EEOICPA BULLETIN NO. 17-02
Issue Date: May 1, 2017
Effective Date: May 1, 2017
Expiration Date: May 1, 2018
Subject: Prior Authorization Required for Enteral Formula.
Background: This Bulletin provides notification to all Division of Energy Employees Occupational Illness Compensation (DEEOIC) staff that prior authorization is required for requests for enteral formula. Enteral formula is a nutritional replacement for patients who are unable to get enough nutrients in their diet. Patients prescribed enteral formula consume it by mouth or through a feeding tube.
Purpose: To provide guidance on handling authorization requests for enteral formula.
Applicability: All staff.
1. Requests for the authorization of enteral formula may originate from an employee, a designated authorized representative or a medical provider. The DEEOIC medical bill processing contractor is tasked with registering all authorization requests for enteral formula in its electronic case tracking system. If the contractor receives the authorization request directly, they will record it and forward the request, as a thread, to the appropriate District Office (DO) for processing. If the DO receives the authorization request via mail or fax, it should be routed through the Fiscal Officer (FO) to the medical bill processing contractor for record creation and thread initiation.
2. Once the assigned Claims Examiner (CE) receives a thread for authorization of enteral formula, he or she must undertake a review of the evidence in the case file to make a determination as to whether or not the request is medically necessary in the care of the covered employee’s accepted work-related medical condition(s).
3. Requests for enteral formula must be substantiated by a Letter of Medical Necessity (LMN) from the employee’s treating physician. The LMN must provide a description of the employee’s medical need for enteral formula based on a face-to-face examination of the patient occurring within 60 days of the date of the LMN. In addition, the physician must identify the accepted work-related medical condition (preferably with a specific diagnosis code) that is necessitating the need for enteral formula. The physician must provide a description of the type of formula he or she is prescribing, along with a discussion of the specific quantity, frequency and duration of use. The physician may also provide guidance on how the patient receives the formula (orally or via feeding tube). The LMN signed by the treating physician must include his or her official practice address, telephone and fax number.
4. When the CE receives a request for authorization of enteral formula accompanied by an appropriate LMN, the CE prepares a decision letter to the claimant authorizing the enteral formula at the prescribed level. The CE grants authorization of enteral formula in six-month increments.
5. Upon receipt of requests for enteral formula unaccompanied by a sufficient LMN, the CE undertakes development by contacting the prescribing physician and the claimant to request evidence necessary to allow for authorization. A CE can refer requests with unclear medical support to a DEEOIC nurse consultant for review and expert advice on the proper course of action. If, after development, the CE determines that the medical evidence is insufficient, he or she issues a letter decision denying the authorization request. The letter decision is to include a narrative as to why the evidence is insufficient to warrant authorization. The CE is to send a copy of the letter decision to the provider, if applicable. The letter decision is to include the following language:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
6. Once the CE determines to approve or deny the request, the CE sends an email to the FO, who prepares and sends a thread to the bill processing contractor, authorizing or denying the enteral formula request. The CE creates a correspondence entry in the Correspondence screen of the Energy Compensation System (ECS), documenting the decision and bronzes the letter along with the supporting documentation into the OWCP Imaging System (OIS).
7. An employee, a designated authorized representative or a medical provider must request a renewal of an expiring authorization or modification of an existing authorization for enteral formula. In either of these situations, a LMN documenting the medical necessity of prescribed formula must accompany the request. A CE may authorize enteral formula in ongoing six-month increments, so long as the requestor continues to submit sufficient evidence of medical necessity.
Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.
RACHEL P. LEITON
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, and District Office Mail and File Sections.