SAMPLE AUTHORIZATION LETTER
Date:
Claimant Name (or Auth Rep)
Street Address
City, State, Zip
Re: Claim Number [Enter Claim Number]
Dear [Enter Claimant or Auth Rep Name]:
This letter is in reference to your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received a request for authorization for the [Enter purchase or rental] of a [Enter the Oxygen Therapy Equipment or Oxygen Medical Supplies] for the following covered medical condition(s):
List the condition(s)
After a thorough review of your case file, including communication with your treating physician (if applicable), the following authorization is granted:
Rental of [Enter type of Oxygen Therapy Equipment or Oxygen Medical Supplies and billing code] for the period of [Enter to and from date] from [Enter vendor name]. You will need to be recertified one year from the date of authorization.
Purchase of [Enter type Oxygen Therapy Equipment or Oxygen Medical Supplies and billing code] from [Enter vendor name].
Note that the DEEOIC requires that the approved vendor noted above be enrolled as a provider in our medical bill payment system to be reimbursed. Vendors may call toll free 1-866-272-2682 for program enrollment information or for answers to payment questions.
All fees for the rental/purchase of Oxygen Therapy Equipment and/or Oxygen Medical Supplies are subject to the OWCP Fee Schedule.
Add-ons and/or upgrades to the Oxygen Therapy Equipment and/or Oxygen Medical Supplies are considered for approval if evidence substantiates a medical need for the enhancement. However, add-ons and/or upgrades to Oxygen Therapy Equipment and/or Oxygen Medical Supplies are not covered when they are intended primarily for the claimant’s convenience and do not significantly enhance the equipment/supplies functionality.
If you have any questions or concerns regarding this authorization, please call your claims examiner at (XXX) XXX-XXXX.
Sincerely,
[Enter CE name]
DEEOIC Claims Examiner
cc: [Enter supplier name]