Federal Employees' Compensation Program
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The Federal Employees’ Compensation Program periodically provides medical providers with information about the FECA program on topics that include medical authorization and bill processing procedures, as well as eligibility for medical services. To receive these updates by email, please sign up for email alerts here.
- Medical Bill Process Portal, Provider Page
- Mailing Addresses:
General Bills, PO Box 8300, London, KY 40742-8300
General Correspondence, PO Box 8311 London, KY 40742-8311 - ECOMP: Providers may upload documentation or correspondence directly to an injured worker’s case file by visiting ECOMP and selecting UPLOAD DOCUMENTS. This does not require a login.
- To speak with a representative about bills or medical authorizations, please call 844-493-1966 (8:00 a.m. – 8:00 p.m. Eastern Time).
- The OWCP Provider Manual is a comprehensive document that has important information on billing, authorizations, enrollment, and program policies.
You must be an enrolled provider to receive reimbursement for treatment of injured federal employees. Enrollment is free and is simply a registration process to ensure proper payments. It is not a PPO enrollment. Without active enrollment, a decision cannot be rendered on authorization requests and bills cannot be processed. Once enrolled, you will receive an OWCP ID that is required in box 33 of a 1500 claim form or box 57 of a UB04 form.
To enroll or learn more information about enrolling visit Provider Enrollment
Once enrolled, you may register for a New Provider Orientation or a Virtual Help Session here: Provider Training
Caring for a Federal Injured Worker with an Accepted Claim – Helpful information for medical providers caring for injured federal workers.
Helpful Hints for Medical Providers – Overview of features, references, and resources available for our medical providers.
Eligibility: Prior to submitting an authorization request, learn how you can check claimant eligibility by visiting: Claimant Eligibility Tutorial
Most routine treatment for accepted conditions such as office visits, x-rays, MRIs without contrast, non-invasive diagnostics, and therapies for a new injury (first 120 days) are a level 1 procedures and do not require authorization.
Level 2 and 3 procedures (like MRIs with contrast and surgeries) require prior authorization. Authorization requests can be submitted via the online provider portal or by faxing a completed authorization request and supporting documentation to 1-800-215-4901.
Authorization Request Templates can be found online.
An Administrative Authorization of Limited Benefits case is a traumatic injury claim that is created and administratively accepted upon receipt, without formal adjudication. When these cases are received, they appear to be minor injuries that result in minimal or no time lost from work. Associated medical expenses are paid up to $1,500 for up to 180 days from the date of injury. These cases may be reopened for formal review and adjudication by the claims examiner if medical treatment is needed beyond the 180th day, medical bills paid will exceed $1,500, a wage loss claim is filed, or surgery is requested.
For an overview of the authorization process, tutorials, forms and references, and FAQS, visit the Provider Authorizations page.
Prescription medication information may be found at the Pharmacy Benefits Management Portal. Claimants and prescribers can access the FECA drug formulary by reviewing formulary documents or by checking prescription coverage on the claimant and prescriber portals. Quick reference guides are available for claimants on how to access formulary documents or check medication coverage after logging into the portal.
A list of NDCs not covered, as outlined in Circulars 18-05 and 19-05, with effective dates is available online.
For an overview of the billing process, tutorials, resources guides, forms and references, and FAQS, visit the Provider Billing page.
The OWCP Medical Fee Schedule is available online. (Scroll down, click License Agreement, then review and click Accept, select the year relevant to the date of service and choose to either View Fee Schedule Files or Download Fee Schedule Files.)
All bills must be timely filed. Timely filing is the end of the year following the date of service or one year from case acceptance.
20 CFR Part 10 Subpart I Information for Medical Providers provides regulations related to Medical Records and Bills, Medical Fee Schedule, and Exclusion of Providers.
Medical providers that have been suspended or debarred may not receive payments under the Federal Employees' Compensation Act. You may review impacted providers online.
For more information visit these sites for FAQs:
Information for Medical Providers
Information on FECA's Consolidated Bill Processing and Medical Authorization Process
OWCP Policy Announcements
The following announcements contain information on OWCP policy pertaining to authorization and payment of specific medical procedures and services:
OWCP has allowed for the provision of telehealth services without interruption and will continue to do so. However, due to the increased use of telehealth, and to ensure consistency and appropriate billing for such services, the Federal Employees’ Program issued a new policy on 10/22/2020 applicable to injured workers receiving medical care via telemedicine for an accepted work related injury. FECA Bulletin 21-08 establishes the routine medical services that are eligible to be provided by telemedicine, and the specific provider types eligible for reimbursement for these services. Covered telemedicine services are analogous with services payable by the Centers for Medicare & Medicaid Services (CMS) but are not inclusive of all CMS approved services. When billed, correct modifiers and place of service indicators are required. In addition, along with the bill for services, appointment notes articulating the method of telemedicine employed, the length of the visit, any information collected, and the need and benefit derived from the appointment must be submitted at the time the bill is submitted for payment.
Effective September 23, 2019, the Federal Employees Program has implemented a new policy applicable to injured workers that are newly prescribed opioid users that will impose additional limitations and reduce the 60-day period for the required prior approval. Injured workers that are newly prescribed opioid users (have not been prescribed an opioid for their work injury in 180 days, if ever) will at the outset be limited to an initial 7-day supply for all opioids. An injured worker may receive a maximum of four sequential 7-day supply prescriptions (an initial and three subsequent prescriptions), a total of 28 days, before prior authorization is required. FECA Bulletin 19-04 (New Opioid Prescribing Guidelines in the FECA Program Limiting Initial Fills to Seven Days and Imposing LMN at 28 Days) outlines these actions.
Please continue to consult our website under "Latest News," for additional updates on our policies, and read carefully any written communications you receive from us. The "Latest News" section on our website will provide additional details prior to implementation. Claimants and their representatives may register to receive periodic email updates regarding this topic, as well as general Federal Employees Program news, on the Claimant and Representative portal. News on billing can be found at the OWCP Web Bill Processing Portal, under "Latest Developments."
In addition, we encourage medical providers to sign up for the Federal Employees Program's email list to receive information about program policies impacting medical authorization.
September 23, 2019
In June 2017, OWCP's Federal Employees Program implemented a policy applicable to newly prescribed opioids. As a result, all new opioid prescriptions lasting more than 60 days require form CA-27, Letter of Medical Necessity (LMN), to be completed by the prescribing physician prior to the authorization of continued prescription of opioids.
We are now instituting a new supplemental policy to address long-term and/or high dose opioid usage. The Federal Employees Program’s Branch of Prescription Management will be examining factors such as the morphine-equivalent dose (MED) and the cumulative, continuous length of treatment in assessing the appropriate action to take in each case. Bulletin 18-04 (Opioid Prescribing Guidelines, Short-Term, Long-Term and High Dose Opioid Use) outlines these actions.
Please continue to consult our website under "Latest News," for additional updates on our policies, and read carefully any written communications you receive from us. The "Latest News" section on our website will provide additional details prior to implementation. Claimants and their representatives may register to receive periodic email updates regarding this topic, as well as general Federal Employees Program news, on the Claimant and Representative portal. News on billing can be found at the OWCP Web Bill Processing Portal, under "Latest Developments."
In addition, we encourage medical providers to sign up for the Federal Employees Program's email list to receive information about program policies impacting medical authorization.
See also: Prior news on FECA's opioid policy
June 18, 2018
OWCP's Federal Employees Program is instituting additional efforts to monitor and manage opioid medication usage, including plans for greater scrutiny of the prescription and utilization of opioid medications. OWCP Federal Employees Program acknowledges that, when prescribed and used appropriately, opioid drugs can provide necessary and safe pain relief to injured workers. However, opioids carry a risk of substance use disorder and accidental overdose. In fact, deaths from prescription painkillers have quadrupled since 1999, killing more than 15,000 people in the U.S. in 20151 Nearly two million Americans, aged 12 or older, either abused or were dependent on opioids in 2014. Appropriate and responsible opioid prescribing and usage saves lives and improves a person's quality of life.
Because the Federal Employees' Compensation Act (FECA) program has safety concerns regarding opioid drugs, we are instituting new procedures to comprehensively review opioid prescriptions for FECA beneficiaries. We strongly urge our claimants and their treating physicians to be mindful of safety concerns relating to opioid medications and to consider alternative drugs that do not pose the same risks for addiction, dependency, and overdose. Furthermore, physicians of patients on opioid dosages over 50 MME/day should consider tapering their dosages according to CDC guidelines: https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf
This policy will be administered in two phases, the first of which addresses FECA claims with newly prescribed opioid use (i.e. claims where an opioid has not been prescribed within the past 180 days, if ever). This policy for newly prescribed opioid use will be implemented in August of 2017. After an initial 60 day period of opioid medication, if an injured worker still needs opioid medication, the treating physician must complete a Certification/Letter of Medical Necessity (LMN) form in order for OWCP Federal Employees Program to authorize any additional opioid medication. All subsequent prescriptions will require that an LMN be received and reviewed by claims staff before opioid medication is authorized and dispensed.
Please be aware that as part of our new policy to address the safety considerations noted above, authorizations for opioid drug prescriptions will be limited to a maximum of 60 days, with initial fills and refills to be issued in no more than 30-day supplies (however physicians are encouraged to prescribe the shortest duration of opioid medication that will provide appropriate pain relief). Providers should utilize "partial fills" for schedule II and schedule III opioids. Please note that no more than two opioids may be authorized at any given time, and concurrent benzodiazepine prescriptions should be avoided to the extent possible. This includes opioid medications included in compounded medications. Additionally, compounded medications containing opioids will require a completed and approved LMN prior to dispensing, effective June 26, 2017.
The second phase will address legacy opioid claims where an opioid claim has been prescribed within the past 180 days. Details on this phase will be forthcoming.
Please continue to consult our website, under "Latest News," for additional updates on our policies, and read carefully any written communications you receive from us. The "Latest News" section on our website will provide additional details prior to implementation. Claimants and their representatives may register to receive periodic email updates regarding this topic, as well as general Federal Employees Program news, on the Claimant and Representative portal. News on billing can be found at the OWCP Web Bill Processing Portal, under "Latest Developments."
In addition, we encourage medical providers to sign up for the Federal Employees Program's email list to receive information about program policies impacting medical authorization. The link can be found on the Medical Provider portal on the Federal Employees Program website.
1https://www.cdc.gov/drugoverdose/data/overdose.html
May 9, 2017
The Division of Federal Employees’ Compensation is requiring an additional data field for all Point of Sale (POS) pharmacy transactions. Effective May 31, 2017, the prescribing provider’s National Provider Identification (NPI) number is a mandatory field for all POS transactions for claimants seeking pharmacy benefits under the Federal Employees’ Compensation Act. POS transactions will be denied for: claims that do not reflect the prescribing provider’s NPI number and/or for claims that reflect an NPI number but the NPI format is not valid.
May 3, 2017
Beginning May 2017, in accordance with the discretion granted to DOL and delegated to the Office of Workers' Compensation Programs (OWCP), the Division of Federal Employees' Compensation (DFEC) is instituting a new policy on filling non-maintenance medications for the treatment of work-related injury or illness. The program's policy will limit the fill of non-maintenance medications to 30 day increments. Additionally, refills cannot be obtained until 75% of the prescription timeline has passed. Maintenance medications (such as those used to treat chronic conditions like high blood pressure and asthma) will not be subject to these limitations. In determining what constitutes a maintenance medication, DFEC will be relying primarily on First Data Bank classifications. Physicians seeking to have the 30 day/75% fill requirement waived for non-maintenance drugs should submit a written request directly to the responsible DFEC district office because there is no method of requesting an exception through the Web Bill Processing Portal. Waiver of the fill requirements for non-maintenance drugs will be authorized on an exception basis only based on approval of the OWCP Chief Medical Officer or his/her designee.
April 12, 2017
Beginning March, 2017, in accordance with the discretion granted to DOL and delegated to the Office of Workers' Compensation Programs (OWCP), the Division of Federal Employees' Compensation (DFEC) is instituting a new policy on herbal supplements prescribed by physicians for treatment of work-related injuries or diseases. The Program's policy will be to not authorize payment for herbal supplements, unless a claimant's treating physician acquires prior authorization by submitting rationalized medical evidence that supports the herbal supplement's safety, effectiveness, and necessity. To implement this policy, OWCP will rely primarily on First DataBank (FDB) classification. Physicians seeking prior authorization for an herbal supplement should submit a written request directly to the responsible District Office as there is no form or other provision for authorization to be requested through the ACS Web Bill Processing Portal. Herbal supplements are authorized only on an exception basis on approval of the OWCP Chief Medical Officer or his/her designee.
March 16, 2017
OWCP's Division of Federal Employees' Compensation (DFEC) has implemented a new prior authorization policy for processing requests for compounded drug medications for claimants under the Federal Employees' Compensation Act (FECA) Program. As noted in previous guidance issued on September 12, 2016, A Letter of Medical Necessity (also referred to as LMN or Form CA-26) must be fully completed by an injured workers' treating physician prior to authorization of any compounded medication by DFEC. Incomplete CA-26s will be returned to the provider without further processing. Authorizations for compounded drug prescriptions will be limited to a maximum of 90 days, with initial fills and refills to be issued in 30-day supplies.
The Letter of Medical Necessity (LMN/Form CA-26) is accessible to OWCP registered providers on the OWCP Web Bill Processing Portal and must be completed by the treating physician and submitted electronically. Instructions on how to submit the LMN are available on the Latest Developments section of the Xerox/ACS website.
Additionally, DFEC recently issued FECA Bulletin No. 17-01, which provides further information on the new policy.
We encourage stakeholders to continue to visit our website and the OWCP Web Bill Processing Portal and/or register on the available portals to receive emails on periodic policy updates.
October 19, 2016
Effective September 25, 2016, TENs Unit Supplies are no longer billable as individual services and must be billed under HCPCS code A4595 (Electrical stimulator supplies, 2 leads, per month). This allowance includes: electrodes (any type), conductive paste or gel, tape or other adhesive, adhesive remover, skin preparation materials, and batteries (9 volt or AA, single use or rechargeable), and a battery charger (if rechargeable batteries are used).
If 2 leads are medically necessary, a maximum of only one unit will be allowed per month for Procedure Code A4595. If 4 leads are medically necessary, a maximum of two units will be allowed per month.
The following HCPCs codes are no longer covered as separately billable services; A4365, A4450, A4452, A4455 A4456, A4558, A4630, A5120, A5126, and A6250. All TENs unit supplies must be billed using HCPCS Procedure Code "A4595."
November 2, 2016
OWCP's Division of Federal Employees' Compensation (DFEC) is instituting additional efforts to monitor and manage compounded drug medications, including plans for greater scrutiny of the prescription and utilization of compounded drugs. OWCP DFEC acknowledges that compounded drugs may be appropriate for a small number of patients who have special circumstances; however, compounded drugs are not subject to the rigorous safety and efficacy testing required for approval by the Food and Drug Administration. There is also evidence that some compounding pharmacies have engaged in fraudulent practices that have both endangered patients and raised the cost of health care for the public.
Because the Federal Employees' Compensation Act (FECA) program has experienced a sharp increase in the use and cost of compound medications and because of safety and fraud concerns regarding compounded drugs, we are instituting new procedures to comprehensively review compounded prescriptions for FECA beneficiaries. We strongly urge our claimants and their treating physicians to be mindful of safety concerns relating to compound medications and to consider them only after careful consideration of FDA-approved, commercially available drugs.
In October of 2016, DFEC will be implementing a new policy that requires an injured worker's treating physician to complete a Certification/Letter of Medical Necessity prior to authorization of any compounded medication by OWCP DFEC. Please be aware that as part of our new policy to address the safety and cost considerations noted above, authorizations for compounded drug prescriptions will be limited to a maximum of 90 days, with initial fills and refills to be issued in 30-day supplies.
Please continue to consult our website, under "Latest News," for additional updates on our policies, and read carefully any written communications you receive from us. The "Latest News" section on our website will provide additional details prior to implementation. Claimants and their representatives may register to receive periodic email updates regarding this topic, as well as general DFEC program news, on the Claimant and Representative portal. News on billing can be found at the OWCP Web Bill Processing Portal, under "Latest Developments."
In addition, we encourage medical providers to sign up for DFEC’s email list to receive information about program policies impacting medical authorization. The link can be found on the Medical Provider portal on the DFEC website.
Finally, we have received anecdotal reports about FECA claimants who have received compound medications that were not prescribed by their authorized treating physician. You should only take medications prescribed to you by your doctor or health care provider. OWCP will continue to work with the Department of Labor’s Office of Inspector General (DOL-OIG), which recently executed federal search warrants on several pharmacies engaged in compounding. If you have received such medications or suspect any related illegal activity, contact the DOL-OIG hotline.
September 12, 2016
The International Classification of Diseases (ICD) is the standard diagnostic tool for health management and clinical purposes and is used to report medical diagnoses and inpatient procedures. On October 1, 2015, the ICD-9 code sets will be replaced by ICD-10 codes. The transition to ICD-10 is coordinated by the Centers for Medicare & Medicaid Services (CMS) in the Department of Health and Human Services (HHS) and is mandatory throughout the country.
ICD-10 codes are alpha-numeric and have different format than ICD-9 codes, thus, providing more detailed information. There are also approximately 68,000 ICD-10 codes, far more than currently available with ICD-9. The benefits of using ICD-10 code sets are:
- Contains an increased number of codes and categories
- Provides more detail and clearer clinical descriptions
- Allows greater accuracy for reporting patient's diagnosis
The Division of Federal Employees' Compensation has commenced work on updating its IT systems to prepare for the ICD-10 transition in time. All data extracts that are routinely sent electronically to employing agencies will be modified for this transition. In addition, all cases created after October 1, 2015 will use ICD-10 codes to designate accepted conditions, and claim examiners will only add ICD-10 codes to the system after that date.
Additional guidance is available in FECA Circular No. 16-01.
Effective February 01, 2015 the Office of Workers’ Compensation Programs (OWCP) Division of Federal Employees’ Compensation (DFEC) will no longer accept CPT code 99070 when the service is billed by a licensed DME provider. If a DME provider submits a bill for DME services utilizing the procedure code 99070, the service will be denied.
(Note: the Division of Energy Employee Occupational Illness Compensation (DEEOIC) Programs implementation of OPPS will be delayed until February 22, 2015)
Effective October 1, 2014, the following Office of Workers' Compensation Programs (OWCP), Division of Federal Employees Compensation (DFEC), will implement a new reimbursement methodology which will be based on the Medicare Outpatient Prospective Payment System (OPPS). The payment method will utilize Medicare's Ambulatory Payment Classifications (APC) as well as the OWCP Fee Schedule. Outpatient bills submitted with a date of service before October 1, 2014, will be priced based on the OWCP Fee Schedule. Outpatient bills submitted with a date of service on or after October 1, 2014 will be priced based on the APC rate and/or OWCP Fee Schedule. The new method will apply to outpatient care in all acute care hospitals, including general hospitals, freestanding rehabilitation hospitals and long-term care hospitals, with the exception of Critical Access Hospitals and Maryland Hospitals. When submitting an OWCP-04 form for Outpatient services, providers will be required to enter their Medicare Number in box 51. If the Medicare Number is missing or invalid, the bill will be denied.
Division of Federal Employees' Compensation (DFEC) Pharmacy Fee Schedule Update
Effective September 1, 2015, the Office of Workers' Compensation Programs (OWCP) Division of Federal Employees' Compensation (DFEC) will be implementing changes to the calculation of the maximum allowable fee for brand name prescription drugs.
OWCP had previously announced the following change to the Division of Federal Employees' Compensation (DFEC) Pharmacy Fee Schedule Update:
The maximum allowable fee for brand name drugs will be calculated at 85% of the average wholesale price (AWP - 15%) plus a $4.00 dispensing fee. The maximum allowable fee for generic drugs and non-drug items is not changing and is calculated at 70% of the average wholesale price (AWP - 30%) plus a $4.00 dispensing fee. The effective date was August 1, 2015. The OWCP has delayed the implementation due to technical difficulties. The new effective date for this change is September 1, 2015.
On October 1, 2015, on a schedule aligned with the Centers for Medicare & Medicaid Services (CMS), the Office of Workers' Compensation Programs (OWCP) implemented the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) code set. For services provided on, or after, October 1, 2015, OWCP will require all providers to use only the ICD-10 code sets. For services provided prior to October 1, 2015, only ICD-9 codes will be accepted. OWCP will not convert current claimant ICD-9 accepted conditions to ICD-10 codes. Claimants will only be given ICD-10 codes for accepted conditions filed on or after 10/1/2015. Providers should submit bills with an ICD-10 diagnosis code(s) that is reflective of the condition(s) being treated.
The Office of Workers' Compensation Programs (OWCP) has released new guidelines implementing service limitations for injection CPT codes 20550, 20551, 20552, 20553, and 20526, which goes into effect August 1, 2013.
CPT codes 20550 and 20551 will reimburse 4 encounters within a 12 month period with no additional encounters for the claimant after that year, and for the same case number.
CPT codes 20552 and 20553 will reimburse 10 encounters within a 12 month period with no additional encounters for the claimant after that year, and for the same case number.
CPT code 20526 will reimburse 3 injections within a 12 month period.
Effective 08/01/2013, The Office of Workers' Compensation (OWCP) will no longer utilize DOL homegrown procedure codes RP120, RP130 AND RP200 (Pain Management). When rendering Pain Management services, providers are to bill and/or submit for prior authorizations using the appropriate HCPCS/CPT codes applicable for the services. Request for prior authorizations for pain management services should include but not be limited to a complete and detailed treatment plan.
Effective June 17, 2012, prescription drugs dispensed from a physician's office, or submitted by non-pharmacy provider’s acting in a capacity as a billing agent for the purpose of dispensing pharmaceuticals, using procedure codes J3490, J8499, J8999, and J9999 will require an accompanying original National Drug Code (NDC), the Days Supply, and the physicians/organizations National Provider Identifier (NPI). All dispensed prescription drugs submitted correctly with the drug's original NDC will process through the Pharmacy Benefits Management System and will be priced based on the date of service in accordance with the published Average Wholesale Price (AWP) or the Medispan Average Wholesale (MAW) benchmark pharmacy rate. Services submitted for any of these codes without an accompanying NDC, Days Supply, line item charge and/or the NPI will be returned back to the sender.
For FECA/Black Lung Program: Any physician dispensed prescription drugs submitted using procedure code 99070 will require an accompanying original National Drug Code (NDC). Services submitted using procedure code 99070 without an accompanying description of the supplies or other materials provided (except spectacles) will be denied.
For Energy Program: Services submitted with procedure code 99070 will be denied. The Energy Program requires a level II HCPCS code.
Effective 03/29/2010 the Office of Workers Compensation Program and the Division of Federal Employees Compensation (DFEC) Program implemented the new "Automated Adjustment Process". This new process will provide the following enhancements in the submission of bill adjustment request, received from the Medical Provider and Claimant community:
- Faster, more efficient processing
- Systematic notification of credit balance(s) owed to DOL
- Automatic recovery of overpayments
- Automated adjustment processing upon receipt of a request.
Additional information and training can be found on the OWCP web bill portal titled "DEFC Automated Adjustment Process".
The US Department of Labor's Office of Workers' Compensation Programs (OWCP) will adhere to the recent decision by the Center for Medicare and Medicaid Services (CMS) that was announced in MLN Matters, #MM6740. Effective March 1, 2010 OWCP will no longer accept the use of the AMA/CPT Consultation codes ranges 99241-99245 and 99251-99255 for inpatient/outpatient facilities and office settings. Any line items submitted with date of service on or after March 1, 2010 will be denied and returned stating “The requested procedure is not a covered service”. For additional information please refer to CMS MLN Matters Number: MM6740 located at: http://www.cms.gov/MLNMattersArticles/downloads/MM6740.pdf
The Department of Labor (DOL), on December 1, 2009, will be implementing a new policy for processing Schedule II drugs for claimants who are identified as recipients of the Federal Employees Compensation Act (FECA) Program. The purpose of the process is to ensure that Schedule II drugs are paid appropriately for patients meeting the following criteria:
- Patients with a cancer diagnosis will continue to be able to receive Schedule II medications in the same manner as today, subject to early refill limitations, including the limitation that a claimant use 75% of the previous fill before being allowed to receive another prescription. However, there will be no limitations on the number of prescriptions of a medication that claimants meeting this criteria can receive.
- Patients without a cancer diagnosis will be limited to only 3 (three) additional prescription re-fills within a 90-day period after the initial fill, and up to a thirty-day supply limitation for each prescription.
In addition to this change, pharmacy providers will also need to begin using Fields 403-D3 Fill Number and 415-DF "Number of Refills Authorized". Currently these fields are not required, but will be required upon the implementation of Schedule II Processing, in addition to the prior requirements of fields; 405-D5(Days Supply), 442-E7 (Quantity Dispensed), and 408-D8 Dispense as Written).
Please begin to prepare your systems for this implementation.
If your pharmacy submissions are being submitted through a Third Party Billing agency, please advise those parties of this change.
Effective 12/05/10, the fee schedule allowance for anesthesia services will be based upon the formula: (Time Units + Base Units) x Conversion Factor. In addition, every anesthesia procedure billed to OWCP must include one of the following modifiers: AA, QY, QK, AD, QX, or QZ. When multiple procedures are performed during a single anesthetic administration, reimbursement is based on the line item representing the most complex procedure.
The Office of Worker's Compensation (OWCP), Federal Employees Compensation Program; effective 07/01/2010 will no longer utilize DOL homegrown procedure code RP100 (Pain Management). When rendering Pain Management services, providers are to bill and/or submit for prior authorizations the appropriate HCPCS/CPT codes applicable for the services. Request for prior authorizations for pain management services should include but not be limited to a complete and detailed treatment plan.
The use of CPT 97799 (Unlisted physical medicine/rehabilitation service or procedure) and CPT 99499 (Unlisted evaluation and management) are not options to be used. The use of an unlisted code will be reviewed for appropriateness, when the provider submits a written explanation for the use of the unlisted code; which must include; service(s) rendered that can not be fully described from any of the HCPCS/CPT coding schemas.
On May 3, 2011, The Department of Labor (DOL) implemented a new policy for processing Schedule II drugs for claimants who are identified as recipients under the Federal Employees Compensation Act (FECA) Program. Patients who do not have a diagnosis of cancer as an accepted work-related medical condition and have not received a fentanyl prescription in the past six months will no longer be able to receive fentanyl prescriptions, except for Duragesic. Patients with a diagnosis of cancer as an accepted work-related medical condition will continue to be able to receive Schedule II medications, including fentanyl products, in the same manner as today. All Schedule 2 prescriptions continue to be subject to early refill limitation and days' supply limitations. This includes the requirement that a claimant use 75% of the previous fill before being allowed to receive another fill of the same Schedule 2 medication and that a Schedule II fill be limited to 30 days. Please contact the PBM call center @ 866-664-5581 with any questions about these changes.