-812.

3. In those cases where the services of an attendant are approved, the claims examiner will prepare a memorandum for the file which indicates the reasons for approving the attendant allowance, and stating the period for which it is approved. A claims examiner may approve the services of an attendant up to one year at a time if the medical evidence supports a long-term need.

4. Enter a note in the automated system stating that an attendant allowance is approved, the period for which it is approved, and that it is limited to the amount of $1500 per month. Advise the claimant of the approval; that the services should be provided by a home health aide, licensed practical nurse, or similarly trained individual; that the amount is limited to $1500 per month; and that the provider should submit their bill for services directly to OWCP using Form HCFA 1500 or OWCP 1500 as directed in 20 CFR 10.801.

5. For cases where an attendant allowance is currently being paid directly to a claimant, continue such payments under the old procedures. After the need for the attendant services ends, consider any new claims for an attendant allowance under the new regulations.

6. Process any pending claims for an attendant allowance, which are postmarked before January 4, 1999 under the old procedures.

7. Process all approved charges for the services of an attendant for payment directly to the provider of the services, up to a maximum of $1500 per month, and subject to the fee schedule. Use provider type C when paying for attendant care. At the present time, there is no indicator in the system to limit the payments for attendant services to $1500 per month. This must be monitored as the bills are paid.

8. If charges over the allowed amount are received, return them to the provider with an explanation that the charges for attendant services exceed the allowed monthly limit.

9. The District Offices should conduct training on this bulletin within 30 days of the date that this bulletin is received.

Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

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FECA BULLETIN NO. 99-12

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: New Regulations - Reconsiderations and Reviews by the Director; Reviews by the Employees' Compensation Appeals Board

Background: The changes to the regulations included additional information regarding the reconsideration process and reviews by the Director on his or her own motion under § 8128 of the FECA. The major substantive change implemented in this area concerns the merit review on the Director's own motion. The new regulations state at § 10.610 that a decision to review on this basis is not subject to a request or petition and that none shall be entertained. That is, the Office has full discretionary authority in these matters, and the claimant cannot request review on the Director's own motion. In § 10.610(a) the regulations point out that a decision to review or not to review on the Director's own motion is also not subject to review by the ECAB, nor can it be the subject of a reconsideration or a hearing request. On the other hand, any decision which results from a review on the Director's own motion can be subject to whichever of the three avenues of appeal the claimant selects, including reconsideration, hearing or review by the Employees' Compensation Appeals Board.

Other changes include an extension of the period (from 15 to 20 days) for comment by the employer on the claimant's application for reconsideration and any additional evidence the claimant submits in support of his or her application. This is balanced by allowing the claimant 20 days (instead of 15) to respond to any comments on his or her application made by the employer.

The only other substantive change is the fact that the new regulations on the reconsideration process and review by the Director are explained in six sections [§10.605 through §10.610] of Subpart G - Appeals Process, making the discussion more thorough. Comparatively, the previous regulations included these topics in one section [§10.138] of Subpart B - Notice of Injury and Claim for Compensation, Administrative Procedures. The six sections provide much greater detail concerning the definition of reconsideration by the Office [§10.605], the procedure for requesting a reconsideration [§10.606] along with the time limits for doing so [§10.607]. These sections go on to explain how the Office evaluates the evidence submitted by the claimant to determine whether it warrants a merit review [§10.608], and if so, whether, upon review, the evidence or arguments presented are sufficient to warrant modification of the previous merit decision [§10.609]. The last of the six sections [§10.610] addresses the process of review on the Director's own motion and is discussed above.

With regard to requests for review by the Employees' Compensation Appeals Board, the changes include a more in-depth discussion of appeals to the Board. Specifically, at §10.625 the new regulations address the types of decisions which may be appealed to the Board. Also in Subpart G at §10.626, the new regulations specify which entity has jurisdiction (the Board or the district office) over the cases while they are on appeal based on the issue(s) being addressed by ECAB in its review.

Reference: 20 CFR Part 10, Subpart G, Sections 10.605 through 10.610; Sections 10.625 and 10.626; Federal (FECA) Procedure Manual, Chapters 2-1600 (paragraphs 2.c. and 2.d.), 2-1602 and 2-1603; FECA Circular 99-04

Purpose: To focus on the part of the new regulations which addresses the reconsideration process and reviews on the Director's motion, and to point out that the deadline has been extended for the employing agency to submit comments on the application for review, and for the claimant to respond to any comments submitted.

Applicability: Regional Directors, District Directors, Claims Examiners, Supervisory Claims Examiners, and appropriate National Office personnel.

Action:

1. The training on the new regulations should include emphasis on the discussion in §10.610 which addresses reviews on the Director's own motion. Most importantly, the CEs should be clear on the point that pursuant to this section a claimant may not request review on the Director's own motion.

2. The district offices should also ensure that any pre-formatted letters used for requesting comments or responses to comments are amended to reflect the changes from 15 to 20 days for submission of comments and responses.

3. Attachments 1, 2, and 3 correspond to Exhibits 2, 3, and 4 of Chapter 2-1602 and are replacements until such time as the FECA Procedure Manual is updated to incorporate these changes. They contain the corrected address for the Employees' Compensation Appeals Board and a corrected reference to the new regulations at 20 CFR 10.607(a) pertaining to timely requests for reconsideration.

4. Training for all claims personnel which focuses on Subpart G-Appeals Process (changes in the appeals process pursuant to the new regulations) should be accomplished within 30 days of receipt of this FECA Bulletin.

Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment 1

SAMPLE LETTER DENYING AN UNTIMELY
REQUEST FOR RECONSIDERATION

Dear CLAIMANT NAME:

This is in reference to your letter dated DATE OF LETTER requesting reconsideration of our decision dated DATE OF LAST MERIT DECISION. Your letter was postmarked [OR dated] on DATE.

As provided by 20 CFR 10.607(a), we will not review a decision unless the request to do so is filed within one year of the date of that decision. Accordingly, your request for reconsideration is hereby denied because it was not postmarked [OR dated] within the one-year time limit.

We have evaluated the evidence you submitted in support of your request to see if it constitutes clear evidence of error [as described in § 10.607(b)] in OWCP's original decision. Such error would require the OWCP to reopen the case even though your request for reconsideration is untimely. However, an evaluation of the evidence you submitted does not show clear evidence of error on the part of OWCP.

If you disagree with this decision, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. This is your only right of appeal. No new evidence may be submitted to the Board. Request for review by the Appeals Board should be made within 90 days from the date of this decision and should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington, D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.

Sincerely,

 

SENIOR CLAIMS EXAMINER

 

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Attachment 2

SAMPLE LETTER DENYING AN APPLICATION WHICH IS PRIMA FACIE
INSUFFICIENT TO WARRANT REVIEW OF THE CASE

Dear CLAIMANT NAME:

We have reviewed your letter of DATE OF LETTER requesting reconsideration of our decision dated DATE OF DECISION.

Please refer to the information which accompanied the original decision. To require the Office to reopen your case, you must clearly identify the grounds upon which reconsideration is being requested. In addition, you must either submit relevant evidence not previously considered, or present legal arguments not previously considered.

Because your letter did not include new and relevant evidence or new legal arguments, it is insufficient to warrant a review of our prior decision at this time. Any future request for reconsideration must be made within one year from the original decision and must be accompanied by statements or evidence as described above.

If you disagree with this specific decision, namely, our denial to review our prior decision, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. This is your only right of appeal. No new evidence may be submitted to the Appeals Board.

A request for review by the Appeals Board should be made within 90 days from the date of this decision. It should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington. D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.

Sincerely,

 

SENIOR CLAIMS EXAMINER

 

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Attachment 3

SAMPLE NOTICE OF THE ONE-YEAR TIME LIMITATION
FOR REQUESTING RECONSIDERATION

FEDERAL EMPLOYEES' COMPENSATION ACT APPEAL RIGHTS

If you disagree with this decision denying reconsideration of your case, you may request review by the Employees' Compensation Appeals Board. No new evidence may be submitted to the Board. Request for review by the Appeals Board should be made within 90 days from the date of this decision and should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington, D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.

NOTICE

Section 10.607(a) of Title 20 of the Code of Federal Regulations, which concerns the reconsideration of a decision by the Office of Workers' Compensation Programs (OWCP), provides that OWCP will not review a decision denying or terminating a benefit unless the claimant's request for review is filed within one year of that decision. This provision of the earlier regulations became effective June 1, 1987. Therefore, even if the decision in your case was issued prior to June 1, 1987 and included the right to reconsideration, without specifying a time limit, a request for reconsideration of that decision will be denied if it is not made within one year from the date of this notice.

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-14

Issue Date: January 4, 1999

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Expiration Date: Janaury 3, 2000

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Subject: New Regulations--Representative Fees

Background: On January 4, 1999, the new Federal Employees' Compensation Act Regulations became final. Subpart H of these regulations contains a discussion concerning who may serve as a representative and how fees will be paid.

The regulations now specify that federal employees may not serve as representatives except in instances where the person they are representing is an immediate family member, or where the representative is an officially sanctioned union official charging no fee or gratuity for his or her services.

Additionally, attorney fee applications have been streamlined. Any fee application accompanied by a signed statement from the claimant agreeing to the fee will be approved. Only where a claimant disagrees with the amount of the fee will further action be taken.

Reference: 20 CFR 10.700 through 10.703

Purpose: To inform OWCP staff of new regulations regarding representatives.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives

Action:

1. All claimants and the representatives they retain will now be advised via newly revised form CA-0143 (Attachment 1) of procedures relating to fee applications.

2. Claims Examiners must now be alert for any federal employee functioning as a representative. Should any documentation be received identifying a representative as a federal employee, the claims examiner should draft correspondence inquiring as to the nature of the relationship between the claimant and representative, and whether remuneration is involved for the representative's services. Attachment 2 is a sample letter for this purpose.

3. In cases where a representative has submitted an itemized billing and the fees have been agreed to, the fee should be approved. Note that to be approvable, the fee application must contain:

a. the representative's hourly rate
b. the number of hours worked
c. the specific work performed
d. a total of charges exclusive of administrative costs
e. concurrence from the claimant

While this is substantially similar to the requirements prior to the regulatory change effective January 4, 1999, OWCP staff are no longer required to evaluate services provided or the hourly rate at which they were charged in order to determine the propriety of the charges where a claimant has concurred with them. Instead, the fees should be approved, and this should be noted via use of form CA-1066, which has been newly revised to reflect these regulatory changes. A copy of this letter is at Attachment 3 for your reference. Note that this is a formal decision, and must be completed at an appropriate signature level as per current procedure and within current limits (up to $10,000 may be issued by claims examiners or senior claims examiners, over $10,000 must be issued by the District Director).

4. Should an application be submitted which does not contain any item cited in action item 3(a) through (e), above, it will be returned as incomplete without comment. Attachment 4 is a sample letter for this purpose.

5. If a representative submits a fee request with which his or her client does not concur, OWCP must review the request and issue a decision either approving or denying it. In order to reach this decision, you must provide a copy of the request to the claimant and ask him or her to provide any additional information in support of his or her objection to the fee within 15 days. After those 15 days, OWCP must evaluate the fee request to determine whether the amount of the fee is substantially in excess of the value of services received. To do this, you must consider:

a. the usefulness of the representative's services
b. the nature and complexity of the claim
c. the actual time spent by the representative
d. customary local charges for similar services.

After fully considering these items, a formal decision must be issued outlining the fee approved and the reasons for denial of any portion of the fee as requested. This decision should be issued at the Senior Claims Examiner level.

Training on these items should be conducted within 30 days of receipt of this bulletin.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment 1: Form CA-0143 and Form CA-1055

File Number: Date of Injury: Employee:

Dear :

This will acknowledge the receipt of a statement from the above-named employee designating you to pursue his/her case before the Office of Workers' Compensation Programs (OWCP).

The OWCP's procedures relative to representatives' fee applications, copy enclosed are designed to reduce or eliminate the timelag between case approval/payment and the decision in respect to the fee request. If a representative submits a fee application in accordance with the enclosed instructions, it will be acted upon at the same time the case is adjudicated.

Sincerely,

 

Claims Examiner

CA0143

INSTRUCTIONS RELATING TO REPRESENTATIVE FEE APPLICATIONS

The Federal Employees' Compensation Act, 5 U.S.C. 8101 et seq., provides that "A claim for legal or other services furnished in respect to a case, claim, or award for compensation under this subchapter is valid only if approved by the secretary." (5 U.S.C. 8127(b))

In each case where a representative's fee is desired, an application for approval of the fee must be submitted to the Office of Workers' Compensation Programs (OWCP). In order to eliminate the time lag between case approval/payment or disallowance and a formal ruling on the fee application, representatives should submit requests for fee approval at the time they submit the final evidence necessary for adjudication of their client's claim. Each fee application must include a complete itemized statement describing the necessary services rendered, including an estimate of the time required to review the award and communicate with the client. The itemization shall include the following:

(a) The dates that services began and ended, in addition to all dates conferences were held, documents or letters prepared, telephone calls made, etc.

(b) A description of each service rendered with the amount of time spent on each type of service.

(c) The total amount of the fee which the representative desires for services performed

(d) The hourly rate at which services were provided.

(e) The amount, if any, of the fee already collected or placed on escrow. If any portion of the requested fee has been placed on escrow, a copy of the escrow agreement must accompany the application for fee approval.

In addition, the representative is responsible for submitting a statement from the client, commenting on the application and the reasonableness and appropriateness of the fee requested. These comments are to be based upon the claimant's review of the fee request and itemization, which should be supplied to the client. The representative should submit this statement with the fee request. In those instances where this is not possible, the representative must advise of the manner and date on which the client was requested to submit such a statement. The representative should submit with the fee application, a copy of the communication sent to the client.

Where the representative has submitted a fee request in accordance with these requirements, a decision relative to the fee request will be issued. If any information as listed above is not provided, the fee request will be returned for proper completion. The collection of the fee is a matter between the representative and the claimant.

No claim for a fee for services is valid unless prior approval is obtained from the OWCP. (20 CFR 10.702) Collection of a fee prior to such approval is a violation of 18 U.S.C. 292.

CA0155 Page 1

Public Burden Statement

You do not have to respond to this collection unless it displays a currently valid OMB number. We estimate that it will take an average of 1-1/2 hours to complete this information collection including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, send them to the Office of Workers' Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

CA0155 Page 2

 

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Attachment 2: Sample Letter

File Number: Employee:

Dear    :

We have received information that you are currently represented by REPRESENTATIVE'S NAME. It appears that this person may be a Federal employee. If this is the case, please note that under 18 U.S.C. 205 and 208, a Federal employee may only represent another injured Federal worker in regard to that worker's claim under the Federal Employees' Compensation Act (FECA) if the representative is either:

a. an immediate family member, defined as a spouse, child, parent, or sibling, and then only if no fee is charged, or

b. a union representative, and then only if an officially sanctioned union official also charging no fee or gratuity.

In light of this, it is necessary for you to provide a statement as to the nature of your relationship with your representative, so that his/her ability to represent you in relation to your FECA claim may be determined. If your representative is not a Federal employee, please provide a signed statement to that effect.

We will be unable to correspond with your representative regarding your case until we receive this information and reach a decision as to the appropriateness of this representative relationship. Should you have any questions, please feel free to contact me.

Sincerely,

 

Claims Examiner

 

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Attachment 3: Form CA-1066

File Number: Date of Injury: Employee:

Dear     :

This is in reference to your application for approval of a fee for services rendered in the compensation case of CLAIMANT NAME.

We have approved your fee of $XXXX.XX as requested for services rendered from 00/00/0000 to 00/00/0000. This fee has been approved because the claimant has not contested the reasonableness of the amount of the fee. Payment of the approved fee is the claimant's responsibility and HE/SHE is so advised by copy of this letter.

Pursuant to 5 U.S.C. 8127 and 20 CFR 10.702, a claimant is legally liable for only those fees for service that have been approved by this office. With respect to services rendered in this claim, any person who requests or receives a fee, gratuity, or other consideration which has not been approved by this office, may be subject to criminal prosecution.

If either party disagrees with this decision, either or both have the right to appeal to the Employees' Compensation Appeals Board (ECAB) for review of the decision. The claimant may also request hearing or reconsideration. These appeal rights are described on the attached sheet.

Sincerely,

 

Claims Examiner

Enclosure: ENAPPC

CA1066

 

FEDERAL EMPLOYEES' COMPENSATION ACT APPEAL RIGHTS

READ THIS NOTICE CAREFULLY AND DECIDE WHAT ACTION YOU WISH TO REQUEST: REVIEW BY THE EMPLOYEES' COMPENSATION APPEALS BOARD (ECAB); HEARING (Oral or Written); or RECONSIDERATION.

Be sure to send your request to the right address.
You may not request more than one form of appeal at a time.

REVIEW BY EMPLOYEES' COMPENSATION APPEALS BOARD (ECAB)
CLAIMANT AND REPRESENTATIVE

If you believe that all available evidence has been submitted, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. The ECAB will review only the evidence of record, and no new evidence may be submitted.

Any request for review by the ECAB should be made within 90 days from the date of this decision. Send it to:

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

The ECAB may waive the failure to file within 90 days if you request review within one year from the date of this decision and show a good reason for the delay.

If you (the claimant) should request a hearing or reconsideration as described below, you may still request review by the ECAB. The 90-day period for requesting review by the ECAB will begin on the date of the hearing or reconsideration decision.

HEARING (CLAIMANT ONLY)

If your injury occurred on or after July 4, 1966, and you have not requested reconsideration (see below), you may request one of the following actions:

Oral hearing. You will be able to present oral and written evidence in further support of your claim. The hearing will be informal and will be held in your area. You may authorize a representative for this hearing in writing should you choose.

Review of the written record. You may submit written evidence, but you will not be asked to attend or give oral testimony. You will have this review instead of an oral hearing. Any additional written evidence you want to submit must be sent with your request for review.

ENAPPC Page 1

 

OWCP hearing representatives conduct both oral hearings and reviews of the written record. To request an oral hearing or a review of the written record, you must write to:

Branch of Hearings and Review
Office of Workers' Compensation Programs
P. O. Box 37117
Washington, D. C. 20013-7117

State clearly whether you want an oral hearing or a review of the written record. Your request must be postmarked within 30 days of the date of this decision.

You will have the right to request reconsideration or ECAB review of the hearing representative's decision if you disagree with it.

You are not required to request a hearing as the first step in the appeal process. However, if you request reconsideration, you will not be entitled to an oral hearing or review of the written record (see 5 U.S.C. 8124(b)(1)).

RECONSIDERATION (CLAIMANT ONLY)

If you have more evidence or legal arguments which you believe apply to your case, you may ask the OWCP district office to reconsider this decision. Such a request must be made within one year of the date of this decision. The request should clearly state your grounds for requesting reconsideration. It should also include evidence not submitted before, such as medical reports or sworn statements, or legal arguments. The new evidence or legal argument should apply directly to the issue addressed by this decision.

Send your request for reconsideration and your new evidence or argument to the district office at the address shown on the letter conveying this decision. So that your new evidence is independently evaluated, your case will be reconsidered by OWCP staff other than those who made this decision.

ENAPPC Page 2

 

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Attachment 4: Sample Letter

File Number: Date of Injury: Employee:

Dear     :

We have received your recent submission of a fee request for services provided to CLAIMANT NAME.

Upon review of this package, it is noted that it is incomplete because it does not contain LIST MISSING ITEM(S).

Per 20 CFR 10. 703(a)(2), the Office of Workers' Compensation Programs cannot consider an incomplete fee request. As such, your submission is being returned to you. Please provide the missing item(s) and resubmit this request.

Should you have any questions regarding this matter, please contact me.

Sincerely,

 

Claims Examiner

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FECA BULLETIN NO. 99-15

Issue Date: March 17, 1999

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Expiration Date: March 16, 2000

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Subject: New Regulations - Withdrawal of Claims

Background: On January 4, 1999, the new Federal Employees' Compensation Act Regulations became final. The final regulations codify the ability of a claimant or survivor to withdraw a claim for benefits prior to the adjudication of the claim.

Subpart 10.100(b)(3) conveys the ability to withdraw claims for traumatic injury at any time prior to adjudication. This includes short-form closure cases, which have not been formally adjudicated. Any continuation of pay paid will be charged to either sick or annual leave or become an overpayment with the employing agency at the choice of the claimant. Although a claim is withdrawn, the notice itself is not.

Subparts 10.101(a) and 10.105(a) apply the same rules for withdrawal to claims for occupational disease and survivor benefits as for traumatic injury claims.

Subpart 10.117(b) advises employing agencies that they may not compel any employee to withdraw a claim.

Reference: 20 CFR 10.100(b)(3), 20 CFR 10.101(a), 20 CFR 10.105(a) and 20 CFR 10.117(b)

Purpose: To inform OWCP staff and employing agencies of the ability for claimants and survivors to withdraw claims for compensation.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives

Action: In any case where written notice of intent to withdraw a claim is received prior to the claim's adjudication, the claimant should be advised that the claim is now viewed as withdrawn. The attached letter is a sample for this purpose. The case file will then be coded as withdrawn and the paper file retained. To code a case as withdrawn, the following coding scheme will be used:

Case Codes

Description	Code
Adjudication Status:	SU
Case Status:	CL
Rep/Acc flag:	N

 

No ICD-9 code can (or should) be entered. This will cause all bills to fail edit 111, based on adjudication status. This edit can be overridden if payment is desired (i.e., if a CA-16 was issued prior to withdrawal). A note saying "pay no bills, claim withdrawn" should also be entered into the notes screen.

Employing agencies are not permitted to compel employees to withdraw claims. Should any staff person believe that such an incident may have occurred, district office management should be notified so that contact may be made with the employing agency to prevent future occurrences. If it is shown that an employee was compelled to withdraw his or her claim, the claim may be reinstated without further notice.

Training should be conducted on the above within 30 days of receipt of this bulletin.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment

Dear:

I have received your written request to withdraw your claim. As your case file has not been adjudicated, this request is granted. The Office of Workers' Compensation Programs will take no further action in consideration of your claim.

Please note that any continuation of pay paid by your employer due to the filing of this claim may be converted to sick or annual leave at your choice. Should you choose not to do so, your employer may view any payments made as an overpayment.

Should you have any questions, please contact me.

Sincerely,

 

Claims Examiner

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FECA BULLETIN NO. 99-17

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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Subject: Compensation Pay: Compensation Rate Changes Effective January 1999.

Background: In December 1998, the President signed an Executive Order implementing a salary increase of 3.10 percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the 3.10 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, 1999.

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, 1999. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $97,201 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:

Compensation Rates

Effective January 3, 1999	Minimum	Maximum
Monthly	$1,251.92	$6,075.06
Weekly	216.68	1,401.94
Daily(5-day week)	43.34	280.39

 

The basis for the minimum compensation rates is the salary of $15,023 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $97,201 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 $1,251.92, effective January 3, 1999. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $6,075.06 per month.

Applicability: Appropriate National and District Office personnel.

Reference: Memorandum For Directors of Personnel dated December 1998; and the attachment for the 1998 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 3, 1999, 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 23, 1999.

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, 1999. 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:

CA-842
1/03/99	43.34-65.01 43.34-57.79	216.68-325.02 216.68-288.91	43.34	216.68	1,251.92
CA-843
1/03/99	280.39	1,401.94		(5,607.76)	6,075.06

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)

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FECA BULLETIN NO. 99-18

Issue Date: December 24, 1998

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Expiration Date: December 23, 1999

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Subject: Forms - Revised Form CA-7, "Claim for Compensation"

Background: One of the tasks of the ACPS reinvention team was to redesign Form CA-7. Extensive input was solicited and received from Federal employing agencies and OWCP field offices. A draft revised form was piloted in two district offices. Field offices submitted comments on the draft revised form. Based on further input, additional changes were made. The revised form has now been cleared by OMB and is ready for use.

The new form is different in several respects. It combines Forms CA-7 and CA-8, so that the Form CA-8 is now obsolete (along with Form CA-20a). Sections of the form are optional for continuing claims. The language and format have been simplified as much as possible. The claimant's portion includes a section for showing clearly what is being claimed (compensation for leave without pay, leave buy back, or schedule award). The claimant is instructed to submit a Form SF-1199A, "Direct Deposit Sign-Up" in addition to the CA-7. The pay rate and schedule sections have been altered to solicit more accurate information. The COP/leave sections on the employer's portion have been revised, and a Form CA-7a, "Time Analysis Sheet" is requested if COP or leave is intermittent. The return to work section was changed, and a section for comments was added.

Reference: FECA Procedure Manual, Chapter 2-0401.12.

Purpose: To notify all employees of the existence of a new Form CA-7, and provide revised procedures for handling the forms.

Applicability: All staff.

Actions:

Effective immediately, the revised Form CA-7 (copy attached), dated November 1998, replaces all prior versions of Forms CA-7 and CA-8.

In Section 4 of the revised form, the claimant is supposed to indicate whether the CA-7 is the first CA-7 filed for the injury in question or not. For purposes of TPCUP tracking, until changes are made to the TPCUP program, if the response in Section 4 is "Yes," the form will be tracked as a CA-7. If the response in Section 4 is "No," the form will be tracked as a CA-8. If there is no response in Section 4, the form should be tracked as a CA-7.

A supply of the new CA-7 has been ordered for each office. Upon receipt of the new form, all previous forms of the CA-7 and CA-8 must be discarded, as they are obsolete.

In all communications and training, employing agencies should be informed that the new CA-7 is to be used. However, older versions of the CA-7 and the CA-8 will continue to be accepted by the district offices if received.

5. The new CA-7 will be available to employing agencies through the Government Printing Office, stock number 029-016-00132-8, revision date November 1998.

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

 

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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FECA BULLETIN NO. 99-19

Issue Date: January 4, 1999

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Expiration Date: September 30, 1999

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Subject: Comp Pay/COP--Sunday Premium Pay

Background: Section 636 of the Treasury and General Government Appropriations Act, 1998 (Public Law 105-61), prohibited any agency funded by appropriated funds from paying Sunday premium pay to any employee who did not actually perform work on Sunday. This prohibition became effective on October 10, 1997. Section 624 of the Treasury and General Government Appropriations Act, 1999, as contained in the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999 (Public Law 105-277), has a similar provision.

In accordance with these two statutory provisions, as well as with a decision of the Federal Labor Relations Authority, Sunday premium pay must be excluded from an agency's calculation of COP where the employee did not actually work on the Sunday or Sundays included in the period of COP, even if the employee was scheduled to do so. This applies to an agency's payment of salary only and is reflected in OWCP's new regulations at 20 CFR §§ 10.216(a)(1) and 10.217.

Given the distinction between COP and compensation payments, Sunday premium pay that is paid to an employee for work actually performed on a Sunday during the 12 months prior to the effective date of any pay rate [selected pursuant to 5 U.S.C. 8101 (4)] will still be included in the employee's pay rate for compensation purposes, as required by 5 U.S.C. 8114.

We are aware of the interim regulations on Holidays and Premium Pay published by the Office of Personnel Management (OPM) on May 23, 1997 (but not yet made final). The preamble contains the following statement:

Similarly, this prohibition appears to preclude a covered agency from reimbursing the Department of Labor for FECA benefits paid to its employees to the extent that the employees have received FECA benefits that are based on Sunday premium pay or night pay differential that the employees would have earned had they worked, but did not earn because they did not actually work on Sunday or at night. The Department of Labor may be able to waive any overpayment that occurred. OPM believes that is an issue to be worked out between affected agencies and the Department of Labor.

(Night differential is addressed because, when this material was published, Public Law 104-208 prohibited the Department of the Treasury and the U.S. Postal Service from paying night differential pay as well as Sunday premium pay for hours not actually worked. However, night differential pay is not at issue at this time.)

OWCP and OPM have since discussed this matter further. OWCP takes the position that it is solely responsible for determining pay rates in claims under the FECA. Because OWCP believes inclusion of Sunday premium pay in such pay rates to be proper, and will continue to do so, there is no reason to consider invoking overpayment procedures. The amounts paid on this basis will continue to be charged back to employing agencies as usual.

Purpose: To provide guidance for claims and technical assistance staff concerning the effect of legislation barring payment of Sunday premium pay when work is not actually performed on Sunday

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, and Technical Assistants

Actions:

With Respect to COP:

1. Any claimant, employing agency, or other party who asks whether Sunday premium pay is included in payments of COP should be advised that after October 10, 1997, the effective date of Public Law 105-61, payments of COP must exclude Sunday premium pay for time not actually worked.

a. For periods prior to January 4, 1999, the effective date of the FECA program's new regulations, the reason is that while OWCP's regulations, at 20 CFR § 10.205(d), called for inclusion of this increment, Public Laws 105-61 and 105-277 require its exclusion.

b. For periods on or after January 4, 1999, the reason is that Public Laws 105-61 and 105-277 require its exclusion, and OWCP's regulations, at 20 CFR § 10.216(a)(1), allow for such exclusion. (That provision states that "The pay rate excludes overtime pay, but includes other applicable extra pay except to the extent prohibited by law".)

2. If a claimant disputes the amount of COP received on the basis that it excludes Sunday premium pay for time not actually worked, it will be necessary to issue a formal decision that affirms the lower rate. The decision should cite both OWCP's regulations and Public Law 105-61 or 105-277, as appropriate.

With Respect to Compensation Payments:

3. If the claimant regularly worked on Sunday, the Claims Examiner (CE) should compute Sunday premium pay on that basis, in accordance with current practice.

4. If the claimant did not regularly work on Sunday, the CE should compute Sunday premium pay on the basis of the Sunday premium pay earned during the year prior to date of injury, date disability began, or date of recurrence, as appropriate. If the employer has not reported these amounts, the CE should request a list of the specific days and hours involved and the hourly differential for each period of Sunday work performed.

5. Any questions about the effect on chargeback payments should be referred to the National Office.

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)

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FECA BULLETIN NO. 99-20

Issue Date: January 4, 1999

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Expiration Date: January 3, 2000

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SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1999.

PURPOSE: To provide the 1999 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1999.

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)

 

Attachment 1

AUTOMATED COMPENSATION PAYMENTS SYSTEM (ACPS) - 1999

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

Bi-Weekly Pay Periods			District Office N.O. Trans-
Check Cycle	Period of Entitlement From   To*	For Health and Life Insurance Purposes	Cut-Off Date to Enter Roll Data	Mission to TREASURY
1	01/03/99 - 01/30/99	01/03/99 - 01/16/99   01/17/99 - 01/30/99	01/20/99	01/22/99
2	01/31/99 - 02/27/99	01/31/99 - 02/13/99   02/14/99 - 02/27/99	02/17/99	02/19/99
3	02/28/99 - 03/27/99	02/28/99 - 03/13/99   03/14/99 - 03/27/99	03/17/99	03/19/99
4	03/28/99 - 04/24/99	03/28/99 - 04/10/99   04/11/99 - 04/24/99	04/14/99	04/16/99
5	04/25/99 - 05/22/99	04/25/99 - 05/08/99   05/09/99 - 05/22/99	05/12/99	05/14/99
6	05/23/99 - 06/19/99	05/23/99 - 06/05/99   06/06/99 - 06/19/99	06/09/99	06/11/99
7	06/20/99 - 07/17/99	06/20/99 - 07/03/99   07/04/99 - 07/17/99	07/07/99	07/09/99
8	07/18/99 - 08/14/99	07/18/99 - 07/31/99   08/01/99 - 08/14/99	08/04/99	08/06/99
9	08/15/99 - 09/11/99	08/15/99 - 08/28/99   08/29/99 - 09/11/99	09/01/99	09/03/99
10	09/12/99 - 10/09/99	09/12/99 - 09/25/99   09/26/99 - 10/09/99	09/29/99	10/01/99
11	10/10/99 - 11/06/99	10/10/99 - 10/23/99   10/24/99 - 11/06/99	10/27/99	10/29/99
12	11/07/99 - 12/04/99	11/07/99 - 11/20/99   11/21/99 - 12/04/99	11/24/99	11/26/99
13	12/05/99 - 01/01/00	12/05/99 - 12/18/99   12/19/99 - 01/01/00	12/22/99	12/23/99

*ENDING PERIOD IS THE CHECK DATE
FOR EFT PAYMENTS, THE DAY BEFORE

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

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

 

Back to Top of FECA Bulletin No. 99-20

 

Attachment 2

DEBT MANAGEMENT REPORT SCHEDULE 1999

Date	Report
01/04/1999	MONTH END PROCESSING (12/31/1998)
01/05/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/26/1998 - 01/01/1999)
01/11/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/02/1999 - 01/08/1999)
01/19/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/09/1999 - 01/15/1999)
01/25/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/16/1999 - 01/22/1999)
02/02/1999	MONTH END PROCESSING (01/31/1999)
02/03/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/23/1999 - 01/29/1999)
02/08/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/30/1999 - 02/05/1999)
02/16/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/06/1999 - 02/12/1999)
02/22/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/13/1999 - 02/19/1999)
03/01/1999	MONTH END PROCESSING (02/28/1999)
03/02/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/20/1999 - 02/26/1999)
03/08/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (02/27/1999 - 03/05/1999)
03/15/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/06/1999 - 03/12/1999)
03/22/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/13/1999 - 03/19/1999)
03/29/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/20/1999 - 03/26/1999)
04/01/1999	MONTH END PROCESSING (03/31/1999)
04/05/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (03/28/1999 - 04/02/1999)
04/12/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/03/1999 - 04/09/1999)
04/19/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/10/1999 - 04/16/1999)
04/26/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/17/1999 - 04/23/1999)
05/03/1999	MONTH END PROCESSING (04/30/1999)
05/04/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (04/24/1999 - 04/30/1999)
05/10/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/01/1999 - 05/07/1999)
05/17/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/08/1999 - 05/14/1999)
05/24/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/15/1999 - 05/21/1999)
06/01/1999	MONTH END PROCESSING (05/31/1999)
06/02/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/22/1999 - 05/28/1999)
06/07/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (05/30/1999 - 06/04/1999)
06/14/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/05/1999 - 06/11/1999)
06/21/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/12/1999 - 06/18/1999)
06/28/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/19/1999 - 06/25/1999)
07/01/1999	MONTH END PROCESSING (06/30/1999)
07/06/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (06/26/1999 - 07/02/1999)
07/12/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/03/1999 - 07/09/1999)
07/19/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/10/1999 - 07/16/1999)
07/26/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/17/1999 - 07/23/1999)
08/02/1999	MONTH END PROCESSING (07/31/1999)
08/03/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/24/1999 - 07/30/1999)
08/09/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (07/31/1999 - 08/06/1999)
08/16/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/07/1999 - 08/13/1999)
08/23/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/14/1999 - 08/20/1999)
08/30/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/21/1999 - 08/27/1999)
09/01/1999	MONTH END PROCESSING (08/31/1999)
09/07/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (08/28/1999 - 09/03/1999)
09/13/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/04/1999 - 09/10/1999)
09/20/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/11/1999 - 09/17/1999)
09/27/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/18/1999 - 09/24/1999)
10/01/1999	MONTH END PROCESSING (09/30/1999)
10/04/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (09/25/1999 - 10/01/1999)
10/12/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/02/1999 - 10/08/1999)
10/18/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/09/1999 - 10/15/1999)
10/25/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/16/1999 - 10/22/1999)
11/01/1999	MONTH END PROCESSING (10/31/1999)
11/02/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/23/1999 - 10/29/1999)
11/08/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (10/30/1999 - 11/05/1999)
11/15/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/06/1999 - 11/12/1999)
11/22/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/13/1999 - 11/19/1999)
11/29/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/20/1999 - 11/26/1999)
12/01/1999	MONTH END PROCESSING (11/30/1999)
12/06/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (11/27/1999 - 12/03/1999)
12/13/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/04/1999 - 12/10/1999)
12/20/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/11/1999 - 12/17/1999)
12/27/1999	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/18/1999 - 12/24/1999)
01/03/2000	MONTH END PROCESSING (12/31/1999)
01/04/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (12/25/1999 - 12/31/1999)
01/10/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/01/2000 - 01/07/2000)
01/17/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/08/2000 - 01/14/2000)
01/24/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/15/2000 - 01/21/2000)
01/31/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/22/2000 - 01/28/2000)
02/01/2000	MONTH END PROCESSING (01/31/2000)
02/07/2000	WEEKLY CASH RECEIPTS/INTEREST REPORT (01/29/2000 - 02/04/2000)

Back to Top of FECA Bulletin No. 99-20

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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. 99-21

Issue Date: January 4, 1999

---

Expiration Date: January 3, 2000

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Subject: Bill Payment/BPS - Modifications to Inpatient Hospital Bill Procedures

Background: A fee schedule for inpatient hospital bills, based on the Medicare system of Diagnosis-Related Groups (DRGs) will be in effect for all bills processed on or after January 4, 1999. To be able to obtain the information needed to process inpatient hospital bills in this manner, it was necessary to make several modifications to the Medical Bill Processing System.

Inpatient hospital bills (with one very limited exception) will no longer be data entered onto Sequent using the FECS001 Bill Input program. Instead, these bills will keyed into a stand-alone computer, using special software. The data will then be transmitted through several intermediaries for processing, and eventually returned to the district office and loaded into the bill tables, where it will be subjected to the revised BILL552 edits, and will then be available for bill resolution, as needed.

In addition to OWCP keying inpatient hospital bills using special software, the hospitals themselves will be able to submit inpatient bills electronically, through an intermediary.

Reference: Federal (FECA) Procedure Manual Chapters 5-0200, 5-0201, 5-0203, 5-0204, and 5-0205; 20 C.F.R. Part 10, Subpart I, published November 25, 1998; FECA Bulletin 99-7.

Purpose: To notify District Offices of revised procedures for processing inpatient hospital bills.

Applicability: All staff.

Actions:

1. Effective January 4, 1999, inpatient hospital bills should be separated from other bills in the mailroom, insofar as possible. Inpatient hospital bills should be on Form UB-92, and should contain room charges. The locator 4 code for inpatient bills most commonly starts with 11* or 12*.

For a limited period of time, until further communication is received from National office, all of the inpatient hospital bills should be placed in bill batches separately from other bills, assigned a batch identification number which is not being used for another batch, and immediately imaged. These batches should include bills for third party and claimant reimbursement, as described in item 19 and Attachment 2, unless the bill is being keyed into the Sequent FECS001 Bill Input program. A daily e-mail from each district office should be sent to William Cole, Chief of Coordination and Control at the National Office, at wfc@fenix2.dol-esa.gov, listing the batch identification number for the imaged inpatient bill batch. One bill batch per office per day will usually be sufficient. The batch cover sheet should show the number of bills in the batch.

3. The National Office will key the bills from the images, after which they will be processed through the intermediaries, and then loaded into the district office systems for editing, bill resolution, and final processing.

4. After each district office has completed training on the new software for inpatient hospital bills, and the go-ahead has been sent by National Office, inpatient bills will no longer be keyed by National Office. The inpatient hospital bills will be given to the individual(s) who have been assigned to data enter inpatient hospital bills on the special software. Training on how to use the software is being provided separately.

5. The inpatient hospital bills may be data entered using the office's existing batch identification scheme. However, extreme caution must be taken to ensure that the batch numbers are entered accurately, and are not used for other bill batches.

6. The special data entry software does not interact with the Sequent system, therefore, accuracy of data entry is critical.

7. The practice of keying outpatient bills from the Department of Veterans Affairs and other federal agencies that are exempt from the fee schedule as inpatient bills will not be allowed. Rather, these bills should be keyed as outpatient bills, using the FECS001 Bill Input program. A fee schedule appeal code of "B," for bypass, should be keyed as the eighth character of the procedure code on each line item (appeal code), so that the fee schedule is not applied.

8. Only bills with certain locator 4 codes will be allowed in the special software. The first number must be 1, 4, or 8; the second number 1, 2, 5, 7 or 8; and the third number 1, 2, or 7. Bills with other locator 4 codes must be data entered in FECS001 bill input as an outpatient bill, or as a different provider type.

9. The FECS001 "Bill Input" program has been modified to block data entry of an inpatient hospital bill, with only one exception (see item 24 below).

Once the inpatient hospital bill has been data entered on the special software, it will be transmitted for grouping (assign a Diagnosis-Related Group) and pricing the bill according to HCFA rules and DFEC's modifications.

11. Following this, the data will be transmitted to the National Office, along with any error codes that arise from the processing. There are three types of error codes that may be assigned: MCE (Medicare Code Editor) errors, grouper errors, and pricer errors. Not all error codes will result in the bill not being payable, as some of the error codes are used by payers other than FEC. Some of the pricer error codes will result in National Office having to compute the allowable fee, based on an alternate formula, which uses the state's average cost-to-charge ratio. The error codes that are significant in terms of district office processing have been incorporated into the BILL552 edits.

12. The National Office will maintain a data file of hospital providers, which will be used to populate the address fields in the bill records. If the tax identification number and Medicare number on the bill record match a record of the National Office hospital file, the address from the file will be placed on the bill record and the address OK flag set to Y for "yes". If the tax identification number and Medicare number on the bill record do not match a record on the National Office hospital file, the address (if any) on the bill record will be retained and the address OK flag set to N for "no". This will cause BILL552 edit 024 to fail. See action item 19 for further information.

13. After the National Office has received and processed the bill, it will be sent to the owning district office, according to the NCMF, and loaded into the bill tables. If a case has been transferred between the time the bill was keyed into the special software and the time the bill is received in the National Office, it will be sent to the new owning office.

Along with bills that have been keyed in the district offices (or initially, National Office) using special software, bills that have been submitted electronically will also be transmitted. Electronic inpatient hospital bills will have batch identification numbers beginning with EDH.

Once the bills are loaded into the district office tables, they will be edited by the BILL552 program. If district office intervention is required, they will suspend for review.

16. Forty-four (44) new edits have been added to BILL552 to accommodate the changes for inpatient hospital bills. Most of these new edits are for MCE/grouper/pricer error codes. All of the MCE/grouper/pricer code edits are in the 400's, starting with 413. Three (3) edits have been added which are based on the DRG alone (352, 353, and 356). Five edits have been added to address the relationship of the assigned DRG to the accepted conditions (754, 757, 758, 764, and 766). One new edit (212) ensures that bills other than hospital bills do not have locator-4 codes associated with them. Edits 001 through 004 have been modified, as have the duplicate edits, 801 through 805. Detailed information of the new and revised edits is being provided under separate cover.

17. The grouping and pricing performed on each inpatient hospital bill is based on information that is provided by the hospital on the UB-92 form, and on information that is maintained by HCFA concerning characteristics of the individual hospital. Several new data elements were required to capture this information. The new data elements have been placed into a new data table (d28). The information may be viewed by using "Inpatient Hospital Bill Query" under the FECS001 Bill Payment and Query menus. This information can also be accessed from within the bill resolution and suspended bill query programs by pressing a function key. A sample screen is shown as Attachment 1.

Because inpatient hospital bills are being grouped and priced by an outside entity, once the bills have been loaded onto the Sequent system, the data fields that can be changed are very limited. In bill resolution, the only fields that may be modified are:

HEADER SCREEN

Authorizing initials
Errors box
Direct Payment Flag
Provider address OK flag

LINE ITEM SCREEN

Ineligible amount
Ineligible amount code
Bypass code
Fee schedule appeals code
Errors box

PROVIDER SCREEN

Address OK flag

The system will block changes to other fields. In most instances, if a keying error was made by the district office, the bill will have to be internally denied, corrected in the special software, and reprocessed under a new batch ID. If the hospital submitted the bill electronically with erroneous data, usually it will be denied automatically with an instruction to resubmit with corrected information.

19. For EDI inpatient hospital bills, the provider screen (in bill resolution) initially shows the provider name and address information from the bill record. The user has the ability to query the district office provider file, to determine whether the address on the bill record matches an address of a provider already on the provider file. Viewing the provider file records for EDI bills does not alter the name and address information on the bill record. If edit failure 024 has been assigned, the user should cycle through the provider addresses and if a match is found, change the address OK flag to Y. If no match is found, a narrative letter should be sent to the provider at the address on the bill record, asking for written verification of their billing address, tax identification number, and Medicare number. Once their response has been received, the provider may be added to the provider file, and the above actions taken.

For non-EDI inpatient hospital bills, normal access to the provider screen is allowed, except that the tax identification number and zip code cannot be changed. Thus, if edit failure 024 has been assigned, with the paper bill in hand (or an image of the paper bill), the user may select a matching provider from the provider file, change the address OK flag to Y if a match is found, and automatically update the bill record with that information.

20. Inpatient hospital bills that are submitted by third parties (such as insurance companies) or claimants for reimbursement will require special handling. In principal, reimbursements to third parties and claimants should not exceed the lesser of the DRG-based price or the amount actually paid. Detailed instructions for handling bills of this nature are shown in Attachment 2.

Disputes regarding the assigned DRG or price (based on the DRG) should be referred in writing to OWCP's Branch of Medical Standards and Rehabilitation, at the following address:

Dr. Virginia Miller - DRG Dispute
U.S. Department of Labor, ESA, OWCP
200 Constitution Ave., N.W. Rm. S-3522
Washington, DC 20210

Keep in mind, however, that most hospitals are already familiar with a DRG-based system through Medicare, and that the DFEC's new fee schedule rates of payment are higher than Medicare, on the average.

22. The DRG system is much more complicated than outlined herein. Attachment 3 lists additional resources that are available.

23. The MCE/grouper/pricer error codes are shown in Attachment 4, along with explanations.

24. Under special circumstances, an inpatient hospital bill may be entered under the FECS001 Payment Input program by using a locator-4 code of 911. However, a locator-4 code of 911 should be used only when it is not possible to handle the bill by using the process described above. Before a bill is data entered using a locator-4 code of 911, written supervisory approval must be obtained. One example of when 911 may be used is when the claimant has paid all or part of a bill, and the hospital is also claiming payment, as found in Attachment 2. Other circumstances that would warrant use of locator-4 code 911 should be extremely rare.

Training on these procedures should be completed prior to January 15, 1999.

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

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

 

Attachment 1

INPATIENT HOSPITAL BILL INFORMATION QUERY
CASE NO: 010111111		BATCH ID: ABC123			BILL ID: 001
PAYEE NO: 555555555 PRINCIPAL DX: 831
	OTHER DX: 8251	74764	111	252
PRINCIPAL PROCEDURE: 818
	OTHER PROCEDURE: 111		222
DRG CODE: 311
DRG AMOUNT: $ 6500.00
DATE OF BIRTH: 02/01/1940			SEX: M		DISCHARGE STATUS: 01
PROVIDER MEDICARE NUMBER: 123456
GROUPER RETURN CODE : G0
GROUPER MCE ERROR CODES:			M4 M5 M6 M7 M8
GROUPER PRICER ERROR CODES:			51 52 53 54 55
PRIOR PAYMENT AMOUNT:		0.00

VIEW NEXT RECORD? [Y/N]

FECA Bulletin 99-21

Attachment 1

 

Back to Top of FECA Bulletin No. 99-21

 

Attachment 2

INPATIENT HOSPITAL BILLS - HOW TO PROCESS PAYMENTS BY THIRD PARTIES AND CLAIMANT REIMBURSEMENTS

Inpatient hospital bills present unique difficulties with respect to third party and claimant reimbursements, due to the need to limit the payment amount to the lesser of the DRG amount or the paid amount, and the DRG amount being dependent on hospital provider-specific information that is contained only in the pricer.

Reimbursement claims from third parties (such as insurance companies):

Will be accepted as paper billing only.

The claim should consist of a UB-92 completed by the hospital which provided the services, and a claim from the third party payer, showing the amount and date paid.

The bill will be entered into Premis as an inpatient hospital bill, with the hospital as a provider.

The amount paid by the third party insurance company will be shown as a prior payment amount. The prior payment amount will be loaded as an ineligible amount in b21.

The bill will be grouped and priced in the usual manner.

The presence of the prior paid amount will cause the direct pay flag to be loaded as N in b20.

The N direct pay flag will cause the bill to suspend with edit failure 210.

If the DRG amount assigned is less than the prior paid amount, the bill will be internally denied. The bill will be rekeyed as a direct payment to the third party payer (provider type O), with the DRG amount as the bill total, the third party paid amount as the line charge, and the difference between the two as an ineligible amount, ineligible amount code I.

If the DRG amount assigned is greater than the third party paid amount, and the hospital has not also made a claim, the bill should be internally denied. A new bill as direct payment to the third party (provider type O) should be keyed in BILL001, with the third party paid amount as both the line charge and the bill total.

If the DRG amount is greater than the third party paid amount, and the hospital has also made a claim, the bill should not be internally denied. The direct pay flag should be changed to Y, and the bill processed (the hospital will be paid the difference between the DRG amount and the prior paid amount. A second payment as noted in item 9 above should be processed for the third party payer. The total of the payment to the hospital and the payment to the third party should not exceed the DRG amount.

 

Reimbursement claims from claimants (injured employees):

Claimants should not be reimbursed for charges for which they are personally responsible, such as television or private room differential (where not medically necessary).

Paper bills only will be accepted. Paper bills should consist of a completed UB-92 from the hospital, with a completed form CA-915 or another written request for reimbursement, and proof of payment.

The bill should be entered on Premis, with the claimant paid amount as a prior paid amount. The prior payment amount will be loaded as an ineligible amount in b21.

The bill will be grouped and priced in the usual manner.

The presence of the prior paid amount will cause the direct pay flag to be loaded as N in b20.

The N direct pay flag will cause the bill to suspend with edit failure 210.

If the DRG amount is less than the claimant paid amount, delete the prior payment amount. The claimant will get the DRG amount. A separate letter should be sent to the claimant, explaining that the paid amount exceeded the allowable fee, and so only a partial payment was made.

If the DRG amount is more than the claimant paid amount, and the hospital has not also made a claim, enter the difference between the two as an ineligible amount, ineligible code [new]. The claimant will be paid the amount they actually paid (less than the DRG amount).

If the DRG amount is more than the claimant paid amount, and the hospital has also made a claim, change the direct pay flag to Y, and continue processing. A second bill should be entered in BILL001 as an indirect hospital bill payment, using a 911 locator 4 code and procedure code 001. The bill total and line charge will equal the claimant paid amount.

FECA Bulletin 99-21

Attachment 2

 

Back to Top of FECA Bulletin No. 99-21

 

Attachment 3

DRG INFORMATION RESOURCES

DRGs Diagnosis Related Groups Definition Manual, Version 16.0
Available from:	3M Health Information Systems 100 Barnes Rd. Wallingform, CT 06492
	Voice # (203) 949-0303

42 CFR parts 405,412,413
Vol.63, No. 147, July 31, 1998

On the internet, HCFA's site at www.hcfa.gov has a wide variety of information.

 

FECA Bulletin 99-21

Attachment 3

 

Back to Top of FECA Bulletin No. 99-21

 

Attachment 4

MEDICARE CODE EDITOR (MCE) ERRORS

Error Code	Error	Explanation
M1	invalid code	A DRG can not be assigned if there is a not a valid ICD-9-CM procedure or diagnosis code
M2	sex conflict	There is a conflict between sex and procedure or diagnosis codes
M3	age conflict	A DRG can not be assigned if there is a conflict between age and procedure or diagnosis codes.
M4	Questionable admit	A DRG can be assigned but admission is questionable under Medicare rules.
M5	Manifestation pdx	A DRG can not be assigned. The diagnosis code describes a manifestation of a disease, not the disease itself.
M6	non-specific pdx	A more specific pdx could have been provided but Grouper can assign a DRG.
M7	e-code pdx	A DRG can not be assigned. E-codes are not acceptable as principal diagnosis.
M8	invalid 4/5 digit	Grouper will not assign a DRG if there is an invalid or missing 4th or 5th digit in the diagnosis code.
M9	non-specific o.r. proc	A more specific procedure code is preferred, but Grouper will assign a DRG.
MA	open biopsy check	Warning of possibility of coding error for open rather than closed biopsy. Grouper will assign a DRG for an open biopsy procedure code.
MB	non-covered o.r. procedures	This error/alert is generated if procedures are not covered by Medicare. A DRG can be assigned.
MC	unacceptable pdx	A DRG can not be assigned if the principal diagnosis code provided is not a current illness or injury.
MD	sdx dup of pdx	The duplicate sdx may cause assignment to a complication/comorbidity DRG in error. A DRG can not be assigned.
ME	mcare secondary payor alert	This is an ALERT. The alert is not likely applicable to DFEC claims. A DRG can be assigned.
MF	bilateral procedure check	This is a warning of a possible procedure code error. A DRG can be assigned.
MG	requires secondary dx	Requires a secondary diagnosis to assign a DRG.
MH	o.r. procedure	Error associated with a procedure.
MI	pre-pay error	Error should be resolved prior to payment.
MJ	post-pay error	Potential discrepancy or error can be resolved after payment has been made.

 

GROUPER ERROR CODES

RTC	Error	Explanation
G1	Diagnosis code cannot be used as principal dx.	A DRG could not be assigned. The diagnosis code can not be used as the principal diagnosis code. The principal dx describes a circumstance which influences health status but is not an illness or injury.
G2	Record does not match criteria for any DRG in MDC indicated by the pdx	A DRG could not be determined for the principal diagnosis.
G3	invalid age	A DRG could not be assigned. The age of the patient submitted on the claim was not between 0 and 124.
G4	invalid sex	A DRG could not be assigned. Must be 1 (male) or 2 (female).
G5	invalid discharge status	The discharge status was not one of the valid HCFA 1450 discharge status codes. A DRG could not be assigned.
G6	Illogical principal diagnosis code	A DRG could not be assigned due to a principal diagnosis code that could not be grouped.
G7	Invalid principal diagnosis code	A DRG could not be assigned due to a principal diagnosis code that was not valid. Diagnosis code does not exist.
G8	"Catch all" error	No standard explanation of why a DRG could not be assigned.

 

PRICER ERROR CODES

Error	Error Description	Explanation Code
51	no provider specific information found	Provider information is not found in HCFA provider file. Price calculated by National Office fee.
52	invalid metropolitan status area (msa) # in provider file	Invalid MSA status area in HCFA provider file. Price calculated by National Office.
53	waiver state - not calculated by pps	Some states are exempt from PPS. Price calculated by National Office.
54	drg < 001 or > 494, or = 109 or 438 or 469 or 470 or 474	Price could not be calculated. A valid DRG could not be assigned based on the data submitted on the claim.
55	discharge date < provider pps start date	Price calculated by National Office.
56	invalid length of stay
57	review code invalid (not 00 03 06 07)	Price calculated by National Office.
58	total charges not numeric	Possible data entry error.
61	lifetime reserve days not numeric	Price calculated by National Office
62	invalid number of covered days	Possible keying error.
65	pay code not = A, B or C on provider specific file for capital	Price calculated by National Office.
67	cost outlier with length of stay (los) > covered days	Price calculated by National Office.
98	cannot process bill older than 5 years	Price calculated by National Office.

 

FECA Bulletin 99-21

Attachment 4

Back to Top of FECA Bulletin No. 99-21

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-22

Issue Date: January 26, 1999

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Expiration Date: January 25, 2000

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Subject: Medical Examinations: Obstruction/Refusal - Suspension under Section 8123(d)

Background: A recent FECA Transmittal, 99-05, regarding the above subject provided the correct information on the procedure manual change, but included an example in the transmittal that was misleading. The example given in FECA Transmittal 99-05 is hereby retracted and another example will be provided below. The points of confusion appear to have been in establishing when the obstruction officially began and when it stopped, for the purposes of establishing the period of entitlement to compensation. The Act, at § 8123(a), states that the employee shall submit to a medical examination once injured as frequently and at the times and places required by the OWCP. The Act at § 8123(d) goes on to state that if an employee refuses to undergo an examination or otherwise obstructs the exam, his or her right to compensation under the FECA will be suspended until the refusal or the obstruction stops.

The FECA Procedure Manual at Chapter 2-810.14.a. quotes from 8123(d), and then adds that prior to invoking the suspension penalty, the CE must ensure that the claimant has been afforded due process. Subparagraphs b., c., and d. go on to spell out what constitutes sufficient notification and the actions that need to be taken by the CE in order to provide due process to the claimant. This includes providing a written warning as to the penalty (at the time notification of the appointment is sent out) if the claimant fails to appear for the scheduled examination. The actual failure to appear for the medical examination scheduled by the Office without giving sufficient explanation for such failure to appear is what constitutes refusal of an examination. In such a case, the period of obstruction begins on the date of the examination for which the claimant failed to appear. This would also constitute the beginning date for the suspension of compensation benefits. On the other hand, stating that one will not attend, but later attending the exam as scheduled, for whatever reason, does not constitute a refusal or obstruction and thus no penalty may be imposed by the Office.

Reference: FECA Bulletin 99-05; 5 U.S.C. 8123(d); Chapter 2-810.14.a., b., c. and d.

Purpose: To clarify what constitutes an obstruction or refusal, and what qualifies as the cessation of an obstruction/refusal for setting the effective date for reinstatement of benefits once an obstruction of a medical examination has ceased.

Applicability: Regional Directors, District Directors, Claims Examiners, Supervisory Claims Examiners, and appropriate National Office personnel.

Action:
1. If it is determined necessary for the claimant to submit to a medical examination (for a second opinion or an impartial evaluation), the CE or MMA must arrange for the examination with the medical specialist and the claimant in writing as described in 2-810, 14.b. The letter used for this purpose must contain a warning that benefits may be suspended under 5 U.S.C. 8123(d) for failure to report for examination.

2. In cases where no medical report is received within 30 days of the date of the appointment, or where the examiner learns by another means that the claimant may not have attended the scheduled examination, the CE should verify by telephone that the claimant reported for the examination, and, if so, should inquire as to when the report may be expected.

3. If the claimant failed to appear for the examination, the CE must request in writing that an explanation be provided within 14 days as to why the claimant did not attend. If the claimant does not provide a sufficient reason justifying the failure to appear for the examination, i.e., good cause is not established, the CE can then find that the claimant refused to attend an examination scheduled by the OWCP. Compensation should then be suspended effective the date the examination was scheduled in accordance with § 8123(d) of the FECA. The suspension period extends from the date of the failure to appear for the exam until the date the claimant agrees to attend the examination.

4. Once the claimant actually appears for the rescheduled examination, the CE should restore benefits retroactively to the date the claimant agreed that he or she would attend the exam.

Example: A second-opinion examination was scheduled by the CE with the specialist and the claimant for December 17th and the claimant was notified by letter of November 24th. The scheduling letter included notification of the claimant's responsibilities regarding attendance at a medical examination scheduled by OWCP. The claimant notifies OWCP that he or she will not appear for the examination (or simply fails to attend). The CE would verify that the claimant did not attend the examination, and then would ask for an explanation as to why the claimant refused to attend (or had failed to attend) the examination. If the claimant provides an explanation that is sufficient to show good cause for his or her nonappearance at the scheduled examination, the CE would allow compensation to continue uninterrupted, and a new examination would be scheduled. However, if the explanation fails to establish good cause, the CE would suspend benefits effective the date of the scheduled examination (or December 17^th).

The claimant subsequently agrees to appear for the medical examination either in writing or via the telephone (documented by a CA-110). The date of the letter of agreement or the CA-110 is January 19^th, and the CE therefore reschedules the examination for the first available appointment, February 19^th. The examination is carried out according to the arrangement and the CE verifies the claimant's attendance on February 22^nd.

The CE can then set up a payment to restore benefits effective January 19^th. The period of suspension in this example would then be from December 17^th through January 18^th.

Chapter 2-810 14.d. adds that the claimant's statement that he or she will not appear for an examination is insufficient to invoke the penalty of suspension under 8123(d) of the FECA (see Leanna Garlington, 37 ECAB 849). Similarly, the claimant's refusal to schedule an examination at the direction of OWCP is also not sufficient to invoke the penalty (see Herbert L. Dazey, 41 ECAB 271).

Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

Back to Top of FECA Bulletin No. 99-22

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-23

Issue Date: March 1, 1999

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Expiration Date: February 29, 2000

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Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1999.

Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1999.

1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 1.6 percent.

2. The increase is effective March 1, 1999, and is applicable where disability or death occurred before March 1, 1998.

3. The new base month is December 1998.

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

Maximum compensation rates

Amount	Span of Time
$ 6,075.06	per month
1,401.94	per week
5,607.76	each four weeks
280.39	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 19, 1999, 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. As the effective date of the CPI is March 1, 1999 and the start date of the periodic and death payroll cycles is February 28, 1999, there will be a supplemental record created for the period March 1 through March 27, 1999. Effective March 28, 1999, the periodic and death payrolls will reflect the increased amount.

b. The CA-816, LWEC, program must be updated with the new CPI percentage. This update must be performed in each district office.

2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 19, 1999, 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. Attached to this directive is a complete list of all the CPI increases and effective dates since October 1, 1966 through March 1, 1999.

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 upon specific request by a District Office.

d. If claimants write or call for verification of the amount of compensation paid (possibly for mortgage verification; insurance verification; loan application; etc., please provide this data in letter form from the district office. Many times the Form CA-837 does not reach the addressee; regeneration of the form is not possible, thus, a simple letter indicating the amount of compensation paid each four weeks will be adequate for this purpose.

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

Attachment

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)

 

Attachment

COST-OF-LIVING ADJUSTMENTS
Under 5 USC 8146(a)

EFFECTIVE DATE	RATE	EFFECTIVE DATE	RATE
10/01/66	12.5%	04/01/80	7.2%
01/01/68	3.7%	09/01/80	4.0%
12/01/68	4.0%	03/01/81	3.6%
09/01/69	4.4%	03/01/82	8.7%
06/01/70	4.4%	03/01/83	3.9%
03/01/71	4.0%	03/01/84	3.3%
05/01/72	3.9%	03/01/85	3.5%
06/01/73	4.8%	03/01/87	.7%
01/01/74	5.2%	03/01/88	4.5%
07/01/74	5.3%	03/01/89	4.4%
11/01/74	6.3%	03/01/90	4.5%
06/01/75	4.1%	03/01/91	6.1%
01/01/76	4.4%	03/01/92	2.8%
11/01/76	4.2%	03/01/93	2.9%
07/01/77	4.9%	03/01/94	2.5%
05/01/78	5.3%	03/01/95	2.7%
11/01/78	4.9%	03/01/96	2.5%
05/01/79	5.5%	03/01/97	3.3%
10/01/79	5.6%	03/01/98	1.5%
		03/01/99	1.6%

 

Prior to 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis or the nearest multiple of $.23 on a weekly basis ($.23, $.46, $.69, or $.92). After 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a "periodic" basis or the nearest $.25 on a weekly basis ($.25, $.50, $.75, or $1.00).

 

New Compensation Rates

Prior to 11/1/74	Effective 11/1/74
Prior to 11/1/74 .08-.34 = .23	Eff. 11/1/74 .13-.37 = .25
35-.57 = .46	.38-.62 = .50
.58-.80 = .69	.63-.87 = .75
.81-.07 = .92	.88-.12 = 1.00

 

Back to Top of FECA Bulletin No. 99-23

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-24

Issue Date: February 9, 1999

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Expiration Date: February 8, 2000

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Subject: Medical Evidence: Appropriate Contact with Medical Specialists

Background: It has come to our attention that surveillance video tapes of claimants obtained by their employing agencies (EAs) are sometimes handled without the appropriate control by OWCP in situations involving medical opinions sought by the Office. More and more we have been made aware of situations in which employing agencies have made surveillance video tapes to be used as evidence in FECA claims, but have sought to contact our medical specialists directly without clearing the contact through OWCP. It is imperative that any surveillance video tapes of claimants under the FECA which are being used or considered as evidence are made a part of the official case record. As part of the official case record, the surveillance video tapes must be made available for review by the claimant or his or her representative upon request.

Reference: Federal (FECA) Procedure Manual Chapter 2-810, paragraph 13.(a).

Purpose: To provide guidance on the handling and disposition of surveillance video tapes by OWCP personnel; and to ensure appropriate contact with medical specialists by the Office with specific regard to providing video taped evidence for their review.

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

Actions:

1. If surveillance video tapes are submitted to the Office by the EA and the CE determines that it is relevant to the issue being resolved by the medical examination, the CE should obtain copies of the video tape for the case record.

2. The CE should initially attempt to get the EA to substitute still pictures which show the activity that it is attempting to focus upon. (This will facilitate both storage in the case record and review of the evidence by the medical specialist.) In the event that still pictures are not possible, the CE should review the video tape and require the EA to edit it to omit having a medical specialist review hours of activity which has no bearing on the issue being considered. Once this is accomplished, the Office will make a copy of the edited video tape, labeling it as such (edited copy), and return the original to the EA.

3. If, on the other hand, upon review of the video tape the CE determines that the information is not relevant to the issue at hand, the video tape should be sent back to the EA with an explanation as to why it is determined not relevant to the issue at hand. (The CE should document the case record to reflect this action.)

4. If the CE determines that the video tape will be used as evidence for the record, he or she will direct the specialist involved to review the video tape and to reference this in his or her medical report.

5. If, somehow, the video tape goes to the second-opinion specialist directly from the employers' IG or Inspection Service, the CE will request a copy of the video for the case record from the EA. If the EA does not provide the video to the Office, the CE will direct the second-opinion specialist to disregard the video tape in coming to his or her opinion.

6. If evidence from a surveillance video tape is used in an Office decision, either directly or indirectly, the CE must reference it in the decision.

7. If, somehow, a surveillance video tape is provided by the EA directly to a medical specialist acting in the capacity of a referee physician, the CE must then advise the EA that the physician's opinion has been tainted and will have to be excluded from consideration in the Office's decision. If the EA insists convincingly that the evidence in the video tape in question about the claimant is vital to the case and must be used, the CE would direct the EA to send a copy of the video tape that they provided to the now-tainted referee, and then use it in conjunction with the referral to a new referee specialist.

8. When placement or maintenance of the video tape(s) becomes cumbersome or impossible as part of the physical case record, adequate provision for safeguarding the tape(s) must be made in the DD's or ADD's office. Similarly, reference to the existence and location of the tape(s) must be placed prominently in the case record itself.

9. When the district offices send cases with video tapes to Hearings and Review or ECAB, the presence of a video tape must be noted on the CA-58. When copies of video tapes are made by the Office, the copies must be labeled as such, adding that the original is owned and in the possession of the employing agency.

Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual Part 2 Chapter 810.

 

THOMAS M. MARKEY
Director for
Federal Employees' Compensation

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

Back to Top of FECA Bulletin No. 99-24

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-25

Issue Date: April 1, 1999

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Expiration Date: March 31, 2000

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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 April 1, 1999, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles is decreased 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 April 1, 1999; however, if inquiry is received, appropriate adjustment should be made. Vouchers being processed for travel periods after April 1, 1999, may be adjusted to reflect this increase.

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)

Attachment: Instructions for Submitting Travel Vouchers

Form SF-1012, front and back (Link to Image)

Form CA-77 (Link to Image)

Back to Top of FECA Bulletin No. 99-25

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-26

Issue Date: May 10, 1999

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Expiration Date: May 9, 2000

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Subject: District Office Use of Nurses Providing Telephonic Services

Background: FECA Bulletin NO. 97-11 provided the initial guidelines for use of Telephonic Case Managers (TCM) in district offices. While these guidelines remain valid, our experience over the last two years and particularly the results of the quality assurance review performed by the National Office staff in 1998 demonstrated the need to revise and clarify certain issues. This bulletin sets forth the revisions to district office procedures for the use of TCMs.

Purpose: This bulletin will provide improved guidelines and procedures for the use of TCMs in the district office.

Reference: Federal (FECA) Procedure Manual Chapters 3-201 and 3-202; FECA Bulletin 97-11.

Applicability: Regional Directors, FEC District Directors, FEC Staff Nurses and Claims Examiners.

Action:

1. Determining the number of TCMs. The District Offices Staff Nurse will continue to determine the number of nurses necessary to handle those cases subject to telephone intervention. Before TCMs are recruited, the SN needs to determine the number of cases suitable for TCM intervention and thus establish the number of TCMs necessary to handle the case load. (Criteria for case selection is discussed in action item # 4.) District offices must continue to maintain referral and reporting procedures which meet QCM time limits and privacy requirements, and the SN must track and monitor TCM progress.

2. Certification of TCMs. TCMs must be certified by OWCP and their recruitment, selection and certification must be in keeping with the process described in the FECA Procedure Manual Chapter 3-201. Nurses selected for telephonic intervention must sign a Memorandum of Agreement (MOA) unique to telephonic intervention activities (see Exhibit #1 (Link to Image)). A nurse cannot perform both face to face and telephonic intervention at the same time. She/he must elect one of the two types of intervention and sign the appropriate MOA. Contract nurses must hold valid licenses in the states where their assigned claimants reside.

3. Establishing TCM work-site. All nurses providing telephonic services must establish their own work sites (e.g. home, office) and cannot perform their routine duties in the district office. They may come into the office as necessary to obtain or drop off documents, etc. While in the office, the nurse may interact with the claims staff, and have access to the telephone and copying machines. They are otherwise responsible for furnishing their own supplies and materials. Data from the TCMs must be added into the Nurse/Rehabilitation Tracking System by FECA or contract staff (Orkand) other than the TCMs. The ability to control and assure accuracy of data input is maintained more effectively if OWCP staff enter this case-specific information.

4. TCM Case Selection, Time Frames and Reporting Format.

a. Case Selection: Telephone intervention can have successful outcomes in cases with widely different diagnoses, length of disability, and/or demographic characteristics. However, because of its total dependence on oral communication at a distance, it may not be appropriate in some instances. Our experience over the last two years (in particular, the National Office quality assurance review conducted on TCM cases) indicates that case selection can enhance results. Based on this review, referrals to TCM should exclude cases involving claimants with recurrences, known multiple claims and/or attending physicians known to provide prolonged care. Additionally, whenever surgery, special nergonomic work accommodations or indications that the return-to-work (RTW) adjustment will be a difficult one either mentally (stress claim) or physically (RTW with special needs such as crutches, splints, casts etc.), TCM intervention needs to cease and referral should be made to a field nurse.

b. Time Frames: To maximize results and to observe QCM time frames, a limit of 60 days should be applied to the TCM intervention activities. If at this point, the return to work has been secured via a completed OWCP–5, or return to work is imminent, the TCM may remain on the case to complete the required sixty day follow-up. In some circumstances, the TCM may accomplish a RTW/modified duty at 30 days into the intervention. In these cases, the TCM may continue to remain on the case in order to achieve either full duty release or at least a lessening of the job modifications, but is not to exceed the 120 day total time on the case. The CE may allow extensions in special circumstances, such as when there are no available field nurses in the claimant's vicinity or when the TCM possess language or professional skills that are necessary for the successful management of the case. Absent these factors, after 60 days the case needs to be transferred to a Field Nurse who will initiate face-to-face intervention.

Given this 60 day time frame-TCMs are not to be put into INTERRUPT as this status typically lasts at least 2-3 months (seeking second opinion examinations and/or performing surgical procedures) with no assurance that there will be a return-to-work at the end of the interruption phase and only delaying the referral to a FN for face-to-face intervention.

c. Reporting Format: Telephonic nurse case managers need to submit monthly reports identifying "plans of action" and results of contacts with attending physicians and employing agencies. The SN or Claims Examiner (CE ) reviewing these reports should be able to judge at a glance what important milestones in the case have been met (RTW date) or missed (no OWCP-5 received from the attending). In addition, when referral to a FN becomes necessary, the TCM must complete a "closure" report which details the factors requiring the transfer for FN intervention. This closure information will not only assist SN/CE in recognizing the need for transfer to a FN but, will help the FN move expeditiously on those areas previously identified by the TCM needing face-to-face intervention. A "sample" TCM reporting format is enclosed for your reference. (Exhibit #2 (Link to Image)

5. General Duties and Guidelines for TCM activities.

a. Duties - As detailed in FECA Bulletin No. 97-11, TCMs may offer medical guidance and input on cases but cannot perform functions which are the responsibilities of the claims examiners such as: preparing statements of accepted facts or questions for a second opinion or referee physician. Further, the nurse's functions are limited to the individual cases assigned to them for medical management and they are not to perform duties such as scheduling second opinion examinations or handling medical authorizations requests on an office-wide scale. The SN provides general instructions to the TCM in order to accomplish a RTW goal. However, once a case is assigned, the TCM does not receive direct and continuing supervision.

b. Guidelines - TCM performance, like FN performance, is evaluated on case outcomes and the timeliness and quality of services. If these actions are deficient, termination of TCM services should follow the same parameters outlined for FNs in FECA Procedure Manual Chapter 3-202, paragraph 13 –Warning And Termination Procedures.

6. Reimbursement Requirements for TCMs.

a. Yearly Maximum - Each district office has the discretion to set the professional and administrative reimbursement rate for their TCMs. However, each nurses providing the telephonic case management cannot exceed a yearly maximum of $50,000. Any TCM who reaches this amount cannot be assigned any more cases for the balance of the year. This cumulative reimbursement excludes all long distance phone and fax charges. To clearly separate these costs from the $50,000 maximum, they should be billed only under the NCPTC. Code.

b. Documentation -TCM activities require documentation in the form of monthly reports. Reports are to be accompanied by bills submitted on the HCFA-1500 form. Unique codes have been developed for use by TCMs not only to identify specific costs and services for this intervention but, to also allow their bills to be processed without being subjected to the prior-authorization edits.

c. Coding –

NCA00 - Telephonic nurse intervention, administrative - increments of time less than 1 hr.;

NCA01 - Telephonic nurse intervention, administrative - 1 hr. increments of time;

NCP00 - Telephonic nurse intervention, professional services increments of time less than 1 hr.;

NCP01 - Telephonic nurse intervention, professional services 1 hr. increments of time.

A review of the ongoing charges of each TCM may be monitored through the use of the monthly NI-7 (B & C) reports.

Disposition: Retain until the expiration date or until superseded.

 

Sheila Williams
Acting Director for
Federal Employees' Compensation

Attachments

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

Back to Top of FECA Bulletin No. 99-26

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-27

Issue Date: June 18, 1999

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Expiration Date: June 17, 2000

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Subject: Bill Pay/BPS - Authorization of High Dollar Medical Bills

Background: Recent OIG audit findings indicate there is a need for documenting the supervisory authorization of payment on medical bills beyond established dollar limits. Although the current FECA Procedures require that bills above established dollar limits (based on the type of provider involved) be authorized by a higher level person, the recurrence of duplicate payments in extremely high dollar amounts suggests the need to document that those procedures are being followed. The ability of OWCP to document the review and authorization of high cost medical bills at the supervisory level (GS-13 and above) will enable the Office to ensure the accountability for payments from the Compensation Fund, and to decrease the number of errors from duplicate payments of large amounts.

Reference: FECA Bulletin 98-5.

Purpose: To provide additional guidance regarding the authorization of medical bills beyond $50,000.00 and to emphasize the importance of accountability with clear documentation that the responsible resolver has taken appropriate action in high dollar medical bill payments.

Applicability: Regional Directors, District Directors, Fiscal Officers, Bill Payment Supervisors, Claims personnel, and appropriate National Office personnel.

Actions:

1. If the district office currently has satisfactory procedures in place for authorizing bills under $50,000.00, they should be continued. The effectiveness of such procedures will continue to be monitored biannually in the accountability review process and annually during the OIG's Consolidated Financial Statement Audit.

2. Regarding bills of $50,000 and above, each district office will devise its own new procedures for ensuring that they are reviewed and authorized by an individual at the appropriate level. In these cases, the district offices will select one of two options. The option chosen by each district office will be operative for all bills at and above the stated amount in the respective office. That is, bills of $50,000 and above will all be handled in a uniform manner based on the option chosen. The two available options are as follows:

(a) The higher level bill authorizer would maintain a personal log of all bills authorized. The log would include all the information necessary to identify the case, the bill, the provider, and the amount authorized.

(b) The second option would involve having the higher level authorizer retain paper copies of the actual bills containing the authorizing official's initials.

In either of the above described options, the auditors would be able to seek out the persons whose initials are in the BPS as having authorized any particular bill for payment. With either method, the auditor would verify that the person whose initials are in the BPS history actually approved that bill for payment.

3. Once the method of documenting the authorization of high cost medical bills has been chosen by the district office, the National Office should be advised via e-mail to Sheila M. Williams, copy to Ken Siglin. The district office plans should be selected and operative within 30 days of the issuance of this FECA Bulletin.

Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual Part 2 Chapter 810.

 

SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation

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

Back to Top of FECA Bulletin No. 99-27

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-28

Issue Date: August 30, 1999

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Expiration Date: August 29, 2000

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Subject: Return to Work--Temporary Assignments During Recovery

Background: Among the factors which the Office of Workers' Compensation Programs (OWCP) considers in assessing whether a job offered to an injured employee is suitable is whether the kind of appointment (permanent, term, or temporary) is at least equivalent to that of the job held on the date of injury.

If the two appointments are not equivalent, then the offered job cannot be found suitable. For instance, if the employee's date of injury job was permanent, OWCP may not find a temporary or term job suitable. Likewise, a term employee must be offered at least a term appointment; a temporary appointment would not be suitable.

This policy is intended to apply to offers of employment which will lead to ratings for loss of wage-earning capacity (LWEC). However, the policy has recently been cited with respect to offers of short-term work made to employees who are still recovering from their injuries and who may be able to perform light duty but who have not reached a level of recovery sufficient to consider rating for LWEC.

A distinction must be made between a position which is temporary, according to the rules promulgated by the Office of Personnel Management, and an assignment which is temporary, and which is made in recognition that a partially disabled employee is able to perform some work during the period of his or her recovery.

An employee who is undergoing vocational rehabilitation efforts at the direction of OWCP may be required to accept an offer of work within his or her limitations while recuperating from a work-related injury, even if that work represents a temporary assignment and the employee has permanent appointment status. Failure to accept such an assignment may be considered failure or refusal to participate in vocational rehabilitation efforts, and such a failure may be sanctioned on that basis.

However, it remains true that a permanent employee may not be rated for LWEC purposes based on a temporary or term position, nor may his or her refusal to accept such an assignment be sanctioned under 5 U.S.C. 8106(c).

Purpose: To provide guidance with respect to short-term job offers made to employees who are in the early stages of recovery from work-related injuries.

Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Technical Assistants, Staff Nurses, and Vocational Rehabilitation Specialists

Reference: 5 U.S.C. 8106(c) and 8113(b); 20 CFR 10.519(b) and (c); Federal (FECA) Procedure Manual Chapter 2-813.11, 2-814.4 and 2-814.7

Actions:

1. Where an employee is undergoing OWCP-directed vocational rehabilitation efforts, either with a registered nurse or a vocational rehabilitation counselor, an employer may offer the employee a temporary assignment pending further recovery from the work-related injury.

2. An employer who takes such an action should notify OWCP of the nature of the offered position and whether its rate of pay is the same as or less than that of the date-of-injury job.

3. For an employee who accepts such an assignment, compensation will be paid on an actual-earnings basis pending further recovery.

4. OWCP will consider an employee who refuses to accept such an assignment as failing or refusing to undergo a vocational rehabilitation effort when so directed. As stated in the program's regulations at 20 CFR § 10.519(b):

Where a suitable job has not been identified, because the failure or refusal occurred in the early but necessary stages of a vocational rehabilitation effort...OWCP cannot determine what would have been the employee's wage-earning capacity.

5. Therefore, in accordance with the procedures outlined in the Federal (FECA) Procedure Manual, Chapter 2-813.11, the Claims Examiner (CE) should warn the employee that, absent evidence to the contrary, OWCP will assume that the vocational rehabilitation effort would have resulted in a return to work with no loss of wage-earning capacity.

6. In addition to any evidence which the employee may present in response to such a warning, the Claims Examiner must consider the rate of pay of the offered assignment. A rate of pay less than that of the date of injury job, due either to a change in differential pay or to provision of different work altogether, will constitute "evidence to the contrary".

7. If the claimant does not resume cooperation with vocational rehabilitation efforts, his or her compensation should be reduced, either to zero if no evidence to the contrary has been presented, or based on the rate of pay of the job assignment if evidence to the contrary has been presented. As stated in 20 CFR § 10.519(c), "The reduction will remain in effect until such time as the employee acts in good faith to comply with the direction of OWCP."

8. However, it is not proper to rate for LWEC an employee who accepts such a temporary assignment unless the terms of the job are modified so that the original and new appointments are equivalent. For instance, a temporary assignment which meets a permanent employee's work limitations may not be used for a rating, but if the employer makes the same job permanent, and the job is classified in accordance with 20 CFR § 10.509(b), such a job would be considered proper for LWEC purposes.

Disposition: Retain until the indicated expiration date.

SHEILA M. WILLIAMS
Acting 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. 99-28

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-29

Issue Date: August 5, 1999

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Expiration Date: August 4, 2000

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Subject: Bill Payment/BPS - Correct Coding Initiative, Part A.

Background: Many medical bill processing systems include edits that are designed to detect certain types of coding error and abuse. While the DFEC bill processing system (BPS) already includes some of these edits, there are additional elements that are being added to enhance the system, under a Correct Coding Initiative (CCI). CCI is modeled on a system implemented by Medicare in 1996. Staff has already been hired in the National Office to implement CCI, and additional staff in each district office will be hired shortly.

CCI implementation will consist of two major parts. Part A includes editing for age-specific procedures, sex-specific procedures, unlisted procedures, excluded procedures, and modifier validity. Parts B and C, to be implemented in the future, will include editing for mutually exclusive procedures, comprehensive/component procedures, add-on codes, and global periods. Part A is in effect with the issuance of this Bulletin, or shortly thereafter. Information concerning Parts B and C will be provided at a later date.

Reference: Federal (FECA) Procedure Manual Chapters 5-0203 and 5-0204.

Purpose: To communicate procedures for processing bills under the CCI, Part A.

Applicability: Claims Examining, Bill Processing and CCI personnel.

Actions:

1. The CCI edits are applicable only to certain CPT-4 codes.

2. Four new BILL552 edits have been developed for CCI Part A. These include an edit for age-specific procedures (361), female-only procedures (362), male-only procedures (363), and unlisted procedures (364). Detailed edit sheets for these four new edits are being sent under separate cover, along with the revised condensed BPS edits, and the revised EOB listing.

3. Attachment 1 shows age-specific procedures. These procedures are only applicable to children. Since FECA claimants are not children, these procedures are not payable under the FECA.

4. Attachment 2 shows female-only procedures. Attachment 3 shows male-only procedures.

5. Attachment 4 shows excluded procedures. These are procedures that are not payable for work-related conditions. Excluded procedures are already identified by BILL552 edit 303.

6. Unlisted procedures are found at the ends of CPT code groupings, and usually end in 99. An example would be 20999, "unlisted procedure, musculoskeletal system." These codes are supposed to be used only when another CPT code cannot be used appropriately, and often require a medical report to support use of the unlisted code.

7. When errors 361, 362, and 363 are assigned, denial is automatic, and the edit failure cannot be overridden. Error 364 failure results in a suspension, which must be manually reviewed and may be overridden if appropriate.

8. Invalid modifiers are already identified by BILL552 edit 318.

9. All billing issues with respect to these edit failures, including resolution of these edit failures, should be referred to the CCI specialist. The CCI specialist is not responsible for other edit failures that may occur on a bill. Other edit failures on the bill should, in general, be resolved before the bill is referred to the CCI specialist. If problems arise with respect to these edits prior to the CCI specialist being on board, contact either Yvette Sanders (202-693-0886) or Cheryl Bullock (202-693-1027) at the National Office. Edit 364 will not be activated until after the CCI specialists have been hired and trained.

Training on this Bulletin should be completed within 30 days of the issuance of this bulletin.

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

 

SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation

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

Attachment 1

AGE-SPECIFIC PROCEDURE CODES
24640
25450
25455
27175
27176
27177
27178
27179
27181
27185
27256
27257
27258
27259
27455
27475
27477
27479
27485
27727
27730
27732
27734
27740
27742
31520
31601
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33692
33694
33697
33730
33732
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
36400
36405
36406
36420
36440
36450
36460
36488
36490
36510
36660
46715
46716
46730
46735
46740
46742
46744
46746
46748
46751
49495
49496
49500
49501
49580
49582
54000
54150
54160
73092
73540
73592
76010
76065
76885
76886
88028
90918
90919
90922
90923
94652
94772
99295
99296
99297
99298
99431
99432
99433
99435
99436
99440

Back to Top of FECA Bulletin No. 99-29

Attachment 2

SEX-SPECIFIC PROCEDURE CODES - FEMALE
00842
00846
00850
00855
00857
00944
00946
00948
00950
00952
00955
19324
19325
19328
19330
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
50722
51845
51900
51920
51925
52285
53210
53230
53250
53430
53502
53660
53661
53665
55980
56301
56302
56307
56308
56309
56343
56344
56350
56351
56352
56353
56354
56355
56356
56405
56420
56440
56441
56501
56515
56605
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
57000
57010
57020
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57280
57282
57284
57288
57289
57291
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57452
57454
57460
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
57556
57700
57720
57800
57820
58100
58120
58140
58145
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58300
58301
58321
58322
58323
58340
58345
58350
58400
58410
58520
58540
58600
58605
58611
58615
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58960
58970
58974
58976
58999
59000
59012
59015
59020
59025
59030
59050
59051
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
58350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59899
74710
74740
74742
74775
76086
76088
76805
76810
76815
76816
76818
76825
76826
76827
76828
76830
76831
76941
76945
76946
76948
80055
80414
80415
80426
82670
82671
82672
82677
82679
83001
83632
84135
84138
84140
84143
84144
84146
84233
84234
84702
84703
84830
88141
88142
88143
88144
88145
88147
88148
88150
88152
88153
88154
88155
88156
88158
88164
88165
88166
88167
88235
89254
89255
89256
89258
89330

Back to Top of FECA Bulletin No. 99-29

Attachment 3

SEX SPECIFIC PROCEDURE CODES - MALE
00865
00908
00914
00916
00920
00922
00924
00926
00928
00930
00932
00934
00936
00938
37788
37790
52450
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
53215
53235
53250
53410
53415
53420
53425
53440
53505
53510
53515
53520
53600
53601
53605
53620
53621
53850
53852
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54150
54152
54160
54161
54200
54205
54220
54230
54231
54235
54240
54250
54200
54204
54208
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54402
54405
54407
54409
54420
54430
54435
54440
54450
54500
54505
54510
54520
54530
54550
54560
54600
54620
54640
54650
54660
54670
54680
54700
54800
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865
55870
55899
55970
56318
56320
74440
74445
76870
78760
78761
82651
84153
84154
84402
84403
89257
89259
89260
89261
89264
89300
89310
89320
89325
89329
89330
93890
93980
93981

Back to Top of FECA Bulletin No. 99-29

Attachment 4

EXCLUDED PROCEDURE CODES

11975
11976
11977
15819
15820
15821
18522
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15876
15877
15878
15879
55870
55970
55980
56302
56343
56344
56700
56720
56805
57335
58300
58301
58321
58322
58323
58345
58350
58600
58605
58611
58615
58970
58974
58976
59840
59841
59850
59851
59852
59855
59856
59857
59866
61000
61001
89250
89251
89252
89253
89254
89255
89256
89257
89258
89260
89261
89329
90744
90918
90919
90922
90923
94150
98943
99295
99296
99297
99381
99382
99383
99384
99391
99392
99392
99393
99394
99431
99432
99433
99435
99450

Back to Top of FECA Bulletin No. 99-29

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Attention: This bulletin has been superseded and is inactive.

FECA BULLETIN NO. 99-31

Issue Date: September 27, 1999

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Expiration Date: September 26, 2000

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Subject: Bill Pay/BPS - Data Entry of Inpatient Hospital Bills

Background: Effective January 4, 1999, a fee schedule for inpatient hospital bills was implemented. Because of the data entry requirements for the new fee schedule, special software was used to data enter inpatient hospital bills. Initially, data entry was performed only in the National Office. During the months of March and April, each district office was trained in the use of the special software, and began performing data entry of their own inpatient hospital bills.

In the months that have followed, the volume of inpatient hospital bills has been much lower than what had been expected, based upon previous years' volume of inpatient bills. In addition, district offices have experienced numerous difficulties in performing the data entry of these bills. The costs associated with maintaining the special software at each site have been considerable.

Effective September 27, 1999, district offices will no longer perform data entry of most inpatient hospital bills. Instead, these bills will be mailed to the National office for data entry, after which the bills will be processed and loaded into the district office systems.

Reference: FECA Bulletin 99-21, "Modifications to Inpatient Hospital Bill Procedures," issued January 4, 1999.

Purpose: To communicate revised procedures for data entry of inpatient hospital bills.

Applicability: All Personnel in the District Offices and National Office.

Action:

1. The District Offices will take the following actions with respect to inpatient hospital bills:

a. Separate inpatient hospital bills from outpatient hospital bills. Hospital bills generally are submitted on form UB-92, although a few other types of providers also use the forms. Only hospital bills which meet the following parameters should be identified as "inpatient" for purposes of keying into the special software:

1) The first digit of the code in form locator 4 must be 1, 4, or 8; the second digit 1, 2, 5, 7 or 8; and the third digit 1, 2, or 7; and

2) Room and board charges are present on the bill. Such charges are shown with RCCs of 100 through 169.

b. Screen the inpatient bill for the presence of a six-character provider Medicare number, usually found in form locator 51. Medicare numbers are usually all numeric, but may also contain one alpha character. If the Medicare number is not on the bill, the bill should be returned to the hospital with an explanation and a request that the number be provided.

c. Make sure that the bill contains a valid case file/claimant name by performing a case or name query. If the case file number is invalid, determine the correct case file number, write it on the bill in form locator 60, and cross out the invalid case file number.

d. Place the bills that pass screening as described in items a through c above in a batch. Arrange the bills in alphabetical order by the claimant's last name.

e. Complete a batch cover sheet, and write the batch ID and bill ID on each bill in form locator 61. The first bill in each batch will be bill 001, the second 002, etc. For example, the batch and bill ID for the first bill in batch GH2822 should be written as GH2822.001. Please note that certain characters are very difficult to discern from each other, such as 1 and I, 0 and O. It is preferred that these characters not be used in the batch IDs, but if they are used, they should be distinguishable.

f. Image the batch. Follow quality control procedures to ensure that the batch has been scanned and is viewable.

g. Mail the original batch(es) to the National Office via overnight mail:

U.S. Department of Labor
ESA, OWCP
200 Constitution Ave., NW
Rm. S-3229, Attn: Yvette Sanders
Washington, D.C. 20210

h. Send e-mail to Yvette Sanders (ysanders@fenix2.dol-esa.gov) in the National Office regarding the batches sent, stating:

1) The number of batches sent;
2) The bill IDs for the batches sent; and
3) The number of bills in each batch.

Inpatient bill batches should be consolidated so that only one or two e-mails are sent to Ms. Sanders in any given week.

2. The National Office will take the following actions:

a. Receive the paper bills from the district offices.

b. Review the bills to ensure that they are appropriate for keying into the special software. Any bills that are not appropriate for such data entry will be returned to the district office with an explanation and instructions for further processing.

c. Compare the hospital name, address, tax identification number, and Medicare number with those found on the National Office hospital provider file, and make any corrections needed.

d. Data enter the bills into the special software.

e. Verify the accuracy of the data entry.

f. Transmit the bills to the hospital clearinghouse.

g. Respond to the e-mail from the district office, providing the date the bills were transmitted to the clearinghouse.

3. The remainder of the inpatient bill processing will remain as it currently exists, namely: the clearinghouse will forward the bills for grouping and pricing; National office will associate a provider address with each bill, and transmit the bills to the appropriate district offices; the bills will be loaded into the FECS bill processing tables and edited by BILL552; the bills will be resolved by the appropriate district office staff.

4. If data entry problems arise with respect to inpatient bills keyed by the National Office, including bills that must be corrected and resubmitted, contact Yvette Sanders. District Offices may now correct errors in bill and batch IDs through the use of BILL515, in the FECS004 menu.

5. The personal computer and phone line that was previously dedicated to inpatient hospital bill data entry should not be used for other purposes until further notice.

6. Training on these procedures should be provided to the appropriate staff as soon as possible.

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

 

NANCY L. RICKER
Acting Director for
Federal Employees' Compensation

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

Back to Top of FECA Bulletin No. 99-31

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