TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Chapter 3-0700 Post-Award Administration
Table of Contents. . . . . . . . . . 09/16 16-12
1 Purpose and Scope. . . . . . . . . . 09/16 16-12
2 Authority. . . . . . . . . . . . . . 09/16 16-12
3 Claims Examiner Responsibilities . . 09/16 16-12
4 National Office Responsibilities . . 09/16 16-12
1. Purpose and Scope. This chapter outlines the actions Claims Examiners (CE) take on Part E cases after a claim has been approved for benefits. The chapter also describes the procedures used by the National Office (NO) to ensure that payment of medical benefits to covered Part E employees is fully coordinated with any state workers’ compensation benefits received by those employees or their survivors.
2. Authority. Section 7385s-11(a) requires that compensation to an individual under Part E be coordinated with state workers’ compensation benefits, other than medical benefits and benefits for vocational rehabilitation, that the individual has received for the same covered illness. The Director of the Division of Energy Employees Occupational Illness Compensation (DEEOIC) has been delegated the authority to request information from state workers’ compensation authorities concerning state workers’ compensation benefits that covered Part E employees receive.
3. Claims Examiner Responsibilities. The CE sends a Form EE-12 letter, accompanied by Form EN-12 enclosure, to each covered Part E employee who receives medical benefits under Part E for a covered illness. These forms are sent on the one-year anniversary of the latest award of any type of Part E benefits, and every year thereafter in which the employee continues to receive medical benefits. The employee must complete and return the EN-12 questionnaire within 30 days.
If the employee does not return the completed form within 30 days, the CE attempts to verify the employee’s contact information in the case file. The CE sends another Form EE/EN-12 and provides the employee with an additional 30 days in which to respond. If the employee does not respond within 30 days, the CE may consider suspending benefits.
Upon receipt of a completed Form EN-12 from an employee, the CE reviews the employee’s responses and takes the appropriate action as noted below.
a. Change of Address. If the employee lists a new address or telephone number, the CE notes the new information in the case file. The CE also ensures that the new contact information is reflected in the Energy Compensation System (ECS).
b. Treatment Concerns. If the employee identifies concerns about the treatment that he or she is receiving for a covered illness, the CE acknowledges these concerns by letter and advises that they are being referred to the appropriate person for further action.
c. Additional Impairment or Wage Loss. If the employee indicates that he or she wishes to claim additional Part E compensation due to increased permanent impairment as a result of an accepted covered illness, or additional compensation for another calendar year of qualifying wage-loss, the CE follows established procedures for facilitating these claims.
d. State Workers’ Compensation. If the employee indicates that he or she has filed for or received state workers’ compensation benefits after the receipt of an award of Part E benefits, the CE ensures that the employee provides all the requested information concerning the state workers’ compensation benefits filed for or received.
e. Tort Awards or Settlements. If the employee indicates that since receiving an award of benefits under Part E, he or she has received a tort award or settlement (other than for a claim for workers’ compensation) in connection with a lawsuit alleging exposure to a toxic substance for which the Part E award was received, the CE ensures that the employee provides all the requested information concerning the tort award or settlement.
4. National Office Responsibilities. At the beginning of each fiscal year, the NO Fiscal Officer (FO) sends a Form EN-13 information request to each state’s workers’ compensation authority advising of the requirement under the EEOICPA that any state workers’ compensation benefits received by a covered Part E employee for an accepted covered illness must be coordinated with Part E benefits received for that same illness, and requesting information about workers’ compensation benefits paid to employees who have been awarded Part E benefits.
Upon receipt from the states, the NO FO must coordinate with each District Office (DO) FO to reassess any need to evaluate a particular claim for coordination with information of payment of state workers’ compensation benefits.
a. Initial Requests. Form EE-13 lists employees who worked at Department of Energy (DOE) facilities in the state in question whose claims for compensation under Part E were accepted during the 12 months preceding issuance of the Form EE-13. For each employee, the list contains the following information:
(1) Name(s) of the claimant(s);
(2) Whether the claimant is the employee or the employee’s survivor;
(3) Social Security Number (SSN) of the employee;
(4) Employee’s accepted medical condition; and
(5) Date the claimant’s eligibility for Part E benefits began.
For each employee listed, the state agency is asked to provide information about any state workers’ compensation claim(s) that was filed on behalf of the same worker, including the name(s) of the claimant(s), whether the claim was accepted, and, if so, the medical condition accepted and the effective date of the award.
b. Subsequent Requests. Form EE-13 also contains a second list of employees for whom information has already been requested by a prior Form EE-13. For each employee on the second list, the state agency will be asked to indicate whether any information provided in response to the initial request has changed.