EEOICPA BULLETIN NO. 18-01
Issue Date: December 4, 2017
Effective Date: January 16, 2018
Expiration Date: January 16, 2019
SUBJECT: Prior authorization for rehabilitative therapy services.
The purpose of this Bulletin is to notify all Division of Energy Employees Occupational Illness Compensation (DEEOIC) staff that prior authorization is required for physical therapy, occupational therapy, speech therapy, and other rehabilitative therapy services.
· Speech Therapy is the treatment of defects and disorders of speech and swallowing.
· Other rehabilitative therapy services is defined as a therapeutic service for which a provider charges a fee to render care outside of the scope of routine and customary medical care generally provided by a qualified physician. The recommended other therapeutic service must be considered safe and effective by the medical community and intended to improve the health of the patient.
An appropriately licensed (in accordance with relevant state requirements) or credentialed specialist must perform the prescribed rehabilitative therapy.
References: 42 U.S.C. § 7384t, 42 U.S.C. § 7385s-8, 20 CFR § 30.400.
Purpose: To provide guidance on handling authorization requests for rehabilitative therapy services.
Applicability: All staff.
1. Requests for the authorization of rehabilitative therapy, including physical therapy, occupational therapy, speech therapy or other rehabilitative therapy, may originate from an employee, a designated authorized representative or a medical provider. The DEEOIC Bill Processing Agent (BPA) must register all authorization requests for rehabilitative therapy services in its electronic case tracking system. The BPA will record authorization requests it receives and then forward the request, as a thread, to the Worker’s Compensation Assistant (WCA)/Fiscal Officer (FO) for processing. Authorization requests received at the District Office (DO) via mail or facsimile (FAX) must be routed through the WCA/FO to the BPA for record creation and thread initiation.
2. Once the assigned Claims Examiner (CE)/Medical Benefits Examiner (MBE) receives a thread for authorization of a rehabilitative therapy, he or she must undertake a review of the evidence in the case 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. The CE/MBE must approve requests for a rehabilitative therapy initial assessment as long as the employee’s treating physician prescribes it. The CE/MBE approves the request and sends an email to the WCA who then notifies the BPA to authorize an initial therapy assessment. The CE/MBE sends a letter authorizing the initial assessment to the requestor with a copy to the employee. If the CE/MBE receives a request for an initial rehabilitative therapy assessment without a physician’s prescription, he or she sends a letter to the employee (with a copy to the therapy provider) requesting a signed prescription for the initial assessment. In the letter, the CE/MBE advises that the employee has 30 days within which to submit a signed physician’s prescription for an initial therapeutic evaluation. If medical documentation or a signed physician’s prescription is not received within 30 days, the CE/MBE must deny the request. The CE/MBE sends an email to the WCA who then notifies the BPA to deny the request. The CE/MBE sends a letter to the requestor with a copy to the employee denying the request and providing instruction to resubmit the request once the threating physician submits a signed prescription.
4. Requests for rehabilitative therapy must be substantiated by the results of the initial evaluation by the applicable therapy specialist and 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 the requested rehabilitative therapy based on the results of the initial evaluation and the physician’s face-to-face examination of the employee occurring within sixty days of the date of the LMN. The physician must provide a description of the type of rehabilitative therapy he or she is prescribing, along with a discussion of the specific quantity, frequency and duration of the therapeutic service. DEEOIC considers rehabilitative therapy services medically appropriate only if a qualified physician describes, with appropriate medical rationale, how the prescribed rehabilitative therapy will lead to an expected measurable improvement in one or more activities of daily living within a reasonable period. The LMN signed by the treating physician must include his or her official practice address, telephone and FAX number.
5. When the CE/MBE receives a request for authorization of rehabilitative therapy accompanied by an appropriate LMN, the CE/MBE prepares a decision letter to the employee authorizing the requested therapy. The initial authorization period may be fewer than, but must not exceed 3 months (90 days). The assigned CE/MBE may approve up to 3 visits per week by therapy discipline. Each visit is equal to a maximum of 1.5 hours (6 units). PT, OT, or ST services are limited to one hour (4 billable units) when the provider bills with combined codes. The CE/MBE may not authorize therapy for any one discipline more than a total of 60 visits per calendar year.
The approval letter must contain the following information:
(a) Covered medical condition(s) for the rehabilitative therapy.
(b) Number and frequency of visits approved (e.g., 3 visits per week for 12 weeks).
(c) Authorized billing code(s) relevant to the approval.
(d) Dates for the authorized period.
(e) Statement to indicate that corresponding medical notes must be provided for each service date.
(f) Statement advising that fees are subject to the OWCP fee schedule.
6. Upon receipt of requests for rehabilitative therapy unaccompanied by a sufficient LMN, the CE/MBE undertakes development by contacting the prescribing physician and the employee to request evidence necessary to allow for authorization. Refer to EEOICPA PM “Ancillary Medical Services and Related Expenses”, Chap. 29.2d for guidelines regarding the development process.
(a) After 30 days has passed with no satisfactory response from the treating physician, or no response from the employee, the CE/MBE prepares a second letter to the employee(accompanied by a copy of the initial letter), advising that following the previous letter, no additional information has been received from the treating physician. The CE/MBE advises that an additional period of 30 days will be granted for the submission of necessary evidence, and if the information is not received in that time, the request for rehabilitative therapy may be denied by the DEEOIC.
(b) If the employee or the physician does not provide a response to the second request for information within the 30-day period allowed, the CE/MBE issues a letter decision to the employee denying the claim for rehabilitative therapy. The CE/MBE further sends an email to the FO, who sends a thread to the BPA for system update.
A CE/MBE can refer requests with unclear medical documentation to a DEEOIC nurse consultant or Contract Medical Consultant for review to obtain expert advice on the recommended course of action. Once the CE/MBE has undertaken development, including allowance for the treating physician to provide further support for an unsubstantiated request for rehabilitative therapy, he or she can issue a letter decision denying the authorization if sufficient medical justification has not been forthcoming. The letter decision is to include a narrative as to why the evidence is insufficient to warrant authorization. The CE/MBE is to send a letter to the employee along with 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.
7. Once the CE/MBE decides to approve or deny the request, he/she sends an electronic mail message to the WCA/FO, who prepares and sends a thread to the BPA, authorizing or denying the rehabilitative therapy request. The CE/MBE creates a correspondence entry on 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).
8. An employee, an authorized representative, treating physician, or rehabilitative therapy provider must request a renewal of an expiring authorization or modification of an existing authorization for rehabilitative therapy and should do so prior to the expiration date of the existing authorization, to allow care to continue uninterrupted. In either of these situations, the requestor must submit a LMN documenting the continuing medical necessity of the request. Requests for rehabilitative therapy outside of the guidance provided in this bulletin must be evaluated on a case-by-case basis, including possible consultation with the DEEOIC Medical Director. The employee, or his or her AR, has final responsibility regarding the amount or type of rehabilitative therapy sought.
9. Rehabilitative therapy providers must conduct services in an appropriate setting; (i.e., in a clinic, professional office, or other similar location). If the CE/MBE receives a request for in-home professional therapy, the employee must be homebound to receive such authorization. Medical evidence from the treating physician must demonstrate that the employee is medically unable to travel to obtain the therapy outside the home. Once the CE/MBE receives convincing medical evidence that the employee is not able to travel for therapy, and sufficient documentation exists regarding the medical necessity for care, the CE/MBE may authorize in-home rehabilitative therapy. Provider travel to and from an employee’s residence is not a billable service.
10. Rehabilitative therapy providers must submit appropriate clinical notes to the BPA, along with their bill, describing in detail the particular therapeutic care provided during each visit, and the time spent providing that care. The therapy notes must document compliance with the LMN. The notes should describe the effect of the rehabilitative therapy specific to unique features of the employee, including any specific improvements in functionality or in achieving relief from the symptoms of a compensable illness. The CE/MBE may refer claims to the Program Integrity Unit for investigation of those situations where an applicable therapy provider does not provide an employee-specific description of the services provided, lists vague or non-descriptive services or conducts therapy services that do not comply with the prescribing physicians LMN.
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 Examiner, Supervisory Claims Examiner, Technical Assistants, Customer Service Representative, Fiscal Officer, FAB District Managers, Operation Chiefs, Hearing Representatives, and District Office Mail and File Sections.
 The maximum visit per CY is based on a comparative analysis of industry standards regarding therapeutic care and in consideration of DEEOIC approved claimants.