U.S. Department of Labor



Office of Workers’ Compensation Programs

Division of Energy Employees Occupational Illness Compensation




                                                                        FILE NUMBER:


Medical Provider

Street Adress

City, State, Zip Code                                                     


Dear Medical Provider;


Our office has determined that the above employee is eligible for an impairment evaluation under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) in relation to the following accepted illness Insert name AND ICD9 of covered illness.


Employee name has identified you as his/her choice to perform an impairment evaluation in relation to his/her covered illness. The Division of Energy Employees Occupational Illness Compensation (DEEOIC) will cover the cost of the impairment evaluation as long as the condition has reached a point where further improvement is not expected (Maximum Medical Improvement/MMI), or the employee is considered to be in the terminal stages of the illness. The evaluation must also be performed within one year of the date DEEOIC receives the completed impairment report, and not performed prior to Filing date (the date he/she filed for benefits under the EEOICPA). The evaluation must be performed in accordance with the 5th Edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides), with specific page and table references included in your report. 


Physicians who perform impairment evaluations for the DEEOIC must hold a valid medical license and Board certification/eligibility in their field of expertise (e.g., toxicology, pulmonary, neurology, occupational medicine, etc.). The physician must also meet at least one of the following criteria:




When your impairment evaluation has been completed, please submit a letter to establish that you meet the criteria listed above.  If you do not possess either the ABIME or AADEP certification, please submit a statement certifying and explaining your familiarity and years of experience in using the AMA’s Guides


Physicians may bill impairment evaluation using CPT Code 99455 or 99456 with ICD-9 code V70.9. Diagnostic services related to impairment evaluations must be billed with the appropriate CPT codes.  Supporting documentation (e.g. medical reports, evaluation reports, assessment reports and diagnostic testing results) must be submitted with the completed Office of Workers’ Compensation Program (OWCP) Health Insurance 1500 Form (OWCP 1500). Reimbursement for these services will be in accordance with the OWCP fee schedule. 


If you have any questions regarding this letter or impairment ratings in general, please contact me directly at (XXX) XXX-XXX.


Thank you for your assistance.






Examiner name

Claims Examiner











U.S. Department of Labor

Office of Workers’ Compensation Programs

Division of Energy Employees Occupational Illness  Compensation



Dear Provider:


Thank you for your interest in participating as a provider of medical services for programs administered by the U.S. Department of Labor’s Office of Workers’ Compensation Programs (OWCP). The OWCP administers the Federal Employees’ Compensation Act (FECA), the Black Lung Benefits Act (BLBA), and the Energy Employees Occupational Illness Compensation Program Act. (EEOICPA).


OWCP has contracted with Affiliated Computer Services (ACS) to provide medical bill processing services to those three programs. As part of their benefit structure, these programs reimburse medical and non-medical providers for services rendered for the care and treatment of a claimant’s compensable condition.


To process your bills, each provider must be enrolled with ACS. Please complete the enclosed provider enrollment form so that a provider identification number can be assigned to you. Instructions for completing the enrollment form and a list of provider types and specialty codes are also included. The Debt Collection Improvement Act of 1996 includes the requirement that payments made by the Federal Government be sent by electronic funds transfer (EFT). EFT payments are mandatory, simplify and speed the billing process and reduce the incidence of billing errors. Therefore, an enrollment form for EFT is enclosed. A remittance advice listing all bills paid on each EFT transaction will be sent to your mailing address.


You must submit current licensure information on the completed enrollment application. Moreover you must maintain appropriate current licensure in order to receive payments under our programs. Where large group practices have providers in the group who are not providing medical services to our program on a regular basis, the group practice is responsible for monitoring the licensure of their entire group.


You may register as a participant in any or all three of OWCP’s compensation programs. Please be sure to send the completed package(s) to the appropriate program(s) at the address (es) listed on P. 2 of the Form OWCP-1168. Please be aware that OWCP, in an effort to assist claimants seeking medical services, is now providing an on-line search capability by one or more of the following: specialty, name, city, state, and zip code. The provider look up feature is meant as a customer service feature for those who may be seeking certain medical services in their area. The FECA program provides search capability for physicians enrolled in their program. In addition to physicians, the EEOICPA program is providing a search capability for home health aides and hospice care. FBLP will include all provider types for the provider lookup with the exception of provider type 53, non-medical vendors from the search. Please advise us in writing when you submit your enrollment application if for some reason you do not wish to be included in this service. Customers using this look-up feature will be advised that this is not an endorsement, referral or an agreement to reimburse for medical services rendered, as the fact that a provider is listed in no way constitutes an endorsement of the provider or that provider's services by the Department of Labor and OWCP. Nor does it guarantee that the medical provider will be reimbursed by OWCP for specific medical services that the provider has billed directly to OWCP or that a medical provider will agree to provide medical services to a particular claimant. The appearance of a specific medical provider’s name in the listing of providers in a certain specialty does not require that provider to treat a particular claimant, even if OWCP has already advised the claimant in writing that medical treatment for a particular condition within the provider’s listed specialty has been authorized.


You will be notified by mail once your enrollment package has been processed. Once you have received your ACS provider number, you may submit your bills to the appropriate program at the following address:


US Department of Labor


P.O. Box 8300

London, KY 40742-8300



P.O. Box 8304

London, KY 40742-8304


DCMWC/Black Lung

P.O. Box 8302

London, KY 40742-8302


If you have any questions regarding this information, please contact us at: 1-850-558-1818. Our business hours are Monday through Friday from 8:00 am to 8:00 pm, Eastern Time.





NOTICE: Please be aware that continued participation as a medical provider under the three DOL programs above is contingent on your maintaining good standing as a medical provider under other federal health benefit programs such as Medicare—exclusion as a medical provider in those circumstances operates as an automatic exclusion under the above- entitled programs administered by OWCP. (See e.g. 20 C.F.R. §§ 10.815, 30.715 and 702.431)