Division of Federal Employees' Compensation (DFEC)
FECA Bulletins have been divided into five-year groups to make it easier for you to search and find the information you are looking for.
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Bulletin |
Subject |
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Medical--Use of Physicians Directory System (PDS) |
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Bill Payment/BPS - Bill Batch Numbers (05/00A) |
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New Regulations – Privacy Act (11/99B) |
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ADP - Formal Decisions/Concurrent Conditions (11/99B) |
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Comp Pay--Extra Pay for Firefighters (06/00A) |
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Debt Collection: Perpetual Debts. Dual Benefits (includes Computer Matches) (01/00A) |
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Compensation Pay: Compensation Rate Changes Effective January 2000 (01/00A) Corrected Copy: (03/00A) |
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Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 2000 (02/00A) |
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BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment (02/00A) |
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Bill Payment/BPS - Correct Coding Initiative, Part B. (03/00A) |
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Automated CA-110, Telephone Message (04/00A) |
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Reporting Injuries--Electronic Submission of Forms CA-1 and CA-2 (05/00A) |
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Compensation Payment - Change of Address in ACPS and CMF (04/00A) |
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COP Nurse Intervention (05/00B) |
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Bill Payment/BPS - Pharmacy Fee Schedule Change (09/00C) |
Back to FECA Bulletins (1996-2000) Table of Contents
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Bulletin |
Subject |
|---|---|
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BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment (10/98B) |
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Case Management--Medical Queries by Contract Nurses (05/99A) |
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Case Management/ADP: Guidelines for Periodic Roll Management (12/98A) |
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Bill Payment/BPS - Medications Which Do Not "Match" Accepted Conditions (11/98B) |
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Case File Imaging (06/99A) |
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New Regulations - Continuation of Pay (01/99A) |
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New Regulations - Subpart I - Information for Medical Providers (01/99A) |
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New Regulations - Privacy Act (01/99A) |
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New Regulations - Attendant's Allowance (02/99A) |
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New Regulations - Continuing Benefits (02/99A) |
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New Regulations - Compensation and Related Benefits (02/99A) |
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New Regulations - Reconsiderations and Reviews by the Director; Reviews by the Employees' Compensation Appeals Board (02/99A) |
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New Regulations - Medical and Related Benefits (02/99A) |
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New Regulations - Representative Fees (02/99A) |
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New Regulations - Withdrawal of Claims (03/99B) |
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New Regulations - Filing Notices and Claims; Submitting Evidence (03/99A) |
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Compensation Pay: Compensation Rate Changes Effective January 1999 (01/99A) |
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Forms - Revised Form CA-7, "Claim for Compensation" (01/99A) |
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Comp Pay/COP - Sunday Premium Pay (01/99A) |
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Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1999 (01/99B) |
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Bill Payment/BPS - Modifications to Inpatient Hospital Bill Procedures (01/99B) |
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Medical Examinations: Obstruction/Refusal - Suspension under Section 8123(d) (02/99A) |
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Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1999 (02/99A) |
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Medical Evidence: Appropriate Contact with Medical Specialists (02/99A) |
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Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment (04/99A) |
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District Office Use of Nurses Providing Telephonic Services (06/99A) |
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Bill Pay/BPS - Authorization of High Dollar Medical Bills (06/99B) |
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Return to Work--Temporary Assignments During Recovery (08/99B) |
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Bill Payment/BP - Correct Coding Initiative, Part A. (08/99A) |
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Third Party--Claims from Certain Census Workers (08/99B) |
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Bill Pay/BPS - Data Entry of Inpatient Hospital Bills (09/99A) |
Back to FECA Bulletins (1996-2000) Table of Contents
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Bulletin |
Subject |
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Case file and Bill Batch Imaging (12/97A) |
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ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1998 (01/98A) |
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Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1998 (02/98A) |
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Bill Payment/BPS - New Edits for Procedure Code Dates of Validity (03/98A) |
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Bill Pay/BPS - Supervisory Sampling of Bills (03/98A) |
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Debt Collection: Referrals to the Department of Treasury (05/98A) |
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Compensation Pay: Compensation Rate Changes Effective January 1998 (01/98B) |
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November 1997 DFEC/OPM Computer Match (04/98A) |
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Performance of Duty--Alternative Worksites (05/98) |
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Bill Payment/BPS - Preparations for Changes to Pharmacy Bill Processing (07/98A) |
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Bill Payment/BPS - Bill Processing Modifications (08/98A) |
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Codes--New QCM Code in Cases Where Claimant is Reemployed in Unclassified Job (09/98A) |
Back to FECA Bulletins (1996-2000) Table of Contents
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Bulletin |
Subject |
|---|---|
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Comp Pay--Direct Deposit |
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ADP - "Reengineered" Coding Scheme and Data Entry for the Quality Case Management (QCM) System |
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ADP - New Case Management File (CMF) Data Elements and New "Case Create" and "Case Change" Coding Requirements |
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Comp Pay--Elimination of Short-Term Roll and Code PI Rehabilitation--Elimination of Code PV |
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ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1997 |
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Fiscal--Updates of Cash Deposits and Cancelled Check Items into the BPS and ACPS History Files (02/97A) |
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Compensation Pay: Compensation Rate Changes Effective January 1997 (02/97A) |
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Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1997 (02/97A) |
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Dual Benefits - Deduction from FECA benefits of Social Security Benefits "Attributable to Federal Service" in FERS Cases (02/97A) |
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Case Doubling (03/97A) |
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District Office Use of Nurses Providing Telephonic Services (03/97A) |
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February 1997 DFEC/OPM Computer Match (05/97A) |
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Contract Observers on Vessels |
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Bill Pay -- Travel Expenses (07/97A) |
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Felony Imprisonment Cases - Reporting Requirements (09/97A) |
Back to FECA Bulletins (1996-2000) Table of Contents
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Bulletin |
Subject |
|---|---|
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Codes--Nature of Injury Codes in Cases for Occupational Illness |
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Dual Benefits--Severance and Separation Pay |
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Excluded Provider Changes |
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September 1995 DFEC/OPM Computer Match |
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ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1996 |
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Case Management--Role of Registered Nurses in QCM Cases |
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Compensation Pay: Compensation Rate Changes Effective January 1996 |
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Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1996 |
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Occupational Rehabilitation Programs (ORPS) |
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Adjudication of Claims: Use of Incorrect Form |
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Compensation - Revised Leave Buy-Back Procedures |
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OWCP Guidelines for General Purpose Functional Capacity Evaluations |
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BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment |
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Employees' Compensation Appeals Board--New Address (07/96B) |
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Forms--Distribution of FECA Customer Service Brochure (08/96A) |
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Bill Payment/BPS - Physical Therapy Authorizations (09/96A) |
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Impairment/Schedule Awards: Further Issues in Computing Awards Using the Fourth Edition of the AMA Guides (09/96B) |
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 00-01
Issue Date: November 5, 1999
Expiration Date: November 4, 2000
Subject: Medical--Use of Physicians Directory System (PDS)
Background: The PDS was originally developed to ensure that referee medical specialists would be chosen in a fair and unbiased manner, and this goal remains as vital as ever to the integrity of the Federal employees' compensation program.
Although the regulations do not impose the same rigorous requirements for second opinion medical examinations, it is the policy of the Office of Workers' Compensation Programs (OWCP) to ensure that such examinations be of the highest quality possible, and that the selection process for second opinion specialists be fair and well documented. Enhancements in the structure and use of the PDS will improve our ability to achieve those goals.
The PDS User Guide, which was published in 1991 and updated in 1993, was recently added to Folioviews as a new infobase. As it stands, this document is probably more useful from a systems viewpoint than for medical schedulers, and it does not explicitly address the role of the district office managers who are charged with overseeing the use of the PDS in their respective offices.
For these reasons, it seems desirable to provide policy guidance for managers and claims staff in addressing bypasses, additions and suspensions (previously termed "inactivations") from the system. Also, because several years have elapsed since the PDS was released and training was provided in its use, basic instruction in the use of the system for medical schedulers will shortly be provided in the form of an FECA circular.
Each district office's PDS database will soon be updated with current information (telephone numbers and addresses) for all physicians now active in the specialties previously included, as well as current information for physicians newly active in those specialties. The update will also contain listings of physicians in several new specialties and subspecialties. All specialties and subspecialties, including those newly added, are shown in Attachment 1.
On a one-time basis, the National Office will send form letters to all physicians whose PDS records are currently annotated "DOL-N" asking whether they are now willing to participate in the program. The results will allow the PDS Administrators to update their respective databases.
When the PDS User Guide is revised to include the material in this bulletin and its companion circular containing instructions for using the PDS, it will be reorganized to reflect the different responsibilities of medical schedulers, district office managers, and claims staff. Guidance for the PDS Administrator (usually the Systems Manager) will remain in its current form.
Reference: PDS User Guide; Federal (FECA) Procedure Manual, Chapter 3-500
Purpose: To provide guidance to district office personnel with respect to the use and maintenance of the PDS
Applicability: Claims Examiners, Senior Claims Examiners, All Claims Supervisors, Medical Schedulers, District Medical Directors, Technical Assistants, Systems Managers, Staff Nurses, and Vocational Rehabilitation Specialists
Action:
1. Roles and Responsibilities. The following individuals are responsible for the indicated actions in PDS:
a. Medical Scheduler. This individual is responsible for all entries in the PDS relating to scheduling specific medical appointments, including bypass codes and updating telephone and address records for physicians in the system. Only the medical scheduler(s) should select physicians; claims staff should not have access to the system.
b. DO Manager. This individual may be the District Director or designee, and contacts with physicians may be assigned to an in-house District Medical Director, at district office option. The DO Manager is responsible for evaluating complaints about specific physicians and problems with the quality and timeliness of their reports. He or she is also responsible for authorizing the addition and suspension of specific doctors. The DO Manager will have a password which will allow him or her to make these changes and also to designate a specific physician for a second opinion examination (but not for a referee examination).
c. Claims Staff. Claims Examiners (CEs) are responsible for ensuring that referee and second opinion medical specialists are chosen through PDS. They are also responsible for advising the DO Manager about medical reports which are of poor quality or very untimely, as well as complaints received from employees.
2. Medical Scheduler. The following guidance is intended to address various problems which may arise in scheduling referee and second opinion examinations.
a. Alternate Zip Codes. The zip code used should normally be that of the employee's home address, though the duty station may be used for good cause, for instance if the employee lives in a rural area and the duty station is located in an urban area with more physicians. Other zip codes should not be used unless:
(1) No physicians in the employee's zip code practice the necessary specialty. In this instance, PDS will select the closest neighboring zip code. Since zip codes are not always contiguous, it may be necessary to check a zip code map (available from the Postal Service) to find the neighboring zip code.
(2) The employee has requested an examination elsewhere. For instance, if the employee will be away from home temporarily, the zip code of the temporary location may be used.
b. Bypass and Suspension Codes. If a bypass code is used, the physician will be eliminated from consideration for a single rotation through the list. If a suspension code is used, the physician will no longer appear in rotation. While the Medical Scheduler may use bypass codes, the DO Manager must authorize any suspension from the PDS database, except for codes M, R, and P. (Suspension codes are shown in Attachment 2.)
If a physician states that he or she is not interested in taking cases from OWCP, the scheduler should ask why.
(1) If the answer reflects a short-term concern, the scheduler should find out when the physician will be able to accept cases from OWCP. For example, if the physician says he or she cannot take any new cases because the practice is totally booked and expected to be so for the next several months, a bypass code "B" should be used.
(2) If the answer reflects a more substantive concern, the scheduler should attempt to address the concern if possible. For example, physicians sometimes think that OWCP may ask them to defend their reports in court. Once they understand that this is not the case, the physician may agree to perform the examination.
However, if the physician clearly does not want to accept cases from OWCP, the medical scheduler should so advise the DO Manager, who can authorize use of the DOL "N" code to suspend the physician from rotation.
c. Interaction with Claims Staff. When an appointment has been scheduled, the medical scheduler should print a copy of the appointment screen and include it in the case file. A copy of this screen will need to appear in the case file.
Any request by a CE to select, or refrain from selecting, a particular physician should be referred to the DO Manager.
d. Interaction with DO Manager. The medical scheduler should inform the DO Manager of any unreasonably late reports. Also, any physician who asks the scheduler to be added to the PDS database (or other party who contacts the scheduler on a physician's behalf) should be advised to submit a copy of the physician's curriculum vitae (CV) to the DO Manager for consideration of inclusion in the system.
3. District Office Manager. With the new PDS database, the designated manager will need to be scrupulous about ensuring that the database is kept current.
a. Adding a Physician. The CV of any physician who expresses interest in being added to the PDS, or who is identified as appropriate by an OWCP nurse or other staff member, should be forwarded to the DO Manager, who will determine if the physician is board-certified in one of the acceptable specialties. (This must be verified with the State medical board, or with the American Board of Medical Specialties (ABMS), whose certification line can be reached at 800-776-2378 or at www.certifieddoctor.org.)
If the physician is board-certified, the DO Manager may authorize addition of the physician to the database, after ensuring (through use of the View or Browse function) that the physician is not already present on the database.
The DO Manager should retain all CVs received in an administrative file.
b. Suspending a Physician. A physician should seldom be suspended from the PDS, since bypass codes cover most situations. Only when the conduct of the physician is in question, or the quality and/or timeliness of his or her reports is at issue, should suspension be considered. The suspension codes are shown in Attachment 2.
Suspension from the PDS is very different from exclusion by regulation. A physician who is suspended from PDS will not be considered for referee and second opinion examinations, but may still continue to serve as an attending physician. A physician who is excluded from the program will be barred from receiving payment for any service to any employee.
c. Canvassing "DOL-N" Physicians. Periodically, the DO Manager will send a form letter asking all physicians in the DO's jurisdiction who have stated that they are unwilling to accept OWCP cases if they will reconsider their position in this matter. For those physicians who agree to accept OWCP cases, the DO Manager will authorize a change in the DOL flag from "N" to "Y".
d. Poor Quality. A physician can be suspended based upon the quality of his or her report. The DO Manager should review the documentation forwarded by the CE and decide whether suspension is proper.
If this is the first time such problems have occurred with this physician, the DO Manager should contact the physician and discuss the issues. The DO Manager should maintain an administrative file which documents the complaint and the discussion.
If more than one complaint has been received about the same physician, the DO Manager should decide if a pattern of unsatisfactory reports exists. If so, the physician should be suspended with a note indicating the reason and activate the "Completeness" flag in PDS.
e. Lack of Timeliness. A physician can also be suspended based on the timeliness of a report. The DO Manager should review the information forwarded by the medical scheduler with respect to any unreasonably late reports and decide whether suspension is proper.
For example, if a physician provides a report one month late on a complex case, the DO Manager may choose to document his or her administrative file but not to suspend the physician. On the other hand, if a physician takes several months to provide a report after many calls from OWCP, or provides no report at all, the DO Manager should suspend the physician and include a note citing the specifics of the incident.
f. Other Complaints. The DO Manager is responsible for reviewing all reports of other kinds of complaints, and for taking action if needed.
If a physician has performed multiple examinations before without reported problems, and the complaint does not appear to be supported by the evidence in the case file, the DO Manager may choose not to act on the complaint.
By contrast, if another complaint has recently been lodged against this physician, and both complaints have been supported by the case files in question, the DO Manager should authorize the suspension of the physician with a note indicating the reason.
No minimum number of complaints need be lodged before suspension. One complaint, if severe enough, can be enough to suspend a physician. Copies of the complaints supporting suspension should be kept in an administrative file.
4. Claims Staff.
a. Second Opinion Examinations. District offices that use PDS for second opinion examinations must henceforth ensure that all such examinations are scheduled through PDS. As with referee medical examinations, the CE should indicate the type of specialty required. The CE should refrain from making a specific request to select or not to select a certain physician.
Ordinarily, the scheduler will attempt to make the appointment within 60 days. The CE should indicate any special time frame within which the examination is required.
b. Copy of Appointment Screen. When the medical scheduler has made the requested appointment (for either a referee or second opinion examination), he or she will run a copy of the appointment screen and drop it in the case file. This screen print must be placed in the case file to document that the physician who performed the examination was selected through PDS.
c. Physicians Suggested by OWCP RNs. OWCP field nurses occasionally suggest physicians who can perform evaluations. This practice may continue, with the understanding that the evaluation represents a consultation, and not an OWCP-directed second opinion examination. A physician suggested by an OWCP staff nurse may be added to the PDS (and therefore used for second opinion and referee examinations) if the physician's CV is obtained and the DO Manager agrees.
An employee who declines to attend an examination arranged by an OWCP nurse may not be sanctioned for failure to do so. Only refusals to attend OWCP-directed examinations may be sanctioned.
d. Complaints. All complaints must be made in writing. If the employee complains about the conduct of the physician during the examination, the CE should forward the complaint and copies of the report, the statement of accepted facts (SOAF), and the questions to the physician, to the DO Manager (through an intermediate supervisor, if any, at district office option). The DO Manager will review the complaint and take any action necessary.
e. Poor Quality. A report may be considered inadequate for any of several reasons, including failure to address the questions posed, failure to provide an opinion within the framework of the SOAF, and/or failure to provide a response to additional questions.
If such problems occur, the CE should work with the physician to obtain the necessary information. However, the CE should also advise the DO Manager that an inadequate report has been received (again, through an intermediate supervisor, if any, at district office option). The notification should include a copy of the medical referral letter, the SOAF and questions, and the medical report.
5. Instruction and Evaluation.
a. Training. All claims staff, medical schedulers, Staff Nurses, and District Medical Directors are to be trained in the procedures set forth above within 30 days of the date of this bulletin.
b. Reports. The National Office will develop new reports to evaluate compliance with the requirements set forth in this bulletin. These reports may be incorporated into the accountability review process.
Disposition: Retain until the indicated expiration date.
NANCY L. RICKER
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
ATTACHMENT 1 - PDS DESK AID - Specialty/Subspecialty Codes
|
Code |
Description |
|---|---|
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AI: |
Allergy and Immunization |
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AN: |
Anesthesiology |
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PN: |
Pain Management |
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CR: |
Colon/Rectal Surgery |
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CV: |
Cardiovascular |
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DE: |
Dermatology |
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EM: |
Emergency Medicine |
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FP: |
Family Practice |
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GE: |
Gastroenterology |
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GS: |
General Surgery |
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HE: |
Hematology |
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HS: |
Hand Surgery |
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ID: |
Infectious Disease |
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IM: |
Internal Medicine |
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SM: |
Sports Medicine |
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ED: |
Endocrinology, Diabetes |
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MO: |
Medical Oncology |
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MT: |
Medical Toxicology |
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NE: |
Neurology |
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NM: |
Nuclear Medicine |
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NP: |
Nephrology |
|
NS: |
Neurosurgery |
|
OG: |
Obstetrics and Gynecology |
|
OM: |
Occupational Medicine |
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OS: |
Orthopedic Surgery |
|
OP: |
Ophthalmology |
|
OT: |
Otolaryngology |
|
PL: |
Plastic Surgery |
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PD: |
Pulmonary Disease |
|
PM: |
Physical Medicine |
|
PS: |
Psychiatry |
|
AP: |
Addiction Psychiatry |
|
RA: |
Radiology |
|
RH: |
Rheumatology |
|
TS: |
Thoracic Surgery |
|
UR: |
Urology |
|
VS: |
Vascular Surgery |
The specialties represented by the following new codes are used very rarely. To schedule an examination using one of them, contact Patricia Wood in the National Office at 202-693-0035.
|
Code |
Description |
|---|---|
|
CP: |
Clinical Pathology |
|
CH: |
Chemical Pathology |
|
CY: |
Cytopathology |
|
MM: |
Medical Microbiology |
|
NU: |
Neuropathology |
|
PA: |
Anatomic Pathology |
|
CH: |
Chemical Pathology |
|
CY: |
Cytopathology |
|
MM: |
Medical Microbiology |
|
NU: |
Neuropathology |
|
PR: |
Radiologic Physics |
Back to Top of FECA Bulletin No. 00-01
|
Code |
Description |
|---|---|
|
B: |
The doctor can't give an appointment in a reasonable amount of time, or the doctor is on long vacation or leave of absence. |
|
C: |
The physician (or his or her associate) was previously associated with the case, or the physician does fitness-for-duty exams for the employee's agency. |
|
L: |
The physician is too far for the employee to travel. |
|
M: |
The physician moved out of zip code area. |
|
S: |
Need a different sub-specialty. |
|
O: |
Other. (Requires a note explaining the reason.) |
|
Use of codes B and O will result in the appearance of a notes window, with the prompt Update DR Notes. |
|
|
Suspension Codes: |
|
|
M: |
Physician moved out of district office's jurisdiction (to be used only when the physician's new address is unknown. Otherwise, the new address should be entered so that it can be made available to the new district office when the PDS database is next refreshed.) |
|
R: |
Physician deceased or retired from practice |
|
P: |
The physician's phone number is missing or wrong, and directory assistance cannot provide a better number. |
|
E: |
Physician excluded under regulations or lost license |
|
D: |
Duplicate of another record |
|
T: |
Timeliness |
|
Q: |
Quality |
|
C: |
Complaint |
|
F: |
Fee |
|
O: |
Other |
|
DOL "N": |
Physician definitely unwilling to take DOL cases. |
Back to Top of FECA Bulletin No. 00-01
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 00-02
Issue Date: May 10, 2000
Expiration Date: May 9, 2001
Subject: Bill Payment/BPS - Bill Batch Numbers
Background: In the next several weeks, DFEC will be preparing to migrate from the Data General software that was previously used for bill batch scanning and the ECAB Pilot to the Kofax software that is used in OASIS (OWCP Automated System for Imaging Services) for bill batch scanning. Offices will use this new software for bill batch scanning well before most offices have OASIS for case files.
As part of this migration, DFEC must use a consistent structure for bill batch identification numbers, to enable proper storage of the bill batches, and retrieval by the users. In the past, each district office has developed its own bill batch numbering scheme. Under the new structure, while some customization is possible, certain elements must be consistent throughout all offices.
Reference: Federal (FECA) Procedure Manual Chapters 5.0200.10 and 5.0201.2.d(3).
Purpose: To communicate new requirements for bill batch numbering.
Applicability: All bill processing and imaging staff, including data entry, bill resolution, fiscal and mail room personnel.
Actions:
1. Effective May 15, 2000, bill batch numbering schemes and batch sizes must conform to the requirements as outlined in items 2 - 9 below. These requirements are applicable only to bills that are imaged. Bill batch numbers used for other purposes (such as adjustment input) need not follow the revised scheme.
2. The first two characters (numeric) will represent the District Office. This portion of the ID is used for the imaging system only, and is not part of batch number that is keyed into the FECS programs. These characters should be the same as the prefixes used for case file numbers (01 for Boston, 02 for New York, etc.)
3. The third character (numeric) will be the last digit of the current year. For the current year, it will be 0 (zero).
4. The fourth character (alpha) will represent the current month, with A for January, B for February, etc., through L for December.
5. The fifth through eighth characters will be assigned by each district office. The office may choose to assign this portion of the batch number sequentially, or use it to designate other information, such as the type of batch, or the date of processing. For example, bill batches created in Jacksonville in March, 2000, could be assigned batch numbers as follows:
|
Imaging Batch ID |
Bill Processing Batch ID |
|---|---|
|
060C0001 |
0C0001 |
6. The bill processing batch ID (third through eighth characters) is entered into FECS applications.
7. All one-sided bills should be scanned using simplex mode (one-sided scan only), to reduce costs. At a minimum, all HCFA-1500 and UB-92 bills should be scanned in simplex mode.
8. No bill batch should be larger than 50 pages. Bills scanned in simplex mode will count as one page each. Bills scanned in duplex mode will count as two pages for each sheet of paper, since both the front and back will be scanned.
9. From time to time, there is confusion between the number 0 (zero) and the letter O (oh), and between the number 1 (one) and the lower-case letter l (el). The letter O should not be used in a bill batch ID. All alpha characters should be upper case.
10. Further information concerning OASIS will be provided under separate cover.
Training on this Bulletin should be completed as soon as possible.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
DEBORAH B. SANFORD
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3 - Folioviews Groups A,B,C, and D (All FECA Employees)
Back to Top of FECA Bulletin No. 00-02
Back to FECA Bulletins (1996-2000) Table of Contents
THIS SUPERCEDES BULLETIN 99-08, ISSUED JANUARY 4, 1999
FECA BULLETIN NO. 00-03
Issue Date: November 1, 1999
Expiration Date: November 1, 2000
Subject: New Regulations – Privacy Act
Background: FECA Bulletin No. 99-08, issued January 4, 1999, discussed new regulations involving the handling of requests submitted by FECA claimants under the Privacy Act. Paragraph five of that bulletin erroneously indicated that a claimant's access to his or her FECA claims file could be denied in only two situations. Additionally, paragraph six indicated, in error, that the 90-day appeal time did not begin to run until the requester received the denial letter. The 90-day period runs from the date of the denial. In light of these misstatements, the bulletin has been revised.
Reference: 20 CFR §§ 10.10 through 10.13 (1999); 29 CFR Part 71 effective December 1, 1998 (63 FR 56740 (October 22, 1998)).
Purpose: To inform OWCP staff, employing agencies and other interested parties of Privacy Act compliance requirements.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistance and Systems Personnel, and Hearing Representatives.
Action:
1. All records in OWCP claim files and all copies of records relating to an on-the-job injury that are in the possession of the employer are considered to be OWCP records covered by the Privacy Act system of Records DOL/GOVT-1. Although employing agencies may establish procedures employees must follow to obtain access to employer-maintained records, any decision to grant or deny access must comply with Department of Labor rules and regulations.
2. Under the amended regulations, only OWCP may respond to requests for the correction or amendment of any FECA-related record. Employing agencies must forward any request they receive seeking to correct or amend such a record to OWCP.
3. The subject of a FECA file is entitled to receive the first copy of the file at no cost. The same rule would apply if the claimant requests copies of any documents not previously provided. OWCP or an employing agency may charge $.15 per page for each additional copy requested.
4. he filing of a request, or multiple requests, for more than one copy of a Privacy Act record will be viewed as an agreement by the requester to pay all applicable fees up to $25.00. When acknowledging a request, the disclosure officer should confirm this agreement by letter to the requester. The requester must be consulted before higher fees are assessed.
5. OWCP may require payment in advance of fees over $250.00. If such a fee is anticipated, a letter should be sent to the requester, noting the amount of the projected fee and advising the person that a designated staff person may be contacted to assist him or her in reformulating the request so that his or her needs may be met at a reduced cost.
6. OWCP may refuse to process any request submitted by an individual who has failed to pay an earlier fee, until the earlier fee is paid.
7. Any decision approving or denying a Privacy Act request must be in writing and signed by the designated Privacy Act disclosure officer. District Directors have been designated as OWCP disclosure officers. If copying of the requested documents will be delayed, an interim response should be sent indicating the reason for the delay and the date on which the documents will be mailed to the requester; this also should be under the signature of the disclosure officer.
8. As a general rule, the claimant may have access to each document in the claim file. There may be exceptions, however, such as where disclosure of medical records may be harmful to the individual. If there is question, the District Office should contact the appropriate regional office of the Solicitor of Labor to determine whether a document or documents may be exempt from disclosure. It should be noted that a request for access by the subject of the claim file shall not be denied unless both a Privacy Act exemption and a Freedom of Information Act exemption apply to the requested document(s).
9. If access to a particular record(s) is being denied, including those cases where OWCP is unable to find the requested record, the letter denying the request should include a statement of the reasons why access is being denied, and should cite to the specific statutory exemption applicable to the request.
10. When a request is denied, in whole or in part, the letter should advise the requester that he or she may, within 90 days of the date of the denial, file an appeal with the Solicitor of Labor. The appeal must be in writing and addressed to the Solicitor of Labor, United States Department of Labor, 200 Constitution Avenue, N.W., Room N-2428, Washington, D.C. 20210-0002. The requester should also be told that both the letter and the envelope should be clearly marked "Privacy Act Appeal."
11. Even if the Disclosure Officer believes that all requested documents are being provided, the letter transmitting the documents should advise the requester that if he or she does not believe the letter to be fully responsive to the request, an appeal may be filed by writing to the Solicitor of Labor within 90 days of the decision. The letter should be sent to the address set forth in Item 10. Please no longer use the letter attached to FECA Bulletin 99-08.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
NANCY L. RICKER
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D. (All FECA Employees)
Back to Top of FECA Bulletin No. 00-03
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FECA BULLETIN NO. 00-04
Issue Date: November 19, 1999
Expiration Date: November 18, 2000
Subject: ADP - Formal Decisions/Concurrent Conditions
Background: The new imaging system, OWCP Automated System for Imaging Services (OASIS), will change the process by which case files are handled. The purpose of this system is to provide DFEC staff with an electronic case file to use in place of a paper file. Implementation of this system will have an impact on all phases of district office procedures for claims processed under OASIS. Since documents imaged under OASIS will be read-only files, no data entry will be permitted. Consequently, no CA-800 will be created for claims imaged through OASIS. While the FECS currently permits input of pay rate history, there was no automated tracking of concurrent medical conditions or formal decisions. Therefore, a new FECS screen has been developed to allow CE's to input concurrent conditions and formal decisions.
Purpose: This bulletin will provide guidelines for accessing and using the new Formal Decisions/Concurrent Conditions screen.
Applicability: Claims Examiners, Supervisors, System Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses.
Action:
Use of the Decisions/Concurrent Conditions screen is now mandatory. Concurrent conditions must be input for all newly created cases and all formal decisions issued after the date of this bulletin must be input. However, CA-800's will continue to be produced for non-imaged cases.
Accepted conditions for claims should be input into Case Management, Option #9 – Status/Accepted Conditions as is currently done. However, concurrent conditions must now be entered in Option #42 DECISIONS/CONCURRENT CONDITIONS of the Case Management menu. The F1 key permits a condition to be entered in text form. No ICD-9 coding is required. The F3 key permits modification of a line of text and the F5 key deletes a line of text. Instructions will appear at the bottom of the screen.
Any formal decision that is released must now be entered into Option #42 DECISIONS/CONCURRENT CONDITIONS. The F9 key permits toggling between the Case Decision Update and the Concurrent Conditions Update portions of the screen.
The date a formal decision is released must be noted in the DECSN DATE field. This is a required entry with the format of MM/DD/YYYY.
Valid entries for the TYPE of decision will be displayed in a drop down menu as follows:
D = District Office
R = Reconsideration
H = Hearings and Review
E = ECAB)
An entry in this field is required.
Valid entries for the ISSUE field will also be displayed in a drop down menu as follows:
01-Time
02-Civil Employee
03-FOI-Factual
04-FOI-Medical
05-Causal Relationship/No Residuals
06-Continuing Injury Related Disability
07-POD
08-Recurrences
09-Schedule Award-Paid
10-Schedule Award-Denied
11-Overpayment
12-COP
13-LWEC - 0%
14-LWEC - Actual Earnings
15-LWEC - Constructed
16-Refusal/Obstruction of Medical Exam
17-Denial of Medical Treatment/Surgery
18-Failure to Accept Suitable Employment
19-Forfeiture
20-Non-cooperation with Rehab/Nurse Efforts
21-Recon Decision-Not Merit Review (ECAB decisions only)
22-Denial of Hearing
23-Recission
24-Third Party
25-Other
Again, an entry in the ISSUE field is required.
An entry in the DISP field is required. Valid entries will again appear in a drop down menu as follows:
D = Denied
A = Affirm
R = Remand
V = Reverse/Vacate
B = Affirm/Remand (affirmed in part and remanded in part)
N = Non-merit Review
C = Acceptance (adverse decision only)
M = Modified
The use of the same issue code, in conjunction with dates, will link an appeal decision to the appropriate adverse decision on a claim. For instance, a claim may be denied initially due to causal relationship and have a decision from Hearings and Review, several reconsiderations and a decision by the ECAB. The issue code would remain causal relationship as long as that is the decision being appealed.
An entry into both the EXAM and CERT fields is required. Both the examiner and the certifier will use the location code assigned to them by their district office.
No entry is required in the EXAMINIT or CERTINIT fields. Use of examiner's initials and certifier's initials fields will be at the discretion of the district office.
New query options have also been added to Case Management and Query. Case Management Option #43 - Query Decisions/Concurrent Conditions, and Query Option #11 – Decisions/Concurrent Conditions will display all concurrent conditions and formal decisions for a particular file number. In addition, the Reported Accepted Conditions portion will display all accepted conditions for the particular case queried as well as conditions for any other cases in the database with the same SSN. This would include cases that have been denied, accepted or administratively closed.
This information will also be available from the Auto 110 menu in the near future.
Examples: A claim is initially denied as FOI (factual) on September 1, 1999. The claimant requests reconsideration of this decision on October 1, 2000. The SrCE denies the request for reconsideration as not timely filed on November 10, 2000. The initial decision would have a type code of D (district office), an issue code of 03 (FOI-factual) and a disposition code of D (denied). The second decision would have a type code of R (reconsideration), an issue code of 03 (FOI-factual) and a disposition code of N (non-merit review).
A claim is initially denied as FOI (medical) on September 2, 1999. On September 3, 1999, the CE receives the necessary medical evidence and realizes the evidence was received in the office on September 1, 1999. On September 3, 1999 the CE vacates the September 2, 1999, decision and accepts the claim. The initial denial of the claim would have a type code of D (district office), an issue code of 04 (FOI-medical) and a disposition code of D (denied). On the date the initial decision is vacated and the claim accepted, the type code would be D (district office), the issue code would be 04 (FOI-medical) and the disposition code would be R (reverse/vacate).
Disposition: Retain until the expiration date or until superseded.
NANCY L. RICKER
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1–-Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
Back to Top of FECA Bulletin No. 00-04
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FECA BULLETIN NO. 00-05
Issue Date: June 8, 2000
Expiration Date: June 7, 2001
Subject: Comp Pay--Extra Pay for Firefighters
Background: In 1989, OWCP determined that pay rates for COP and compensation would properly include extra pay authorized under the Fair Labor Standards Act, 29 U.S.C. 207(k), for firefighters, emergency medical technicians, and other employees who earned and used leave on the basis of their entire tour of duty, and who were required to work more than 106 hours per pay period. This policy was first addressed in FECA Bulletin 89-26, and it now appears in FECA Procedure Manual Chapter 2-900, paragraphs 7b(21) and 8c.
However, Public Law No. 105-277 amended Title 5 of the U. S. Code to define hours worked by firefighters in excess of 106 biweekly, or 53 weekly, as overtime. It also states that firefighters shall not receive premium pay authorized by other provisions of subchapter V of chapter 55 of Title 5. The effective date of this provision was the first day of the first pay period after October 1, 1998, which was October 11, 1998.
Section 5 U.S.C. 8114(e) of the FECA bars inclusion of overtime pay in pay rates for compensation purposes. As the extra pay earned by firefighters is now classified as overtime, this rule will therefore apply to these employees as of October 11, 1998. Firefighters with pay rate effective dates on or after that date are not entitled to receive the "extra pay" discussed in PM 2-900.7b(21) and 8c (either "FLSA OT" or "standby premium pay").
Public Law No. 105-277 also provided that certain firefighters would be entitled to an increase in basic pay equal to two step increases of the employee's grade at the time the law took effect.
Finally, although PM 2-900.7b(21) refers to Emergency Medical Technicians (EMTs) and other employees with similar schedules, Public Law No. 105-277 applies only to firefighters.
Reference: FECA Bulletin 89-26; FECA Procedure Manual Chapter 2-900.7b(21) and 8c.
Purpose: To advise claims staff of the provisions of Public Law No. 105-277 as they apply to the pay rates of firefighters.
Applicability: Claims Examiners, Senior Claims Examiners, Claims Supervisors, Fiscal Officers, Technical Assistants, Hearing Representatives, and Hearing Examiners
Action:
1. The procedures that follow apply only to firefighters who earned and used leave on the basis of their entire tour of duty, and who were required to work more than 106 hours per pay period. Some firefighters work fewer hours per pay period, and because their pay rates should never have included the extra increments which are the subject of this bulletin, no adjustments are needed.
2. For firefighters with pay rate effective dates (whether date of injury, date of recurrence, or date disability began) from July 21, 1987 to October 10, 1998, "FLSA extra pay" and standby premium pay should still be included in the pay rates. The calculation of these increments is described in PM 2-900.8c.
3. For firefighters with pay rate effective dates on or after October 11, 1998, "FLSA extra pay" and standby premium pay may no longer be included in pay rates. While firefighters may well work more than 106 hours per pay period, the annual or biweekly rate of pay provided by employing agencies should not include overtime.
4. Hourly rates of pay may be derived by dividing the annual rate of pay by 2756 (the number of hours in a work year for these employees, analogous to the figure of 2087 hours used for regular federal employees). The rate of pay per pay period may be obtained by multiplying the hourly rate by 106. (Or, the rate of pay per pay period may be obtained by dividing the annual rate by 26.)
5. When making loss of wage-earning capacity determinations, the step increases granted by Public Law No. 105-277 should not be considered in calculating the current pay for grade and step when injured. Rather, the original grade and step should govern the figure used.
6. District office managers will be advised by memorandum of any cases in their respective jurisdictions for firefighters (occupation code G0081) with pay rate effective dates on or after October 11, 1998. These cases must be examined to determine if the pay rates are accurate, and if not, the pay rates must be adjusted.
Disposition: Retain until the indicated expiration date.
DEBORAH B. SANFORD
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 00-05
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FECA BULLETIN NO. 00-06
Issue Date: December 27, 1999
Expiration Date: December 27, 2000
Subject: Debt Collection: Perpetual Debts
Background: A recent audit by the Office of Inspector General has noted that, despite efforts to review all debts and forward all required debts to the Treasury Department for collection activity, there is another universe of debts which, although not delinquent, are not being adequately collected.
Specifically, these have been termed "perpetual debts" because, often, there are regular payments (or a payment plan) which are not adequate to meet accruing interest, hence the debt is not being reduced although it is also not showing as overdue.
It is necessary that district office staff begin taking action to review these debts and, where necessary, take action to resolve the perpetual debt status.
Purpose: To inform District Offices of the need to evaluate perpetual debts for either Treasury referral or compromise.
Reference: FECA Bulletin 98-06; FECA PM Ch.6-300
Applicability: All Claims and Fiscal staff.
Action:
1. All District Offices must take action to review all debts to locate any on which regular payments are being received over an extended period but where the payments are inadequate to pay down the debt balance in a reasonable period.
2. Any debt identified as a perpetual debt must be evaluated and either
(a) compromised to limit the repayment period (this would include waiver of charges if not previously considered); or
(b) referred to National Office for referral to Treasury per procedures outlined in FECA Bulletin 98-06; or
(c) referred to National Office for referral to the Department of Justice for compromise if the debt is more than $100,000 (or more than $600 when fraud is involved).
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
DENNIS M. MANKIN
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
Back to Top of FECA Bulletin No. 00-06
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FECA BULLETIN NO. 00-07
Corrected Copy
Issue Date: January 3, 2000
Expiration Date: January 2, 2001
Subject: Compensation Pay: Compensation Rate Changes Effective January 2000.
Background: The new GS-15, Step 10, salary was shown incorrectly in the original Bulletin. This Bulletin reflects the correct salary for GS-15, Step 10. In December 1999, the President signed an Executive Order implementing a salary increase of 3.80 percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the 3.80 percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 2000.
Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The new rates will be effective with the first compensation payroll period beginning on or after January 1, 2000. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $100,897 per annum.
The minimum increase specified in this Bulletin is applicable to Postal employees.
The effect on 5 U.S.C. 8112 is as follows:
|
Effective January 2, 2000 |
Minimum |
Maximum |
|---|---|---|
|
Monthly |
$ 1,299.50 |
$6,306.06 |
|
Weekly |
224.91 |
1,455.25 |
|
Daily (5-day week) |
44.98 |
291.05 |
The basis for the minimum compensation rates is the salary of $15,594 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $100,897 per annum (GS-15, Step 10).
The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,299.50, effective January 2, 2000. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $6,306.06 per month.
Applicability: Appropriate National and District Office personnel.
Reference: Memorandum For Directors of Personnel dated December 1999; and the attachment for the 1999 General Schedule.
Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustments Dates.
a. As the effective date of the adjustment is January 2, 2000, there will be no supplemental payroll necessary for the periodic disability and death payrolls.
b. The new minimum/maximum compensation rates will be available in ACPS on or about January 21, 2000.
2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 2000. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.
3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows:
| Date | Rate | Rate | Rate | Rate | Rate |
|---|---|---|---|---|---|
|
1/02/00 |
44.98-67.47 |
224.91-337.37 |
44.98 |
224.91 |
1,299.50 |
| Date | Rate | Rate | Rate | Rate | Rate |
|---|---|---|---|---|---|
|
1/02/00 |
291.05 |
1,455.25 |
(5,821.00) |
6,306.06 |
|
4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. It should be noted that this adjustment process re-calculates EVERY ACPS record from very beginning to current date, thus, it may be that minor changes in the gross compensation are noted; this is not necessarily incorrect. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose. Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.
Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 00-07
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FECA BULLETIN NO. 00-09
Issue Date: March 1, 2000
Expiration Date: February 28, 2001
Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 2000.
Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 2000.
1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 2.7 percent.
2. The increase is effective March 1, 2000, and is applicable where disability or death occurred before March 1, 1999.
3. The new base month is December 1999.
4. The maximum compensation rates, which must not be exceeded, are the following:
$ 6,306.06 per month
1,455.25 per week
5,821.00 each four weeks
291.05 per day (for a 5-day week)
Applicability: Appropriate National Office and District Office personnel.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.
Action: On or about March 17, 2000, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustment Dates.
a. As the effective date of the CPI is March 1, 2000 and the start date of the periodic and death payroll cycles is February 27, 2000, there will be a supplemental record created for the period March 1 through March 25, 2000. Effective March 26, 2000, the periodic and death payrolls will reflect the increased amount.
b. The CA-816, LWEC, program will be updated with the new CPI percentage. This update will be performed for all district offices by the National Office.
2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until March 20, 2000, daily roll payment cases requiring the new CPI should be held for data entry until that date. ACPS RECORDS THAT REQUIRE ADJUSTMENT SHOULD NOT BE ENTERED BETWEEN MARCH 17, 2000 AND MARCH 20, 2000. ACPS data entry may resume on March 21, 2000.
3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information. Attached to this directive is a complete list of all the CPI increases and effective dates since October 1, 1966 through March 1, 2000.
4. Forms.
a. Beginning with the compensation payment cycle that covers March 26, 2000 to April 22, 2000, the Office will issue a monthly Benefit Statement to each individual receiving benefits on the 28-day periodic roll cycle. This Benefit Statement will state the gross amount of compensation, the period of compensation covered by the statement, and the pertinent deductions made from the gross compensation. For compensation payments made via paper checks, the Benefit Statement will accompany the check. For compensation payments made through Electronic Fund Transfer (EFT), the Benefit Statement will be mailed separately.
b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.
c. A CP-140 report will be printed for each case adjusted, upon specific request by a District Office.
d. If claimants write or call for verification of the amount of compensation paid (possibly for mortgage verification; insurance verification; loan application; etc.), please provide this data in letter form from the district office. Many times a benefit statement may not reach the addressee, and regeneration of the form is not possible. Thus, a simple letter indicating the amount of compensation paid every four weeks will be an adequate substitute for this purpose.
Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)
ATTACHMENT - Cost of Living Adjustments
|
EFFECTIVE DATE |
RATE |
EFFECTIVE DATE |
RATE |
|---|---|---|---|
|
10/01/66 |
12.5% |
09/01/80 |
4.0% |
|
01/01/68 |
3.7% |
03/01/81 |
3.6% |
|
12/01/68 |
4.0% |
03/01/82 |
8.7% |
|
09/01/69 |
4.4% |
03/01/83 |
3.9% |
|
06/01/70 |
4.4% |
03/01/84 |
3.3% |
|
03/01/71 |
4.0% |
03/01/85 |
3.5% |
|
05/01/72 |
3.9% |
03/01/87 |
0.7% |
|
06/01/73 |
4.8% |
03/01/88 |
4.5% |
|
01/01/74 |
5.2% |
03/01/89 |
4.4% |
|
07/01/74 |
5.3% |
03/01/90 |
4.5% |
|
11/01/74 |
6.3% |
03/01/91 |
6.1% |
|
06/01/75 |
4.1% |
03/01/92 |
2.8% |
|
01/01/76 |
4.4% |
03/01/93 |
2.9% |
|
11/01/76 |
4.2% |
03/01/94 |
2.5% |
|
07/01/77 |
4.9% |
03/01/95 |
2.7% |
|
05/01/78 |
5.3% |
03/01/96 |
2.5% |
|
11/01/78 |
4.9% |
03/01/97 |
3.3% |
|
05/01/79 |
5.5% |
03/01/98 |
1.5% |
|
10/01/79 |
5.6% |
03/01/99 |
1.6% |
|
04/01/80 |
7.2% |
03/01/00 |
2.7% |
Prior to 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis or the nearest multiple of $.23 on a weekly basis ($.23, $.46, $.69, or $.92). After 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a "periodic" basis or the nearest $.25 on a weekly basis ($.25, $.50, $.75, or $1.00).
| >Prior to 11/1/74 | Eff. 11/1/74 |
|---|---|
|
Prior to 11/1/74 .08-.34 = .23 |
Eff. 11/1/74 .13-.37 = .25 |
|
.35-.57 = .46 |
.38-.62 = .50 |
|
.58-.80 = .69 |
.63-.87 = .75 |
|
.81-.07 = .92 |
.88-.12 = 1.00 |
Back to Top of FECA Bulletin No. 00-09
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FECA BULLETIN NO. 00-10
Issue Date: February 1, 2000
Expiration Date: January 31, 2001
Subject: BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: Effective January 14, 2000, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles is increased to 32.5 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.
Applicability: Appropriate National Office and District Office personnel.
Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual; Instruction CA-77, Instructions for Submitting Travel Vouchers; and 5 USC 8103.
Action: Instruction CA-77, Instructions for Submitting Travel Vouchers, has been revised to reflect the indicated rate change. A copy of the revised instructions is attached to this bulletin and may be reproduced at local levels. It will not be necessary to search and locate vouchers processed subsequent to February 1, 2000; however, if inquiry is received, appropriate adjustment should be made. Vouchers being processed for travel periods after February 1, 2000, may be adjusted to reflect this increase.
Disposition: This Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 -- Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
ATTACHMENT - Form CA-77
Instructions for Submitting Travel Vouchers U.S. Department of Labor (For reimbursement of travel and related expenses Employment Standards Administration under the Federal Employees' Compensation Act)
Office of Workers' Compensation Programs
-------------------------------------------------------------------------------------------------------------
Note: Any item not in conformity with the following instructions and not legible will be deducted from the voucher. Both forms SF-1012 and SF-1012a MUST be submitted with a valid case file number.
Claim for necessary and reasonable expense incident to travel authorized in accordance with provisions of the Federal Employees Compensation Act may be submitted for consideration on Voucher Forms SF-1012 and SF-1012a. Travel must be by shortest route and, if practicable, by public conveyance (streetcar, bus, boat, or train).
The Office will promptly reimburse all bills received on the approved form and submitted in a timely manner. However, no bill will be paid for expenses incurred if the bill is submitted more than one year beyond the calendar year in which the expense was incurred or the service or supply was provided, or more than one year beyond the calendar year in which the claim was first accepted as compensable by the Office, whichever is later (per CFR §10.413).
Payment will be made for taxicab fare or the hire of special conveyance where streetcars, buses, or other public and regular means of transportation are not available, except where these cannot be used because of the injured employee's disability. If claim is made for payment of expenses for taxicabs or hire of special conveyances, a full explanation must be made showing the necessity thereof.
Reimbursement for transportation by automobile owned by an employee or a member of his/her immediate family or another Government employee, may be claimed when no public conveyance is available or where the physical condition of the injured employee requires the use of special conveyance.
Mileage expenses will be reimbursed at the following rates for travel during the following periods:
| Date | Rate |
|---|---|
|
January 1, 1995 - June 6, 1996 |
30 cents per mile |
|
June 7, 1996 – September 7, 1998 |
31 cents per mile |
|
September 8, 1998 – March 31, 1999 |
32.5 cents per mile |
|
April 1, 1999 – January 13, 2000 |
31 cents per mile |
|
January 14, 2000 - and after |
32.5 cents per mile |
If mileage expense is claimed prior to January 1, 1995, contact your OWCP district office for rates.
Claim may be made for parking fees. If travel must be over a toll route, toll charges may be claimed. The voucher must show the locations where travel began and ended, mode of travel, and name of the transportation company (if by public conveyance). List each item of expense separately, showing the date incurred, place, and cost of the travel.
There will be no reimbursement for meals or lodging when travel is for less than 12 hours in total. If the authorized travel was for longer than 12 hours, and a claim for meals or lodging is made, the dates and hours must be shown on the voucher. The necessity for lodging must be explained in detail. All charges must be reasonable, and will be reimbursed at the per diem rate for the locality of travel.
Any stopover or delay en route should be carefully explained. If several trips are covered by the same voucher, list each separately, indicate the purpose of each trip, and secure the approval of the attending physician, certifying that the dates are correct according to his/her records.
Original itemized receipts made out in factor of the person making payment, signed in ink or indelible pencil by the person receiving payment must be furnished for all items in excess of $75.00.
After a voucher SF-1012 has been completed, it must be signed in ink or indelible pencil in the space provided for the payee.
The travel voucher should not be submitted if there is no expense claimed.
INSTRUCTION CA-77
Revised January 2000
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FECA BULLETIN NO. 00-11
Issue Date: February 25, 2000
Expiration Date: February 24, 2001
Subject: Bill Payment/BPS - Correct Coding Initiative, Part B.
Background: In August of 1999, Part A of OWCP's Correct Coding Initiative (CCI) was implemented. Since that time, coding specialists have been hired in each district office, and training has been provided to them.
Effective on or about February 25, 2000, Part B of the CCI will be implemented. Part B contains editing for mutually exclusive procedures, comprehensive/component procedures, and add-on codes. Editing for global periods will be implemented at a later date.
The source for the mutually exclusive and comprehensive/component code pairs is HCFA (Health Care Financing Administration). This information is updated quarterly. The source for the add-on codes is the AMA CPT Coding Manual. This information will be updated annually.
Mutually exclusive procedures are defined as procedure code pairs for which there is a medical impossibility or improbability that they would be performed at the same session. An example of mutually exclusive procedures is code 27332 (arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial or lateral) and code 27310 (arthrotomy, knee, with exploration, drainage, or removal of foreign body).
Comprehensive/component procedures are code pairs for which a more comprehensive procedure code includes several procedures that also have individual component procedure codes. Providers are not allowed to bill separately for a comprehensive code and the related component codes. An example of this type of coding error would be using component code 97750 (physical performance test or measurement, with written report, each 15 minutes) with comprehensive code 97003 (occupational therapy evaluation).
Add-on codes are procedures that are carried out in addition to the primary procedure performed. The add-on codes can never be reported alone. The add-on codes are listed in Appendix E of the CPT Coding Manual. An example of an add-on code is code 22632 (each additional interspace), which must be used with code 22630 (arthrodesis, posterior interbody technique, single interspace, lumbar).
At approximately the same time that the CCI Part B edits are installed, the edit for unlisted procedures (edit 364) will be activated. Information concerning this edit was provided previously, and additional information is being provided to the coding specialists under separate cover.
Reference: Federal (FECA) Procedure Manual Chapters 5-0203 and 5-0204; FECA Bulletin No. 99-29, issued August 5, 1999.
Purpose: To communicate procedures for processing bills under the CCI, Part B.
Applicability: Claims Examining, Bill Processing and CCI personnel.
Actions:
The CCI edits are applicable only to certain CPT-4 and HCPCS codes.
For some mutually exclusive and comprehensive/component code pairs, a procedure code modifier may be used to indicate that the procedures are not truly mutually exclusive or comprehensive/component. However, a modifier does not have this effect for all code pairs. The data provided by HCFA includes a modifier indicator, which is being used by the system in the CCI edits. It is critical that modifiers present on the bill be data entered when the bills are keyed. There are several additional modifiers that have recently been added to the system. Currently, all of the modifiers listed on the inside front cover of the CPT 2000 coding book are valid in the FECS system.
Seven new edits have been developed for CCI Part B. These include edits for mutually exclusive codes (edits 372 and 373), comprehensive/component codes (edits 374, 375, and 377), and add-on codes (370 and 371). Detailed edit sheets for these seven new edits are being sent under separate cover, along with the revised condensed BPS edits, and the revised EOB listing.
When errors 370, 372, and 374 are assigned, denial is automatic, and the edit failure cannot be overridden. Edit 371, 373, 375, and 377 failures result in suspensions, which must be manually reviewed and may be overridden or set to deny as appropriate.
All billing issues with respect to these edit failures, including resolution of these edit failures, should be referred to the coding specialist. The coding specialist is not responsible for other edit failures that may occur on a bill. Other edit failures on the bill should, in general, be resolved before the bill is referred to the coding specialist.
To assist in resolving CCI edit failures, and to provide information on the outcomes of the CCI editing, a "CCI Edit Report" will be produced each time BILL552 is run. This report should be provided to the coding specialist.
Job aids for resolving these new CCI edits will be provided to the coding specialists under separate cover.
Training on this Bulletin should be completed within 30 days of the issuance of this bulletin.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 00-11
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FECA BULLETIN NO. 00-12
Issue Date: March 15, 2000
Expiration Date: March 15, 2001
Subject: Automated CA-110, Telephone Message
Background: In November of 1994, the automated CA-110 program was created to address the Program's lack of a comprehensive telephone call tracking system as well as various communication concerns.
The use of the automated form has become widespread, and use of the data on these forms has been helpful both on a District Office and National Office level to address ongoing communication concerns. A current such concern is the level of service given to requests for authorization for physical therapy and other medical services. In light of this, the current automated CA-110 has been enhanced to include additional codes to address the level of response given when a request is telephonic. This will allow offices (as well as the National Office) to track level of responsiveness and to assure that all authorizations which are sought are answered timely.
Reference: FECA Bulletin 95-2
Purpose: To outline and provide guidance for the use of enhancements to the automated CA-110.
Applicability: All District Office and National Office personnel who use CA-110 forms to record and track responses to telephone messages.
Action:
1. When any telephone call is received that addresses an authorization for a medical service or procedure (including requests for physical therapy), an automated CA-110 should be used. This is true whether authorization is given immediately (therefore requiring no further response) or whether further communication is necessary. This procedure does not differ from that outlined in FECA Bulletin 95-2.
2. The PTA and OMA codes now in existence for physical therapy and other medical authorizations are now to be used only by a person initially taking a telephone call, whether in a contact office or off of the voice mail system. Any response where the caller actually speaks to a claims examiner concerning the authorization should use one of the new codes outlined in item 3.
3. There are now six new codes available to indicate the level of response to an inquiry for physical therapy or other medical authorization. These codes should be used to specify the type of answer given to any authorization request. They are:
PTAI - Physical Therapy Authorization, Interim
PTAS - Physical Therapy Authorization, Substantive
PTAF - Physical Therapy Authorization, Final
OMAI- Other Medical Authorization, Interim
OMAS- Other Medical Authorization, Substantive
OMAF- Other Medical Authorization, Final
"Interim" should be used if the telephone call was answered, but the authorization sought was not yet granted or denied; generally this will be the case if more information is necessary prior to a decision and if the response given to the person contacting the office is brief. In such an instance, a response in further depth will be required, whether telephonically or in writing.
"Substantive" is the appropriate status if the caller was advised of some indication of the current status of the case, but an answer on the authorization remains unavailable. An example of this is a surgery request, where a second opinion has been scheduled to address the issue. Advising a caller of the appointment's existence and date would be sufficient to make the response substantive.
"Final" should only be used if the authorization sought was given or denied during the telephone call. Note that any decision on authorization should be appropriately documented in the case file and in the FECS.
4. While coding in the automated CA-110 will address the level of response to a request for authorization, the actual data concerning the period of any such authorization should be recorded as appropriate in other FECS applications--that is, authorization for physical therapy should be recorded in Case Management item 34, and any other authorization should be the subject of a Case Management note and, possibly, the addition of an ICD-9 procedure code.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
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FECA BULLETIN NO. 00-13
Issue Date: March 27, 2000
Expiration Date: March 27, 2001
Subject: Reporting Injuries--Electronic Submission of Forms CA-1 and CA-2
Background: As efforts continue to streamline the adjudication and case management process, employing agencies have sought the ability to submit initial claim forms electronically, eliminating the mailing lag time that is occasionally involved with paper submissions.
Agreements are now in place for this to happen, and programming allowing this type of submission is complete. Shortly, employing agencies will begin to submit batches of forms CA-1 and CA-2 electronically. The first agency to do so will be Veterans Affairs(VA), which will submit both their own claims and, in the future, claims as a batching representative for other agencies, forwarding claims from various smaller employers. It is anticipated that both the Department of Defense and U.S. Postal Service will follow soon thereafter.
Purpose: To inform all DFEC staff of the impending submission of initial claim forms electronically.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants, Systems Personnel, and Hearing Representatives.
Action:
1. Batching agencies (such as the VA) will submit a daily batch of new claim forms for all employing agencies they represent. This batch will be submitted electronically to the Branch of Coordination and Control in the National Office (NO). The files will be retrieved in NO Sequent and placed in a directory accessible to DFEC. They will then be archived (to retain a record of information submitted), assigned a batch number (typically the agency identification and a date), and then copied to a working directory.
2. The files will then be translated electronically and edited to ensure that they are in the proper format and contain all required information. Any errors will be noted via electronic communication to the submitting agency.
3. All properly submitted and translated files are then placed in a directory on the Sequent, sorted by District Office, in fixed format. All information received is then added to an NO cross-reference table which will be used to track the case number assigned by the DO. The employing agencies submitting information in this fashion will retain the paper claim forms supporting the electronic data submitted.
4. The files are then transmitted to the DO and the data is placed into CA-1 and CA-2 database files in the DO. Each DO should set up an e-mail list so that a report, created when the files are received in the DO, may be e-mailed notifying DO management of the receipt of a new batch. This group should be created on the DO level and entitled "DO Name CA-1/2 Group." Included should be the Regional Director, District Director, Systems Manager, Case Create Supervisor (if different from Systems Manager), and William Cole, Chief, Branch of Coordination and Control. Case files must be created within 48 hours of receipt of this e-mail.
5. The case create staff will then review electronic CA-1 or CA-2 forms online. The screen on which this will be done approximates the current paper CA-1 or CA-2. It can be accessed as a sub-menu to item 01 in Case Management on Sequent.
6. After the claim form is reviewed, a case number will be assigned by the case create clerk just as if a paper form were received. When the case number is entered, the system will automatically add the case to case management and pull all necessary info from the electronic form without the need for further keying. The postcards generated via current case create procedures will also be run automatically.
7. The electronic CA-1 or CA-2 will be printed and placed into the paper file (in offices not yet using the OASIS system). This screen print does not, currently, approximate the paper form CA-1 or CA-2 in format, although all of the information it contains is identical. The system is being enhanced so that the printout, will, eventually, mimic the paper forms in style and format.
If a DO is currently imaging new files, the electronic CA-1 or CA-2 will be printed and scanned into OASIS so it may be reviewed onscreen along with all other case documents. Case files will be routed to claims examiners in the same manner as those created from paper claim forms. Claims examiners will also be able to access a sequent query screen (query item 13) showing the online claim form for both imaged and non-imaged cases should they so choose.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
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FECA BULLETIN NO. 00-14
Issue Date: April 12, 2000
Expiration Date: April 11, 2001
Subject: Compensation Payment - Change of Address in ACPS and CMF
Background: Recent OIG audit findings indicate a need to modify the process of changing addresses in ACPS and CMF to ensure that adequate separation of duties exists. It has been demonstrated that such separation is necessary, not only for the effective processing of compensation payments, but also for the security of our mission and accountability of OWCP in disbursing monies from the Compensation Fund.
Reference: FECA Procedure Manual Chapter 2-401.3a, and Chapter 5-308.5n. and 5o.
Purpose: To emphasize the importance of separation of duties between the personnel who receive the written request for an address change and initiate action to make the change in the ACPS or CMF, and the personnel who verify and enter the change for the purpose of directing compensation payments. In addition, to provide procedures for all FEC offices and to ensure that personnel affected by these procedures know how to implement them.
Applicability: Regional Directors, District Directors, Fiscal Officers, Bill Payment Supervisors, Claims personnel, and appropriate National Office personnel.
Actions: Satisfactory procedures for handling changes of address in the CMF and ACPS include several elements described as follows:
1. The action to change an address must be initiated by the claimant/payee or authorized representative in written form. A telephone contact is not sufficient to cause OWCP to change an address.
2. No person with ACPS access will be involved in the process of changing addresses for directing compensation payments. This includes address changes for checks and EFT account information. Both the person who enters the change of address into the system and the person who verifies it will be non-claims personnel. That is, they are not to have access to any other claims payment options in the ACPS menu. Each District Office will designate the appropriate staff person(s), and the list of such persons will be maintained in the District Director's office. The District Director's list will be updated immediately as changes in this responsibility occur.
3. The source document for the address change must be signed by the claimant/payee or the authorized representative. A typical example of a source document would be a letter from the claimant/payee or representative. Another common document for this purpose would be a standard form such as the SF-1199a, which is used to switch from receiving the mailed check at the home address to receiving payment by EFT (electronic funds transfer), where the compensation payment is deposited directly into the claimant's bank account from Treasury. An existing EFT address (bank account number or routing number) should be changed in ACPS with a signed SF-1199a form or a similar form generated by the financial institution and signed by an institution official. We strongly encourage the use of the SF-1199a; however, any official bank document is acceptable so long as it is accompanied by the original signature of the claimant.
4. The person initiating the change of address action and the non-claims person entering the change into ACPS must initial and date the input documents. The person who completes the action by verifying the accuracy of the change on the output document (also a non-claims person) must initial and date the output document. With all changes of address, the payment must be treated as an initial payment, and as such must be certified by a person qualified to certify payments.
5. All ACPS payment inputs requiring certification must be documented with the following:
Source documents (i.e., a letter from the claimant/representative, CA-7, or SF-1199a).
Input documents (CA-25, screen prints, etc.)
All output documents (e.g., CP-030, CP-040, CP-045, CP-230, CP-285).
Source documents must be present for any certified input. For any EFT changes, such as in routing or account number, the source document must be either an SF-1199a or a similar form. Any form must include information provided by the bank and must be signed by the claimant/representative and, preferably, by an official of the financial institution.
Whoever pulls and distributes outputs must assure that outputs are delivered to a single person designated by management in each unit/area. This person will then assure that all outputs are properly distributed.
The source document, input document and output document, once certified/verified, must be stapled or spindled together in the case file. All such documents must be retained, and no output document may be discarded.
6. If your District Office currently has satisfactory procedures in place for processing changes of address in the ACPS and CMF (which adhere to all of the stipulations described above), they should be continued.
7. District Office managers must ensure that all affected personnel are aware of this process and recognize its importance. Adherence to these procedures will be monitored biannually in the accountability review process and annually during the OIG's Consolidated Financial Statement Audit.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual Chapter 2-401 and Chapter 5-308.
DENNIS M. MANKIN
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 00-14
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FECA BULLETIN NO. 00-15
Issue Date: September 18, 2000
Expiration Date: September 17, 2001
Subject: COP Nurse Intervention
Background: The President's Federal Worker 2000 initiative directs the Secretary of Labor to reduce the overall occurrence of injuries by 3 percent per year, while improving the timeliness of reporting of injuries and illnesses by agencies to the Department of Labor by 5 percent per year, reduce the occurrence of such injuries by 10 percent per year for those work sites with the highest rates of serious injuries and reduce the rate of lost production days by 2 percent per year.
In order to meet these goals, OWCP has placed strategic emphasis on prompt adjudication and payment of benefits, early intervention in new injuries, active disability management and prompt, appropriate return to the workplace. It is felt that early intervention during the Continuation of Pay (COP) period will have a favorable impact on these goals by permitting early identification of injuries that may result in additional lost time after the COP period.
To this end, OWCP is implementing a nurse intervention program during the COP period that will be solely telephonic in nature and will be limited to thirty days of case management. Such early intervention depends on prompt submission of claim forms by employing agencies, since any cases with an initial work stoppage date more than thirty days prior to the date the case is received by OWCP will not be considered for this program.
Although nurse intervention will not be extensive during the COP period, the nurses' medical knowledge and experience will permit them to identify cases that will require more extensive nurse intervention due to the severity of the injuries, contemplated surgical intervention, or other such issues. They will also be able to discuss injured workers' medical concerns and offer advice.
Changes have already been made to the Case Create program which prompts the case create clerk to enter the date the employee stopped work (if applicable) and the date the employee returned to work, if available, for all lost time traumatic injury cases. This data will be used to identify cases appropriate for COP telephonic nurse intervention.
Triage codes will be used by the COP telephonic nurses, or Telephonic Case Managers (TCM) in cases with no full-time return to work. The codes, which will be checked off on the COP/RTW Case Worksheet, allow the TCMs to alert the district office regarding cases in need of follow-up action. The triage codes are: "1" - no return to work due to surgery, invasive diagnostic testing, hospitalization or catastrophic injury; "2" - no return to work due to other reasons; "3" - part-time return to work; "4" - claimant not cooperating with nurse.
System enhancements are planned to include new QCM status codes for COP-QCM cases and to automatically create QCM records on accepted cases with triage codes.
Purpose: To provide COP telephonic nurse guidelines for Staff Nurses, TCMs, and claims staff.
Applicability: Regional Directors, FEC District Directors, Claims Examiners, Supervisors, Technical Assistants, Staff Nurses and Vocational Rehabilitation Specialists
Action:
Staff Nurse Responsibilities
1. Each District Office should recruit COP/TCMs from the existing TCM nurses or existing field nurse pool. Cases assigned to the COP/TCM can be in addition to cases assigned in the normal rotation. If a selection is made from the existing TCM nurses, the fees paid for cases assigned under the COP nurse intervention program will not be counted toward their income cap. The Staff Nurse (SN) should recruit at least two COP/TCM per state/territory serviced by the district office and must ensure that each COP/TCM possesses all RN licenses needed to cover their assigned area.
2. COP/TCM intervention will be telephonic only and is limited to a maximum intervention period of thirty days. No extensions of this thirty-day period will be permitted.
3. In those cases where there is no "RETURN TO WORK DATE" and fifteen days have elapsed since the date the claimant stopped work, a daily report will be produced listing those injury claims with no return to work. (See Attachment 1 - Sample COP/RTW Tracking Nurse Referrals.) All traumatic injury cases with lost time will be reported, including unadjudicated cases. This report will be e-mailed to the SN for assignment to the COP/TCM. She or he will then e-mail this list to the COP/TCM for action. This listing will show claim number, date referred, and employing agency (EA) contact name and telephone number for each selected case. The claim number will remain on the list until the COP/TCM enters a date of first telephone call or the case is closed. The daily e-mail listing received by the SN will be sorted first by state and then by date referred with the most recent referrals appearing at the top of the list.
4. The COP/TCM will be reimbursed at a "global fixed fee" rate of $100.00 per case. This amount represents reimbursement for both the professional and administrative services on the case and will be paid only at case closure using the unique code: COPTN (COP telephonic nurse). Reimbursement must be claimed on an HCFA-1500 and submitted with the completed COP/RTW Case Worksheet.
5. Once the COP/TCM has closed a case, the SN will forward the COP/RTW Case Worksheet with any recommendations to the CE.
COP/TCM Nurse Responsibilities
1. Upon receipt of the e-mail list from the SN, the COP/TCM will access a web-based "home page," which will provide relevant claimant information for all cases referred. (See Attachment 2 - Sample COP/RTW Case Update screen.) Claimant information available to the COP/TCM will include: the claimant's name and telephone number, date of birth, date of injury, a narrative diagnosis, the employer's name and telephone number, and case status. The COP/TCM will also be able to ascertain whether the claim has been reviewed by the CE or is a short-form closure case. This information will appear as Initial Claim Adjudication, and will be Short Form Closure; Pending; Accepted, Denied. If the case is in a denied status, no further input will be permitted. A prompt at the bottom of the screen will state RECORD COMPLETE/CLOSED; NO FURTHER UPDATE ALLOWED.
2. After accessing the "home page," if the record is not complete or closed, the COP/TCM will initiate a telephone call to the EA to ascertain the claimant's return to work status. If contact with the EA is unproductive, the COP/TCM should initiate contact with the claimant to discuss return to work capabilities/status.
3. The "home page" will also permit access to the new COP/RTW Case Update screen for data entry by the COP/TCM. If the claimant has returned to work, the COP/TCM will input into this screen the date of the telephone call, to whom the call was made, the date of the claimant's return, whether the return was part-time or full-time, and whether the return was to regular duty or light duty. In cases where the claimant is losing intermittent time from work, the "DATE RETURNED TO WORK" will be the claimant's most recent return to work. The COP/TCM should also respond to "DID THE CLAIMANT USE 45 DAYS OF COP?" prompt, with "Y" for yes or "N" for no. The COP/TCM should ask this question of the claimant or the EA and enter the answer provided. If no answer is yet available, an entry in this field is not required. The COP/TCM will then close the file, input the date of closure in the COP/RTW Case Update screen and forward a completed worksheet to the SN. (See Attachment 3 - Sample COP/RTW Case Worksheet.)
4. A total of three calls should be attempted by the COP/TCM to reach either the claimant or the EA. If the claimant has not returned to work and there is some indication either from the claimant or the E/A that a return to work is planned within one week, the COP/TCM will note the projected return to work date on the COP/RTW Case Worksheet. The COP/TCM should then contact the claimant as soon as possible following the return to work date to verify that the return to work did occur. Once confirmed, the return to work date, type (i.e., full-time, part-time, regular or light duty) is entered into the COP/RTW Case Update screen. The date of the follow-up telephone call should be entered as well. The COP/TCM will then close the file, input the date of closure in the COP/RTW Case Update screen and forward a completed COP/RTW Case Worksheet to the SN.
5. If the claimant does not have a plan to return to work and/or has not returned to work by the second contact, the COP/TCM will initiate a call to the attending physician (AP) to request updated medical reports and physical limitations for a return to work. The AP should be requested to provide this information directly to the district office. The COP/TCM should then document this as the final call in the COP/RTW Case Update screen.
6. For those cases where the claimant does not return to work within the thirty-day intervention period, the COP/TCM will terminate the intervention and complete the COP/RTW Case Worksheet, including the appropriate triage code and recommending future actions to be taken by the CE. The COP/RTW Case Worksheet will be forwarded to the SN. Once the thirty-day intervention period has ended, the COP/TCM will not be permitted to input any further data into the COP/RTW Case Update screen. Under no circumstances will this period be extended.
7. At specific points in the case intervention, it will be appropriate for the COP/TCM to cease intervention, enter the data into the COP/RTW Case Update screen, document the details (return to work, no return to work, medical information obtained, etc.) and return all claimant related information to the SN who will distribute it to the appropriate CE. If, in the course of intervention activities, the COP/TCM discovers: A) the AP is planning imminent surgery prior to release for return to work; B) the AP is planning any invasive diagnostic examination; C) the claimant's injuries are catastrophic; or D) the claimant refuses to discuss his/her case with the COP/TCM, intervention ceases immediately. The COP/TCM will inform the claimant that the CE will be handling the case. The COP/TCM will record the appropriate triage code on the COP/RTW Case Worksheet, input the appropriate data into the COP/RTW Case Update screen and forward all documentation to the SN.
8. The COP/TCM should claim reimbursement at a "global fixed fee" rate of $100.00 per case. This amount represents reimbursement for both the professional and administrative services on the case and will be paid only at case closure using the unique code: COPTN (COP telephonic nurse). Reimbursement must be claimed on an HCFA-1500 and submitted with the completed COP/RTW Case Worksheet.
Claims Examiner Responsibilities
1. The CE should promptly input a return to work date, if he or she becomes aware of that information prior to the COP/TCM, by accessing Case Management Screen 41 (also listed as COP/RTW Case Update). The CE should include whether the return was full-time, part-time, regular, or light duty by completing the field marked "RTW TYPE." After a return to work date has been entered, the record will be locked and no further data input will be permitted.
2. In cases where the claimant is losing intermittent time from work, the "DATE STOPPED WORK" will be the first date the claimant stopped work and the "DATE RETURNED TO WORK" will be the claimant's most recent return to work. The CE should also respond to "DID THE CLAIMANT USE 45 DAYS OF COP?" prompt. Valid entries are "Y" and "N." An entry in this field is not required if the answer is not known.
3. The CE may view information recorded by the COP/TCM in Query screen 12, COP/RTW Case Update.
4. All short-form closure cases with a part-time return to work and 45 days or less of COP used will "flip" to UD status with an expired call-up note. The CE must then expedite adjudication and immediately initiate QCM, including referral to a field nurse. A QCM record should be created using the part-time return to work date as the track date.
5. Receipt of a completed COP/TCM Case Worksheet indicating a part-time return to work on an accepted case should also prompt immediate QCM action.
6. Once thirty-five days have elapsed since the claimant stopped work and no "RETURN TO WORK DATE" has been input, all short-form closure cases which meet the criteria for COP nurse intervention will "flip" to UD status with an expired call-up note. The CE must then expedite adjudication, and initiate QCM action, including referral to a field nurse. A QCM record should be created using the date of injury as the track date.
7. Receipt of a COP/TCM Case Worksheet which shows that there has been no return to work due to surgery, invasive diagnostic testing, hospitalization or catastrophic injury (triage code 1), or that the claimant is not cooperating with the nurse (triage code 4) on an accepted case should also prompt immediate QCM action.
8. Upon initial acceptance of a traumatic injury claim, the CE will be prompted to enter a COP/RTW date if the COP/RTW record is not complete. A response will be required. For cases not meeting the criteria for referral to the COP/TCM the prompt will read "DID THE CLAIMANT STOP WORK FOLLOWING THE INJURY? (Y/N)". Valid entries are "Y" or "N". A "Y" response will open the COP/RTW Case Update window. For cases that have been referred to the COP/TCM the prompt will read "HAS THE CLAIMANT RETURNED TO WORK? (Y/N/U)". Valid entries are "Y", "N" or "U" (unknown). A "Y" response will also open the COP/RTW Case Update window. If the response is "N" and forty-five to sixty days have elapsed since the "DATE STOPPED WORK", the CE will be prompted with the question "DID THE CLAIMANT USE THE FULL 45 DAYS OF COP?". The CE may answer "Y" or "N" or may skip this field by using the Tab, Space or Enter keys. If it has been over sixty days since the "DATE STOPPED WORK" the system will automatically set the "DID THE CLAIMANT USE THE FULL 45 DAYS OF COP?" to yes. If the response is "U," neither the "RETURN TO WORK DATE" nor the "DID THE CLAIMANT USE THE FULL 45 DAYS OF COP?" fields will be updated.
9. Once a claim has been denied, no entry will be permitted in the COP/RTW Case Update screen.
10. If a Timely Payment of Compensation claim (TPCUP)is later paid for wage loss on a COP-QCM case with no return to work, the QCM track date should be changed to reflect the first date claimed on the paid Form CA-7. If a TPCUP record is later paid for wage loss on a COP-QCM case with part-time return to work, the track date should be changed to reflect the decision date on the approved CA-7 record. A weekly COP-QCM Cases Report will identify any cases with accepted wage loss claims whose track dates have not been changed.
11. QCM cases closed during the COP period for return to work full-time in regular or light duty should have their records "zeroed out". System enhancements are planned that will utilize the new COP-QCM status codes to automatically perform this function.
District Office Systems Manager Responsibilities
1. On a weekly basis, the Systems Manager in each district office will run two reports that identify cases for expedited adjudication and QCM action. Both reports will be sorted by responsible CE and triple-terminal digit.
a) The Adjudication Triage Report will identify UN/UD cases with either no return to work (when > 35 days since date stopped work) or part-time return to work (when < 45 days since date stopped work). The report will provide the claim number, claimant name, number of days elapsed since date stopped work, return to work date and type (if applicable), and the date of COP/TCM closure (if applicable).
b) The QCM Referral Triage Report will identify accepted cases with either no return to work or part-time return to work, COP/TCM closure and no QCM activity. The report will provide the claim number, claimant name, number of days elapsed since date stopped work, return to work date and type (if applicable), number of days elapsed since COP/TCM closure, and accepted ICD-9 codes.
2. On a weekly basis, the Systems Manager in each district office will run a report that identifies COP-QCM cases with wage loss and no adjustment to the QCM record. The COP-QCM Cases report will identify QCM cases in categories A, B or C with a track date equal to the date of injury, or a track date equal to the return to work date and part-time return to work, and a CA-7 with decision codes of A1/2 or I1/2. The report will provide the claim number, claimant name, decision date on approved CA-7 record, and beginning date claimed on the paid Form CA-7.
Disposition: Retain until the expiration date or until superseded.
DEBORAH B. SANFORD
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
|
CASE NO |
CITY |
STATE |
CLAIMANT PHONE |
REFER DATE |
AGENCY |
|---|---|---|---|---|---|
|
|
|||||
|
502222293 |
BALTIMORE |
MD |
(999) 999-9999 |
03/15/2000 |
1100FF |
|
Agency Contact ( ) -
|
|||||
|
505055569 |
GAITHERSBURG |
MD |
(202) 693-1029 |
03/15/2000 |
560000 |
|
Agency Contact: INJURY COMPENSATION SUPERVISOR (617) 654-5525
|
|||||
|
505555595 |
BATTLE CREEK |
MD |
(616) 962-6646 |
03/15/2000 |
2150BB |
|
Agency Contact: CASE MANAGER (804) 771-2900
|
|||||
|
505555596 |
WASHINGTON |
DC |
(616) 968-0191 |
03/09/2000 |
2150EE |
|
Agency Contact: CASE MANAGER (804) 771-2900
|
|||||
|
156666666 |
WASHINGTON |
DC |
(203) 637-4146 |
03/01/2000 |
2520BU |
|
Agency Contact: INJURY COMPENSATION OFFICER (617) 273-7332
|
|||||
|
505555569 |
BOSTON |
MD |
(301) 555-1212 |
03/01/2000 |
2520BU |
|
Agency Contact: INJURY COMPENSATION OFFICER (617) 273-7332
|
|||||
|
015555666 |
BOSTON |
DC |
(301) 555-1212 |
02/14/2000 |
560000 |
|
Agency Contact: INJURY COMPENSATION SUPERVISOR (617) 654-5525
|
|||||
|
062000007 |
ALEXANDRIA |
VA |
(707) 555-1212 |
02/10/2000 |
99995J |
|
Agency Contact: NOT FOUND IN DEPARTMENT AGENCY TABLE (V01). |
|||||
ATTACHMENT 2 - COP/RTW Case Update
ATTACHMENT - 3 COP/RTW CASE WORKSHEET
Worksheet - Page 1
Worksheet - Page 2
Back to Top of FECA Bulletin No. 00-15
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 00-16
Issue Date: September 5, 2000
Expiration Date: September 4, 2001
Subject: Bill Payment/BPS - Pharmacy Fee Schedule Change
Background: Effective January 4, 1999, a fee schedule for prescription drugs was implemented for charges processed on and after that date. The formula for computing the allowable fee was based upon the two-year high average wholesale price (AWP), plus a dispensing fee equal to 20% of the AWP. The dispensing fee could not be less than $2.50, nor greater than $15.00. The calculated amount was then rounded up to the nearest whole dollar.
Effective September 5, 2000, the formula for computing the allowable fee for prescription drugs will be changed, and will be applicable to prescriptions filled on and after September 5, 2000. The new formula will be based upon 95% of the two-year high AWP, plus a set dispensing fee of $4.00. The calculated amount will no longer be rounded up to the nearest whole dollar.
A private vendor is still the source of the AWP information. The data is updated weekly. The web page for performing pharmacy fee calculations has been revised to apply the new calculation formula. For dates of service prior to September 5, 2000, the allowable fee should be calculated manually using the AWP available on the web page.
Reference: FECA Bulletin No. 99-07, issued January 4, 1999.
Purpose: To communicate new formula for calculation of the allowable fee for prescription drugs.
Applicability: Claims Examining, Bill Processing and Contact personnel, and Coding Specialists.
Actions:
1. Prescription drug calculations for allowable fees should be performed in accordance with the following formula for service dates on and after September 5, 2000:
(AWP X quantity X 95%) + $4.00
2. If the calculated amount is less than the billed amount, the calculated amount is the payable amount. If the billed amount is less than the calculated amount, the billed amount is the payable amount.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
DEBORAH B. SANFORD
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 00-16
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-01
Issue Date: September 8, 1998
Expiration Date: September 7, 1999
Subject: BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: Effective September 8, 1998, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles was increased to 32.5 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.
Applicability: Appropriate National Office and District Office personnel.
Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual; Instruction CA-77, Instructions for Submitting Travel Vouchers; and 5 USC 8103.
Action: Instruction CA-77, Instructions for Submitting Travel Vouchers, has been revised to reflect the indicated rate change. A copy of the revised instructions is attached to this bulletin and may be reproduced at local levels. It will not be necessary to search and locate vouchers processed subsequent to September 8, 1998; however, if inquiry is received, appropriate adjustment should be made. Vouchers being processed for travel periods after September 8, 1998, may be adjusted to reflect this increase.
Disposition: This Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 -- Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Attachment: Form CA-77, Instructions for Submitting Travel Voucher (Link to Image)
Back to Top of FECA Bulletin No. 99-01
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-02
Issue Date: May 3, 1999
Expiration Date: May 2, 2000
Subject: Case Management--Medical Queries by Contract Nurses
Background: OWCP nurses, both those working in the field and those working by telephone, assist claims staff in many ways: by gathering information from employing agencies and medical providers; by helping claimants to understand their medical care and limitations; and by coordinating return-to-work efforts, to name just three areas where they commonly provide assistance.
In their efforts to obtain medical information, some contract nurses take a very active role in posing questions to attending physicians. Such an approach is proper when the questions involve work limitations, expected length of recovery, and prognosis.
However, matters such as the diagnosis, the presence or absence of objective findings, and causal relationship are adjudicatory in nature, and queries addressing such matters may interfere with case management efforts by claims staff, either because they are redundant or because they inadvertently expand the scope of the claim. Therefore, only claims staff should pose such questions.
Reference: Federal (FECA) Procedure Manual Chapter 2-600, subparagraphs 3 and 5
Purpose: To clarify the kinds of information which may properly be requested by contract nurses, and the kinds of information which should be requested only by claims staff
Applicability: Claims Examiners, Staff Nurses, and Supervisors
Actions:
1. Claims Examiners remain responsible for managing claims. They may not delegate this task to OWCP nurses. While it is permissible for OWCP nurses to help claims staff compose questions to medical providers with respect to adjudicatory issues, and for second opinion medical examinations, the Claims Examiner must have the final say in wording these questions.
2. Claims supervisors and the Staff Nurse, as the manager of the contract nurses, should be alert to statements in letters from contract nurses to medical providers which indicate that contract nurses, rather than Claims Examiners, are managing claims.
In particular, contract nurses should avoid posing questions such as the following:
What is your diagnosis of Mr. X?
Are Mr. X's symptoms related to his occupational trauma on 06/06/98?
When such instances are identified, the Staff Nurse should counsel the contract nurse as to questions which may properly be asked of medical providers and questions which should be avoided.
Attached is a sample notification that can be shared with the contract nurses. The notice emphasizes the general guidelines for types of questions to be posed to physicians.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Attachment
ATTENTION ALL OWCP CONTRACT NURSES
In reviewing monthly reports of both telephonic and field nurses' services, I have identified a need to share some general guidelines to be used when posing questions to the attending physician.
Questions regarding clarifying work limitations, expected length of recovery and prognosis are not only proper but should be posed in order to obtain a clear picture of the return to work potential. However, questions that relate to either the presence or absence of objective findings and/or causal relationships are adjudicatory in nature. Since repsonses to these questions could inadvertently expand the scope of the claim, these types of questions need to be posed only by the claims examiner.
For example, asking the physician whether "Mr. X's symptoms are related to his occupational trauma on 6/6/98" would not be appropriate. However, posing the question "Will Mr. X's cervical strain result in release to full or part time work activity" captures the real issue of what return to work capacity can be anticipated.
In some cases claims examiners will request your assistance in formulating questions to medical providers which involve adjudicatory issues. You may certainly assist them in phrasing these questions but the final wording resides with the claims examiner.
Thank you for your cooperation on this issue. Please contact me should there be any questions on this matter.
Sincerely,
Staff Nurse
Back to Top of FECA Bulletin No. 99-02
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-03
CORRECTED COPY
Issue Date: January 27, 1999
Expiration Date: January 27, 2000
Subject: Case Management/ADP: Guidelines for Periodic Roll Management
Background: In FY 1992, the Periodic Roll Management Project (PRMP) began. The PRMP was designed to review a set universe of cases on the long-term disability rolls with an eye toward resolution of these cases. This was a four-year term project, with some district offices (Boston, Jacksonville, San Francisco, and Seattle) beginning in 1992 and completing the project in 1996. Other district offices began PRMP in either 1995 or 1997 and their teams remain active.
Owing to the success of this project, it has become a permanent initiative of the program in FY 1999. Every district office will have permanent Periodic Roll Management (PRM) staff. These examiners will continue to pursue the goals outlined for the PRMP--review and resolution of long-term disability cases.
The performance measure for resolution of periodic roll cases is defined as an entitlement decision that brings some closure to the case. Usually, the entitlement decision would be the result of a full-fledged review by the PRM claims examiner. In cases where there is no change in the entitlement level, this will include at a minimum a second-opinion examination or a directed examination by the attending physician, with specific questions regarding ongoing injury-related disability.
As part of the transition from a project to a permanent initiative, changes have been made to both the composition of the PRM universe, altering it from a set group of cases to a fluid one, and to coding under the Periodic Roll Management System (PRMS). The coding changes will better allow the tracking of program goals.
Reference: FECA Bulletin 95-15
Purpose: To inform all claims staff of updates to PRM universe composition and to the PRMS coding scheme.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel
Action:
1. The base PRM universe will be identified for each district office using all cases on the periodic roll as of the October 10, 1998 payment except those cases active in QCM (category A or B) which are less than 30 months old.
2. Cases will be added to this universe as follows:
a. Non-QCM cases placed on the periodic roll will be added to the universe immediately;
b. Any non-QCM periodic roll case transferred in to a district office will be immediately part of the new owning district office's PRM universe;
c. Any periodic roll case which is closed, removed (zeroed out) or expired (more than 30 months old) from QCM tracking will immediately become part of the PRM universe.
3. Cases will be removed from the PRM universe as follows:
a. PRM cases transferred to another district office will leave the prior owning office's PRM universe;
b. Any PRM case with a new recurrence that is approved, causing it to drop into QCM will leave the PRM universe.
c. Any case deleted from the periodic roll will be removed from the universe. These should also be tracked in PRMS as discussed below.
4. The System Manager at each District Office will be able to produce a report as frequently as needed to identify cases that have been added to or dropped from PRM per these guidelines.
5. Using the report described in item 4, district offices must manually reassign cases to the appropriate responsible claims examiner or unit on a periodic basis. The National Office is looking at the feasibility of creating new and/or modifying existing programs to automate this case reassignment process.
6. Coding in PRMS has been streamlined, to focus emphasis on the resolution of cases in the PRM universe. While codes for actions not affecting entitlement continue to be available, these codes are optional. All actions which resolve a PRM case, however, must be tracked in the PRMS. Attached is a list of all PRMS codes now available for use. Note that codes for increases in compensation are no longer being used. Additionally, election of OPM benefits is considered a resolution only when it results in termination of all compensation payments, including periodic payments for schedule award. Coding for the conclusion of a schedule award (without further loss of wage earning capacity) has been separated into codes that reflect whether intervention was taken in the case to bring about the resolution. This will assure that the ending of a schedule award, without any action on the part of claims staff, does not count as a resolution.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment
|
|
Resolution Codes |
|
Optional Codes |
|---|---|---|---|
|
|
|||
|
Reduction of compensation: |
IR |
Initial Review Done |
|
|
R1 |
Constructed LWEC |
MN |
Narrative Requested |
|
R2 |
RTW with LWEC |
MR |
Narrative Received |
|
R3 |
S/A expired with LWEC |
SE |
SECOP scheduled |
|
|
|
RF |
Referee scheduled |
|
Suspension of compensation: |
VR |
Referred for rehab |
|
|
S2 |
Suspension 5 USC 8123 |
JO |
Job offer made |
|
S3 |
Suspension 5 USC 8113 |
PR |
Pre-reduction sent |
|
|
|
PT |
Pre-term sent |
|
|
|
EO |
Elected OPM |
|
Termination of compensation: |
|
|
|
|
T1 |
Terminated, no continuing IRD |
|
|
|
T2 |
RTW, no LWEC |
|
|
|
T3 |
S/A expired, intervention, no LWEC |
|
|
|
T4 |
Refused suitable work |
|
|
|
T5 |
Death of claimant |
|
|
|
T6 |
Elected OPM with no periodic |
|
|
|
|
|
|
|
|
Case reviewed, no change: |
|
|
|
|
CR |
No change in entitlement after review |
|
|
|
|
|
|
|
|
Necessary code, not counted as resolution: |
|
|
|
|
S1 |
Suspension no 1032 |
|
|
|
T0 |
S/A expired, no intervention, no LWEC |
|
|
|
|
|
|
|
Back to Top of FECA Bulletin No. 99-03
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-04
Issue Date: November 20, 1998
Expiration Date: November 19, 1999
Subject: Bill Payment/BPS--Medications Which Do Not "Match" Accepted Conditions
Background: The new procedures for processing pharmacy bills have prompted queries about handling "mismatches" between accepted conditions and medications billed. Such "mismatches" may come to OWCP's attention either because the Bill Processing System (BPS) flags the medication as questionable in the case at hand or because a bill has been denied and the claimant or the pharmacy has returned the explanation of benefits (EOB) to OWCP.
In either instance, OWCP must take further action. While some medications may prove to be payable, others will continue to be ineligible for payment or reimbursement. This bulletin describes the actions which bill resolvers and claims staff will need to take in processing bills for medications which do not "match" the accepted condition(s) in the case.
Reference: FECA Bulletin 98-11
Purpose: To describe the actions to be taken when a particular medication does not "match" the accepted condition
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Bill Processing Staff, Rehabilitation Specialists, Staff Nurses, and Technical Assistants
Actions:
1. Where OWCP has already denied a bill for a "mismatch", the edit code is likely to be one of the following: 734 (therapeutic class is not payable for the accepted condition(s); 738 (the relationship between the therapeutic class and the accepted condition(s) requires manual review); and 746 (the accepted condition is missing from the relationship table).
Edit 734 results in an automatic denial, while edits 738 and 746 result in suspension. The suspension can be overridden if the bill is payable, or set to deny if the bill is not payable.
2. When an EOB letter is returned, and the reason for denial was code 734, an NDC query should be performed. The relationship file has recently been updated, and additional changes will continue to be made periodically. As a result of these changes, a medication that was previously denied may now be payable. Also, if the accepted conditions have been updated, the medication may now be payable.
3. If the bill is now payable, it should be rekeyed. If the bill was originally denied with EOB 738 or 746, and it should have been paid, it should be rekeyed, and the edit suspension overridden. Entry of a note to indicate that the medication is payable should prevent erroneous denials in the future.
4. If the bill is not payable, but experience has shown that the medication is often used to treat the condition in question, the District Medical Advisor (DMA) should be consulted. If the DMA agrees that the medication is properly used to treat the condition, the issue should be referred to Dr. Virginia Miller, OWCP Medical Director, so that modification of the relationship table may be considered.
5. If the bill remains unpayable after these steps have been taken, the Claims Examiner (CE) will need to review the medical evidence in file and/or obtain additional medical evidence to determine whether the medication is correctly used in the case at hand. The Physicians' Desk Reference (PDR) may be consulted to determine the proper use of various medications.
As always, the CE will need to exercise judgment in deciding if a particular medication should be (or continue to be) authorized. The CE should ensure that the accepted conditions accurately reflect the scope and severity of the claimant's injury and update the ICD-9 codes if warranted.
6. If the medical evidence supports payment but is not conclusive, the CE may obtain the advice of a District Medical Adviser. It is not anticipated that second opinion or impartial referrals will be needed to adjudicate such questions.
7. In long-term cases, OWCP may have paid for a questionable medication for many months or years. (By one estimate, over a third of periodic roll cases involve at least one medication where the relevance to the accepted condition(s) is questionable.)
In such instances the CE should add "P99" as a temporarily accepted condition to allow for payment during development of the issue. (This code should also be used to indicate an adjunct condition, and instead of any "placeholder" acceptance codes.)
A note showing that the medication is payable should be placed on the system, as edit 746 will suspend the bill if it is not otherwise payable.
8. If payment is denied, the responsible CE may release a letter decision to that effect. A sample is shown as Attachment 1. It is being added to the Letter Generator system.
9. A claimant who objects to this decision, either in writing or by telephone, should be issued a formal decision with full appeal rights. However, receipt of additional bills for the medication in question will not, by itself, be considered an "objection" to the letter decision. The claimant must actually express disagreement with the letter decision. Any formal decision must be based on the medical evidence of record, not the outcome of relationship editing by the BPS.
10. At present, there is no vehicle for advising injured workers with new claims that pharmacies may bill OWCP directly using the Universal Claim Form, or that injured workers should use Form CA-915 if they are seeking reimbursement of pharmacy expenses. Form CA-1008 is being revised with this information (a copy of the revised form is shown as Attachment 2.) The information will be added to Forms CA-14 and CA-1009 as soon as the forms are revised in conjunction with the program's new regulations.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Attachment 1: Form CA-1008
|
|
(999) 999-9999 File Number: 11-1111111 |
0000000000000000000000000000000
0000000000000000000000000000000
0000000000000000000000000000000
0000000000000000000000000000000
Dear CLAIMANT M. NAME:
I am writing in reference to your claim for injury on 02/02/1900, which you sustained while employed by the agency identified below. Your claim is accepted for:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
If your injury results in disability for work or the need for medical treatment, you may be eligible to receive continuation of pay (COP) until you recover or return to light duty, up to a maximum of 45 calendar days. If wage loss continues after the expiration of COP, you are eligible to claim disability compensation on Form CA-7. Bills for medical expenses related to the accepted condition(s) noted above will be processed for payment by this office following proper submission of charges. This includes medications which are prescribed for the accepted condition(s) noted above.
Pharmacies may bill this office directly using the Universal Claim Form. The pharmacy should include the following information: the case file number, the nine-digit tax ID number, the NDC number, the prescription number, the quantity of medication prescribed, the name of the prescribing physician, and the date of purchase. If you request reimbursement, please complete Form CA-915, which is used in addition to the Universal Claim Form. You may obtain Form CA-915 from your employing agency or from this office.
The enclosure, which is entitled "Now That Your Claim Has Been Accepted...", provides information about payment of bills, claims for compensation, and other matters pertinent to your claim.
Sincerely,
NAME OF SIGNER
TITLE
|
|
CA1008-1098 |
Page 1 |
Back to Top of FECA Bulletin No. 99-04
Attachment 2: Sample Letter--Prescription Bill Denied
Dear NAME OF CLAIMANT:
I am writing in reference to prescription bills submitted in your claim for injury on 02/02/1900, which has been accepted for:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
All claims for prescription payments must contain a National Drug Council (NDC) code for each drug billed. Each NDC code is an 11-digit number which represents a specific medication, made by a specific manufacturer, of a certain strength. The NDC coding system is used by pharmacies all over the United States.
On receipt of a bill for prescription expenses, the Office of Workers' Compensation Programs (OWCP) compares the NDC code to the medical condition(s) which OWCP has accepted as work-related. Sometimes, this comparison shows that the medication is not one which is properly used to treat the accepted condition.
In your case, OWCP received a bill from NAME OF PHARMACY on DATE OF RECEIPT for NAME OF MEDICATION. The NDC code for this medication, which is 99999999999, does not correspond to your accepted condition of ACCEPTED CONDITION. This means that the medical community does not generally recognize NAME OF MEDICATION as effective or safe to use in treating ACCEPTED CONDITION. For this reason, payment for NAME OF MEDICATION is denied.
This does not mean that your physician has prescribed NAME OF MEDICATION in error, or that you should not take this medication. Of course, NAME OF MEDICATION may be needed to treat some other, condition which is not related to your work, and you should consult your physician before changing the kind or amount of any medication you are taking. You may wish to submit bills for NAME OF MEDICATION to your health insurance carrier for consideration of payment.
If you have any questions, please do not hesitate to contact this office.
Sincerely,
NAME OF SIGNER
TITLE
Back to Top of FECA Bulletin No. 99-04
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-05
Issue Date: May 17, 1999
Expiration Date: May 17, 2000
Subject: Case File Imaging
Background: In November of 1997, via FECA Bulletin 98-01, a pilot imaging program was implemented to facilitate the maintenance of case files where the physical file was with the Employees' Compensation Appeals Board. Prior to this pilot, all maintenance of cases before the Board was handled by the Branch of Hearings and Review, although the claims examiners in the Branch were not familiar with the cases and often did not have possession of the physical case files.
The pilot has been successful in that it has allowed maintenance of Board cases in the owning District Office, where the staff is better equipped to address the issues that arise. There have been, however, some difficulties in adapting to the imaging technology selected for the pilot. In light of these difficulties, a new prototype imaging system will be selected prior to transitioning to an imaged environment for new cases. Presentation and implementation of this system will commence in May of 1999.
Reference: FECA Bulletin 98-01
Purpose: To describe changes in imaging of cases before the Board.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel
Action:
Effective May 17, 1999, all ECAB requests are to be routed to the National Office for review prior to imaging. The new system will function as follows:
The ECAB will electronically request a docketed case.
District Office staff will transfer the case file to location code T51 (as done prior to the imaging pilot).
National Office staff will review the file to determine whether it will be imaged. This decision will be based upon the nature of decision at issue in the case and the level of maintenance expected to be needed during its tenure at the Board (the attached chart outlines some general guidelines that may be followed in making this decision, but these guidelines will be applied loosely as necessitated by the judgement of the National Office staff member).
If the case file is not to be imaged, National Office mailroom staff will number the case file and forward it to the Board.
If the case file is to be imaged, National Office staff will forward the case to the FEC Imaging Center for imaging.
Claims Examiners in the Branch of Hearings and Review will once again perform case maintenance on all non-imaged cases. This maintenance will be limited, however, due to the nature of these non-imaged cases. When these cases are returned, as paper files, to the District Office after the Board reaches a decision, they will remain non-imaged and will continue to be handled as paper files. Due to budgetary constraints, it is not foreseen that open cases, including these, will be imaged until FY 2001, when a conversion of paper files may be possible.
District Office staff will remain responsible for maintenance of any imaged case before the Board. This will include holding the case file jacket and CA-800 as outlined in FECA Bulletin 98-01, and imaging all new mail as it arrives in the District Office. National Office mailroom staff will image all documents created in relation to the appeal prior to the return of the paper file to the District Office. When the paper file is returned, it should be associated with the jacket and CA-800 as per current practice. The image file will remain the primary record, again in keeping with current practice.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 99-05
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FECA BULLETIN NO. 99-06
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations: Continuation of Pay
Background: Part C of the Regulations, which includes sections 10.200 through 10.224, has been substantially revised. The revisions are as follows.
INITIAL CLAIM FOR COP:
Section 10.205(a)(3) revises the 90 days in which a person must begin losing time from work, in order to receive COP, to 45 days. Timely submission and adjudication of claims has dramatically improved since the 90-day period was adopted. Therefore, this grace period is no longer necessary to ensure that the injured worker's pay continues uninterrupted. The Program's focus on minimizing lost work time requires early intervention, which can only occur when OWCP is aware that an employee has lost time. The proposed time frame was 30 days, but upon consideration of comments received from various agencies and labor organizations, the time frame in the final rule is 45 days.
Thus, COP is payable only when disability begins, or time is lost for medical care, within 45 days of the date of injury.
While COP has always been appropriately used for medical treatment, a phrase specifying that has been included in section 10.205(a)(1).
Section 10.205(a)(2) clarifies existing practice that if Form CA-1 is not available, another form (CA-2 or CA-7, which contain words of claim) could be used to claim COP. The word "form" in this section does denote an OWCP-approved form, and a letter would not serve the purpose of timely filing.
RECURRENCE:
Consistent with Section 10.205, Section 10.207(c) allows any balance of COP remaining after the injured employee returns to duty to be used for a recurrence of disability, or for medical treatment, which begins within 45 days of the first return to work.
Section 10.207(a) clarifies that Form CA-2a is required to receive COP for a recurrence of disability.
While it does not specifically pertain to the new Regulations, the question has arisen, "When does time begin to toll for using a balance of COP in cases where there is no lost time immediately following an injury?". Various OWCP publications could be read differently on this issue. The Regulations, Procedure Manual, Publication CA-810, and the Resource Book for the Agency Workshop use the terms "work stoppage", "disability", and "lost time" variously in reference to when time begins to toll for using a balance of COP.
To clarify, time lost on the day of injury that is charged to administrative leave is considered a work stoppage, whether the time is used to obtain medical treatment or for disability. If the time away from work is so minimal that no administrative leave is charged, such as a brief visit to the health unit, this is not considered a work stoppage for the purpose of tolling time. Where administrative leave is charged on the date of injury, that constitutes a work stoppage, and the return to work after the administrative leave, whether that be on the date of injury or the following day, is considered the first return to work, and the 45 days for using any balance of COP begins to toll on that date.
MEDICAL EVIDENCE IN SUPPORT OF COP:
Section 10.210(b) reduces the time allowed for the employee to provide the employer with a medical report supporting disability from 10 working days to 10 calendar days, and includes a requirement that the medical evidence contain a statement of when the employee can return to the date of injury job. This is consistent with the emphasis on early intervention.
Section 10.506 allows an employer to contact the employee's physician in writing, for the purpose of monitoring an employee's medical progress and duty status, and specifically prohibits telephone contact and personal visits by the employer with the physician. This applies to an agency's monitoring of medical evidence during the COP period as well as later in the life of the claim. This section is discussed further in the FECA Bulletin covering an employer's responsibility in returning employees to suitable work.
INCLUSION OF SUNDAY PREMIUM IN COP:
Section 10.216 outlines the calculation of COP. Generally, the various increments of pay are included in the pay rate for COP. However, several appropriation bills recently signed into law prohibited Federal agencies funded by those bills from paying Sunday premium pay to their employees unless they actually performed work during the time period relevant to such pay. As OWCP cannot become involved in payroll functions among various agencies, section 10.216(a)(1) includes the phrase "except to the extent prohibited by law" to reflect these circumstances.
TERMINATION OF COP FOR DISCIPLINARY ACTION:
New section 10.222(b) allows an employer to terminate COP when a preliminary notice of a disciplinary action is issued before the injury, and becomes final or otherwise effective during the COP period. This revises previous section 10.201, which stated that the final written notice of termination must have been issued before the date of injury in order for the agency to terminate COP on that basis. The revision ensures that both the employee and the employer are in the same position as they would have been in but for the injury. As salary would not continue because of the disciplinary action, COP should not be paid.
Reference: 20 CFR 10.200 through 10.224, and 20 CFR 10.506
Purpose: To inform all claims staff of the revisions to the Regulations as they pertain to entitlement to COP
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Fiscal Personnel, Technical Assistants and Systems Personnel
Action:
1. The claims examiner will decide claims for COP, which are challenged by either the agency or the claimant, according to the provisions of the revised Regulations outlined above. In most cases, Form CA-1050 can be used for formal denials of COP.
2. The District Offices should conduct training on this bulletin within 30 days of the date of the bulletin.
Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 – Folioviews Groups A,B, and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
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FECA BULLETIN NO. 99-07
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations - Subpart I - Information for Medical Providers
Background: On November 25, 1998, new final regulations for the FECA program were published. These regulations are effective January 4, 1999. Regulations previously found at 20 CFR 10.410 through 10.413 and 10.450 through 10.457 have been consolidated in Subpart I. Among the changes included in Subpart I are provisions for fee schedules for prescription medications, and inpatient hospital bills. In addition, National Drug Codes (NDCs) and Revenue Center Codes (RCCs) have been added to the list of codes which a provider must specify, the required form for hospitals has been changed from the UB-82 to the UB-92, and the required form for pharmacy bills is the Universal Claim Form.
The pharmacy fee schedule is based upon the average wholesale price (AWP), plus a dispensing fee equal to 20% of the AWP. The dispensing fee cannot be less than $2.50, nor greater than $15.00. A private vendor is the source of the AWP information. The data is updated monthly. The highest AWP over the prior two years is the price that will be used to calculate the allowable fee. If the amount charged for a prescription is more than the calculated fee (AWP plus dispensing fee), the calculated fee will be paid. If the amount charged is less than the calculated fee, the amount charged will be paid.
The inpatient hospital fee schedule is based on the prospective payment system (PPS) used by the Health Care Financing Administration's (HCFA's) Medicare program. Using the ICD-9 diagnosis and procedure codes that are found on the UB-92 billing form, along with other data, the hospitalization is assigned to a Diagnosis-Related Group (DRG), and is priced according to that DRG and other hospital-specific data. The HCFA PPS is based on the premise that similar medical conditions and surgeries require similar inpatient services and resources.
Certain inpatient hospital facilities (such as those that provide rehabilitation and psychiatric services) are not covered under the HCFA PPS. For those providers, OWCP will use HCFA-calculated cost to charge ratio (CCR) data to calculate the allowable fee.
Both the grouping (assigning the DRG) and pricing of inpatient hospital bills (except for non-PPS facilities, which will be calculated by National Office) will be performed by another Federal agency. The calculated allowable fee may be more or less than the billed amount. Unlike other FECA fee schedules, however, the allowable payment amount will nearly always be the calculated amount. Therefore, if the calculated fee is greater than the billed amount, the amount paid for an inpatient hospitalization may exceed the amount billed. This practice is consistent with the way Medicare processes their bills.
Notifications concerning the new fee schedules are being sent to all hospitals and pharmacies to whom payment was made during the last six months, as well as claimants who have received pharmacy reimbursements during the last year. Copies of those notices are attached (Attachments 1 - 3).
References: Federal Register, Volume 62, No. 246, published December 23, 1997; 20 CFR, Part 10, Subpart I, published November 25, 1998; FECA Bulletin 98-11; Federal (FECA) Procedure Manual Chapter 5-0206.
Purpose: To notify District Offices of changes in regulations regarding medical bills, and provide procedures for implementation of the pharmacy and inpatient hospital fee schedules.
Applicability: All staff.
Actions:
1. Bills for prescription drugs should continue to be keyed in accordance with FECA Bulletin 98-11.
2. Since pricing for prescription drugs is calculated using the number of units, accuracy of the units (quantity) is critical.
3. The allowable fees for each prescription will be calculated after the bills have been approved for payment and transmitted to the Central system. The allowable fee for a particular drug does not vary by location of the pharmacy.
4. By regulation, the only allowable bases for reconsideration of any fee schedule reductions are:
a. The procedure was incorrectly identified by original code;
b. The presence of a severe or concomitant condition made treatment especially difficult; or
c. The provider possessed unusual qualifications, beyond Board-certification in a specialty.
Requests for reconsideration must be made within 30 days of the payment, be in writing, and be accompanied by documentary evidence. Obvious errors may be corrected without going through the full appeals process as described in Federal (FECA) Procedure Manual Chapter 5-0206, but should be processed with an appeal code of 7.
The presence of a severe or concomitant medical condition which made treatment especially difficult will generally not be a relevant factor in pharmacy bills, nor will the qualifications of the pharmacy provider. Most frequently, the basis of an appeal would be:
a. Incorrect NDC code (appeal code 1 or 4);
b. Incorrect number of units (quantity)(appeal code 1 or 4); or
c. Incorrect data entry by OWCP (appeal code 7).
6. To process a request for reconsideration of a pharmacy fee schedule reduction:
a. Determine whether there is a valid basis for appeal;
b. If the basis for appeal is valid, calculate the allowable fee. The allowable fee per unit may be obtained by contacting OWCP's Branch of Medical Standards and Rehabilitation, telephone number (202) 693-0035. The per unit price should be multiplied by the quantity, and then to that amount add 20 percent of the product, no less than $2.50, no more than $15.00. The end result is rounded up to the nearest whole dollar. If the calculated fee amount is less than the amount already paid, no additional amount is payable, and the provider should be so informed at the appropriate signature level. If the calculated amount is greater than the amount already paid, a new payment should be entered on the system, with the calculated allowable amount as the bill total and the line charge amount, the prior paid amount as an ineligible amount, ineligible code C, bypass code 1, 2, or 3 as appropriate, and an appropriate appeal code.
c. If the basis for an appeal is not valid, the request should be denied at the appropriate signature level.
7. The allowable fee for inpatient hospital bills (with the exception of those keyed with a locator 4 code of 911) will be calculated after the bills have been keyed into special software and transmitted to the clearinghouse, and before the bills are loaded onto the Sequent systems in each district office. The allowable fee amount cannot be changed in bill resolution, but ineligible amounts and ineligible codes may be added.
8. New procedures for processing inpatient hospital bills are outlined in FECA Bulletin 99-21.
9. Generally, the only allowable basis for appeals of inpatient hospital bill payment amounts is coding error. The location and individual characteristics of the hospital are already factored into the price calculation. Severe or concomitant medical conditions are already part of the process for assigning the DRG, and the length of stay is factored into the pricing.
10. To process a reconsideration of an inpatient hospital fee reduction, take the following steps:
a. Determine whether the basis for the appeal is valid;
b. If the basis for the appeal is not valid, deny at the appropriate signature level;
c. If the basis for the appeal is valid, the bill should be rekeyed in the special inpatient hospital software, with the previously paid amount as a prior paid amount. The bill will then be forwarded for the usual processing (grouping and pricing). The presence of a prior paid amount will cause the bill to be loaded on the Sequent system as an indirect payment, which will cause edit 210 to suspend the bill. Upon reviewing the bill, the calculated DRG amount should be compared to the prior paid amount. If the prior paid amount is greater than the DRG amount, no additional payment is due. The bill should be internally denied, and the provider informed at the appropriate signature level. If the DRG amount is greater than the prior paid amount, an ineligible code of C should be added, and change the direct pay flag to Y (if direct pay) or override the edit 210 failure (if it is a claimant reimbursement with adequate proof of payment), enter an appropriate appeal code and bypass code, and recycle the bill.
11. The CA-91 Payment Notice is being revised to include general information concerning fee schedule appeals. A copy of the added text is shown as Attachment 4. Note that the reader is directed to contact the servicing district office for specific information on a fee reduction.
Training on these procedures should be completed as soon as possible, no later than January 15, 1999.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment 1
IMPORTANT NOTICE FOR HOSPITAL PROVIDERS
This notice applies to inpatient hospital payments made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.
FEE SCHEDULE FOR INPATIENT HOSPITAL BILLS - EFFECTIVE JANUARY 4, 1999
Charges for inpatient hospitalization will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.810, published on November 25, 1998.
The allowable amount will be calculated using formulae based on Medicare's Prospective Payment System (PPS) and Diagnosis-Related Groups (DRGs), with adjustments that reflect FECA-specific factors. These formulae always result in payments greater than Medicare's allowable per diem rate. Hospitals not subject to the PPS will be reimbursed according to formulae based on the cost-to-charge ratio.
Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The hospital provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. Non-covered items, such as television and telephone charges, are always the responsibility of the patient. There is no deductible amount.
If the provider disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.
BILLING INFORMATION
Claims for inpatient hospital services must be submitted on a completed Form UB-92. The UB-92 must contain the provider's name, address, Tax Identification Number (TIN), and Medicare Number. In addition, the injured worker's name and OWCP claim number, the type of bill (Locator 4), the period covered by the statement (Locator 6), covered days (Locator 7), birth date (Locator 14), sex (Locator 15), discharge status (Locator 22), total charges (Locator 47), and the discharge diagnoses and procedures (if any) must be present on the UB-92. Bills not submitted properly will be returned or denied.
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Attachment 1 |
Back to Top of FECA Bulletin No. 99-07
Attachment 2
IMPORTANT NOTICE FOR PHARMACY PROVIDERS
This notice applies to payments for pharmaceutical drugs made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.
FEE SCHEDULE FOR PHARMACY BILLS - EFFECTIVE JANUARY 4, 1999
All charges for medications will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.809, published on November 25, 1998. The maximum allowable amount will be calculated based on the Average Wholesale Price (AWP) for the medication, plus a calculated dispensing fee, not to exceed $15.00. Dispensing fees should not be billed separately. Payment will be the lesser of the calculated fee or the billed amount. Charges that exceed the calculated fee will be reduced to the maximum allowable.
Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The pharmacy provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. Non-covered items are always the responsibility of the patient. There is no co-pay amount.
If the provider disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.
BILLING INFORMATION
All claims for prescription payments must be coded using National Drug Codes (NDCs), and must also contain the prescription number, refill number, decimal quantity, and date filled. The pharmacy's Tax Identification Number (TIN), full name and address, and the name and OWCP case file number of the injured employee must appear on the claim. Bills not submitted properly will be returned or denied.
Bills must be submitted either in electronic format through an intermediary (preferred), or on the paper Universal Claim Form. For information about electronic billing, contact William Cole at (202) 693-0041.
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FECA Bulletin 99-07 |
Attachment 2 |
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Attachment 3
IMPORTANT NOTICE CONCERNING PAYMENTS FOR MEDICATIONS
This notice applies to payments for pharmaceutical drugs made by the Office of Workers' Compensation Programs (OWCP) on behalf of injured federal workers covered under the Federal Employees' Compensation Act (FECA). The program provides coverage for work-related injuries and diseases for civilian employees of the Federal government. State and private sector employees are not covered by this Act.
FEE SCHEDULE FOR PHARMACY BILLS - EFFECTIVE JANUARY 4, 1999
All charges for medications will be subject to a fee schedule, as described in the Federal regulations at 20 C.F.R. 10.809, published on November 25, 1998. The maximum allowable amount will be calculated based on the Average Wholesale Price (AWP) for the medication, plus a calculated dispensing fee, not to exceed $15.00. Dispensing fees should not be billed separately. Payment will be the lesser of the calculated fee or the billed amount. Charges that exceed the calculated fee will be reduced to the maximum allowable.
Under the regulations governing the FECA, the program's payment constitutes the maximum payment. The pharmacy provider is not permitted to bill the injured employee for the difference between the OWCP allowable amount and the charged amount. If the injured employee has already paid for the medication in full, and reimbursement is being made to that employee, the reimbursement amount will not exceed the OWCP allowable amount. The employee should seek reimbursement for any remaining balance from the pharmacy provider. Non-covered items are always the responsibility of the patient. There is no co-pay amount.
If the provider (or a reimbursed employee) disagrees with a fee reduction, a reconsideration request may be made within 30 days of the payment. The request should be sent to the district office that has jurisdiction over the employee's claim.
BILLING INFORMATION
All claims for prescription payments must be coded using National Drug Codes (NDCs), and must also contain the prescription number, refill number, decimal quantity, and date filled. The pharmacy's 9-digit Federal Tax Identification Number (TIN), full name and address, and the name and OWCP case file number of the injured employee must appear on the claim. Bills not submitted properly will be returned or denied.
Bills must be submitted either in electronic format through an intermediary (preferred), or on the paper Universal Billing Form. For reimbursement to injured employees, a Form CA-915, claimant reimbursement form, is preferred. This form is used in addition to the Universal Billing Form.
Direct billings from pharmacies involve less paperwork than reimbursements to injured employees. If your pharmacy is not already billing OWCP directly for medications prescribed for your work-related conditions, you may wish to discuss this matter with them. Many pharmacies are willing to bill OWCP directly.
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Attachment 3 |
Back to Top of FECA Bulletin No. 99-07
Attachment 4
FEE SCHEDULE APPEAL RIGHTS
The accompanying card shows charged amounts, reduction amounts, and paid amounts. Unless a different explanation is shown on the accompanying card, any reduction shown was made under the schedule of maximum allowable charges used by the Office of Workers' Compensation Programs (OWCP). The fee schedule applies to professional medical services, medicinal drugs, and inpatient hospital services, in accordance with 20 CFR 10.805 through 10.813. For additional information about the reduction, contact the servicing OWCP Office shown on the accompanying card.
A provider may not seek from the patient any additional charge or fee in excess of the charge allowed by OWCP. A provider who collects or attempts to collect any additional amount from the patient may be excluded from participating in the Federal Employees' Compensation Program and other Federal programs.
By regulation, the ONLY circumstances which will justify reevaluation of the amount paid are: (1) the service was incorrectly identified by code; or (2) the presence of a severe or concomitant medical condition made treatment especially difficult; or (3) the provider possesses unusual qualifications (beyond Board certification).
PROVIDER: If you disagree with the fee schedule reduction, you may take the following action within 30 days: (1) make written request for reconsideration of the fee determination, (2) identify the service in question, (3) attach documentary evidence relevant to one of the three circumstances described above, (4) attach a copy of this notice to your request, and (5) submit to the servicing OWCP Office, ATTENTION: FEE SCHEDULE APPEAL.
REIMBURSED PATIENT: If you paid the medical provider more than the OWCP reimbursement amount, take the following actions in the order presented: (1) show this notice to the medical provider and request a refund or credit of the difference; (2) ask the medical provider to submit an appeal as described above on your behalf; (3) request in writing that the servicing OWCP Office contact the medical provider concerning the amount you paid in excess of the fe schedule.
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Attachment 4 |
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FECA BULLETIN NO. 99-08
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations--Privacy Act
Background: On October 22, 1998, the Department of Labor issued new regulations codifying changes in case law involving the Privacy Act. On January 4, 1999, the new Federal Employees' Compensation Act Regulations, further referencing the Privacy Act regulatory changes, became final.
The regulatory changes involving the Privacy Act primarily serve to formalize handling of Privacy Act requests. There is a major change, however, in the delineation of which specific situations may require exemption of records from disclosure.
Reference: 29 CFR Parts 70a and 71; 20 CFR 10.10 through 10.13
Purpose: To inform OWCP staff and employing agencies of Privacy Act compliance requirements.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives
Action:
1. All records in OWCP's files and all copies of these records in the possession of the employer are considered to be OWCP records, covered by the DOL/GOVT-1 system of records. This means that although employing agencies may establish procedures for access to the records that they maintain, their decisions to grant/deny access must comply with Department of Labor rules and regulations.
2. This said, only OWCP may respond to requests for correction or amendment to any OWCP record. Employing agencies must forward such requests to OWCP without acting upon them.
If release of records is approved, the request may be read to consent to copying fees up to $25.00. The requester must be consulted before higher fees will be assessed. Fees will apply as follows:
The first copy of the requested information must be provided at no cost. Any additional/later copy should be provided at a cost of $.15 per page, but the first 100 pages will be free of charge.
OWCP may require payment in advance of fees over $250. If such a fee is anticipated, a letter should be sent to the requester, noting the amount of the fee and advising that the requester may contact a designated OWCP staff person to attempt to reformulate the request to meet his or her needs at a reduced cost.
4. Any decision on a Privacy Act request must be given in writing, whether an approval or denial. An approval should include discussion of any fees, if over $25.00, and should, whenever possible, also include the copy of the records requested. Should copying be delayed, an interim response notifying the requester of the approval, the length of the anticipated delay, and a reason for the delay, should be provided. All decisions should be issued over the signature of the designated Privacy Act officer. At the District Office level, this is the District Director or his or her designee.
5. A Privacy Act request may be denied only if the information requested is excepted from release for one of the following reasons:
a. Release of the records would allow the subject of an investigation to know he or she was the subject of an investigation, to determine the nature of the investigation, or to determine the identity of witnesses/informants, or
b. Release of the records would inform the subject of an investigation of other actual/potential violations of law that have been uncovered via investigation.
6. If access to a certain record (or records) is being denied, the denial must be formal, in writing, over the signature of the District Director, and include a statement of the reasons for denial, including the specific exemption, and a statement that appeal is possible. The appeal statement should indicate that appeal must be made within 90 days of the receipt of the denial notice, and that it must be made to the Solicitor of Labor. A sample letter for this purpose is attached.
7. If OWCP is unable to locate a record for which a Privacy Act request has been made, OWCP should notify the requester of this in writing, with the same 90-day appeal rights as outlined in item 6 above.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment: Sample Letter
DATE
File #
Dear NAME:
We have received your recent request for release of (LIST INFORMATION HERE). After full consideration of your request, it has been determined that we are unable to release this information. Our inability to release the information is because (LIST EXEMPTION HERE).
You have the right to appeal this decision. Your appeal must be dated within 90 days of your receipt of this notice. Should you wish to appeal, please state your reasons in writing to:
Solicitor of Labor
U.S. Department of Labor
Room S-4325
200 Constitution Avenue, NW
Washington, DC 20210-0002
Note that both your letter and envelope should be marked "Privacy Act Appeal." If they are not so marked, they will not be counted by the Solicitor of Labor as received until identified as a Privacy Act appeal and forwarded to the appropriate office for handling.
Sincerely,
DISTRICT DIRECTOR
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FECA BULLETIN NO. 99-09
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations: Attendant's Allowance
Background: New section 10.314 of the regulations allows payment for the services of an attendant to be made only directly to the provider of the service, up to the maximum of $1500 per month allowed by 5 U.S.C. 8111. There will be no further payments made directly to claimants for the services of an attendant for any new claims for such services.
Where direct payments were being made to the claimant to cover the services of an attendant prior to January 4, 1999, such payments will continue until such time as the services of an attendant are no longer necessary.
In order for claims to be handled in a uniform manner in each district office, any claim for attendant services that is postmarked prior to January 4, 1999, the effective date of the new regulations, will be considered under the old regulations. Payments will be made directly to the claimant until the need for the attendant ceases. Once the services of the attendant are terminated, any new claims for attendant services will be considered under the new regulations.
OWCP will pay for attendant services as a medical service under 5 U.S.C. 8103, rather than under 5 U.S.C. 8111(a). This will allow for greater fiscal control, as bills submitted directly to OWCP will be subject to the fee schedule, and will be reviewed to ensure that charges are correct. It will also allow for quality review, ensuring that necessary services are being provided by a home health aide, licensed practical nurse or similarly trained individual.
The criteria for determining whether the services of an attendant are required have not changed. However, the method of payment has changed, and any references in the Procedure Manual to payment of an attendant allowance to the claimant is superceded by this bulletin.
The system updates required to support the payment of an attendant allowance as a medical expense are under development. Additional procedures in this regard will be issued when they are finalized. For now, use provider type code C when paying for attendant care.
References: 20 CFR 10.314
Purpose: To inform all claims, rehabilitation, and fiscal staff of the revisions to the Regulations as they pertain to the payment for the services of an attendant.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Rehabilitation Specialists, Technical Assistants, and District Medical Advisors
Action:
1. Upon receipt of a request for payment of the services of an attendant, release Form Letter CA-1090 to the claimant's physician. Form Letter CA-1086 is no longer relevant as that primarily addresses the claimant's method of paying the attendant.
2. Upon receipt of the reply from the claimant's physician, consider entitlement to an attendant allowance according to the criteria found in the Procedure Manual in Chapter 2-812.
3. In those cases where the services of an attendant are approved, the claims examiner will prepare a memorandum for the file which indicates the reasons for approving the attendant allowance, and stating the period for which it is approved. A claims examiner may approve the services of an attendant up to one year at a time if the medical evidence supports a long-term need.
4. Enter a note in the automated system stating that an attendant allowance is approved, the period for which it is approved, and that it is limited to the amount of $1500 per month. Advise the claimant of the approval; that the services should be provided by a home health aide, licensed practical nurse, or similarly trained individual; that the amount is limited to $1500 per month; and that the provider should submit their bill for services directly to OWCP using Form HCFA 1500 or OWCP 1500 as directed in 20 CFR 10.801.
5. For cases where an attendant allowance is currently being paid directly to a claimant, continue such payments under the old procedures. After the need for the attendant services ends, consider any new claims for an attendant allowance under the new regulations.
6. Process any pending claims for an attendant allowance, which are postmarked before January 4, 1999 under the old procedures.
7. Process all approved charges for the services of an attendant for payment directly to the provider of the services, up to a maximum of $1500 per month, and subject to the fee schedule. Use provider type C when paying for attendant care. At the present time, there is no indicator in the system to limit the payments for attendant services to $1500 per month. This must be monitored as the bills are paid.
8. If charges over the allowed amount are received, return them to the provider with an explanation that the charges for attendant services exceed the allowed monthly limit.
9. The District Offices should conduct training on this bulletin within 30 days of the date that this bulletin is received.
Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 – Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Hearing Representatives, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-09
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FECA BULLETIN NO. 99-10
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations--Continuing Benefits
Background: The new regulations governing claims under the FECA contain a subpart headed "Continuing Benefits" that codifies several OWCP procedures and marks some changes in those procedures.
For the first time, the regulations at 10.502 explain how OWCP weighs medical evidence in reaching final decisions. This section codifies the long-held practice of weighing medical reports, including those of a second opinion and a treating physician, to determine whether a referee examination is warranted or whether a decision on ongoing compensation entitlement may be made without further medical opinion.
Section 10.505 clarifies that OPM, not OWCP, is responsible for ensuring that employing agencies make all reasonable efforts to re-employ injured workers who have fully recovered after more than one year.
Section 10.506 contains a change from the previous regulations to indicate that while employers may contact employees' treating physicians for periodic medical progress reports, this should be done only in writing. All such correspondence must also be forwarded to OWCP for inclusion in the file. Employers are also given permission to contact injured workers directly at reasonable intervals to obtain periodic medical reports addressing return to work.
OWCP's handling of reduction in force (RIF) situations is outlined in Section 10.509. This section indicates that elimination of a light-duty position via RIF or downsizing is not prima facie evidence of recurrence. Instead, OWCP must determine the injured worker's wage earning capacity based on his or her actual earnings in the light-duty job if such earnings fairly and reasonably represent his or her wage-earning capacity and no wage earning capacity decision has previously been issued. This section also indicates that, in order for an actual earnings wage earning capacity rating to be issued, the position must formally be classified by occupational series and grade level and include a written position description. Otherwise, OWCP assumes that the injured worker was employed in a non-competitive position not representative of his or her wage-earning capacity.
Section 10.516 codifies the decision of the Employees' Compensation Appeals Board in the case of Maggie Moore. It is now part of the regulations that, in order to terminate compensation based on refusal of a suitable position, OWCP must first give a 30-day notice that the job was found suitable and request reasons for refusal and then, if a response is received and found to be invalid, the injured worker must be given an additional 15 days to accept the position without penalty. If an injured worker does not respond to the 30 day letter, no further action is required prior to termination of benefits, as has been OWCP procedure.
On the same topic, section 10.517 notes that although compensation is terminated under 5 U.S.C. 8105, 8106 and 8107 in the case of refusal of suitable employment, entitlement to medical benefits continues.
Section 10.518 affords OWCP nurse intervention services the same status as vocational rehabilitation services under 5 U.S.C. 8104. This also allows the same penalty provisions for non-compliance with vocational rehabilitation services to apply to non-compliance with nurse intervention. The section, in part (b), also formally makes Functional Capacity Evaluations (FCE's) part of vocational rehabilitation services, in effect giving the current Occupational Rehabilitation Program (ORP) procedures the force of regulation.
Section 10.526 provides that individuals receiving compensation for partial or total disability are required to report volunteer activity when reporting all work activity. This will be incorporated into the new version of the CA-1032 effective January 4, 1999.
Section 10.527 provides notice that OWCP may use computer matching with various Federal and state agencies to verify wage information.
Reference: 20 CFR 10.500 through 10 CFR 10.541
Purpose: To inform OWCP staff of significant regulatory changes regarding continuing benefits.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives
Action:
1. Claims Examiners should continue basing decisions on the weight of medical evidence, only utilizing referee examinations when the weight of the medical evidence of record is truly equal, and a conflict exists therein.
2. In cases where a recurrence is claimed due to the removal of light duty, determine whether the removal was due to RIF or downsizing. If not, as has been the current practice, the claimant has established a recurrence of disability.
If the recurrence claim is due to RIF or downsizing and an actual earnings LWEC decision is in place, the claims examiner must determine whether the position utilized for that LWEC determination was classified as outlined above. If the LWEC determination was in fact based on a classified position the LWEC remains in force and the recurrence should be denied. If not, the claimant's entitlement to compensation is based upon the compensable recurrence.
If no LWEC decision is in place, the claims examiner must determine whether the light duty position the claimant was performing is appropriate for an actual earnings LWEC. To be appropriate, the position must have been classified as indicated above. If this is the case, an actual earnings LWEC should be issued. As in the case of previously issued LWEC decisions, if the position the claimant worked until the RIF is not classified, he or she is entitled to compensation due to the claimed recurrence.
3. In cases where an injured worker has refused a job offer deemed suitable, be certain to allow the full due process now required by regulation. This means that a 30-day response period must be provided initially, followed by a 15-day period to accept the job if the employee provides reasons for his or her refusal.
Note that injured workers are now required to undergo nurse intervention services, or face sanctions for non-compliance as outlined at 20 CFR 10.519. Refusal to participate at the nurse intervention stage would most generally be construed as early-stage refusal. Therefore, non-compliance with nurse intervention services would result in the assumption that participation would have resulted in employment with no loss of wage-earning capacity, and OWCP will reduce compensation to zero until the employee acts in good faith to comply with nurse intervention services. A new letter is being added to Forms Correspondence to outline the penalties for non-compliance with nurse intervention. The number of this letter will be made available separately. A copy of the letter is attached, however, so that claims examiners may begin to use it effective January 4, 1999 in appropriate situations.
5. The CA-1657, applying to early non-cooperation with vocational rehabilitation efforts, has been altered to reflect the new regulatory sections from which the authority for sanctions stem. This letter will also be made available via forms correspondence.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment: Sample Letter--Cooperation with nurse services
File #
DATE
ADDRESS
ADDRESS
ADDRESS
Dear :
A Registered Nurse has attempted to contact you in relation to your claim under the Federal Employees' Compensation Act. The main purpose of this contact is to assist you in returning to gainful employment. Nurse services include (but are not limited to) important steps toward reemployment such as work evaluations, coordination of medical efforts, and facilitation of efforts between you and your employer. Your refusal without good cause to meet with the nurse and assist in these efforts may be seen as refusal to undergo vocational rehabilitation.
The following specific circumstances support a finding that you are refusing to cooperate with the nurse intervention, and by association, the vocational rehabilitation efforts of the Office of Workers' Compensation Programs (OWCP):
FREEFLOW TEXT
PROVISIONS OF THE LAW AND REGULATIONS
The Federal Employees' Compensation Act (FECA) at Section 5 U.S.C. 8113(b), states that a claimant must undergo vocational rehabilitation when OWCP so directs, unless there is a good reason not to do so. Therefore, if you do not undergo vocational rehabilitation as directed, including nurse services, and OWCP finds that your wage-earning capacity would likely have increased a great deal, OWCP may reduce your compensation. The amount of the reduction will be based on what you would probably have earned had you undergone nurse intervention and/or vocational rehabilitation.
Also, the Code of Federal Regulations at 20 CFR 10.518 and 20 CFR 10.519 states that an injured worker must take the steps described above to prepare for reemployment, unless there is a good reason not to do so. Therefore, unless you produce evidence to the contrary, OWCP will assume that nurse intervention would have resulted in return to work with no loss of wage-earning capacity, and will reduce your compensation accordingly--that is, to zero. This reduction will continue until you comply in good faith with OWCP's directions concerning nursing services. If you do comply, compensation will then be paid to you, except for the period when you did not comply.
If your compensation is reduced to zero under the provisions of Section 20 CFR 10.518 and 10.519, any deductions which OWCP is making for health benefits (HB) and/or optional life insurance (OLI) premiums will cease and any HB/OLI coverage will be terminated. If you later comply with OWCP's instructions, OWCP will reinstate HB/OLI coverage and deduct any past due premiums from continuing compensation.
REQUIREMENTS FOR RESPONSE
You are hereby directed to contact me within 30 days from the date of this letter to make a good faith effort to participate in the Registered Nurse's efforts to return you to gainful employment.
If you believe you have good reason for not participating in this effort, so advise this office within 30 days from the date of this letter. Give your reasons and submit any evidence to support your position. Also, if you believe that nursing services would not reduce your wage-earning capacity to zero, submit evidence to support your position within 30 days.
If you do not comply with the instructions contained in this letter within 30 days, we will end the rehabilitation effort and reduce your compensation under the provisions of Section 8113(b) and Section 20 CFR 10.519 as described above.
If you have any questions, please contact this office using the address or telephone number shown on the previous page.
Sincerely,
CLAIMS EXAMINER
Back to Top of FECA Bulletin No. 99-10
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FECA BULLETIN NO. 99-11
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations: Compensation and Related Benefits
Background: Subpart E of the Regulations includes sections 10.400 through 10.441, and addresses the payment of compensation and overpayments. This subpart includes several revisions which formalize current practice. There are no new procedures related to these revisions.
COMPENSATION PAYMENTS
Section 10.400, in defining total disability, now includes a statement that OWCP expects that most employees will eventually return to work.
Section 10.404 formalizes the fact that OWCP uses the AMA Guides to the Evaluation of Permanent Impairment as its frame of reference for calculating schedule awards.
In sections 10.406 and 10.411, which concern maximum and minimum rates of compensation, the word "basic" has been prefixed to "monthly pay" to make clear that locality adjustments are not included in these determinations. Statements have also been added to recognize that compensation paid due to an assault which occurred during an attempted or actual assassination of a federal official in the performance of duty is exempted from the maximum rates.
Section 10.417, provides that OWCP may, at least twice each year, request reports to verify student status or the inability of a child over 18 to support himself or herself. This is consistent with most school enrollment schedules, and reminds recipients that a child over 18, not enrolled in school for a semester, is not eligible for survivor benefits for that semester.
New Section 10.421(c) formalizes the fact that a claimant cannot receive benefits for total disability and severance or separation pay for the same period. A schedule award or an LWEC can be paid concurrently with separation or severance pay.
New section 10.421(d) includes changes made to the FECA when the Federal Employees' Retirement System (FERS) was instituted. The relevant procedures are outlined in FECA Bulletin 97-9.
Section 10.423 reflects changes to various federal laws, making it clear that compensation payments can be garnished to collect overdue alimony and child support payments, upon presentation of a State agency or court order.
Section 10.424 condenses the material regarding representative payees into one paragraph, as the detailed guidance previously given was largely procedural rather than regulatory.
LEAVE BUY-BACK
The only reference in the revised regulations to the leave buy-back process is found in section 10.425. This section states only that an employee may claim compensation for restorable leave in accordance with the rules of the employing agency. Leave buy-back is not authorized or required by the FECA, and is not controlled by OWCP. It is controlled by each employing agency. The only relationship between those rules and the FECA is the general prohibition against paying wage-loss benefits for a period where leave was used. The previous regulatory reference to the repurchase of leave inadvertently gave the impression that OWCP controlled leave buy-back.
OVERPAYMENTS
The regulations concerning overpayments have been extensively rewritten to make it clear that a FECA beneficiary is obligated to be aware of the period for which benefits are paid and the manner in which overpayments are declared, contested and collected. The revised overpayment regulations are in sections 10.430 through 10.441.
New section 10.430 describes the method by which OWCP notifies recipients of payments. In the absence of evidence to the contrary, it will be presumed that the beneficiary received the notice. Once put on notice of a payment and the amount, the recipient is responsible for notifying OWCP of any discrepancies.
Sections 10.436 and 10.437 discuss the two circumstances under which an overpayment can be waived, and makes it clear that the equity and good conscience test for waiver applies to all individuals who are without fault regardless of whether they are present or former beneficiaries under the Act. This restores the statutory distinction between the application of the two tests for waiver, which was unintentionally removed as a result of the 1987 revision of the regulations.
Section 10.441 clarifies the fact that an overpayment is a debt subject to the Debt Collection Act of 1982, and if not paid, OWCP will recover the debt by any available means.
Reference: 20 CFR 10.400 through 10.441, FECA Bulletin 97-9
Purpose: To inform all claims staff of the revisions to the Regulations as they pertain to the payment of compensation and overpayments
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Fiscal Personnel, Technical Assistants and Systems Personnel
Action:
The District Offices should conduct training on this bulletin within 30 days of the date that this bulletin is received.
Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 – Folioviews Groups A,B, and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses
Back to Top of FECA Bulletin No. 99-11
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FECA BULLETIN NO. 99-12
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations - Reconsiderations and Reviews by the Director; Reviews by the Employees' Compensation Appeals Board
Background: The changes to the regulations included additional information regarding the reconsideration process and reviews by the Director on his or her own motion under § 8128 of the FECA. The major substantive change implemented in this area concerns the merit review on the Director's own motion. The new regulations state at § 10.610 that a decision to review on this basis is not subject to a request or petition and that none shall be entertained. That is, the Office has full discretionary authority in these matters, and the claimant cannot request review on the Director's own motion. In § 10.610(a) the regulations point out that a decision to review or not to review on the Director's own motion is also not subject to review by the ECAB, nor can it be the subject of a reconsideration or a hearing request. On the other hand, any decision which results from a review on the Director's own motion can be subject to whichever of the three avenues of appeal the claimant selects, including reconsideration, hearing or review by the Employees' Compensation Appeals Board.
Other changes include an extension of the period (from 15 to 20 days) for comment by the employer on the claimant's application for reconsideration and any additional evidence the claimant submits in support of his or her application. This is balanced by allowing the claimant 20 days (instead of 15) to respond to any comments on his or her application made by the employer.
The only other substantive change is the fact that the new regulations on the reconsideration process and review by the Director are explained in six sections [§10.605 through §10.610] of Subpart G - Appeals Process, making the discussion more thorough. Comparatively, the previous regulations included these topics in one section [§10.138] of Subpart B - Notice of Injury and Claim for Compensation, Administrative Procedures. The six sections provide much greater detail concerning the definition of reconsideration by the Office [§10.605], the procedure for requesting a reconsideration [§10.606] along with the time limits for doing so [§10.607]. These sections go on to explain how the Office evaluates the evidence submitted by the claimant to determine whether it warrants a merit review [§10.608], and if so, whether, upon review, the evidence or arguments presented are sufficient to warrant modification of the previous merit decision [§10.609]. The last of the six sections [§10.610] addresses the process of review on the Director's own motion and is discussed above.
With regard to requests for review by the Employees' Compensation Appeals Board, the changes include a more in-depth discussion of appeals to the Board. Specifically, at §10.625 the new regulations address the types of decisions which may be appealed to the Board. Also in Subpart G at §10.626, the new regulations specify which entity has jurisdiction (the Board or the district office) over the cases while they are on appeal based on the issue(s) being addressed by ECAB in its review.
Reference: 20 CFR Part 10, Subpart G, Sections 10.605 through 10.610; Sections 10.625 and 10.626; Federal (FECA) Procedure Manual, Chapters 2-1600 (paragraphs 2.c. and 2.d.), 2-1602 and 2-1603; FECA Circular 99-04
Purpose: To focus on the part of the new regulations which addresses the reconsideration process and reviews on the Director's motion, and to point out that the deadline has been extended for the employing agency to submit comments on the application for review, and for the claimant to respond to any comments submitted.
Applicability: Regional Directors, District Directors, Claims Examiners, Supervisory Claims Examiners, and appropriate National Office personnel.
Action:
1. The training on the new regulations should include emphasis on the discussion in §10.610 which addresses reviews on the Director's own motion. Most importantly, the CEs should be clear on the point that pursuant to this section a claimant may not request review on the Director's own motion.
2. The district offices should also ensure that any pre-formatted letters used for requesting comments or responses to comments are amended to reflect the changes from 15 to 20 days for submission of comments and responses.
3. Attachments 1, 2, and 3 correspond to Exhibits 2, 3, and 4 of Chapter 2-1602 and are replacements until such time as the FECA Procedure Manual is updated to incorporate these changes. They contain the corrected address for the Employees' Compensation Appeals Board and a corrected reference to the new regulations at 20 CFR 10.607(a) pertaining to timely requests for reconsideration.
4. Training for all claims personnel which focuses on Subpart G-Appeals Process (changes in the appeals process pursuant to the new regulations) should be accomplished within 30 days of receipt of this FECA Bulletin.
Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Attachment 1
SAMPLE LETTER DENYING AN UNTIMELY
REQUEST FOR RECONSIDERATION
Dear CLAIMANT NAME:
This is in reference to your letter dated DATE OF LETTER requesting reconsideration of our decision dated DATE OF LAST MERIT DECISION. Your letter was postmarked [OR dated] on DATE.
As provided by 20 CFR 10.607(a), we will not review a decision unless the request to do so is filed within one year of the date of that decision. Accordingly, your request for reconsideration is hereby denied because it was not postmarked [OR dated] within the one-year time limit.
We have evaluated the evidence you submitted in support of your request to see if it constitutes clear evidence of error [as described in § 10.607(b)] in OWCP's original decision. Such error would require the OWCP to reopen the case even though your request for reconsideration is untimely. However, an evaluation of the evidence you submitted does not show clear evidence of error on the part of OWCP.
If you disagree with this decision, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. This is your only right of appeal. No new evidence may be submitted to the Board. Request for review by the Appeals Board should be made within 90 days from the date of this decision and should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington, D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.
Sincerely,
SENIOR CLAIMS EXAMINER
Back to Top of FECA Bulletin No. 99-12
Attachment 2
SAMPLE LETTER DENYING AN APPLICATION WHICH IS PRIMA FACIE
INSUFFICIENT TO WARRANT REVIEW OF THE CASE
Dear CLAIMANT NAME:
We have reviewed your letter of DATE OF LETTER requesting reconsideration of our decision dated DATE OF DECISION.
Please refer to the information which accompanied the original decision. To require the Office to reopen your case, you must clearly identify the grounds upon which reconsideration is being requested. In addition, you must either submit relevant evidence not previously considered, or present legal arguments not previously considered.
Because your letter did not include new and relevant evidence or new legal arguments, it is insufficient to warrant a review of our prior decision at this time. Any future request for reconsideration must be made within one year from the original decision and must be accompanied by statements or evidence as described above.
If you disagree with this specific decision, namely, our denial to review our prior decision, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. This is your only right of appeal. No new evidence may be submitted to the Appeals Board.
A request for review by the Appeals Board should be made within 90 days from the date of this decision. It should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington. D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.
Sincerely,
SENIOR CLAIMS EXAMINER
Back to Top of FECA Bulletin No. 99-12
Attachment 3
SAMPLE NOTICE OF THE ONE-YEAR TIME LIMITATION
FOR REQUESTING RECONSIDERATION
FEDERAL EMPLOYEES' COMPENSATION ACT APPEAL RIGHTS
If you disagree with this decision denying reconsideration of your case, you may request review by the Employees' Compensation Appeals Board. No new evidence may be submitted to the Board. Request for review by the Appeals Board should be made within 90 days from the date of this decision and should be addressed to Employees' Compensation Appeals Board, U.S. Department of Labor, 200 Constitution Avenue, N.W., Room N-2609, Washington, D.C. 20210. For good cause shown, the Appeals Board may waive the failure to file within 90 days if application is made within one year from the date of the decision being appealed.
NOTICE
Section 10.607(a) of Title 20 of the Code of Federal Regulations, which concerns the reconsideration of a decision by the Office of Workers' Compensation Programs (OWCP), provides that OWCP will not review a decision denying or terminating a benefit unless the claimant's request for review is filed within one year of that decision. This provision of the earlier regulations became effective June 1, 1987. Therefore, even if the decision in your case was issued prior to June 1, 1987 and included the right to reconsideration, without specifying a time limit, a request for reconsideration of that decision will be denied if it is not made within one year from the date of this notice.
Back to Top of FECA Bulletin No. 99-12
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FECA BULLETIN NO. 99-13
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations: Medical and Related Benefits
Background: Subpart D of the Regulations, which includes sections 10.300 through 10.337, has been substantially revised. This bulletin discusses the revisions to subpart D.
FORMALIZING CURRENT PRACTICE
Most of the additions merely formalize current practice. Those are as follows.
In 10.300, the statement that the employer need not issue a Form CA-16 more than one week after the occurrence of the claimed injury has been added. The purpose of the issuance of this form is to ensure that necessary immediate medical care is not hindered through uncertainty by the provider of who is responsible for payment.
Sections 10.301 and 10.316 address physician referrals. 10.301 now states that the physician designated on the CA-16 may refer a claimant for additional treatment and OWCP will pay the associated costs. 10.316 clarifies that an employee need not consult OWCP for approval when the physician initially selected refers the employee to a specialist appropriate to the nature of the injury.
Section 10.312 concerns the services of clinical psychologists. It specifies that a clinical psychologist may treat a FECA claimant within the scope of practice allowed by applicable state law.
Section 10.313 reflects OWCP policy as stated in internal procedures that preventive treatment may only be authorized where a verifiable work-related injury is present.
Sections 10.320 and 10.321 address medical referrals initiated by OWCP. A statement has been added to make clear that the claimant is not entitled to have anyone attend such examinations (except for a physician of his or her choice, at a second opinion examination) unless OWCP finds that exceptional circumstances, such as the need for having an interpreter for a hearing-impaired claimant, exist. A statement has also been added that a case file may be sent for second opinion or referee review where an actual examination is not needed, or where the employee is deceased.
Section 10.330 now includes "extent of disability" and "prognosis" in the list of items that a medical report from the attending physician should include.
To reduce confusion, a statement that the use of form reports is not required has been added to section 10.331. This section also makes it clear that medical reports must have signatures. OWCP recognizes that many medical providers use signature stamps, but reserves the right to request an original signature on any medical report.
Section 10.324 formalizes the long-standing position of OWCP that any authority that an employing agency has to require an employee to undergo a medical examination does not come from the FECA, and nothing in the FECA or the regulations affects such authority. In addition, no agency-required medical examination or related activity shall interfere with the employee's initial choice of physician or the issuance of Form CA-16.
NEW PROCEDURES
A few revisions represent new procedure. There are two significant new procedures added to this subpart. One is in section 10.314, which changes the way attendant allowances are paid. The revised procedures for attendant allowances are the subject of FECA Bulletin 99-09, and will not be repeated here.
The other significant revision is to section 10.337, regarding the reimbursement of claimants for medical expenses. When a claimant pays for medical services directly, and then applies to OWCP for reimbursement, the amount payable by OWCP will be limited by the fee schedule. The claimant may be only partially reimbursed because the amount paid to the provider exceeds the maximum allowable charge.
It is then the claimant's responsibility to ask the provider to refund to the claimant, or credit to the claimant's account, the amount he or she paid which exceeds the maximum allowable charge. If the provider does not refund or credit the excess amount paid, the employee should submit documentation of the attempt to obtain such refund or credit to OWCP. OWCP may reimburse the employee the difference after reviewing the facts of the case.
A notice, which will accompany all bill payments, is currently under development. The notice will advise providers and claimants of the provisions of the fee schedule, and the prohibition of a provider seeking additional charges from the patient. It will also provide instructions to the provider and the claimant in this regard.
In addition to the two significant revisions noted above, there are a few less significant revisions that represent new procedures. They are as follows.
Section 10.303 instructs employers not to use a Form CA-16 to authorize medical testing for an employee who has merely been exposed to a workplace hazard, unless the employee has sustained an identifiable injury or medial condition as a result of that exposure.
Section 10.310 includes new references to cost effectiveness with respect to appliances and supplies, and to generic equivalents of prescribed medications. It states that OWCP will not approve an elaborate appliance or service where a more basic one is suitable. This section also gives OWCP the authority to require the use of generic medications where they are available. District office personnel are not to make determinations regarding generic medications at this time. When guidelines are developed by the National Office, you will be advised.
A statement has been added to section 10.311, which addresses the services of chiropractors, that OWCP will not necessarily require the x-ray or the report of the x-ray before adjudication. It may be requested if there is any indication in the factual or medical evidence of file that there may not be a subluxation present.
A sentence has been added to section 10.323 providing that the actions of an employee's representative will be considered the actions of the employee for the purposes of determining whether a claimant refused to submit to or in any way obstructed an examination required by OWCP.
Reference: 20 CFR 10.300 through 10.337
Purpose: To inform all claims staff of the revisions to the Regulations as they pertain to medical and related benefits
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Fiscal Personnel, Technical Assistants and Systems Personnel
Action:
1. The claims examiner will evaluate claims for medical and related benefits according to the provisions of the new regulations outlined above.
2. When OWCP receives documentation from a claimant that they requested refund or credit from the provider, and the provider failed to refund or credit the claimant's account, the claims examiner should review the facts of the case and make any reasonable reimbursement to the employee. The CE should also advise the claimant that they may not be reimbursed the excess amount in the future. Once such a payment is made, and the employee is aware of the monetary costs of continuing to seek treatment with such a provider, the claims examiner should consider not reimbursing the employee for any subsequent excess charges.
3. In claims where a medical report is received from a chiropractor indicating that x-rays demonstrate a subluxation, other factual and medical evidence in file should be carefully evaluated for consistency with this diagnosis. Where the evidence is consistent with the diagnosis of subluxation, that condition should be accepted, and appropriate benefits paid, without requiring the submission of the x-ray or the report of x-ray upon which the diagnosis is based. Where either factual or medical evidence of file suggests that the diagnosis of subluxation may not be accurate, the claims examiner should request that the x-ray or the report of the x-ray upon which the diagnosis was based be submitted for review prior to accepting this diagnosis.
4. The District Offices should conduct training on this bulletin within 30 days of the date that this bulletin is received.
Disposition: This Bulletin should be retained until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 – Folioviews Groups A,B, and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses
Back to Top of FECA Bulletin No. 99-13
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FECA BULLETIN NO. 99-14
Issue Date: January 4, 1999
Expiration Date: Janaury 3, 2000
Subject: New Regulations--Representative Fees
Background: On January 4, 1999, the new Federal Employees' Compensation Act Regulations became final. Subpart H of these regulations contains a discussion concerning who may serve as a representative and how fees will be paid.
The regulations now specify that federal employees may not serve as representatives except in instances where the person they are representing is an immediate family member, or where the representative is an officially sanctioned union official charging no fee or gratuity for his or her services.
Additionally, attorney fee applications have been streamlined. Any fee application accompanied by a signed statement from the claimant agreeing to the fee will be approved. Only where a claimant disagrees with the amount of the fee will further action be taken.
Reference: 20 CFR 10.700 through 10.703
Purpose: To inform OWCP staff of new regulations regarding representatives.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives
Action:
1. All claimants and the representatives they retain will now be advised via newly revised form CA-0143 (Attachment 1) of procedures relating to fee applications.
2. Claims Examiners must now be alert for any federal employee functioning as a representative. Should any documentation be received identifying a representative as a federal employee, the claims examiner should draft correspondence inquiring as to the nature of the relationship between the claimant and representative, and whether remuneration is involved for the representative's services. Attachment 2 is a sample letter for this purpose.
3. In cases where a representative has submitted an itemized billing and the fees have been agreed to, the fee should be approved. Note that to be approvable, the fee application must contain:
a. the representative's hourly rate
b. the number of hours worked
c. the specific work performed
d. a total of charges exclusive of administrative costs
e. concurrence from the claimant
While this is substantially similar to the requirements prior to the regulatory change effective January 4, 1999, OWCP staff are no longer required to evaluate services provided or the hourly rate at which they were charged in order to determine the propriety of the charges where a claimant has concurred with them. Instead, the fees should be approved, and this should be noted via use of form CA-1066, which has been newly revised to reflect these regulatory changes. A copy of this letter is at Attachment 3 for your reference. Note that this is a formal decision, and must be completed at an appropriate signature level as per current procedure and within current limits (up to $10,000 may be issued by claims examiners or senior claims examiners, over $10,000 must be issued by the District Director).
4. Should an application be submitted which does not contain any item cited in action item 3(a) through (e), above, it will be returned as incomplete without comment. Attachment 4 is a sample letter for this purpose.
5. If a representative submits a fee request with which his or her client does not concur, OWCP must review the request and issue a decision either approving or denying it. In order to reach this decision, you must provide a copy of the request to the claimant and ask him or her to provide any additional information in support of his or her objection to the fee within 15 days. After those 15 days, OWCP must evaluate the fee request to determine whether the amount of the fee is substantially in excess of the value of services received. To do this, you must consider:
a. the usefulness of the representative's services
b. the nature and complexity of the claim
c. the actual time spent by the representative
d. customary local charges for similar services.
After fully considering these items, a formal decision must be issued outlining the fee approved and the reasons for denial of any portion of the fee as requested. This decision should be issued at the Senior Claims Examiner level.
Training on these items should be conducted within 30 days of receipt of this bulletin.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment 1: Form CA-0143 and Form CA-1055
|
File Number: |
Dear :
This will acknowledge the receipt of a statement from the above-named employee designating you to pursue his/her case before the Office of Workers' Compensation Programs (OWCP).
The OWCP's procedures relative to representatives' fee applications, copy enclosed are designed to reduce or eliminate the timelag between case approval/payment and the decision in respect to the fee request. If a representative submits a fee application in accordance with the enclosed instructions, it will be acted upon at the same time the case is adjudicated.
Sincerely,
Claims Examiner
CA0143
INSTRUCTIONS RELATING TO REPRESENTATIVE FEE APPLICATIONS
The Federal Employees' Compensation Act, 5 U.S.C. 8101 et seq., provides that "A claim for legal or other services furnished in respect to a case, claim, or award for compensation under this subchapter is valid only if approved by the secretary." (5 U.S.C. 8127(b))
In each case where a representative's fee is desired, an application for approval of the fee must be submitted to the Office of Workers' Compensation Programs (OWCP). In order to eliminate the time lag between case approval/payment or disallowance and a formal ruling on the fee application, representatives should submit requests for fee approval at the time they submit the final evidence necessary for adjudication of their client's claim. Each fee application must include a complete itemized statement describing the necessary services rendered, including an estimate of the time required to review the award and communicate with the client. The itemization shall include the following:
(a) The dates that services began and ended, in addition to all dates conferences were held, documents or letters prepared, telephone calls made, etc.
(b) A description of each service rendered with the amount of time spent on each type of service.
(c) The total amount of the fee which the representative desires for services performed
(d) The hourly rate at which services were provided.
(e) The amount, if any, of the fee already collected or placed on escrow. If any portion of the requested fee has been placed on escrow, a copy of the escrow agreement must accompany the application for fee approval.
In addition, the representative is responsible for submitting a statement from the client, commenting on the application and the reasonableness and appropriateness of the fee requested. These comments are to be based upon the claimant's review of the fee request and itemization, which should be supplied to the client. The representative should submit this statement with the fee request. In those instances where this is not possible, the representative must advise of the manner and date on which the client was requested to submit such a statement. The representative should submit with the fee application, a copy of the communication sent to the client.
Where the representative has submitted a fee request in accordance with these requirements, a decision relative to the fee request will be issued. If any information as listed above is not provided, the fee request will be returned for proper completion. The collection of the fee is a matter between the representative and the claimant.
No claim for a fee for services is valid unless prior approval is obtained from the OWCP. (20 CFR 10.702) Collection of a fee prior to such approval is a violation of 18 U.S.C. 292.
CA0155 Page 1
Public Burden Statement
You do not have to respond to this collection unless it displays a currently valid OMB number. We estimate that it will take an average of 1-1/2 hours to complete this information collection including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this survey, including suggestions for reducing this burden, send them to the Office of Workers' Compensation Programs, Department of Labor, Room S-3229, 200 Constitution Avenue, NW, Washington, DC 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
CA0155 Page 2
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Attachment 2: Sample Letter
|
File Number: |
Dear :
We have received information that you are currently represented by REPRESENTATIVE'S NAME. It appears that this person may be a Federal employee. If this is the case, please note that under 18 U.S.C. 205 and 208, a Federal employee may only represent another injured Federal worker in regard to that worker's claim under the Federal Employees' Compensation Act (FECA) if the representative is either:
a. an immediate family member, defined as a spouse, child, parent, or sibling, and then only if no fee is charged, or
b. a union representative, and then only if an officially sanctioned union official also charging no fee or gratuity.
In light of this, it is necessary for you to provide a statement as to the nature of your relationship with your representative, so that his/her ability to represent you in relation to your FECA claim may be determined. If your representative is not a Federal employee, please provide a signed statement to that effect.
We will be unable to correspond with your representative regarding your case until we receive this information and reach a decision as to the appropriateness of this representative relationship. Should you have any questions, please feel free to contact me.
Sincerely,
Claims Examiner
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Attachment 3: Form CA-1066
|
File Number: |
Dear :
This is in reference to your application for approval of a fee for services rendered in the compensation case of CLAIMANT NAME.
We have approved your fee of $XXXX.XX as requested for services rendered from 00/00/0000 to 00/00/0000. This fee has been approved because the claimant has not contested the reasonableness of the amount of the fee. Payment of the approved fee is the claimant's responsibility and HE/SHE is so advised by copy of this letter.
Pursuant to 5 U.S.C. 8127 and 20 CFR 10.702, a claimant is legally liable for only those fees for service that have been approved by this office. With respect to services rendered in this claim, any person who requests or receives a fee, gratuity, or other consideration which has not been approved by this office, may be subject to criminal prosecution.
If either party disagrees with this decision, either or both have the right to appeal to the Employees' Compensation Appeals Board (ECAB) for review of the decision. The claimant may also request hearing or reconsideration. These appeal rights are described on the attached sheet.
Sincerely,
Claims Examiner
Enclosure: ENAPPC
CA1066
FEDERAL EMPLOYEES' COMPENSATION ACT APPEAL RIGHTS
READ THIS NOTICE CAREFULLY AND DECIDE WHAT ACTION YOU WISH TO REQUEST: REVIEW BY THE EMPLOYEES' COMPENSATION APPEALS BOARD (ECAB); HEARING (Oral or Written); or RECONSIDERATION.
Be sure to send your request to the right address.
You may not request more than one form of appeal at a time.
REVIEW BY EMPLOYEES' COMPENSATION APPEALS BOARD (ECAB)
CLAIMANT AND REPRESENTATIVE
If you believe that all available evidence has been submitted, you have the right to appeal to the Employees' Compensation Appeals Board for review of the decision. The ECAB will review only the evidence of record, and no new evidence may be submitted.
Any request for review by the ECAB should be made within 90 days from the date of this decision. Send it to:
Employees' Compensation Appeals Board
U.S. Department of Labor
200 Constitution Ave., N.W., Room N-2609
Washington, D. C. 20210
The ECAB may waive the failure to file within 90 days if you request review within one year from the date of this decision and show a good reason for the delay.
If you (the claimant) should request a hearing or reconsideration as described below, you may still request review by the ECAB. The 90-day period for requesting review by the ECAB will begin on the date of the hearing or reconsideration decision.
HEARING (CLAIMANT ONLY)
If your injury occurred on or after July 4, 1966, and you have not requested reconsideration (see below), you may request one of the following actions:
Oral hearing. You will be able to present oral and written evidence in further support of your claim. The hearing will be informal and will be held in your area. You may authorize a representative for this hearing in writing should you choose.
Review of the written record. You may submit written evidence, but you will not be asked to attend or give oral testimony. You will have this review instead of an oral hearing. Any additional written evidence you want to submit must be sent with your request for review.
ENAPPC Page 1
OWCP hearing representatives conduct both oral hearings and reviews of the written record. To request an oral hearing or a review of the written record, you must write to:
Branch of Hearings and Review
Office of Workers' Compensation Programs
P. O. Box 37117
Washington, D. C. 20013-7117
State clearly whether you want an oral hearing or a review of the written record. Your request must be postmarked within 30 days of the date of this decision.
You will have the right to request reconsideration or ECAB review of the hearing representative's decision if you disagree with it.
You are not required to request a hearing as the first step in the appeal process. However, if you request reconsideration, you will not be entitled to an oral hearing or review of the written record (see 5 U.S.C. 8124(b)(1)).
RECONSIDERATION (CLAIMANT ONLY)
If you have more evidence or legal arguments which you believe apply to your case, you may ask the OWCP district office to reconsider this decision. Such a request must be made within one year of the date of this decision. The request should clearly state your grounds for requesting reconsideration. It should also include evidence not submitted before, such as medical reports or sworn statements, or legal arguments. The new evidence or legal argument should apply directly to the issue addressed by this decision.
Send your request for reconsideration and your new evidence or argument to the district office at the address shown on the letter conveying this decision. So that your new evidence is independently evaluated, your case will be reconsidered by OWCP staff other than those who made this decision.
ENAPPC Page 2
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Attachment 4: Sample Letter
|
File Number: |
Dear :
We have received your recent submission of a fee request for services provided to CLAIMANT NAME.
Upon review of this package, it is noted that it is incomplete because it does not contain LIST MISSING ITEM(S).
Per 20 CFR 10. 703(a)(2), the Office of Workers' Compensation Programs cannot consider an incomplete fee request. As such, your submission is being returned to you. Please provide the missing item(s) and resubmit this request.
Should you have any questions regarding this matter, please contact me.
Sincerely,
Claims Examiner
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FECA BULLETIN NO. 99-15
Issue Date: March 17, 1999
Expiration Date: March 16, 2000
Subject: New Regulations - Withdrawal of Claims
Background: On January 4, 1999, the new Federal Employees' Compensation Act Regulations became final. The final regulations codify the ability of a claimant or survivor to withdraw a claim for benefits prior to the adjudication of the claim.
Subpart 10.100(b)(3) conveys the ability to withdraw claims for traumatic injury at any time prior to adjudication. This includes short-form closure cases, which have not been formally adjudicated. Any continuation of pay paid will be charged to either sick or annual leave or become an overpayment with the employing agency at the choice of the claimant. Although a claim is withdrawn, the notice itself is not.
Subparts 10.101(a) and 10.105(a) apply the same rules for withdrawal to claims for occupational disease and survivor benefits as for traumatic injury claims.
Subpart 10.117(b) advises employing agencies that they may not compel any employee to withdraw a claim.
Reference: 20 CFR 10.100(b)(3), 20 CFR 10.101(a), 20 CFR 10.105(a) and 20 CFR 10.117(b)
Purpose: To inform OWCP staff and employing agencies of the ability for claimants and survivors to withdraw claims for compensation.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Fiscal Personnel, Technical Assistants and Systems Personnel, and Hearing Representatives
Action: In any case where written notice of intent to withdraw a claim is received prior to the claim's adjudication, the claimant should be advised that the claim is now viewed as withdrawn. The attached letter is a sample for this purpose. The case file will then be coded as withdrawn and the paper file retained. To code a case as withdrawn, the following coding scheme will be used:
| Description | Code |
|---|---|
|
Adjudication Status: |
SU |
|
Case Status: |
CL |
|
Rep/Acc flag: |
N |
No ICD-9 code can (or should) be entered. This will cause all bills to fail edit 111, based on adjudication status. This edit can be overridden if payment is desired (i.e., if a CA-16 was issued prior to withdrawal). A note saying "pay no bills, claim withdrawn" should also be entered into the notes screen.
Employing agencies are not permitted to compel employees to withdraw claims. Should any staff person believe that such an incident may have occurred, district office management should be notified so that contact may be made with the employing agency to prevent future occurrences. If it is shown that an employee was compelled to withdraw his or her claim, the claim may be reinstated without further notice.
Training should be conducted on the above within 30 days of receipt of this bulletin.
Disposition: Retain until incorporated into the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment
Dear:
I have received your written request to withdraw your claim. As your case file has not been adjudicated, this request is granted. The Office of Workers' Compensation Programs will take no further action in consideration of your claim.
Please note that any continuation of pay paid by your employer due to the filing of this claim may be converted to sick or annual leave at your choice. Should you choose not to do so, your employer may view any payments made as an overpayment.
Should you have any questions, please contact me.
Sincerely,
Claims Examiner
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FECA BULLETIN NO. 99-16
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: New Regulations - Filing Notices and Claims; Submitting Evidence
Background: With regard to this subject matter, the filing of notices and claims for compensation and the submission of evidence, the new regulations have organized the information differently. This involved moving some of the sections previously included in Subpart B (topics related to the appeals process) to other subparts (Subparts G and H). The new regulations have divided the topics relating to giving notice and filing claims into actions required of the claimant (§§10.100 to 10.105), and actions required of the employer (§§10.110 to 10.113).
A change that has occurred with respect to the filing of notices is referred to in §§ 10.100, 10.101, and 10.105. It is now mentioned in those sections that an employer may file a notice of injury, occupational disease or death if the employee or survivor cannot do so. Another change that is noted in the above-mentioned sections is the fact that a claimant may withdraw his or her claim for traumatic injury, occupational disease, or survivor's benefits at any time prior to the determination of eligibility for FECA benefits. However, such withdrawal must be in writing and may not include withdrawal of the notice of injury, occupational disease, or death. This will be addressed further in FECA Bulletin 99-15.
The sections which discuss the Notice of Traumatic Injury (Form CA-1) and the Notice of Occupational Disease (Form CA-2), §§10.100 and 10.101, respectively, explain how to file these forms and provide the applicable time requirements for filing. These sections also provide the web site address (www.dol.gov./dol/esa/owcp.htm) for obtaining these forms. It is also important to note that §10.102, which describes the process for filing a wage-loss claim, contains several references to Form CA-8 for claiming additional wage loss, and to Form CA-20a as the supplemental medical report form. As these forms are no longer to be used, all references to them are to be deleted and the appropriate FECA forms (CA-7 and CA-20, respectively) are to be used instead. (FECA Bulletin 99-18 discusses the CA-7 form and its uses in greater detail.) The Correction to the Final Rule, published December 23, 1998, explains exactly how all of the deletions and insertions should occur.
Section 10.102 describes the process for filing a wage-loss claim, and § 10.103 the filing process for permanent impairment (Schedule Award) claims. Section 10.104 describes situations in which it is, or is not, appropriate to file a notice and claim for recurrence of disability, along with the type of evidence required to have a recurrence claim approved. Section 10.105 gives examples for the dependent survivor of the situations in which it is appropriate, and describes how to file a claim for survivor's benefits.
The actions to be taken by the employer with regard to the filing of notices and claims for traumatic injury, occupational disease or death are addressed in §§ 10.110 through 10.113. Sections 10.115 through 10.121 of this subpart address the evidence needed to establish the claimant's burden of proof, or OWCP's burden with regard to justifying a formal decision. The basic evidence necessary to establish a claim, and the additional evidence needed for submission by the claimant in occupational disease claims are described in §§ 10.115 and 10.116. Sections 10.120 and 10.121 discuss the claimant's opportunity to submit additional evidence if desired, and OWCP's burden to request additional evidence when necessary, allowing 30 days for the submission.
The information contained in §§ 10.117, 10.118, and 10.119 pertains to the employer's responsibility to provide requested evidence in order to assist in the claims process, and opportunities for the employer to participate by submitting factual and/or medical evidence when there is disagreement as to the validity of the claim and the employer wishes to contest it.
The last few sections of this subpart, §§ 10.125 through 10.127, discuss determinations on entitlement to benefits under the FECA, or formal decisions. There is a brief discussion of how OWCP arrives at the decision, what information a decision must contain, and advice as to whom the decision is sent.
Reference: FECA Circular 99-04; 5 U.S.C. §§ 8107, 8119, 8121, 8122(b); CA-1; CA-2; CA-5 and CA-5b; CA-2a; CA-7; and CA-20.
Purpose: To focus attention on this portion of the new regulations, especially with respect to the substantive changes and to the organization of Subpart B.
Applicability: Regional Directors, District Directors, Claims Examiners, Supervisory Claims Examiners, and appropriate National Office personnel.
Action:
Training by the district offices on the subject matter of this FECA Bulletin should be incorporated into other training scheduled pertaining to the new regulations. This training should be accomplished within 30 days of receipt of this bulletin.
Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
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FECA BULLETIN NO. 99-17
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: Compensation Pay: Compensation Rate Changes Effective January 1999.
Background: In December 1998, the President signed an Executive Order implementing a salary increase of 3.10 percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the 3.10 percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 1999.
Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The new rates will be effective with the first compensation payroll period beginning on or after January 1, 1999. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $97,201 per annum.
The minimum increase specified in this Bulletin is applicable to Postal employees.
The effect on 5 U.S.C. 8112 is as follows:
|
Effective January 3, 1999 |
Minimum |
Maximum |
|---|---|---|
|
Monthly |
$1,251.92 |
$6,075.06 |
|
Weekly |
216.68 |
1,401.94 |
|
Daily(5-day week) |
43.34 |
280.39 |
The basis for the minimum compensation rates is the salary of $15,023 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $97,201 per annum (GS-15, Step 10).
The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,251.92, effective January 3, 1999. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $6,075.06 per month.
Applicability: Appropriate National and District Office personnel.
Reference: Memorandum For Directors of Personnel dated December 1998; and the attachment for the 1998 General Schedule.
Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustments Dates.
a. As the effective date of the adjustment is January 3, 1999, there will be no supplemental payroll necessary for the periodic disability and death payrolls.
b. The new minimum/maximum compensation rates will be available in ACPS on or about January 23, 1999.
2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 1999. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.
3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows:
|
CA-842 |
|||||
|
1/03/99 |
43.34-65.01 |
216.68-325.02 |
43.34 |
216.68 |
1,251.92 |
|
CA-843 |
|||||
|
1/03/99 |
280.39 |
1,401.94 |
|
(5,607.76) |
6,075.06 |
4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose. Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.
Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
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FECA BULLETIN NO. 99-18
Issue Date: December 24, 1998
Expiration Date: December 23, 1999
Subject: Forms - Revised Form CA-7, "Claim for Compensation"
Background: One of the tasks of the ACPS reinvention team was to redesign Form CA-7. Extensive input was solicited and received from Federal employing agencies and OWCP field offices. A draft revised form was piloted in two district offices. Field offices submitted comments on the draft revised form. Based on further input, additional changes were made. The revised form has now been cleared by OMB and is ready for use.
The new form is different in several respects. It combines Forms CA-7 and CA-8, so that the Form CA-8 is now obsolete (along with Form CA-20a). Sections of the form are optional for continuing claims. The language and format have been simplified as much as possible. The claimant's portion includes a section for showing clearly what is being claimed (compensation for leave without pay, leave buy back, or schedule award). The claimant is instructed to submit a Form SF-1199A, "Direct Deposit Sign-Up" in addition to the CA-7. The pay rate and schedule sections have been altered to solicit more accurate information. The COP/leave sections on the employer's portion have been revised, and a Form CA-7a, "Time Analysis Sheet" is requested if COP or leave is intermittent. The return to work section was changed, and a section for comments was added.
Reference: FECA Procedure Manual, Chapter 2-0401.12.
Purpose: To notify all employees of the existence of a new Form CA-7, and provide revised procedures for handling the forms.
Applicability: All staff.
Actions:
Effective immediately, the revised Form CA-7 (copy attached), dated November 1998, replaces all prior versions of Forms CA-7 and CA-8.
In Section 4 of the revised form, the claimant is supposed to indicate whether the CA-7 is the first CA-7 filed for the injury in question or not. For purposes of TPCUP tracking, until changes are made to the TPCUP program, if the response in Section 4 is "Yes," the form will be tracked as a CA-7. If the response in Section 4 is "No," the form will be tracked as a CA-8. If there is no response in Section 4, the form should be tracked as a CA-7.
A supply of the new CA-7 has been ordered for each office. Upon receipt of the new form, all previous forms of the CA-7 and CA-8 must be discarded, as they are obsolete.
In all communications and training, employing agencies should be informed that the new CA-7 is to be used. However, older versions of the CA-7 and the CA-8 will continue to be accepted by the district offices if received.
5. The new CA-7 will be available to employing agencies through the Government Printing Office, stock number 029-016-00132-8, revision date November 1998.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
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FECA BULLETIN NO. 99-19
Issue Date: January 4, 1999
Expiration Date: September 30, 1999
Subject: Comp Pay/COP--Sunday Premium Pay
Background: Section 636 of the Treasury and General Government Appropriations Act, 1998 (Public Law 105-61), prohibited any agency funded by appropriated funds from paying Sunday premium pay to any employee who did not actually perform work on Sunday. This prohibition became effective on October 10, 1997. Section 624 of the Treasury and General Government Appropriations Act, 1999, as contained in the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999 (Public Law 105-277), has a similar provision.
In accordance with these two statutory provisions, as well as with a decision of the Federal Labor Relations Authority, Sunday premium pay must be excluded from an agency's calculation of COP where the employee did not actually work on the Sunday or Sundays included in the period of COP, even if the employee was scheduled to do so. This applies to an agency's payment of salary only and is reflected in OWCP's new regulations at 20 CFR §§ 10.216(a)(1) and 10.217.
Given the distinction between COP and compensation payments, Sunday premium pay that is paid to an employee for work actually performed on a Sunday during the 12 months prior to the effective date of any pay rate [selected pursuant to 5 U.S.C. 8101 (4)] will still be included in the employee's pay rate for compensation purposes, as required by 5 U.S.C. 8114.
We are aware of the interim regulations on Holidays and Premium Pay published by the Office of Personnel Management (OPM) on May 23, 1997 (but not yet made final). The preamble contains the following statement:
Similarly, this prohibition appears to preclude a covered agency from reimbursing the Department of Labor for FECA benefits paid to its employees to the extent that the employees have received FECA benefits that are based on Sunday premium pay or night pay differential that the employees would have earned had they worked, but did not earn because they did not actually work on Sunday or at night. The Department of Labor may be able to waive any overpayment that occurred. OPM believes that is an issue to be worked out between affected agencies and the Department of Labor.
(Night differential is addressed because, when this material was published, Public Law 104-208 prohibited the Department of the Treasury and the U.S. Postal Service from paying night differential pay as well as Sunday premium pay for hours not actually worked. However, night differential pay is not at issue at this time.)
OWCP and OPM have since discussed this matter further. OWCP takes the position that it is solely responsible for determining pay rates in claims under the FECA. Because OWCP believes inclusion of Sunday premium pay in such pay rates to be proper, and will continue to do so, there is no reason to consider invoking overpayment procedures. The amounts paid on this basis will continue to be charged back to employing agencies as usual.
Purpose: To provide guidance for claims and technical assistance staff concerning the effect of legislation barring payment of Sunday premium pay when work is not actually performed on Sunday
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, and Technical Assistants
Actions:
With Respect to COP:
1. Any claimant, employing agency, or other party who asks whether Sunday premium pay is included in payments of COP should be advised that after October 10, 1997, the effective date of Public Law 105-61, payments of COP must exclude Sunday premium pay for time not actually worked.
a. For periods prior to January 4, 1999, the effective date of the FECA program's new regulations, the reason is that while OWCP's regulations, at 20 CFR § 10.205(d), called for inclusion of this increment, Public Laws 105-61 and 105-277 require its exclusion.
b. For periods on or after January 4, 1999, the reason is that Public Laws 105-61 and 105-277 require its exclusion, and OWCP's regulations, at 20 CFR § 10.216(a)(1), allow for such exclusion. (That provision states that "The pay rate excludes overtime pay, but includes other applicable extra pay except to the extent prohibited by law".)
2. If a claimant disputes the amount of COP received on the basis that it excludes Sunday premium pay for time not actually worked, it will be necessary to issue a formal decision that affirms the lower rate. The decision should cite both OWCP's regulations and Public Law 105-61 or 105-277, as appropriate.
With Respect to Compensation Payments:
3. If the claimant regularly worked on Sunday, the Claims Examiner (CE) should compute Sunday premium pay on that basis, in accordance with current practice.
4. If the claimant did not regularly work on Sunday, the CE should compute Sunday premium pay on the basis of the Sunday premium pay earned during the year prior to date of injury, date disability began, or date of recurrence, as appropriate. If the employer has not reported these amounts, the CE should request a list of the specific days and hours involved and the hourly differential for each period of Sunday work performed.
5. Any questions about the effect on chargeback payments should be referred to the National Office.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-19
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-20
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1999.
PURPOSE: To provide the 1999 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1999.
APPLICABILITY: All appropriate personnel are to be made aware of the periods and "cut-off" dates for the ACPS periodic disability, death, and daily payrolls.
The production schedule for the DMS periodic reports is made available for the appropriate personnel. IT IS IMPERATIVE THAT THIS SCHEDULE BE CLOSELY FOLLOWED.
DISPOSITION: This bulletin should be retained in front of Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachments
Distribution: List No. 2--Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Attachment 1
|
Bi-Weekly Pay Periods |
District Office N.O. Trans- |
|||
|---|---|---|---|---|
|
Check |
Period of Entitlement |
For Health and Life |
Cut-Off Date to |
Mission to |
|
1 |
01/03/99 - 01/30/99 |
01/03/99 - 01/16/99 |
01/20/99 |
01/22/99 |
|
2 |
01/31/99 - 02/27/99 |
01/31/99 - 02/13/99 |
02/17/99 |
02/19/99 |
|
3 |
02/28/99 - 03/27/99 |
02/28/99 - 03/13/99 |
03/17/99 |
03/19/99 |
|
4 |
03/28/99 - 04/24/99 |
03/28/99 - 04/10/99 |
04/14/99 |
04/16/99 |
|
5 |
04/25/99 - 05/22/99 |
04/25/99 - 05/08/99 |
05/12/99 |
05/14/99 |
|
6 |
05/23/99 - 06/19/99 |
05/23/99 - 06/05/99 |
06/09/99 |
06/11/99 |
|
7 |
06/20/99 - 07/17/99 |
06/20/99 - 07/03/99 |
07/07/99 |
07/09/99 |
|
8 |
07/18/99 - 08/14/99 |
07/18/99 - 07/31/99 |
08/04/99 |
08/06/99 |
|
9 |
08/15/99 - 09/11/99 |
08/15/99 - 08/28/99 |
09/01/99 |
09/03/99 |
|
10 |
09/12/99 - 10/09/99 |
09/12/99 - 09/25/99 |
09/29/99 |
10/01/99 |
|
11 |
10/10/99 - 11/06/99 |
10/10/99 - 10/23/99 |
10/27/99 |
10/29/99 |
|
12 |
11/07/99 - 12/04/99 |
11/07/99 - 11/20/99 |
11/24/99 |
11/26/99 |
|
13 |
12/05/99 - 01/01/00 |
12/05/99 - 12/18/99 |
12/22/99 |
12/23/99 |
*ENDING PERIOD IS THE CHECK DATE
FOR EFT PAYMENTS, THE DAY BEFORE
|
DATE OF CHECK TO ENTER DATA INTO ACPS |
DISTRICT OFFICE CUT-OFF DATE TO TREASURY |
N.O. TRANSMISSION |
|---|---|---|
|
|
|
|
|
EACH FRIDAY** |
PREVIOUS TUESDAY |
PREVIOUS WEDNESDAY |
|
**FOR EFT PAYMENTS, EACH FRIDAY |
Back to Top of FECA Bulletin No. 99-20
Attachment 2
| Date | Report |
|---|---|
|
01/04/1999 |
MONTH END PROCESSING (12/31/1998) |
|
01/05/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/26/1998 - 01/01/1999) |
|
01/11/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/02/1999 - 01/08/1999) |
|
01/19/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/09/1999 - 01/15/1999) |
|
01/25/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/16/1999 - 01/22/1999) |
|
02/02/1999 |
MONTH END PROCESSING (01/31/1999) |
|
02/03/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/23/1999 - 01/29/1999) |
|
02/08/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/30/1999 - 02/05/1999) |
|
02/16/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/06/1999 - 02/12/1999) |
|
02/22/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/13/1999 - 02/19/1999) |
|
03/01/1999 |
MONTH END PROCESSING (02/28/1999) |
|
03/02/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/20/1999 - 02/26/1999) |
|
03/08/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/27/1999 - 03/05/1999) |
|
03/15/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/06/1999 - 03/12/1999) |
|
03/22/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/13/1999 - 03/19/1999) |
|
03/29/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/20/1999 - 03/26/1999) |
|
04/01/1999 |
MONTH END PROCESSING (03/31/1999) |
|
04/05/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/28/1999 - 04/02/1999) |
|
04/12/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/03/1999 - 04/09/1999) |
|
04/19/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/10/1999 - 04/16/1999) |
|
04/26/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/17/1999 - 04/23/1999) |
|
05/03/1999 |
MONTH END PROCESSING (04/30/1999) |
|
05/04/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/24/1999 - 04/30/1999) |
|
05/10/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/01/1999 - 05/07/1999) |
|
05/17/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/08/1999 - 05/14/1999) |
|
05/24/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/15/1999 - 05/21/1999) |
|
06/01/1999 |
MONTH END PROCESSING (05/31/1999) |
|
06/02/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/22/1999 - 05/28/1999) |
|
06/07/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/30/1999 - 06/04/1999) |
|
06/14/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/05/1999 - 06/11/1999) |
|
06/21/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/12/1999 - 06/18/1999) |
|
06/28/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/19/1999 - 06/25/1999) |
|
07/01/1999 |
MONTH END PROCESSING (06/30/1999) |
|
07/06/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/26/1999 - 07/02/1999) |
|
07/12/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/03/1999 - 07/09/1999) |
|
07/19/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/10/1999 - 07/16/1999) |
|
07/26/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/17/1999 - 07/23/1999) |
|
08/02/1999 |
MONTH END PROCESSING (07/31/1999) |
|
08/03/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/24/1999 - 07/30/1999) |
|
08/09/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/31/1999 - 08/06/1999) |
|
08/16/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/07/1999 - 08/13/1999) |
|
08/23/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/14/1999 - 08/20/1999) |
|
08/30/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/21/1999 - 08/27/1999) |
|
09/01/1999 |
MONTH END PROCESSING (08/31/1999) |
|
09/07/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/28/1999 - 09/03/1999) |
|
09/13/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/04/1999 - 09/10/1999) |
|
09/20/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/11/1999 - 09/17/1999) |
|
09/27/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/18/1999 - 09/24/1999) |
|
10/01/1999 |
MONTH END PROCESSING (09/30/1999) |
|
10/04/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/25/1999 - 10/01/1999) |
|
10/12/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/02/1999 - 10/08/1999) |
|
10/18/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/09/1999 - 10/15/1999) |
|
10/25/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/16/1999 - 10/22/1999) |
|
11/01/1999 |
MONTH END PROCESSING (10/31/1999) |
|
11/02/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/23/1999 - 10/29/1999) |
|
11/08/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/30/1999 - 11/05/1999) |
|
11/15/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/06/1999 - 11/12/1999) |
|
11/22/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/13/1999 - 11/19/1999) |
|
11/29/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/20/1999 - 11/26/1999) |
|
12/01/1999 |
MONTH END PROCESSING (11/30/1999) |
|
12/06/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/27/1999 - 12/03/1999) |
|
12/13/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/04/1999 - 12/10/1999) |
|
12/20/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/11/1999 - 12/17/1999) |
|
12/27/1999 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/18/1999 - 12/24/1999) |
|
01/03/2000 |
MONTH END PROCESSING (12/31/1999) |
|
01/04/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/25/1999 - 12/31/1999) |
|
01/10/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/01/2000 - 01/07/2000) |
|
01/17/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/08/2000 - 01/14/2000) |
|
01/24/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/15/2000 - 01/21/2000) |
|
01/31/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/22/2000 - 01/28/2000) |
|
02/01/2000 |
MONTH END PROCESSING (01/31/2000) |
|
02/07/2000 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/29/2000 - 02/04/2000) |
Back to Top of FECA Bulletin No. 99-20
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-21
Issue Date: January 4, 1999
Expiration Date: January 3, 2000
Subject: Bill Payment/BPS - Modifications to Inpatient Hospital Bill Procedures
Background: A fee schedule for inpatient hospital bills, based on the Medicare system of Diagnosis-Related Groups (DRGs) will be in effect for all bills processed on or after January 4, 1999. To be able to obtain the information needed to process inpatient hospital bills in this manner, it was necessary to make several modifications to the Medical Bill Processing System.
Inpatient hospital bills (with one very limited exception) will no longer be data entered onto Sequent using the FECS001 Bill Input program. Instead, these bills will keyed into a stand-alone computer, using special software. The data will then be transmitted through several intermediaries for processing, and eventually returned to the district office and loaded into the bill tables, where it will be subjected to the revised BILL552 edits, and will then be available for bill resolution, as needed.
In addition to OWCP keying inpatient hospital bills using special software, the hospitals themselves will be able to submit inpatient bills electronically, through an intermediary.
Reference: Federal (FECA) Procedure Manual Chapters 5-0200, 5-0201, 5-0203, 5-0204, and 5-0205; 20 C.F.R. Part 10, Subpart I, published November 25, 1998; FECA Bulletin 99-7.
Purpose: To notify District Offices of revised procedures for processing inpatient hospital bills.
Applicability: All staff.
Actions:
1. Effective January 4, 1999, inpatient hospital bills should be separated from other bills in the mailroom, insofar as possible. Inpatient hospital bills should be on Form UB-92, and should contain room charges. The locator 4 code for inpatient bills most commonly starts with 11* or 12*.
For a limited period of time, until further communication is received from National office, all of the inpatient hospital bills should be placed in bill batches separately from other bills, assigned a batch identification number which is not being used for another batch, and immediately imaged. These batches should include bills for third party and claimant reimbursement, as described in item 19 and Attachment 2, unless the bill is being keyed into the Sequent FECS001 Bill Input program. A daily e-mail from each district office should be sent to William Cole, Chief of Coordination and Control at the National Office, at wfc@fenix2.dol-esa.gov, listing the batch identification number for the imaged inpatient bill batch. One bill batch per office per day will usually be sufficient. The batch cover sheet should show the number of bills in the batch.
3. The National Office will key the bills from the images, after which they will be processed through the intermediaries, and then loaded into the district office systems for editing, bill resolution, and final processing.
4. After each district office has completed training on the new software for inpatient hospital bills, and the go-ahead has been sent by National Office, inpatient bills will no longer be keyed by National Office. The inpatient hospital bills will be given to the individual(s) who have been assigned to data enter inpatient hospital bills on the special software. Training on how to use the software is being provided separately.
5. The inpatient hospital bills may be data entered using the office's existing batch identification scheme. However, extreme caution must be taken to ensure that the batch numbers are entered accurately, and are not used for other bill batches.
6. The special data entry software does not interact with the Sequent system, therefore, accuracy of data entry is critical.
7. The practice of keying outpatient bills from the Department of Veterans Affairs and other federal agencies that are exempt from the fee schedule as inpatient bills will not be allowed. Rather, these bills should be keyed as outpatient bills, using the FECS001 Bill Input program. A fee schedule appeal code of "B," for bypass, should be keyed as the eighth character of the procedure code on each line item (appeal code), so that the fee schedule is not applied.
8. Only bills with certain locator 4 codes will be allowed in the special software. The first number must be 1, 4, or 8; the second number 1, 2, 5, 7 or 8; and the third number 1, 2, or 7. Bills with other locator 4 codes must be data entered in FECS001 bill input as an outpatient bill, or as a different provider type.
9. The FECS001 "Bill Input" program has been modified to block data entry of an inpatient hospital bill, with only one exception (see item 24 below).
Once the inpatient hospital bill has been data entered on the special software, it will be transmitted for grouping (assign a Diagnosis-Related Group) and pricing the bill according to HCFA rules and DFEC's modifications.
11. Following this, the data will be transmitted to the National Office, along with any error codes that arise from the processing. There are three types of error codes that may be assigned: MCE (Medicare Code Editor) errors, grouper errors, and pricer errors. Not all error codes will result in the bill not being payable, as some of the error codes are used by payers other than FEC. Some of the pricer error codes will result in National Office having to compute the allowable fee, based on an alternate formula, which uses the state's average cost-to-charge ratio. The error codes that are significant in terms of district office processing have been incorporated into the BILL552 edits.
12. The National Office will maintain a data file of hospital providers, which will be used to populate the address fields in the bill records. If the tax identification number and Medicare number on the bill record match a record of the National Office hospital file, the address from the file will be placed on the bill record and the address OK flag set to Y for "yes". If the tax identification number and Medicare number on the bill record do not match a record on the National Office hospital file, the address (if any) on the bill record will be retained and the address OK flag set to N for "no". This will cause BILL552 edit 024 to fail. See action item 19 for further information.
13. After the National Office has received and processed the bill, it will be sent to the owning district office, according to the NCMF, and loaded into the bill tables. If a case has been transferred between the time the bill was keyed into the special software and the time the bill is received in the National Office, it will be sent to the new owning office.
Along with bills that have been keyed in the district offices (or initially, National Office) using special software, bills that have been submitted electronically will also be transmitted. Electronic inpatient hospital bills will have batch identification numbers beginning with EDH.
Once the bills are loaded into the district office tables, they will be edited by the BILL552 program. If district office intervention is required, they will suspend for review.
16. Forty-four (44) new edits have been added to BILL552 to accommodate the changes for inpatient hospital bills. Most of these new edits are for MCE/grouper/pricer error codes. All of the MCE/grouper/pricer code edits are in the 400's, starting with 413. Three (3) edits have been added which are based on the DRG alone (352, 353, and 356). Five edits have been added to address the relationship of the assigned DRG to the accepted conditions (754, 757, 758, 764, and 766). One new edit (212) ensures that bills other than hospital bills do not have locator-4 codes associated with them. Edits 001 through 004 have been modified, as have the duplicate edits, 801 through 805. Detailed information of the new and revised edits is being provided under separate cover.
17. The grouping and pricing performed on each inpatient hospital bill is based on information that is provided by the hospital on the UB-92 form, and on information that is maintained by HCFA concerning characteristics of the individual hospital. Several new data elements were required to capture this information. The new data elements have been placed into a new data table (d28). The information may be viewed by using "Inpatient Hospital Bill Query" under the FECS001 Bill Payment and Query menus. This information can also be accessed from within the bill resolution and suspended bill query programs by pressing a function key. A sample screen is shown as Attachment 1.
Because inpatient hospital bills are being grouped and priced by an outside entity, once the bills have been loaded onto the Sequent system, the data fields that can be changed are very limited. In bill resolution, the only fields that may be modified are:
HEADER SCREEN
Authorizing initials
Errors box
Direct Payment Flag
Provider address OK flag
LINE ITEM SCREEN
Ineligible amount
Ineligible amount code
Bypass code
Fee schedule appeals code
Errors box
PROVIDER SCREEN
Address OK flag
The system will block changes to other fields. In most instances, if a keying error was made by the district office, the bill will have to be internally denied, corrected in the special software, and reprocessed under a new batch ID. If the hospital submitted the bill electronically with erroneous data, usually it will be denied automatically with an instruction to resubmit with corrected information.
19. For EDI inpatient hospital bills, the provider screen (in bill resolution) initially shows the provider name and address information from the bill record. The user has the ability to query the district office provider file, to determine whether the address on the bill record matches an address of a provider already on the provider file. Viewing the provider file records for EDI bills does not alter the name and address information on the bill record. If edit failure 024 has been assigned, the user should cycle through the provider addresses and if a match is found, change the address OK flag to Y. If no match is found, a narrative letter should be sent to the provider at the address on the bill record, asking for written verification of their billing address, tax identification number, and Medicare number. Once their response has been received, the provider may be added to the provider file, and the above actions taken.
For non-EDI inpatient hospital bills, normal access to the provider screen is allowed, except that the tax identification number and zip code cannot be changed. Thus, if edit failure 024 has been assigned, with the paper bill in hand (or an image of the paper bill), the user may select a matching provider from the provider file, change the address OK flag to Y if a match is found, and automatically update the bill record with that information.
20. Inpatient hospital bills that are submitted by third parties (such as insurance companies) or claimants for reimbursement will require special handling. In principal, reimbursements to third parties and claimants should not exceed the lesser of the DRG-based price or the amount actually paid. Detailed instructions for handling bills of this nature are shown in Attachment 2.
Disputes regarding the assigned DRG or price (based on the DRG) should be referred in writing to OWCP's Branch of Medical Standards and Rehabilitation, at the following address:
Dr. Virginia Miller - DRG Dispute
U.S. Department of Labor, ESA, OWCP
200 Constitution Ave., N.W. Rm. S-3522
Washington, DC 20210
Keep in mind, however, that most hospitals are already familiar with a DRG-based system through Medicare, and that the DFEC's new fee schedule rates of payment are higher than Medicare, on the average.
22. The DRG system is much more complicated than outlined herein. Attachment 3 lists additional resources that are available.
23. The MCE/grouper/pricer error codes are shown in Attachment 4, along with explanations.
24. Under special circumstances, an inpatient hospital bill may be entered under the FECS001 Payment Input program by using a locator-4 code of 911. However, a locator-4 code of 911 should be used only when it is not possible to handle the bill by using the process described above. Before a bill is data entered using a locator-4 code of 911, written supervisory approval must be obtained. One example of when 911 may be used is when the claimant has paid all or part of a bill, and the hospital is also claiming payment, as found in Attachment 2. Other circumstances that would warrant use of locator-4 code 911 should be extremely rare.
Training on these procedures should be completed prior to January 15, 1999.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment 1
|
INPATIENT HOSPITAL BILL INFORMATION QUERY |
|||||
|
CASE NO: 010111111 |
BATCH ID: ABC123 |
BILL ID: 001 |
|||
|
PAYEE NO: 555555555 PRINCIPAL DX: 831 |
|||||
|
OTHER DX: 8251
|
74764
|
111
|
252
|
||
|
PRINCIPAL PROCEDURE: 818 |
|||||
|
OTHER PROCEDURE: 111
|
222
|
||||
|
DRG CODE: 311
|
|||||
|
DRG AMOUNT: $ 6500.00 |
|||||
|
DATE OF BIRTH: 02/01/1940
|
SEX: M
|
DISCHARGE STATUS: 01
|
|||
|
PROVIDER MEDICARE NUMBER: 123456
|
|||||
|
GROUPER RETURN CODE : G0 |
|||||
|
GROUPER MCE ERROR CODES: |
M4 M5 M6 M7 M8 |
||||
|
GROUPER PRICER ERROR CODES: |
51 52 53 54 55 |
||||
|
PRIOR PAYMENT AMOUNT: |
0.00 |
||||
VIEW NEXT RECORD? [Y/N]
|
FECA Bulletin 99-21 |
Attachment 1 |
Back to Top of FECA Bulletin No. 99-21
Attachment 2
INPATIENT HOSPITAL BILLS - HOW TO PROCESS PAYMENTS BY THIRD PARTIES AND CLAIMANT REIMBURSEMENTS
Inpatient hospital bills present unique difficulties with respect to third party and claimant reimbursements, due to the need to limit the payment amount to the lesser of the DRG amount or the paid amount, and the DRG amount being dependent on hospital provider-specific information that is contained only in the pricer.
Reimbursement claims from third parties (such as insurance companies):
Will be accepted as paper billing only.
The claim should consist of a UB-92 completed by the hospital which provided the services, and a claim from the third party payer, showing the amount and date paid.
The bill will be entered into Premis as an inpatient hospital bill, with the hospital as a provider.
The amount paid by the third party insurance company will be shown as a prior payment amount. The prior payment amount will be loaded as an ineligible amount in b21.
The bill will be grouped and priced in the usual manner.
The presence of the prior paid amount will cause the direct pay flag to be loaded as N in b20.
The N direct pay flag will cause the bill to suspend with edit failure 210.
If the DRG amount assigned is less than the prior paid amount, the bill will be internally denied. The bill will be rekeyed as a direct payment to the third party payer (provider type O), with the DRG amount as the bill total, the third party paid amount as the line charge, and the difference between the two as an ineligible amount, ineligible amount code I.
If the DRG amount assigned is greater than the third party paid amount, and the hospital has not also made a claim, the bill should be internally denied. A new bill as direct payment to the third party (provider type O) should be keyed in BILL001, with the third party paid amount as both the line charge and the bill total.
If the DRG amount is greater than the third party paid amount, and the hospital has also made a claim, the bill should not be internally denied. The direct pay flag should be changed to Y, and the bill processed (the hospital will be paid the difference between the DRG amount and the prior paid amount. A second payment as noted in item 9 above should be processed for the third party payer. The total of the payment to the hospital and the payment to the third party should not exceed the DRG amount.
Reimbursement claims from claimants (injured employees):
Claimants should not be reimbursed for charges for which they are personally responsible, such as television or private room differential (where not medically necessary).
Paper bills only will be accepted. Paper bills should consist of a completed UB-92 from the hospital, with a completed form CA-915 or another written request for reimbursement, and proof of payment.
The bill should be entered on Premis, with the claimant paid amount as a prior paid amount. The prior payment amount will be loaded as an ineligible amount in b21.
The bill will be grouped and priced in the usual manner.
The presence of the prior paid amount will cause the direct pay flag to be loaded as N in b20.
The N direct pay flag will cause the bill to suspend with edit failure 210.
If the DRG amount is less than the claimant paid amount, delete the prior payment amount. The claimant will get the DRG amount. A separate letter should be sent to the claimant, explaining that the paid amount exceeded the allowable fee, and so only a partial payment was made.
If the DRG amount is more than the claimant paid amount, and the hospital has not also made a claim, enter the difference between the two as an ineligible amount, ineligible code [new]. The claimant will be paid the amount they actually paid (less than the DRG amount).
If the DRG amount is more than the claimant paid amount, and the hospital has also made a claim, change the direct pay flag to Y, and continue processing. A second bill should be entered in BILL001 as an indirect hospital bill payment, using a 911 locator 4 code and procedure code 001. The bill total and line charge will equal the claimant paid amount.
|
FECA Bulletin 99-21 |
Attachment 2 |
Back to Top of FECA Bulletin No. 99-21
Attachment 3
DRG INFORMATION RESOURCES
|
DRGs Diagnosis Related Groups |
|
|
Available from: |
3M Health Information Systems |
|
Voice # (203) 949-0303 |
|
42 CFR parts 405,412,413
Vol.63, No. 147, July 31, 1998
On the internet, HCFA's site at www.hcfa.gov has a wide variety of information.
|
FECA Bulletin 99-21 |
Attachment 3 |
Back to Top of FECA Bulletin No. 99-21
Attachment 4
|
Error |
Error |
Explanation |
|---|---|---|
|
M1 |
invalid code |
A DRG can not be assigned if there is a not a valid ICD-9-CM procedure or diagnosis code |
|
M2 |
sex conflict |
There is a conflict between sex and procedure or diagnosis codes |
|
M3 |
age conflict |
A DRG can not be assigned if there is a conflict between age and procedure or diagnosis codes. |
|
M4 |
Questionable |
A DRG can be assigned but admission is questionable under Medicare rules. |
|
M5 |
Manifestation |
A DRG can not be assigned. The diagnosis code describes a manifestation of a disease, not the disease itself. |
|
M6 |
non-specific |
A more specific pdx could have been provided but Grouper can assign a DRG. |
|
M7 |
e-code pdx |
A DRG can not be assigned. E-codes are not acceptable as principal diagnosis. |
|
M8 |
invalid 4/5 |
Grouper will not assign a DRG if there is an invalid or missing 4th or 5th digit in the diagnosis code. |
|
M9 |
non-specific |
A more specific procedure code is preferred, but Grouper will assign a DRG. |
|
|
||
|
MA |
open biopsy |
Warning of possibility of coding error for open rather than closed biopsy. Grouper will assign a DRG for an open biopsy procedure code. |
|
MB |
non-covered |
This error/alert is generated if procedures are not covered by Medicare. A DRG can be assigned. |
|
MC |
unacceptable |
A DRG can not be assigned if the principal diagnosis code provided is not a current illness or injury. |
|
MD |
sdx dup of |
The duplicate sdx may cause assignment to a complication/comorbidity DRG in error. A DRG can not be assigned. |
|
ME |
mcare |
This is an ALERT. The alert is not likely applicable to DFEC claims. A DRG can be assigned. |
|
MF |
bilateral |
This is a warning of a possible procedure code error. A DRG can be assigned. |
|
MG |
requires |
Requires a secondary diagnosis to assign a DRG. |
|
MH |
o.r. |
Error associated with a procedure. |
|
MI |
pre-pay error |
Error should be resolved prior to payment. |
|
MJ |
post-pay |
Potential discrepancy or error can be resolved after payment has been made. |
|
RTC |
Error |
Explanation |
|---|---|---|
|
G1 |
Diagnosis code cannot be used as principal dx. |
A DRG could not be assigned. The diagnosis code can not be used as the principal diagnosis code. The principal dx describes a circumstance which influences health status but is not an illness or injury. |
|
|
||
|
G2 |
Record does not match criteria for any DRG in MDC indicated by the pdx |
A DRG could not be determined for the principal diagnosis. |
|
G3 |
invalid age |
A DRG could not be assigned. The age of the patient submitted on the claim was not between 0 and 124. |
|
G4 |
invalid sex |
A DRG could not be assigned. Must be 1 (male) or 2 (female). |
|
G5 |
invalid discharge status |
The discharge status was not one of the valid HCFA 1450 discharge status codes. A DRG could not be assigned. |
|
G6 |
Illogical principal diagnosis code |
A DRG could not be assigned due to a principal diagnosis code that could not be grouped. |
|
G7 |
Invalid principal diagnosis code |
A DRG could not be assigned due to a principal diagnosis code that was not valid. Diagnosis code does not exist. |
|
G8 |
"Catch all" error |
No standard explanation of why a DRG could not be assigned. |
|
Error |
Error Description |
Explanation Code |
|---|---|---|
|
51 |
no provider specific information found |
Provider information is not found in HCFA provider file. Price calculated by National Office fee. |
|
52 |
invalid metropolitan status area (msa) # in provider file |
Invalid MSA status area in HCFA provider file. Price calculated by National Office. |
|
53 |
waiver state - not calculated by pps |
Some states are exempt from PPS. Price calculated by National Office. |
|
54 |
drg < 001 or > 494, or = 109 or 438 or 469 or 470 or 474 |
Price could not be calculated. A valid DRG could not be assigned based on the data submitted on the claim. |
|
55 |
discharge date < provider pps start date |
Price calculated by National Office. |
|
56 |
invalid length of stay |
|
|
57 |
review code invalid (not 00 03 06 07) |
Price calculated by National Office. |
|
58 |
total charges not numeric |
Possible data entry error. |
|
61 |
lifetime reserve days not numeric |
Price calculated by National Office |
|
62 |
invalid number of covered days |
Possible keying error. |
|
65 |
pay code not = A, B or C on provider specific file for capital |
Price calculated by National Office. |
|
67 |
cost outlier with length of stay (los) > covered days |
Price calculated by National Office. |
|
98 |
cannot process bill older than 5 years |
Price calculated by National Office. |
|
FECA Bulletin 99-21 |
Attachment 4 |
Back to Top of FECA Bulletin No. 99-21
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-22
Issue Date: January 26, 1999
Expiration Date: January 25, 2000
Subject: Medical Examinations: Obstruction/Refusal - Suspension under Section 8123(d)
Background: A recent FECA Transmittal, 99-05, regarding the above subject provided the correct information on the procedure manual change, but included an example in the transmittal that was misleading. The example given in FECA Transmittal 99-05 is hereby retracted and another example will be provided below. The points of confusion appear to have been in establishing when the obstruction officially began and when it stopped, for the purposes of establishing the period of entitlement to compensation. The Act, at § 8123(a), states that the employee shall submit to a medical examination once injured as frequently and at the times and places required by the OWCP. The Act at § 8123(d) goes on to state that if an employee refuses to undergo an examination or otherwise obstructs the exam, his or her right to compensation under the FECA will be suspended until the refusal or the obstruction stops.
The FECA Procedure Manual at Chapter 2-810.14.a. quotes from 8123(d), and then adds that prior to invoking the suspension penalty, the CE must ensure that the claimant has been afforded due process. Subparagraphs b., c., and d. go on to spell out what constitutes sufficient notification and the actions that need to be taken by the CE in order to provide due process to the claimant. This includes providing a written warning as to the penalty (at the time notification of the appointment is sent out) if the claimant fails to appear for the scheduled examination. The actual failure to appear for the medical examination scheduled by the Office without giving sufficient explanation for such failure to appear is what constitutes refusal of an examination. In such a case, the period of obstruction begins on the date of the examination for which the claimant failed to appear. This would also constitute the beginning date for the suspension of compensation benefits. On the other hand, stating that one will not attend, but later attending the exam as scheduled, for whatever reason, does not constitute a refusal or obstruction and thus no penalty may be imposed by the Office.
Reference: FECA Bulletin 99-05; 5 U.S.C. 8123(d); Chapter 2-810.14.a., b., c. and d.
Purpose: To clarify what constitutes an obstruction or refusal, and what qualifies as the cessation of an obstruction/refusal for setting the effective date for reinstatement of benefits once an obstruction of a medical examination has ceased.
Applicability: Regional Directors, District Directors, Claims Examiners, Supervisory Claims Examiners, and appropriate National Office personnel.
Action:
1. If it is determined necessary for the claimant to submit to a medical examination (for a second opinion or an impartial evaluation), the CE or MMA must arrange for the examination with the medical specialist and the claimant in writing as described in 2-810, 14.b. The letter used for this purpose must contain a warning that benefits may be suspended under 5 U.S.C. 8123(d) for failure to report for examination.
2. In cases where no medical report is received within 30 days of the date of the appointment, or where the examiner learns by another means that the claimant may not have attended the scheduled examination, the CE should verify by telephone that the claimant reported for the examination, and, if so, should inquire as to when the report may be expected.
3. If the claimant failed to appear for the examination, the CE must request in writing that an explanation be provided within 14 days as to why the claimant did not attend. If the claimant does not provide a sufficient reason justifying the failure to appear for the examination, i.e., good cause is not established, the CE can then find that the claimant refused to attend an examination scheduled by the OWCP. Compensation should then be suspended effective the date the examination was scheduled in accordance with § 8123(d) of the FECA. The suspension period extends from the date of the failure to appear for the exam until the date the claimant agrees to attend the examination.
4. Once the claimant actually appears for the rescheduled examination, the CE should restore benefits retroactively to the date the claimant agreed that he or she would attend the exam.
Example: A second-opinion examination was scheduled by the CE with the specialist and the claimant for December 17th and the claimant was notified by letter of November 24th. The scheduling letter included notification of the claimant's responsibilities regarding attendance at a medical examination scheduled by OWCP. The claimant notifies OWCP that he or she will not appear for the examination (or simply fails to attend). The CE would verify that the claimant did not attend the examination, and then would ask for an explanation as to why the claimant refused to attend (or had failed to attend) the examination. If the claimant provides an explanation that is sufficient to show good cause for his or her nonappearance at the scheduled examination, the CE would allow compensation to continue uninterrupted, and a new examination would be scheduled. However, if the explanation fails to establish good cause, the CE would suspend benefits effective the date of the scheduled examination (or December 17th).
The claimant subsequently agrees to appear for the medical examination either in writing or via the telephone (documented by a CA-110). The date of the letter of agreement or the CA-110 is January 19th, and the CE therefore reschedules the examination for the first available appointment, February 19th. The examination is carried out according to the arrangement and the CE verifies the claimant's attendance on February 22nd.
The CE can then set up a payment to restore benefits effective January 19th. The period of suspension in this example would then be from December 17th through January 18th.
Chapter 2-810 14.d. adds that the claimant's statement that he or she will not appear for an examination is insufficient to invoke the penalty of suspension under 8123(d) of the FECA (see Leanna Garlington, 37 ECAB 849). Similarly, the claimant's refusal to schedule an examination at the direction of OWCP is also not sufficient to invoke the penalty (see Herbert L. Dazey, 41 ECAB 271).
Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-22
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-23
Issue Date: March 1, 1999
Expiration Date: February 29, 2000
Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1999.
Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1999.
1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 1.6 percent.
2. The increase is effective March 1, 1999, and is applicable where disability or death occurred before March 1, 1998.
3. The new base month is December 1998.
4. The maximum compensation rates which must not be exceeded are the following:
| Amount | Span of Time |
|---|---|
|
$ 6,075.06 |
per month |
|
1,401.94 |
per week |
|
5,607.76 |
each four weeks |
|
280.39 |
per day (for a 5-day week) |
Applicability: Appropriate National Office and District Office personnel.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.
Action: On or about February 19, 1999, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustment Dates.
a. As the effective date of the CPI is March 1, 1999 and the start date of the periodic and death payroll cycles is February 28, 1999, there will be a supplemental record created for the period March 1 through March 27, 1999. Effective March 28, 1999, the periodic and death payrolls will reflect the increased amount.
b. The CA-816, LWEC, program must be updated with the new CPI percentage. This update must be performed in each district office.
2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 19, 1999, daily roll payment cases requiring the new CPI should be held for data entry until that date.
3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information. Attached to this directive is a complete list of all the CPI increases and effective dates since October 1, 1966 through March 1, 1999.
4. Forms.
a. Form CA-837, Notice to Payee, will be sent to the payees on the periodic disability and death payrolls. The notice will be sent to the payees from the National Office. The CA-837 will be addressed using the ACPS Correspondence Address File. PLEASE be sure to maintain the address file as you do with the Payee Address File and the CMF. PLEASE remember that an address change to the CMF DOES NOT automatically change the ACPS check address or correspondence address. ACPS must be accessed and the enter key must be depressed through the address areas. Be watchful for those payments being sent via Direct Deposit.
b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.
c. CP-140 will be printed for each case adjusted upon specific request by a District Office.
d. If claimants write or call for verification of the amount of compensation paid (possibly for mortgage verification; insurance verification; loan application; etc., please provide this data in letter form from the district office. Many times the Form CA-837 does not reach the addressee; regeneration of the form is not possible, thus, a simple letter indicating the amount of compensation paid each four weeks will be adequate for this purpose.
Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)
Attachment
|
EFFECTIVE DATE
|
RATE
|
EFFECTIVE DATE
|
RATE
|
|---|---|---|---|
|
10/01/66 |
12.5% |
04/01/80 |
7.2% |
|
01/01/68 |
3.7% |
09/01/80 |
4.0% |
|
12/01/68 |
4.0% |
03/01/81 |
3.6% |
|
09/01/69 |
4.4% |
03/01/82 |
8.7% |
|
06/01/70 |
4.4% |
03/01/83 |
3.9% |
|
03/01/71 |
4.0% |
03/01/84 |
3.3% |
|
05/01/72 |
3.9% |
03/01/85 |
3.5% |
|
06/01/73 |
4.8% |
03/01/87 |
.7% |
|
01/01/74 |
5.2% |
03/01/88 |
4.5% |
|
07/01/74 |
5.3% |
03/01/89 |
4.4% |
|
11/01/74 |
6.3% |
03/01/90 |
4.5% |
|
06/01/75 |
4.1% |
03/01/91 |
6.1% |
|
01/01/76 |
4.4% |
03/01/92 |
2.8% |
|
11/01/76 |
4.2% |
03/01/93 |
2.9% |
|
07/01/77 |
4.9% |
03/01/94 |
2.5% |
|
05/01/78 |
5.3% |
03/01/95 |
2.7% |
|
11/01/78 |
4.9% |
03/01/96 |
2.5% |
|
05/01/79 |
5.5% |
03/01/97 |
3.3% |
|
10/01/79 |
5.6% |
03/01/98 |
1.5% |
|
03/01/99 |
1.6% |
Prior to 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis or the nearest multiple of $.23 on a weekly basis ($.23, $.46, $.69, or $.92). After 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a "periodic" basis or the nearest $.25 on a weekly basis ($.25, $.50, $.75, or $1.00).
| Prior to 11/1/74 | Effective 11/1/74 |
|---|---|
|
Prior to 11/1/74 .08-.34 = .23 |
Eff. 11/1/74 .13-.37 = .25 |
|
35-.57 = .46 |
.38-.62 = .50 |
|
.58-.80 = .69 |
.63-.87 = .75 |
|
.81-.07 = .92 |
.88-.12 = 1.00 |
Back to Top of FECA Bulletin No. 99-23
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-24
Issue Date: February 9, 1999
Expiration Date: February 8, 2000
Subject: Medical Evidence: Appropriate Contact with Medical Specialists
Background: It has come to our attention that surveillance video tapes of claimants obtained by their employing agencies (EAs) are sometimes handled without the appropriate control by OWCP in situations involving medical opinions sought by the Office. More and more we have been made aware of situations in which employing agencies have made surveillance video tapes to be used as evidence in FECA claims, but have sought to contact our medical specialists directly without clearing the contact through OWCP. It is imperative that any surveillance video tapes of claimants under the FECA which are being used or considered as evidence are made a part of the official case record. As part of the official case record, the surveillance video tapes must be made available for review by the claimant or his or her representative upon request.
Reference: Federal (FECA) Procedure Manual Chapter 2-810, paragraph 13.(a).
Purpose: To provide guidance on the handling and disposition of surveillance video tapes by OWCP personnel; and to ensure appropriate contact with medical specialists by the Office with specific regard to providing video taped evidence for their review.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Rehabilitation Specialists, Staff Nurses, and Technical Assistants
Actions:
1. If surveillance video tapes are submitted to the Office by the EA and the CE determines that it is relevant to the issue being resolved by the medical examination, the CE should obtain copies of the video tape for the case record.
2. The CE should initially attempt to get the EA to substitute still pictures which show the activity that it is attempting to focus upon. (This will facilitate both storage in the case record and review of the evidence by the medical specialist.) In the event that still pictures are not possible, the CE should review the video tape and require the EA to edit it to omit having a medical specialist review hours of activity which has no bearing on the issue being considered. Once this is accomplished, the Office will make a copy of the edited video tape, labeling it as such (edited copy), and return the original to the EA.
3. If, on the other hand, upon review of the video tape the CE determines that the information is not relevant to the issue at hand, the video tape should be sent back to the EA with an explanation as to why it is determined not relevant to the issue at hand. (The CE should document the case record to reflect this action.)
4. If the CE determines that the video tape will be used as evidence for the record, he or she will direct the specialist involved to review the video tape and to reference this in his or her medical report.
5. If, somehow, the video tape goes to the second-opinion specialist directly from the employers' IG or Inspection Service, the CE will request a copy of the video for the case record from the EA. If the EA does not provide the video to the Office, the CE will direct the second-opinion specialist to disregard the video tape in coming to his or her opinion.
6. If evidence from a surveillance video tape is used in an Office decision, either directly or indirectly, the CE must reference it in the decision.
7. If, somehow, a surveillance video tape is provided by the EA directly to a medical specialist acting in the capacity of a referee physician, the CE must then advise the EA that the physician's opinion has been tainted and will have to be excluded from consideration in the Office's decision. If the EA insists convincingly that the evidence in the video tape in question about the claimant is vital to the case and must be used, the CE would direct the EA to send a copy of the video tape that they provided to the now-tainted referee, and then use it in conjunction with the referral to a new referee specialist.
8. When placement or maintenance of the video tape(s) becomes cumbersome or impossible as part of the physical case record, adequate provision for safeguarding the tape(s) must be made in the DD's or ADD's office. Similarly, reference to the existence and location of the tape(s) must be placed prominently in the case record itself.
9. When the district offices send cases with video tapes to Hearings and Review or ECAB, the presence of a video tape must be noted on the CA-58. When copies of video tapes are made by the Office, the copies must be labeled as such, adding that the original is owned and in the possession of the employing agency.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual Part 2 Chapter 810.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-24
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-25
Issue Date: April 1, 1999
Expiration Date: March 31, 2000
Subject: BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: Effective April 1, 1999, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles is decreased to 31 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.
Applicability: Appropriate National Office and District Office personnel.
Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual; Instruction CA-77, Instructions for Submitting Travel Vouchers; and 5 USC 8103.
Action: Instruction CA-77, Instructions for Submitting Travel Vouchers, has been revised to reflect the indicated rate change. A copy of the revised instructions is attached to this bulletin and may be reproduced at local levels. It will not be necessary to search and locate vouchers processed subsequent to April 1, 1999; however, if inquiry is received, appropriate adjustment should be made. Vouchers being processed for travel periods after April 1, 1999, may be adjusted to reflect this increase.
Disposition: This Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 -- Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Attachment: Instructions for Submitting Travel Vouchers
Form SF-1012, front and back (Link to Image)
Back to Top of FECA Bulletin No. 99-25
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-26
Issue Date: May 10, 1999
Expiration Date: May 9, 2000
Subject: District Office Use of Nurses Providing Telephonic Services
Background: FECA Bulletin NO. 97-11 provided the initial guidelines for use of Telephonic Case Managers (TCM) in district offices. While these guidelines remain valid, our experience over the last two years and particularly the results of the quality assurance review performed by the National Office staff in 1998 demonstrated the need to revise and clarify certain issues. This bulletin sets forth the revisions to district office procedures for the use of TCMs.
Purpose: This bulletin will provide improved guidelines and procedures for the use of TCMs in the district office.
Reference: Federal (FECA) Procedure Manual Chapters 3-201 and 3-202; FECA Bulletin 97-11.
Applicability: Regional Directors, FEC District Directors, FEC Staff Nurses and Claims Examiners.
Action:
1. Determining the number of TCMs. The District Offices Staff Nurse will continue to determine the number of nurses necessary to handle those cases subject to telephone intervention. Before TCMs are recruited, the SN needs to determine the number of cases suitable for TCM intervention and thus establish the number of TCMs necessary to handle the case load. (Criteria for case selection is discussed in action item # 4.) District offices must continue to maintain referral and reporting procedures which meet QCM time limits and privacy requirements, and the SN must track and monitor TCM progress.
2. Certification of TCMs. TCMs must be certified by OWCP and their recruitment, selection and certification must be in keeping with the process described in the FECA Procedure Manual Chapter 3-201. Nurses selected for telephonic intervention must sign a Memorandum of Agreement (MOA) unique to telephonic intervention activities (see Exhibit #1 (Link to Image)). A nurse cannot perform both face to face and telephonic intervention at the same time. She/he must elect one of the two types of intervention and sign the appropriate MOA. Contract nurses must hold valid licenses in the states where their assigned claimants reside.
3. Establishing TCM work-site. All nurses providing telephonic services must establish their own work sites (e.g. home, office) and cannot perform their routine duties in the district office. They may come into the office as necessary to obtain or drop off documents, etc. While in the office, the nurse may interact with the claims staff, and have access to the telephone and copying machines. They are otherwise responsible for furnishing their own supplies and materials. Data from the TCMs must be added into the Nurse/Rehabilitation Tracking System by FECA or contract staff (Orkand) other than the TCMs. The ability to control and assure accuracy of data input is maintained more effectively if OWCP staff enter this case-specific information.
4. TCM Case Selection, Time Frames and Reporting Format.
a. Case Selection: Telephone intervention can have successful outcomes in cases with widely different diagnoses, length of disability, and/or demographic characteristics. However, because of its total dependence on oral communication at a distance, it may not be appropriate in some instances. Our experience over the last two years (in particular, the National Office quality assurance review conducted on TCM cases) indicates that case selection can enhance results. Based on this review, referrals to TCM should exclude cases involving claimants with recurrences, known multiple claims and/or attending physicians known to provide prolonged care. Additionally, whenever surgery, special nergonomic work accommodations or indications that the return-to-work (RTW) adjustment will be a difficult one either mentally (stress claim) or physically (RTW with special needs such as crutches, splints, casts etc.), TCM intervention needs to cease and referral should be made to a field nurse.
b. Time Frames: To maximize results and to observe QCM time frames, a limit of 60 days should be applied to the TCM intervention activities. If at this point, the return to work has been secured via a completed OWCP–5, or return to work is imminent, the TCM may remain on the case to complete the required sixty day follow-up. In some circumstances, the TCM may accomplish a RTW/modified duty at 30 days into the intervention. In these cases, the TCM may continue to remain on the case in order to achieve either full duty release or at least a lessening of the job modifications, but is not to exceed the 120 day total time on the case. The CE may allow extensions in special circumstances, such as when there are no available field nurses in the claimant's vicinity or when the TCM possess language or professional skills that are necessary for the successful management of the case. Absent these factors, after 60 days the case needs to be transferred to a Field Nurse who will initiate face-to-face intervention.
Given this 60 day time frame-TCMs are not to be put into INTERRUPT as this status typically lasts at least 2-3 months (seeking second opinion examinations and/or performing surgical procedures) with no assurance that there will be a return-to-work at the end of the interruption phase and only delaying the referral to a FN for face-to-face intervention.
c. Reporting Format: Telephonic nurse case managers need to submit monthly reports identifying "plans of action" and results of contacts with attending physicians and employing agencies. The SN or Claims Examiner (CE ) reviewing these reports should be able to judge at a glance what important milestones in the case have been met (RTW date) or missed (no OWCP-5 received from the attending). In addition, when referral to a FN becomes necessary, the TCM must complete a "closure" report which details the factors requiring the transfer for FN intervention. This closure information will not only assist SN/CE in recognizing the need for transfer to a FN but, will help the FN move expeditiously on those areas previously identified by the TCM needing face-to-face intervention. A "sample" TCM reporting format is enclosed for your reference. (Exhibit #2 (Link to Image)
5. General Duties and Guidelines for TCM activities.
a. Duties - As detailed in FECA Bulletin No. 97-11, TCMs may offer medical guidance and input on cases but cannot perform functions which are the responsibilities of the claims examiners such as: preparing statements of accepted facts or questions for a second opinion or referee physician. Further, the nurse's functions are limited to the individual cases assigned to them for medical management and they are not to perform duties such as scheduling second opinion examinations or handling medical authorizations requests on an office-wide scale. The SN provides general instructions to the TCM in order to accomplish a RTW goal. However, once a case is assigned, the TCM does not receive direct and continuing supervision.
b. Guidelines - TCM performance, like FN performance, is evaluated on case outcomes and the timeliness and quality of services. If these actions are deficient, termination of TCM services should follow the same parameters outlined for FNs in FECA Procedure Manual Chapter 3-202, paragraph 13 –Warning And Termination Procedures.
6. Reimbursement Requirements for TCMs.
a. Yearly Maximum - Each district office has the discretion to set the professional and administrative reimbursement rate for their TCMs. However, each nurses providing the telephonic case management cannot exceed a yearly maximum of $50,000. Any TCM who reaches this amount cannot be assigned any more cases for the balance of the year. This cumulative reimbursement excludes all long distance phone and fax charges. To clearly separate these costs from the $50,000 maximum, they should be billed only under the NCPTC. Code.
b. Documentation -TCM activities require documentation in the form of monthly reports. Reports are to be accompanied by bills submitted on the HCFA-1500 form. Unique codes have been developed for use by TCMs not only to identify specific costs and services for this intervention but, to also allow their bills to be processed without being subjected to the prior-authorization edits.
c. Coding –
NCA00 - Telephonic nurse intervention, administrative - increments of time less than 1 hr.;
NCA01 - Telephonic nurse intervention, administrative - 1 hr. increments of time;
NCP00 - Telephonic nurse intervention, professional services increments of time less than 1 hr.;
NCP01 - Telephonic nurse intervention, professional services 1 hr. increments of time.
A review of the ongoing charges of each TCM may be monitored through the use of the monthly NI-7 (B & C) reports.
Disposition: Retain until the expiration date or until superseded.
Sheila Williams
Acting Director for
Federal Employees' Compensation
Attachments
Distribution: List No. 1
(Claims Examiners, All Supervisors, System Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
Back to Top of FECA Bulletin No. 99-26
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-27
Issue Date: June 18, 1999
Expiration Date: June 17, 2000
Subject: Bill Pay/BPS - Authorization of High Dollar Medical Bills
Background: Recent OIG audit findings indicate there is a need for documenting the supervisory authorization of payment on medical bills beyond established dollar limits. Although the current FECA Procedures require that bills above established dollar limits (based on the type of provider involved) be authorized by a higher level person, the recurrence of duplicate payments in extremely high dollar amounts suggests the need to document that those procedures are being followed. The ability of OWCP to document the review and authorization of high cost medical bills at the supervisory level (GS-13 and above) will enable the Office to ensure the accountability for payments from the Compensation Fund, and to decrease the number of errors from duplicate payments of large amounts.
Reference: FECA Bulletin 98-5.
Purpose: To provide additional guidance regarding the authorization of medical bills beyond $50,000.00 and to emphasize the importance of accountability with clear documentation that the responsible resolver has taken appropriate action in high dollar medical bill payments.
Applicability: Regional Directors, District Directors, Fiscal Officers, Bill Payment Supervisors, Claims personnel, and appropriate National Office personnel.
Actions:
1. If the district office currently has satisfactory procedures in place for authorizing bills under $50,000.00, they should be continued. The effectiveness of such procedures will continue to be monitored biannually in the accountability review process and annually during the OIG's Consolidated Financial Statement Audit.
2. Regarding bills of $50,000 and above, each district office will devise its own new procedures for ensuring that they are reviewed and authorized by an individual at the appropriate level. In these cases, the district offices will select one of two options. The option chosen by each district office will be operative for all bills at and above the stated amount in the respective office. That is, bills of $50,000 and above will all be handled in a uniform manner based on the option chosen. The two available options are as follows:
(a) The higher level bill authorizer would maintain a personal log of all bills authorized. The log would include all the information necessary to identify the case, the bill, the provider, and the amount authorized.
(b) The second option would involve having the higher level authorizer retain paper copies of the actual bills containing the authorizing official's initials.
In either of the above described options, the auditors would be able to seek out the persons whose initials are in the BPS as having authorized any particular bill for payment. With either method, the auditor would verify that the person whose initials are in the BPS history actually approved that bill for payment.
3. Once the method of documenting the authorization of high cost medical bills has been chosen by the district office, the National Office should be advised via e-mail to Sheila M. Williams, copy to Ken Siglin. The district office plans should be selected and operative within 30 days of the issuance of this FECA Bulletin.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual Part 2 Chapter 810.
SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-27
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-28
Issue Date: August 30, 1999
Expiration Date: August 29, 2000
Subject: Return to Work--Temporary Assignments During Recovery
Background: Among the factors which the Office of Workers' Compensation Programs (OWCP) considers in assessing whether a job offered to an injured employee is suitable is whether the kind of appointment (permanent, term, or temporary) is at least equivalent to that of the job held on the date of injury.
If the two appointments are not equivalent, then the offered job cannot be found suitable. For instance, if the employee's date of injury job was permanent, OWCP may not find a temporary or term job suitable. Likewise, a term employee must be offered at least a term appointment; a temporary appointment would not be suitable.
This policy is intended to apply to offers of employment which will lead to ratings for loss of wage-earning capacity (LWEC). However, the policy has recently been cited with respect to offers of short-term work made to employees who are still recovering from their injuries and who may be able to perform light duty but who have not reached a level of recovery sufficient to consider rating for LWEC.
A distinction must be made between a position which is temporary, according to the rules promulgated by the Office of Personnel Management, and an assignment which is temporary, and which is made in recognition that a partially disabled employee is able to perform some work during the period of his or her recovery.
An employee who is undergoing vocational rehabilitation efforts at the direction of OWCP may be required to accept an offer of work within his or her limitations while recuperating from a work-related injury, even if that work represents a temporary assignment and the employee has permanent appointment status. Failure to accept such an assignment may be considered failure or refusal to participate in vocational rehabilitation efforts, and such a failure may be sanctioned on that basis.
However, it remains true that a permanent employee may not be rated for LWEC purposes based on a temporary or term position, nor may his or her refusal to accept such an assignment be sanctioned under 5 U.S.C. 8106(c).
Purpose: To provide guidance with respect to short-term job offers made to employees who are in the early stages of recovery from work-related injuries.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Hearing Representatives, Technical Assistants, Staff Nurses, and Vocational Rehabilitation Specialists
Reference: 5 U.S.C. 8106(c) and 8113(b); 20 CFR 10.519(b) and (c); Federal (FECA) Procedure Manual Chapter 2-813.11, 2-814.4 and 2-814.7
Actions:
1. Where an employee is undergoing OWCP-directed vocational rehabilitation efforts, either with a registered nurse or a vocational rehabilitation counselor, an employer may offer the employee a temporary assignment pending further recovery from the work-related injury.
2. An employer who takes such an action should notify OWCP of the nature of the offered position and whether its rate of pay is the same as or less than that of the date-of-injury job.
3. For an employee who accepts such an assignment, compensation will be paid on an actual-earnings basis pending further recovery.
4. OWCP will consider an employee who refuses to accept such an assignment as failing or refusing to undergo a vocational rehabilitation effort when so directed. As stated in the program's regulations at 20 CFR § 10.519(b):
Where a suitable job has not been identified, because the failure or refusal occurred in the early but necessary stages of a vocational rehabilitation effort...OWCP cannot determine what would have been the employee's wage-earning capacity.
5. Therefore, in accordance with the procedures outlined in the Federal (FECA) Procedure Manual, Chapter 2-813.11, the Claims Examiner (CE) should warn the employee that, absent evidence to the contrary, OWCP will assume that the vocational rehabilitation effort would have resulted in a return to work with no loss of wage-earning capacity.
6. In addition to any evidence which the employee may present in response to such a warning, the Claims Examiner must consider the rate of pay of the offered assignment. A rate of pay less than that of the date of injury job, due either to a change in differential pay or to provision of different work altogether, will constitute "evidence to the contrary".
7. If the claimant does not resume cooperation with vocational rehabilitation efforts, his or her compensation should be reduced, either to zero if no evidence to the contrary has been presented, or based on the rate of pay of the job assignment if evidence to the contrary has been presented. As stated in 20 CFR § 10.519(c), "The reduction will remain in effect until such time as the employee acts in good faith to comply with the direction of OWCP."
8. However, it is not proper to rate for LWEC an employee who accepts such a temporary assignment unless the terms of the job are modified so that the original and new appointments are equivalent. For instance, a temporary assignment which meets a permanent employee's work limitations may not be used for a rating, but if the employer makes the same job permanent, and the job is classified in accordance with 20 CFR § 10.509(b), such a job would be considered proper for LWEC purposes.
Disposition: Retain until the indicated expiration date.
SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-28
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-29
Issue Date: August 5, 1999
Expiration Date: August 4, 2000
Subject: Bill Payment/BPS - Correct Coding Initiative, Part A.
Background: Many medical bill processing systems include edits that are designed to detect certain types of coding error and abuse. While the DFEC bill processing system (BPS) already includes some of these edits, there are additional elements that are being added to enhance the system, under a Correct Coding Initiative (CCI). CCI is modeled on a system implemented by Medicare in 1996. Staff has already been hired in the National Office to implement CCI, and additional staff in each district office will be hired shortly.
CCI implementation will consist of two major parts. Part A includes editing for age-specific procedures, sex-specific procedures, unlisted procedures, excluded procedures, and modifier validity. Parts B and C, to be implemented in the future, will include editing for mutually exclusive procedures, comprehensive/component procedures, add-on codes, and global periods. Part A is in effect with the issuance of this Bulletin, or shortly thereafter. Information concerning Parts B and C will be provided at a later date.
Reference: Federal (FECA) Procedure Manual Chapters 5-0203 and 5-0204.
Purpose: To communicate procedures for processing bills under the CCI, Part A.
Applicability: Claims Examining, Bill Processing and CCI personnel.
Actions:
1. The CCI edits are applicable only to certain CPT-4 codes.
2. Four new BILL552 edits have been developed for CCI Part A. These include an edit for age-specific procedures (361), female-only procedures (362), male-only procedures (363), and unlisted procedures (364). Detailed edit sheets for these four new edits are being sent under separate cover, along with the revised condensed BPS edits, and the revised EOB listing.
3. Attachment 1 shows age-specific procedures. These procedures are only applicable to children. Since FECA claimants are not children, these procedures are not payable under the FECA.
4. Attachment 2 shows female-only procedures. Attachment 3 shows male-only procedures.
5. Attachment 4 shows excluded procedures. These are procedures that are not payable for work-related conditions. Excluded procedures are already identified by BILL552 edit 303.
6. Unlisted procedures are found at the ends of CPT code groupings, and usually end in 99. An example would be 20999, "unlisted procedure, musculoskeletal system." These codes are supposed to be used only when another CPT code cannot be used appropriately, and often require a medical report to support use of the unlisted code.
7. When errors 361, 362, and 363 are assigned, denial is automatic, and the edit failure cannot be overridden. Error 364 failure results in a suspension, which must be manually reviewed and may be overridden if appropriate.
8. Invalid modifiers are already identified by BILL552 edit 318.
9. All billing issues with respect to these edit failures, including resolution of these edit failures, should be referred to the CCI specialist. The CCI specialist is not responsible for other edit failures that may occur on a bill. Other edit failures on the bill should, in general, be resolved before the bill is referred to the CCI specialist. If problems arise with respect to these edits prior to the CCI specialist being on board, contact either Yvette Sanders (202-693-0886) or Cheryl Bullock (202-693-1027) at the National Office. Edit 364 will not be activated until after the CCI specialists have been hired and trained.
Training on this Bulletin should be completed within 30 days of the issuance of this bulletin.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
SHEILA M. WILLIAMS
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachment 1
AGE-SPECIFIC PROCEDURE CODES
24640
25450
25455
27175
27176
27177
27178
27179
27181
27185
27256
27257
27258
27259
27455
27475
27477
27479
27485
27727
27730
27732
27734
27740
27742
31520
31601
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33692
33694
33697
33730
33732
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
36400
36405
36406
36420
36440
36450
36460
36488
36490
36510
36660
46715
46716
46730
46735
46740
46742
46744
46746
46748
46751
49495
49496
49500
49501
49580
49582
54000
54150
54160
73092
73540
73592
76010
76065
76885
76886
88028
90918
90919
90922
90923
94652
94772
99295
99296
99297
99298
99431
99432
99433
99435
99436
99440
Back to Top of FECA Bulletin No. 99-29
Attachment 2
SEX-SPECIFIC PROCEDURE CODES - FEMALE
00842
00846
00850
00855
00857
00944
00946
00948
00950
00952
00955
19324
19325
19328
19330
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
50722
51845
51900
51920
51925
52285
53210
53230
53250
53430
53502
53660
53661
53665
55980
56301
56302
56307
56308
56309
56343
56344
56350
56351
56352
56353
56354
56355
56356
56405
56420
56440
56441
56501
56515
56605
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
57000
57010
57020
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57280
57282
57284
57288
57289
57291
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57452
57454
57460
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
57556
57700
57720
57800
57820
58100
58120
58140
58145
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58300
58301
58321
58322
58323
58340
58345
58350
58400
58410
58520
58540
58600
58605
58611
58615
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58960
58970
58974
58976
58999
59000
59012
59015
59020
59025
59030
59050
59051
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
58350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59899
74710
74740
74742
74775
76086
76088
76805
76810
76815
76816
76818
76825
76826
76827
76828
76830
76831
76941
76945
76946
76948
80055
80414
80415
80426
82670
82671
82672
82677
82679
83001
83632
84135
84138
84140
84143
84144
84146
84233
84234
84702
84703
84830
88141
88142
88143
88144
88145
88147
88148
88150
88152
88153
88154
88155
88156
88158
88164
88165
88166
88167
88235
89254
89255
89256
89258
89330
Back to Top of FECA Bulletin No. 99-29
Attachment 3
SEX SPECIFIC PROCEDURE CODES - MALE
00865
00908
00914
00916
00920
00922
00924
00926
00928
00930
00932
00934
00936
00938
37788
37790
52450
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
53215
53235
53250
53410
53415
53420
53425
53440
53505
53510
53515
53520
53600
53601
53605
53620
53621
53850
53852
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54150
54152
54160
54161
54200
54205
54220
54230
54231
54235
54240
54250
54200
54204
54208
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54402
54405
54407
54409
54420
54430
54435
54440
54450
54500
54505
54510
54520
54530
54550
54560
54600
54620
54640
54650
54660
54670
54680
54700
54800
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865
55870
55899
55970
56318
56320
74440
74445
76870
78760
78761
82651
84153
84154
84402
84403
89257
89259
89260
89261
89264
89300
89310
89320
89325
89329
89330
93890
93980
93981
Back to Top of FECA Bulletin No. 99-29
Attachment 4
EXCLUDED PROCEDURE CODES
11975
11976
11977
15819
15820
15821
18522
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15876
15877
15878
15879
55870
55970
55980
56302
56343
56344
56700
56720
56805
57335
58300
58301
58321
58322
58323
58345
58350
58600
58605
58611
58615
58970
58974
58976
59840
59841
59850
59851
59852
59855
59856
59857
59866
61000
61001
89250
89251
89252
89253
89254
89255
89256
89257
89258
89260
89261
89329
90744
90918
90919
90922
90923
94150
98943
99295
99296
99297
99381
99382
99383
99384
99391
99392
99392
99393
99394
99431
99432
99433
99435
99450
Back to Top of FECA Bulletin No. 99-29
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-30
Issue Date: August 30, 1999
Expiration Date: August 29, 2000
Subject: Third Party--Claims from Certain Census Workers
Background: To conduct the Decennial Census and other kinds of census surveys, the Bureau of the Census employs enumerators and field representatives who visit private properties and interview residents of the properties to gather statistical data.
Section 5 U.S.C. 8131(a) states in part that:
If an injury or death for which compensation is payable...is caused under circumstances creating a legal liability on a person other than the United States to pay damages, the Secretary of Labor may require the beneficiary to-- (1) assign to the United States any right of action he may have...; or (2) prosecute the action in his own name.
If the beneficiary does not do so, he or she is not entitled to benefits under the Federal Employees' Compensation Act.
However, 13 U.S.C. 9(a)(2) prohibits employees of the Bureau of the Census from releasing or allowing "any publication whereby the data furnished by any particular establishment or individual under this title can be identified...." Furthermore, under 13 U.S.C. 214, anyone who releases information protected by 13 U.S.C. 9 "shall be fined not more than $5,000 or imprisoned not more than five years, or both".
Given these provisions of the law, an enumerator or field representative injured while on private property for the purpose of gathering data through an interview with a resident would either have to breach confidentiality, thus risking discipline by the Bureau of the Census and possible prosecution, or lose his or her compensation benefits.
It has therefore been determined that, except where the injury is the result of a deliberate act by the resident, OWCP claims staff should not pursue the third party aspect of a claim for injury or death filed by an enumerator or field representative of the Bureau of the Census.
Reference: 5 U.S.C. 8131(a); 13 U.S.C. 9(a)(2); 13 U.S.C. 214; and Federal (FECA) Procedure Manual Chapter 2-1100
Applicability: Supervisors, Claims Examiners, and Technical Assistants
Action:
1. For cases where an enumerator or field representative is injured while on private property for the purpose of interviewing a resident, the National Office has advised the Bureau of the Census to answer "no" to the question on Form CA-1 which asks whether the injury was caused by a third party. Doing so will allow short form closure if the claim is otherwise eligible for this action, and it will ensure that the case is coded properly for third party tracking purposes.
2. Except as stated in item 3 below, the RCE should not send Form CA-1045 to an enumerator or field representative who is injured while on private property for the purpose of interviewing a resident. Also, the RCE should not refer the case to the designated third party Claims Examiner (DCE).
3. Only if the Bureau of the Census has determined that a deliberate act of a resident caused the injury should the RCE send a CA-1045 and refer the case to the DCE. If it appears to the RCE that a deliberate act of a resident was the proximate cause of the injury, illness or death, and the Bureau of the Census has not made such a determination, the RCE should contact the Bureau of the Census for clarification before taking any third party action.
4. Claims staff should continue to take third party actions on any claim filed by an enumerator or field representative which indicates a potential third party liability due to other activities within performance of duty. For instance, an enumerator traveling from one interview site to another may be involved in an automobile accident on a public street. Here, the provisions of 13 U.S.C. 9 and 13 U.S.C. 214 would not apply, and it would be proper to pursue the third party aspect of the claim.
Disposition: Retain until the indicated expiration date.
SHEILA M. WILLIAMS
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 99-30
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 99-31
Issue Date: September 27, 1999
Expiration Date: September 26, 2000
Subject: Bill Pay/BPS - Data Entry of Inpatient Hospital Bills
Background: Effective January 4, 1999, a fee schedule for inpatient hospital bills was implemented. Because of the data entry requirements for the new fee schedule, special software was used to data enter inpatient hospital bills. Initially, data entry was performed only in the National Office. During the months of March and April, each district office was trained in the use of the special software, and began performing data entry of their own inpatient hospital bills.
In the months that have followed, the volume of inpatient hospital bills has been much lower than what had been expected, based upon previous years' volume of inpatient bills. In addition, district offices have experienced numerous difficulties in performing the data entry of these bills. The costs associated with maintaining the special software at each site have been considerable.
Effective September 27, 1999, district offices will no longer perform data entry of most inpatient hospital bills. Instead, these bills will be mailed to the National office for data entry, after which the bills will be processed and loaded into the district office systems.
Reference: FECA Bulletin 99-21, "Modifications to Inpatient Hospital Bill Procedures," issued January 4, 1999.
Purpose: To communicate revised procedures for data entry of inpatient hospital bills.
Applicability: All Personnel in the District Offices and National Office.
Action:
1. The District Offices will take the following actions with respect to inpatient hospital bills:
a. Separate inpatient hospital bills from outpatient hospital bills. Hospital bills generally are submitted on form UB-92, although a few other types of providers also use the forms. Only hospital bills which meet the following parameters should be identified as "inpatient" for purposes of keying into the special software:
1) The first digit of the code in form locator 4 must be 1, 4, or 8; the second digit 1, 2, 5, 7 or 8; and the third digit 1, 2, or 7; and
2) Room and board charges are present on the bill. Such charges are shown with RCCs of 100 through 169.
b. Screen the inpatient bill for the presence of a six-character provider Medicare number, usually found in form locator 51. Medicare numbers are usually all numeric, but may also contain one alpha character. If the Medicare number is not on the bill, the bill should be returned to the hospital with an explanation and a request that the number be provided.
c. Make sure that the bill contains a valid case file/claimant name by performing a case or name query. If the case file number is invalid, determine the correct case file number, write it on the bill in form locator 60, and cross out the invalid case file number.
d. Place the bills that pass screening as described in items a through c above in a batch. Arrange the bills in alphabetical order by the claimant's last name.
e. Complete a batch cover sheet, and write the batch ID and bill ID on each bill in form locator 61. The first bill in each batch will be bill 001, the second 002, etc. For example, the batch and bill ID for the first bill in batch GH2822 should be written as GH2822.001. Please note that certain characters are very difficult to discern from each other, such as 1 and I, 0 and O. It is preferred that these characters not be used in the batch IDs, but if they are used, they should be distinguishable.
f. Image the batch. Follow quality control procedures to ensure that the batch has been scanned and is viewable.
g. Mail the original batch(es) to the National Office via overnight mail:
U.S. Department of Labor
ESA, OWCP
200 Constitution Ave., NW
Rm. S-3229, Attn: Yvette Sanders
Washington, D.C. 20210
h. Send e-mail to Yvette Sanders (ysanders@fenix2.dol-esa.gov) in the National Office regarding the batches sent, stating:
1) The number of batches sent;
2) The bill IDs for the batches sent; and
3) The number of bills in each batch.
Inpatient bill batches should be consolidated so that only one or two e-mails are sent to Ms. Sanders in any given week.
2. The National Office will take the following actions:
a. Receive the paper bills from the district offices.
b. Review the bills to ensure that they are appropriate for keying into the special software. Any bills that are not appropriate for such data entry will be returned to the district office with an explanation and instructions for further processing.
c. Compare the hospital name, address, tax identification number, and Medicare number with those found on the National Office hospital provider file, and make any corrections needed.
d. Data enter the bills into the special software.
e. Verify the accuracy of the data entry.
f. Transmit the bills to the hospital clearinghouse.
g. Respond to the e-mail from the district office, providing the date the bills were transmitted to the clearinghouse.
3. The remainder of the inpatient bill processing will remain as it currently exists, namely: the clearinghouse will forward the bills for grouping and pricing; National office will associate a provider address with each bill, and transmit the bills to the appropriate district offices; the bills will be loaded into the FECS bill processing tables and edited by BILL552; the bills will be resolved by the appropriate district office staff.
4. If data entry problems arise with respect to inpatient bills keyed by the National Office, including bills that must be corrected and resubmitted, contact Yvette Sanders. District Offices may now correct errors in bill and batch IDs through the use of BILL515, in the FECS004 menu.
5. The personal computer and phone line that was previously dedicated to inpatient hospital bill data entry should not be used for other purposes until further notice.
6. Training on these procedures should be provided to the appropriate staff as soon as possible.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
NANCY L. RICKER
Acting Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 99-31
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-01
Issue Date: November 30, 1997
Expiration Date: November 29, 1998
Subject: Case File and Bill Batch Imaging
Background: While cases are before the Employees' Compensation Appeals Board (ECAB), issues often arise which are not related to the issue(s) for which the cases are before the Board. In the past, when a case file was requested by the Board, it was transferred to the National Office (T51), where the case record itself was sent on to the Board, and the case jacket, CA-800, and incoming correspondence were retained in the Branch of Hearings and Review. Claims examiners in the Branch of Hearings and Review were responsible for taking case actions on issues which were not before the Board, without the benefit of the case record or prior experience with the case.
Medical bill batches are generally retained in the district offices for a minimum of two years, after which they can be retired. Finding space for storage of bill batches has been difficult, as has retrieving particular bill batches when needed for review.
During the past several months, the Division of Federal Employees' Compensation (DFEC) has developed a pilot using imaging technology to assist in the processing of cases before the ECAB, and to enhance bill batch maintenance. Each district office has been provided with scanners, personal computers with monitors large enough to view imaged documents, imaging software, and training on how to use this new technology. A centralized imaging center has been established in the National Office. Cases going to the ECAB and medical bill batches have been imaged. An imaged case tracking system has been established to keep track of the physical case file associated with an imaged case.
Reference: FECA Procedure Manual, Chapter 2-1603.4-5, Chapter 5-0200.7.
Purpose: To describe new guidelines and procedures for case file and bill batch imaging.
Applicability: All staff in the district offices, National Office, and the FEC Imaging Center.
Action:
1. Effective November 24, 1997, when a district office receives a request for a case file from ECAB, the electronic records for the case file will not be transferred to the ECAB (T51). Instead, the district office will remain responsible for the case, and the following actions will be taken:
National Office adds the case to the imaged case tracking program;
a. the district office:
(1) runs the CASE642 report, "Image Tracking Inquiry" showing the ECAB request; this report should be run on a daily basis (see item 2 below);
(2) locates the case file;
(3) files down any documents that are loose in the file, in the appropriate order; if actions are pending a note is made on the Sequent and a call-up established by appropriate staff;
(4) completes a form CA-67 (case transmittal sheet) to list the case(s) being sent;
(5) mails (certified or overnight) the case(s) with the jackets and CA-67 to the FEC Imaging Center (FIC);
(6) enters the date that each case was mailed in the imaged case tracking program (option 38 on the FECS001 Case Management menu is "Imaged Case Update").
The case file location changes to NB1 automatically when the mailing date is entered.
b. FIC:
(1) receives the case file;
(2) images and indexes it (see items 9 and 10 below for a description of indexing);
(3) updates the imaged case tracking program with the date received, date imaged, and date mailed to National Office;
(4) delivers the case file to the National Office mail room.
Once the imaging date has been entered on the imaged case tracking program, the case location in the District Office changes to NB2 overnight.
c. The National Office:
(1) receives the case file;
(2) copies the CA-800s;
(3) marks the file "Imaged";
(4) updates the imaged case tracking with the date received, the issue code (see item 14 below), and comments (if any);
(5) delivers the case file and copy of the CA-800 to ECAB;
(6) mails the case jacket and the original CA-800 back to the district office (see paragraph 3 below).
d. When the ECAB is finished with the case file, the National Office mail room will:
(1) scan the ECAB decision and any accompanying documents; mark documents "document imaged";
(2) send the case contents and the ECAB decision back to the district office;
(3) update the imaged case tracking with the date mailed to the district office.
e. The district office:
(1) receives the case contents;
(2) places the contents back into the permanent jacket;
(3) updates imaged case tracking with the date the case was received;
(4) reviews the ECAB decision and accompanying documents and takes appropriate action.
The case location changes to NB3 automatically as soon as the received date is entered by the district office.
2. The CASE642 report, which is "Image Tracking" under the FECS002 (FECA Report Generation) Menu, lists cases which have been requested by ECAB, but for which the district office has not yet entered the date the case was mailed to the FIC. The report can be simply viewed on the screen or printed. The report should be run daily to track outstanding ECAB requests for cases. It should be noted that the existing daily report which requests cases for both ECAB and Hearings and Review will continue to include ECAB cases for at least a period of time.
3. As previously indicated, after a case file has been imaged and is delivered to the National Office mail room, the case jacket and CA-800 will be returned to the district office. The case jackets and CA-800s should be retained in the district office, either in a separate location in the file room, or another special location. Any mail received in the district office after the case has been mailed to the FIC needs to be scanned, including mail received after the case contents with ECAB decisions have been returned to the district office. If multiple copies of a document are received, such as an original of a medical report plus two copies, only one copy should be scanned and dropfiled. Prior to scanning, the district offices should ensure that the case is showing a location of NB2 or NB3 and that an accurate case file number is present on each page to be scanned. If the case location is NB1, the mail should be held until the location changes to NB2, then it can be scanned. If there are several pages of mail for the same case file, and each page does not have the case file number on it, a header sheet indicating that the following xx pages are all for case file xx-xxxxxxx may be used. Scanned mail should be stamped as "document imaged," and maintained in a batch in the file room until verification that the mail has been indexed by the FIC. The mail should then be dropfiled in the appropriate case jacket.
4. On a daily basis, the FIC will send to each office, via e-mail, a list of case files for which new mail has been indexed and appended to the case file. Each office has identified the recipients of this e-mail for their office. Receivers of the e-mail are responsible for ensuring that the responsible claims examiners are notified that there is new mail in their cases.
5. Any mail which must receive special tracking (CA-7, CA-8, CA-2a, CA-16) should be entered into the appropriate tracking system, and then given to the scanner.
6. Once a case file has been imaged, all subsequent case actions should be taken based upon the imaged case. Obviously, while the case contents are with the ECAB, the imaged case must be the basis for case actions taken. Once the case file contents have been returned from the ECAB, the imaged file becomes the official file. Except for unusual circumstances, the case file contents should not move from the file room (special location) again.
7. No imaged files and case records should be transferred between district offices while the case is before the ECAB (case location NB1 or NB2). After the case contents have been returned from the ECAB (case location NB3), the case may be transferred in accordance with existing procedures.
8. Any correspondence or internal documents produced in an imaged case that would normally be filed in the case file must be scanned and then dropfiled, in accordance with item 3 above. This includes letters (including decisions in any format) to claimants and others, payment worksheets, reports, statements of accepted facts, CA-110s, etc.
9. Each document in an imaged case file is indexed by the FIC. Indexing allows the user to identify documents needed for review more readily. Indexing categories for complete case files imaged are:
a. Medical evidence - includes medical reports, office notes, hospital records, and letters to medical providers;
b. Forms - includes only certain forms: CA-1, CA-2, CA-2a, CA-4, CA-5, CA-6, CA-7, CA-7a, CA-7b, CA-8, CA-12 (most recent two only), CA-16, CA-20, CA-800, CA-1032 (most recent two only), and OWCP-5 (also a, b, and c);
c. Decisions (most recent two, or within the past year, which ever is greatest); and
d. Miscellaneous - includes everything else.
10. For case files imaged prior to September 1997, and for new mail (in all previously imaged cases), a more extensive indexing has been/will be done, which, in addition to the categories shown in item 9, includes:
a. Payment documentation - includes payment work sheets, ACPS reports, and CA-7s and CA-8s;
b. Congressional - includes inquiries from Congressional offices and responses;
c. Communication - includes general correspondence, both incoming and outgoing, CA-110s, transmittal documents, and memoranda to the file;
d. All other forms.
11. A date is associated with all indexed documents, other than those indexed prior to November 24, 1997 and classified as miscellaneous. For the forms, the date is the date the form was signed. For medical evidence, the date is the date of the report or letter. For decisions, congressionals, and communications, the date is the date of the decision, etc. Documents are imaged in the order they are filed in the case file, and should therefore be in approximate date of receipt order.
12. If a piece of mail or an internal document has been scanned, but not yet indexed by FIC, it will not be viewable by making an inquiry using the case file number. Mail will be viewable within 18 hours if it is scanned by 12:00 noon, district office time. If the mail is scanned after noon, indexing will take an additional day.
13. When updates are made to the CA-800 in an imaged case, the paper CA-800 will be updated, and the updated CA-800 should be rescanned so that the current version may be viewed.
14. Even though many cases before the ECAB will be available through imaging in the district offices, and district offices will be responsible for maintaining the imaged case while it is before the ECAB, district offices may not take action on any issue which is simultaneously before the Board. Decisions may be issued by the district offices on issues which are not before the Board. Issue codes and comments are entered by the National Office into the imaged case tracking program, and may be viewed in the district offices under item 31 of the FECS001 query menu. For example, if a case file is with the Board for an appeal on a schedule award, the district office may take action on a claimed recurrence of disability for work. The issue codes are as follows:
01—Time
02—Civil Employee
03—Fact of Injury
04—Performance of Duty
05—Causal Relationship
06—Continuing Injury-Related Disability
07—Recurrence
08—Schedule Award
09—Overpayment
10—COP
11—LWEC
12—Pay Rate
13—Attorney Fee
14—Refusal/Obstruction of Examination
15—Denial of medical treatment
16—Failure to accept suitable job
17—Forfeiture
18—Non-cooperation with Rehabilitation efforts
19—Reconsideration Decision (not merit review)
20—Denial of hearing
21—Compensation Rate
22—Third Party
23—Other
15. The imaged record should be used to produce copies of documents from the case file, such as when a copy of the file is requested under the Privacy Act, or a copy of all medical evidence is needed for a second opinion evaluation. If the number of documents to be printed is large, printing should be done in smaller blocks of no more than 35 pages at a time. If a large number of pages are involved, the FIC should be notified. The FIC will generate a copy of the case file and mail it to the district office, so that it will be received within two days of the request. The customary charges for second copies still apply.
16. In addition to imaging case files going to ECAB, all district offices have the ability to image medical bill batches. The bill batches will be imaged after they are keyed by data entry personnel. Bill resolvers may work from either the actual bill batches, or the bill images. Detailed procedures for bill batch imaging will be issued under separate cover.
17. The appearance and functioning of the imaged document screens have been addressed in the training which has been conducted in each district office. A user guide is under development and should be available within the next month. In the meanwhile, the training materials can be used as a user guide.
18. Doubled cases will be imaged as a single case file, using the master file number. The subsidiary files are not cross-referenced in the imaged file data base. Therefore, if one wishes to view a subsidiary record of an imaged file, the master file number should be used. The presence of the CA-800 and/or CA-1 or CA-2 within the imaged record should help to delineate separate injury records.
19. Once a case has been imaged, all secondary appeals (such as a request for a hearing on a new decision, or another appeal on the case) will be conducted based upon the imaged record.
20. Cases which were transferred to T51 prior to the beginning of the imaging pilot will not be imaged. Maintenance of these files will continue to be performed by the Branch of Hearings and Review.
Training for all personnel affected by these changes should be conducted no later than November 21, 1997.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 98-01
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-02
Issue Date: January 2, 1998
Expiration Date: January 1, 1999
SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1998
PURPOSE: To provide the 1998 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1998.
APPLICABILITY: All appropriate personnel are to be made aware of the periods and "cut-off" dates for the ACPS periodic disability, death, and daily payrolls.
The production schedule for the DMS periodic reports is made available for the appropriate personnel. IT IS IMPERATIVE that this schedule be closely followed.
DISPOSITION: This bulletin should be retained in front of Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachments
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 98-02
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-03
Issue Date: March 1, 1998
Expiration Date: February 28, 1999
Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1998.
Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1998.
1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 1.5 percent.
2. The increase is effective March 1, 1998, and is applicable where disability or death occurred before March 1, 1997.
3. The new base month is December 1997.
4. The maximum compensation rates which must not be exceeded are the following:
| Amount | Time |
|---|---|
|
$ 5,892.94 |
per month |
|
1,359.91 |
per week |
|
5,439.64 |
each four weeks |
|
271.98 |
per day (for a 5-day week) |
Applicability: Appropriate National Office and District Office personnel.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.
Action: On or about February 20, 1998, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustment Dates.
a. As the effective date of the CPI is March 1, 1998 and the start date of the periodic and death payroll cycles is March 1, 1998, there will be no supplemental record created.
b. The CA-816, LWEC, program must be updated with the new CPI percentage. This update must be performed in each district office.
2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 20, 1998, daily roll payment cases requiring the new CPI should be held for data entry until that date.
3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information. Attached to this directive is a complete list of all the CPI increases and effective dates since October 1, 1966 through March 1, 1998.;
4. Forms.
a. Form CA-837, Notice to Payee, will be sent to the payees on the periodic disability and death payrolls. The notice will be sent to the payees from the National Office. The CA-837 will be addressed using the ACPS Correspondence Address File. PLEASE be sure to maintain the address file as you do with the Payee Address File and the CMF. PLEASE remember that an address change to the CMF DOES NOT automatically change the ACPS check address or correspondence address. ACPS must be accessed and the enter key must be depressed through the address areas. Be watchful for those payments being sent via Direct Deposit.
b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.
c. CP-140 will be printed for each case adjusted. These may be drop filed in the case file.
d. If claimants write or call for verification of the amount of compensation paid (possibly for mortgage verification; insurance verification; loan application; etc., please provide this data in letter form from the district office. Many times the Form CA-837 does not reach the addressee; regeneration of the form is not possible, thus, a simple letter indicating the amount of compensation paid each four weeks will be adequate for this purpose.
Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)
|
EFFECTIVE DATE |
RATE |
EFFECTIVE DATE |
RATE |
|---|---|---|---|
|
|
|||
|
10/01/66 |
12.5% |
04/01/80 |
7.2% |
|
01/01/68 |
3.7% |
09/01/80 |
4.0% |
|
12/01/68 |
4.0% |
03/01/81 |
3.6% |
|
09/01/69 |
4.4% |
03/01/82 |
8.7% |
|
06/01/70 |
4.4% |
03/01/83 |
3.9% |
|
03/01/71 |
4.0% |
03/01/84 |
3.3% |
|
05/01/72 |
3.9% |
03/01/85 |
3.5% |
|
06/01/73 |
4.8% |
03/01/87 |
.7% |
|
01/01/74 |
5.2% |
03/01/88 |
4.5% |
|
07/01/74 |
5.3% |
03/01/89 |
4.4% |
|
11/01/74 |
6.3% |
03/01/90 |
4.5% |
|
06/01/75 |
4.1% |
03/01/91 |
6.1% |
|
01/01/76 |
4.4% |
03/01/92 |
2.8% |
|
11/01/76 |
4.2% |
03/01/93 |
2.9% |
|
07/01/77 |
4.9% |
03/01/94 |
2.5% |
|
05/01/78 |
5.3% |
03/01/95 |
2.7% |
|
11/01/78 |
4.9% |
03/01/96 |
2.5% |
|
05/01/79 |
5.5% |
03/01/97 |
3.3% |
|
10/01/79 |
5.6% |
03/01/98 |
1.5% |
Prior to 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis or the nearest multiple of $.23 on a weekly basis ($.23, $.46, $.69, or $.92). After 09/07/74, the new compensation after adding the CPI is rounded to the nearest $1.00 on a "periodic" basis or the nearest $.25 on a weekly basis ($.25, $.50, $.75, or $1.00).
| Prior to 11/1/74 | Effective 11/1/74 |
|---|---|
|
Prior to 11/1/74 .08-.34 = .23 |
Eff. 11/1/74 .13-.37 = .25 |
|
.35-.57 = .46 |
.38-.62 = .50 |
|
.58-.80 = .69 |
.63-.87 = .75 |
|
.81-.07 = .92 |
.88-.12 = 1.00 |
Back to Top of FECA Bulletin No. 98-03
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-04
Issue Date: February 28, 1998
Expiration Date: February 27, 1999
Subject: Bill Payment/BPS - New Edits for Procedure Code Dates of Validity.
Background: Each year, the American Medical Association (AMA) revises the Physicians' Current Procedural Terminology (CPT) codes. The revised codes are generally effective the first day of each calendar year. The revisions usually include the deletion of certain codes, addition of others, and changes to the narrative description for some codes.
In the past, when AMA deleted a code, OWCP kept the code in the system for one year past the effective deletion date, to allow for payment of bills for the prior calendar year. After the year was over, the code was deleted.
Begin and end dates have been added to OWCP's procedure code file (v30). These begin and end dates are applicable to all procedure codes, not just the CPT procedure codes.
Three new edits using procedure code begin and end dates have been added to the bill editing program (BILL552), and are operational with the February 18 installation of the updated program.
Editing for procedure code dates of validity will allow offices to process bills using the procedure codes which were valid at the time the services were rendered, rather than having to substitute a currently valid code. In addition, it is anticipated that some charges which now suspend with edit 014 failures will either be paid or will be denied automatically with an appropriate EOB message.
Reference: Federal (FECA) Procedure Manual, Chapters 5-0200 and 5-0204.
Purpose: To advise office staff of new BPS edits which verify the validity of procedure codes for the dates of service billed.
Applicability: All bill resolution staff, contact representa- tives, claims examiners, supervisors, and systems managers.
Action:
1. Detailed edit sheets for the three new edits are attached. The sheets explain each new edit, provide resolution instructions, if applicable, and provide other relevant information. These should be inserted in the appropriate place in the expanded bill resolution job aid.
2. In addition to these new edits, several new alternate EOB messages (900 series) have been added at the request of field personnel. The new EOB messages are as follows:
942 Billed service denied. Duplicate of service previously reimbursed to the injured employee.
(This message would be used when a medical provider or health insurance carrier claims payment, and the claimant has already been paid for the same services.)
943 Billed service denied. Duplicate of service previously paid to the medical provider.
(This message would be used when the claimant or a health insurance carrier claims payment, and the medical provider has already been paid for the same services.)
944 Billed service denied. Duplicate of service previously paid to another carrier.
(This message would be used when the claimant or the medical provider claims payment, and the health insurance carrier has already been paid for the same services.)
3. A complete listing of all EOB messages and a revised con- densed edit job aid has been made available under separate cover.
4. In working with these edits, resolvers must be aware of the potential for duplicate billing due to use of more than one procedure code for the same service.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
February 18, 1998
MEDICAL BILL SYSTEM
EDITS
EDIT NO. 322L
|
ERROR DESCRIPTION: |
DATES OF SERVICE ARE PRIOR TO EFFECTIVE |
|
EDIT DESCRIPTION: |
TO DATE_OF_SERVICE IS PRIOR TO V30 BEGIN DATE FOR THIS PROCEDURE CODE |
SUSPEND/DENY: S
OVERRIDE: Y
EOB: This procedure code did not become valid until after the dates of service. If services have not already been paid using another code, please rebill using a procedure code which was valid at the time services were rendered.
PRIORITY: 4
BILL RESOLUTION:
1. Verify accurate keying of procedure code and dates of service.
2. Check online history to ensure that charge has not already been paid using a different procedure code. If it has already been paid, set to deny with alternate EOB 933.
3. Check the begin date for the procedure code in question. If the billed service dates predate the begin date by only one or two months, or if the bill is an old (more than two years) one which is only now being processed because of delays in adjudication, the edit failure may be overridden. Otherwise, set to deny with EOB 322 (above).
February 18, 1998
MEDICAL BILL SYSTEM
EDITS
EDIT NO. 323L
|
ERROR DESCRIPTION: |
PROCEDURE CODE NOT VALID FOR DATES OF SERVICE |
|
EDIT DESCRIPTION: |
FROM DATE_OF_SERVICE IS AFTER V30 END DATE FOR THIS PROCEDURE CODE |
SUSPEND/DENY: D
OVERRIDE: N
EOB: This procedure code was no longer valid as of the dates of service. If services have not already been paid using another code, please rebill using a code which is valid for the period of service.
PRIORITY: 4
BILL RESOLUTION:
N/A
February 18, 1998
MEDICAL BILL SYSTEM
EDITS
EDIT NO. 324L
|
ERROR DESCRIPTION: |
DATES OF SERVICE OVERLAP PERIOD PROCEDURE CODE WAS VALID |
|
EDIT DESCRIPTION: |
PERIOD OF TIME REPRESENTED BY FROM/TO DATES_OF_SERVICE OVERLAPS V30 |
SUSPEND/DENY: D
OVERRIDE: N
EOB: During a portion of the period covered by these dates of service, the procedure code was not valid. Please resubmit, breaking down the period of time further, using valid codes (and units) for each period of time.
PRIORITY: 4
BILL RESOLUTION: N/A
Back to Top of FECA Bulletin No. 98-04
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-05
Issue Date: March 5, 1998
Expiration Date: Indefinite
Subject: Bill Pay/BPS - Supervisory Sampling of Bills
Background: Recent reports from the Office of Inspector General cite numerous errors in bill processing. Some of these errors, such as failure to key procedure code modifiers, inaccurate units, overuse of bypass code 1, making payment to the wrong provider, misuse of authorizing initials, and incorrect dates of service, are due to inaccurate keying of bills. Other errors, such as inadequate authorization for bills over certain dollar limits, misuse of all bypass codes, and the failure to detect keying errors, are due to mistakes made in the bill resolution process.
FECA Bulletin 94-10, issued November 2, 1993, outlined revised procedures for supervisory sampling of bills. Recent accountability reviews have shown that some district offices are not carrying out regular supervisory sampling of bills.
It is critical that thorough supervisory sampling of bills be carried out on a regular basis, and that corrective actions be taken when problems are found.
A computer-based training package for keying bills is under development.
Reference: FECA Bulletin 94-10.
Purpose: To reissue and update procedures for supervisory sampling of bills.
Applicability: Regional Directors, District Directors, Fiscal Officers, Bill Payment Supervisors, and appropriate National Office personnel.
Action:
1. Bills processed through the BPS will be sampled on a monthly basis by supervisory personnel.
2. By the tenth day of each quarter, the individuals performing the bill sampling will provide a report of the previous quarter's findings to the District Director, with proposed corrective actions, if needed. Consideration of corrective action must be given for any error detected.
3. A copy of the quarterly report (findings and corrective actions) will be provided via E-mail to the Director for FEC, with a copy to Sheila Williams, Deputy Director for FEC, no later than the 20th day of the quarter, along with a time table for the corrective actions.
4. Offices will perform two separate bill reviews: one of the physical batches; the other of individual bills. Work sheets and instructions for each type of review are attached.
5. For the batch review, 1% of the bill batches completed during the month will be reviewed. If 1% of the batches completed during a month exceeds 20 batches, then 20 batches will be reviewed. The batches should include work from all keyers and resolvers, if possible. This review will involve examination of the physical bill batches only, although further investigation may be made, when indicated. Examples of situations warranting further review include: the presence of bill with no date stamp; or the presence of a bill on an incorrect form. During the batch review, the reviewer should also make note of bills with extended service date ranges, procedure code modifiers, multiple units, high dollar amounts, and repetitions of the same procedure code for the same date of service on the same bill, for inclusion in the bill reviews.
6. For the bill reviews, a minimum of 42 individual bills should be reviewed. The bills should not be selected randomly, but should include all keyers and resolvers, and as many different bill types as possible. Bills with extended service date ranges, procedure code modifiers, multiple units, high dollar amounts, and repetitions of the same procedure code for the same date of service, as identified during the batch review, must be included in the sample. If no such bills were found during the batch review, a reasonable effort should be made to identify bills of this nature from other bill batches. Both paid and denied bills should be selected, with at least 80% of the bills being paid bills. Overnight histories should be obtained for all of the paid bills, using specific provider identification numbers and dates of service to reduce the size of the report. The on-line bill payment history will be used to evaluate certain items. The BP40 report (Register of Miscellaneous Checks Paid) will also be used.
7. The purpose of these reviews is to ensure the accuracy, quality, and security of the bill processing operation. Therefore, more extensive reviews should be made if the initial findings indicate the potential for a problem.
8. Bills will also be reviewed using these procedures as part of the Accountability Review and Management Review processes.
Disposition: This Bulletin should be retained until incorporated into the Federal (FECA) Procedure Manual, or otherwise superseded.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 4--Folioviews Groups B and D
(Fiscal Officers, Benefit Payroll Clerks and Assistants, All Supervisors, Systems Managers, Technical Assistants)
INSTRUCTIONS FOR COMPLETION OF BILL SAMPLING WORKSHEET
Obtain a Central history for each paid bill being sampled. The Central history contains receive date, bypass codes, payee address, authorizing initials, units, and ineligible amounts and codes, which are not available in the on-line history. [Bypass codes and units are being added to on-line history.] The on-line history contains information on both paid and denied bills, including service dates, procedure codes, charge amounts, paid amounts, check date, EOB date, EOB numbers, and resolver ID. In addition, the on-line history displays information on bills which reject in the Central processing. The BP040 reports will also be needed.
Bill No. - The 9-digit bill number, which includes the 6-digit batch ID number and the 3-digit sequence of the bill within the batch.
Def.? - If any of the following items is found to be deficient, this box should be checked.
Approp. Form? - Was the form type appropriate for the provider type (HCFA-1500, UB-82, UB-92, etc.)? (Y/N)
Receive Date OK? - Is the receive date as stamped on the bill the same as the receive date entered on the system (as found in history)? (Y/N)
Keyed OK? - Compare the information found on the bill with the information found in history (note that service dates, procedure codes, and bypass codes are covered separately). Were the correct number of units keyed? If the bill was paid, examine the BP040 to determine whether the address on the bill matches the address to which payment was made. If the bill suspended, look at the BILL552 batch report to determine whether keying errors caused the bill to fail edits. Was the correct provider selected? (Y/N)
Auth. Amt.? - If the bill total was over the maximum for that provider type, does the bill show the initials of the authorizing individual, and are those initials in agreement with the authorizing initials in the history? (N/A, Y, or N)
Altered Charges? - Are any of the charge amounts on the bill different from the amounts on the history? If yes, were changes made to the bill, and are the changes justified? Ineligible amount codes and amounts should also be considered. (Y/N)
Service Dates OK? - Do the dates of service on the bill agree with the dates of service in the history? Be especially mindful of whether the dates on the bill reflect a single date, or a date range. (Y/N)
Bypass Codes OK? - Does the bill or history reflect use of bypass codes, and if so, were they used appropriately? (Bypass code 1 need not appear on the bill itself. Bypass codes 2 or 3 must be written on the bill. Note that if the bill was paid as the result of the bill resubmit program, the bypass code may be written on the duplicate bill report, rather than the original bill itself.) (N/A, Y, or N)
Proc. Codes - If procedure codes were required, were they used appropriately? Are the procedure codes on the bill in agreement with the procedure codes in the on-line history and the codes in history? Were procedure code modifiers present on the bill keyed? (N/A, Y, or N)
Adj. OK? - Whether the bill was paid, denied, partially paid/partially denied, or internally denied, was the adjudication of the bill correct? Case notes on the system, accepted conditions, or other information may need to be reviewed to answer this question. (Y/N)
EOB OK? - If the bill was denied, were the EOB messages that went to the biller appropriate? Review the on-line history to determine the EOB messages, and consult with the list of EOB messages to determine what they actually were. Note that if more than two EOB messages were used, only the two highest priority EOB messages will be recorded in the on-line history. The EOBs used should reflect the most appropriate message to the biller. (N/A, Y, or N)
Remarks - Any other irregularities about how the bill was processed should be noted here, including inaccurate units. If the bill rejected at Central, is there an adequate audit trail of the final disposition of the bill?
Back to Top of FECA Bulletin No. 98-05
INSTRUCTIONS FOR COMPLETION OF THE BATCH SAMPLING WORKSHEET
This review is to be based solely upon examination of the physical bill batches. For "tally" items, make a tally mark (/) for each bill in which there is an error with respect to the indicated area.
Batch No. - The 6-digit batch identification number.
No. of bills - The number of bills contained in this batch, as indicated on the CA-D-9 batch cover sheet. Does this number agree with the number indicated on the BILL552 report, and the actual number of bills physically present in the batch?
Case File # - Make a hash mark here if the case file number is not present on the bill.
Provider EIN - Make a hash mark here if provider EIN is not present on the bill. If bill is for pharmacy, travel, maintenance or training reimbursement to the claimant, no provider EIN is required.
Provider address - Make a hash mark here if full provider address is not present on the bill. No provider address is required if bill is for pharmacy, travel, maintenance or training reimbursement to the claimant.
Date stamp - Make a hash mark here if there are irregularities with respect to the date stamp. Irregularities would include no date stamp, or more than one date stamp with no indication that the bill had at some point been returned.
Form - Make a hash mark here if bill is not on an appropriate form.
Back to Top of FECA Bulletin No. 98-05
Attachment A2 BILL SAMPLING WORKSHEET (Link to Image)
Attachment B2 BILL SAMPLING WORKSHEET (Link to Image)
Back to Top of FECA Bulletin No. 98-05
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-06
Issue Date: April 10, 1998
Expiration Date: April 9, 1999
Subject: Debt Collection: Referrals to the Department of Treasury.
Background: In April 1996, the Debt Collection Improvement Act of 1996 was passed. This Act mandates referral of debts to Federal agencies that are more than 180 days delinquent to the Department of Treasury for administrative offset. The Department of Treasury has designated the Financial Management Service (FMS) to oversee the two offset programs, cross-servicing and the Treasury Offset Program.
Cross-servicing makes the Department of Treasury responsible for all collection efforts. A variety of methods are used, from letter writing to salary offsets to, in some cases, referral to a private collection agency. Any debt referred for cross-servicing will also be handled under the Treasury Offset Program.
The Treasury Offset Program maintains a delinquent debtor database nationwide, and all federal payments disbursed by the FMS will be matched against this database for potential offset. The FMS may also refer debts to private collection agencies and may undertake other debt collection duties.
Under this system, debts will no longer be transferred to the National Office for referral directly to private collection agencies.
Purpose: To inform District Offices of the change in procedure for collection of delinquent debts and to advise of specific procedures to follow for referral for administrative offset.
Applicability: All claims and fiscal staff.
Action: Debt management will continue to be handled in its preliminary stages according to current procedure. Referral of debt for cross-servicing by FMS is only to occur when a debt is 180 days or more delinquent. Referral of debt to the Department of Treasury will replace referral to Private Collection Agencies as outlined in FECA PM 6-300.12.
District Offices must monitor all debts approaching or over 180 days delinquent for possible treasury referral, and must ready cases for such referral when needed.
1. When any debt is at least 90 days but not more than 120 days delinquent, the responsible Senior Claims Examiner should review the case to ensure that a letter outlining due process requirements for debt referral has been issued, and, if not, issue one. The letter must:
a. Provide written notification of the nature and amount of the debt and of the Office's intention to collect the debt via administrative offset;
b. Give the debtor the opportunity to inspect the file for all records concerning the debt;
c. Note that the debtor has been given the opportunity to appeal the debt;
d. Note that the debtor has been given the opportunity to enter into a written repayment agreement;
e. State a specific contact name and note that the debt may be referred for litigation.
The current system-generated collection letters, Forms CA-9001 and CA-9002, have been amended to meet this requirement. Examples of these letters are attached as Exhibits 1 and 2.
2. Each month, District Office staff should review the DMS aging report and, for all debts turning 180 days old where the claimant has received proper notice as outlined above, complete the package shown at Exhibit 3 and forward this package to the attention of Sheila Baker in the National Office. A guide for completion of this form is attached as Exhibit 4. A copy of all letters and decisions concerning the debt, especially the due process letter, must be attached. Ms. Baker will request appropriate debts for transfer to District 90 under code 08, Treasury referral. No debt may be referred without National Office request.
3. The District Office may not refer debts that are:
a. In litigation or referred to the Justice Department;
b. Already with a private collection agency;
c. On appeal (this includes debts currently before the ECAB);
d. Covered by Bankruptcy.
4. The District Office must immediately stop all collection efforts. If an FMS request is made of the District Office, the National Office should be contacted immediately.
5. If a debtor contacts the District Office about the debt, only questions regarding the validity of the debt may be answered. Any questions concerning the amount due or debt balance must be referred to FMS at 202-874-6660.
Debts referred for cross-servicing will remain transferred to District 90 until they are closed or returned by FMS. The National Office will then review the debt and take appropriate action or return the debt to the District Office.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2—Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
FB 98-06 Exhibit 1: CA-9001
|
|
File Number: 20001_010000001 |
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
Dear CLAIMANT NAME:
This letter is in further reference to your debt in the amount of $999,999.99, which resulted from the overpayment of benefits in your case. A copy of our final decision and first demand for payment, dated 01/01/1901, is enclosed. We have not received payment from you or any indication that you intend to cooperate in this matter.
If we do not receive payment, or some indication that you intend to make payment, within 30 days of the date of this letter, we may add the following charges to the debt:
1. Interest at the current rate of the U.S. Treasury Bill. It will begin to accrue as of the date of this letter.
Interest charges will be waived if payment is received within 30 days.
2. Administrative charges for sending any additional demands for payment. If necessary, the Office of Workers' Compensation Programs (OWCP) can ask a debtor's federal employing agency to recover an overpayment from the debtor's salary. OWCP can also ask the Office of Personnel Management to recover the overpayment from money payable to the debtor from the Civil Service Retirement Fund. If you do not send us a check or contact us about this debt within 30 days, and you work for the federal government or are eligible for or in receipt of a Civil Service annuity, we may pursue one of these courses of action.
Also, if your debt remains delinquent, we may refer it to the Department of the Treasury for collection by administrative offset from any federal payments which may be due you. We will assess an additional administrative cost to help defray the expense of this referral. Information about the status and delinquency of your debt is reportable to credit bureaus.
You have the following rights with respect to referral of your debt to the Department of the Treasury or to credit bureaus:
|
EXHIBIT 1 |
CA-9001, page 1 |
You may inspect and request copies of your records about this debt;
You may enter into a mutually agreeable written repayment agreement; and
You may request a review of our determinations about the amount of your debt, its past-due status, and its legal enforceability. To exercise this right, you must state your request in writing, state your reason(s) for challenging our determinations, and sign your statement. If you believe that any information of record concerning your debt is not accurate, timely, relevant, or complete, you must provide information or documentation to support your belief.
You are expected to reply within 30 days. Make your check payable to the U.S. Department of Labor, OWCP, and include your FECA file number on the check. Send payment to:
District Office Lockbox Address Line 1
District Office Lockbox Address Line 2
District Office Lockbox Address Line 3
District Office Lockbox Address Line 4
District Office Lockbox Address Line 5
If you wish to enter into a written repayment agreement, contact me immediately on 999-999-9999.
Sincerely,
NAME OF SIGNER
TITLE
Enclosure(s):
|
|
CA-9001, page 2 |
Back to Top of FECA Bulletin No. 98-06
FB 98-06 Exhibit 2: CA-9002
|
|
File Number: 01_0000001 Date of Injury: 01/01/1901 Employee: CLAIMANT NAME |
CLAIMANT NAME
00000000000000000000000000000000000
00000000000000000000000000000000000
00000000000000000000000000000000000
00000000000000000000000000000000000
00000000000000000000000000000000000
Dear CLAIMANT NAME:
This letter is in further reference to your debt in the amount of $999,999.99, which resulted from the overpayment of benefits in your case.
Because 30 days have passed and we have not received payment or an indication that you intent to repay this money, your debt is now considered to be delinquent. Interest will therefore be assessed at the rate which applied when you received your first notice of indebtedness, or 99%. Penalty charges of 6% per year for any portion of the debt remaining delinquent for more than 90 days and administrative charges may also be added.
We may refer the debt to a credit bureau and to the Department of the Treasury for administrative offset if payment is not made within 60 days of the date of this letter. Information which will be given to a credit bureau is limited to your name, address and Social Security Number; the amount, status and history of the debt; and the program under which the debt arose, that is, the Federal Employees' Compensation Program.
Once your debt has been referred to the Department of the Treasury, administrative charges will be added to the current principal amount. These charges, which are computed as a percentage of the debt, reflect our collection cost. They are authorized by the Debt Collection Improvement Act of 1996 (Public Law 104-134). This referral will therefore result in a large increase in the size of your debt.
You may avoid these outcomes by sending your check in the amount stated above. Make your check payable to the U.S. Department of Labor, OWCP, and include your FECA file number on the check. Send it to:
District Office Lockbox Address Line 1
District Office Lockbox Address Line 2
District Office Lockbox Address Line 3
District Office Lockbox Address Line 4
District Office Lockbox Address Line 5
|
EXHIBIT 2 |
CA-9002, page 1 |
As you have been advised previously, you have certain rights in with respect to referral of your debt to the Department of the Treasury or to credit bureaus:
You may inspect and request copies of your records about this debt;
You may enter into a mutually agreeable written repayment agreement; and
You may request a review of our determinations about the amount of your debt, its past-due status, and its legal enforceability. To exercise this right, you must state your request in writing, state your reason(s) for challenging our determinations, and sign your statement. If you believe that any information of record concerning your debt is not accurate, timely, relevant, or complete, you must provide information or documentation to support your belief.
If you wish to enter into a written repayment agreement, contact me immediately on 999-999-9999.
Sincerely,
NAME OF SIGNER
TITLE
Back to Top of FECA Bulletin No. 98-06
CA-9002, page 2
| Bulletin | Exhibits | |
|---|---|---|
|
FECA Bulletin 98-06 |
Exhibit 3: Referral of Debt to Treasury for Offset |
|
|
FECA Bulletin 98-06 |
Exhibit 4: Guide for Form Completion |
|
Back to Top of FECA Bulletin No. 98-06
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-07
Issue Date: January 5, 1998
Expiration Date: January 4, 1999
Subject: Compensation Pay: Compensation Rate Changes Effective January 1998.
Background: In December 1997, the President signed an Executive Order implementing a salary increase of 2.30 percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the 2.30 percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 1998.
Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The new rates will be effective with the first compensation payroll period beginning on or after January 1, 1998. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $94,287 per annum.
The minimum increase specified in this Bulletin is applicable to Postal employees.
The effect on 5 U.S.C. 8112 is as follows:
|
Effective January 4, 1998 |
Minimum |
Maximum |
|---|---|---|
|
Monthly |
$1,214.25 |
$5,892.94 |
|
Weekly |
210.16 |
1,359.91 |
|
Daily(5-day week) |
42.03 |
271.98 |
The basis for the minimum compensation rates is the salary of $14,571 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $94,287 per annum (GS-15, Step 10).
The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,214.25, effective January 4, 1998. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $5,892.94 per month.
Applicability: Appropriate National and District Office personnel.
Reference: Memorandum For Directors of Personnel dated December 1997; and the attachment for the 1998 General Schedule.
Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustments Dates.
a. As the effective date of the adjustment is January 4, 1998, there will be no supplemental payroll necessary for the periodic disability and death payrolls.
b. The new minimum/maximum compensation rates will be available in ACPS on or about January 23, 1998.
2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 1998. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.
3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows:
|
CA-842 |
|||||
|
1/04/98 |
42.03-63.05 |
210.16-315.24 |
42.03 |
210.16 |
1,214.25 |
|
CA-843 |
|||||
|
1/04/98 |
271.98 |
1,359.91 |
(5,439.64) |
5,892.94 |
|
4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.
Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 98-07
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-08
Issue Date: March 24, 1998
Expiration Date: March 23, 1999
Subject: November 1997 DFEC/OPM Computer Match
Background: Another DFEC/OPM computer match, designed to identify possible occurrences of prohibited concurrent dual benefit payment, was completed last month using the data for the November 8, 1997 periodic roll cycle. The data shared with OPM again included the death roll, and excluded schedule award cases. 74 cases survived the manual and automated screening processes employed by OPM. The last DFEC/OPM Computer Match was conducted in February, 1997.
With its advance copy of this bulletin, each District Office will receive a computer printout of the cases under its jurisdiction which should be screened, followed and reported on in accordance with the procedures described in FECA Bulletin 96-4 and again specified below. The presence of a case on the list should indicate that benefits were being paid by both DFEC and OPM on November 8, 1997, in apparent violation of the dual benefit prohibitions.
For this, and future matches, we will continue to follow the procedures used in the past; that is, OPM and the responsible District Offices will directly converse and correspond in order to resolve the hits. The District Offices will continue to have National Office reporting requirements, as detailed below. However, any problems that arise with OPM, or with any other aspect of processing the match hits, should be raised with Sheila Baker (202) 219-8461 for resolution. Telephone inquiries to OPM should be directed to Eugene Wooldridge at (202) 606-0228 (or 606-0228). Written inquiries or other correspondence should be directed to the Office of Personnel Management, Retirement Inspection Branch, P.O. Box 7174, Room 2309, Washington, D.C. 20044-7174, Attention: Eugene Wooldridge.
Purpose: To inform District Offices of the procedures for follow-up review and reporting requirements concerning the "hits" identified in the November, 1997 DFEC/OPM match, and to reiterate continuing reporting requirements for the previous OPM matches.
Applicability: District Directors, Assistant District Directors.
Action: Each District Office with one or more cases appearing as hits from this match will receive a copy of a computer printout detailing the information on those cases, in a combined listing of disability and death cases. (On this printout the OPM Claim Number begins with "A" for disability cases and begins with "F" for death cases. Also, if the first digit of the OPM Claim Number is 7 or 8 then benefits are being paid under FERS rather than CSRS.) In addition, individual "hit sheets" completed by OPM are in the process of being mailed directly to the District Offices by OPM. Please note that the field identified on the printouts as "OWCP Gross" is actually the FECA 28 day payment amount converted to a 30 day equivalent for easy comparison purposes. The "OWCP Net" field is the actual 28-day gross compensation amount paid.
1. Immediately pull and review each disability (OPM "A" prefix) case listed in which the OPM gross payment amount exceeds the FECA gross payment amount. (For these cases the OPM amount is underlined on the printout.) If a review of the case confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
2. Review the remaining disability cases (those where FECA benefits exceed OPM benefits), and the death (OPM "F" prefix) cases (as detailed below). In the disability cases where FECA benefits are greater, OPM will seek the election and return a copy of the election along with a completed OPM "hit sheet" to DFEC.
3. In death/survivor cases (OPM "F" prefix), an informed election must be made before either benefit is terminated. Please remember that split elections can be made. In fact, several de facto split elections were discovered during previous matches; that is, there appeared to be dual benefits situations when in fact different beneficiaries were receiving OPM and FECA benefits. In other cases split elections have been made as a result of the matches. It is important that truly informed elections are made in these cases. During the 3rd match you were advised of our revised policy regarding the revocability of elections in death cases.
That change was formalized by revision to the regulations. However, OPM maintains that survivor elections are irrevocable; that is, that once an election of FECA benefits is made, the beneficiary may not subsequently elect OPM benefits, unless the FECA entitlement is later determined to have been mistaken, or there is a third-party credit absorption.
Therefore, included in the information provided to a beneficiary in order for him/her to make an informed election should be a statement that an election of OPM benefits can later be changed to elect FECA benefits, but that the reverse is not possible. In addition, an informed election should be based on a comparison of each beneficiary's benefits. Where the total converted gross FECA benefit is greater than the total OPM benefit, OPM will obtain the election of benefits and return a copy of the election along with a copy of the OPM "hit sheet" to DFEC.
Where the total OPM benefit exceeds the total converted gross FECA benefit and the review of the file confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
4. In any case which results in a DFEC overpayment, the District Office should take immediate action in accordance with the overpayment procedures specified in Part 6 of the Procedure Manual.
5. Each DFEC overpayment case should be reviewed in order to determine whether the usual notifications concerning the prohibition against receiving concurrent retirement and compensation payments have been made. If so, the assumption must be made that the claimant is not without fault when such an overpayment occurs. Thus, except where this assumption is overcome by the evidence in the case file, a CA-2201 should be released immediately. Examiners are reminded that the supporting memorandum should explicitly detail the notification made.
6. When the appropriate overpayment letter is released, a 30-day call-up should be placed in the file. As soon as possible after a final decision has been released, administrative offset should be requested from OPM.
7. Initial review of all the listed cases should be completed and a report submitted by May 1, 1998 and quarterly thereafter until each "hit" is resolved. This review should confirm or refute the information supplied, the receipt of dual benefits and, where receipt of dual benefits is confirmed, determine whether or not there is an election of benefits on file. Each report must include, as appropriate:
a. The FECA case number and beneficiary name for each listing.
b. For death cases, the name, date of birth and relationship to the decedent should be listed for each eligible beneficiary.
c. Periods for which FECA benefits have been paid (specify schedule award periods).
d. Was the payment of dual benefits discovered through this match? (yes/no)
e. Is there an election on file? (yes/no) If yes, a copy of the election letter should be attached.
f. Have compensation payments been terminated? If so, effective on what date?
g. Is there an overpayment of compensation? (yes/no)
h. Is DFEC responsible for recovery?
i. What is the amount of the OPM overpayment?
j. What is the amount of the FECA overpayment transferred to the Accounts Receivable ledger?
k. Dates of subsequent due process and collection actions, including issuance of overpayment letters, final decision, release of SF-2805 to OPM requesting offset, etc. (Note: The current version of the SF-2805, Revised October 1988, should be used.)
Follow-up reporting for this match and for unresolved cases from prior matches should continue quarterly (by the 15th day of the first month of each quarter, i.e., 7/15, 10/15, 1/15, 4/15) until final resolution of the matter, until, for example, either the debt has been collected in full, a repayment schedule has been established and met at least once, or the account is otherwise closed. The final report should describe the repayment plan and/or date of payment. For example, the final report should show that a CA-2201 was issued on July 7, 1998; a final decision was issued on August 11, 1998 finding an overpayment of $2000; an SF-2805 was issued on September 22, 1998; the first payment of $200 was received from OPM on December 1, 1998; the debt will be recovered by October 1999. (Note: For OPM debts, reporting may cease once the OPM overpayment amount has been reported. You no longer need to report any actions on OPM debts beyond this point.)
Disposition: This Bulletin should be retained until all actions have been completed.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 6
(Regional Directors, District Directors, Assistant District Directors, Chiefs of Operations, Systems Managers, Technical Assistants and National Office Staff)
Back to Top of FECA Bulletin No. 98-08
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FECA BULLETIN NO. 98-09
Issue Date: June 5, 1998
Expiration Date: June 6, 1999
Subject: Performance of Duty--Alternative Worksites
Background: For some time now, federal agencies have experimented with programs which allow employees to work from locations other than the federal agency's premises. Such locations include "satellite" offices in outlying areas as well as individual employees' homes. The performance of duty issues with respect to "satellite" offices are straightforward, since these sites are in fact regular offices, though employees from a variety of agencies may work there. However, for employees working at home, performance of duty issues are less clear.
While OWCP has received very few claims from employees in such programs (sometimes called "telecommuting" or "flexiplace"), we anticipate more in the future due to the growth of such programs, and we need to ensure that such claims are handled uniformly in all district offices.
Purpose: To provide guidance for determining whether employees injured while working at alternative worksites meet the "performance of duty" criterion for coverage under the FECA
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Rehabilitation Specialists, Staff Nurses, and Technical Assistants
Actions:
1. Employees who are directly engaged in performing the duties of their jobs are covered by the FECA, regardless of whether the work is performed on the agency's premises or at an alternative worksite. There is no statement (such as a "safety checklist") that can be signed by the employee to negate this coverage. As always, any affirmative defense of "willful misconduct" must be substantiated by evidence that the employee disobeyed an order that was routinely enforced.
2. However, when an employee is on property under his or her own control, activities which are not immediately directed toward the actual performance of regular duties do not arise out of employment. An employee who works at a desk at home removes himself or herself from the performance of regular duties as soon as he or she walks away from that desk to use the bathroom, get a cup of coffee, or seek fresh air. The "Personal Comfort Doctrine" does not apply, and coverage cannot be extended for injuries which result from such activities.
This point is illustrated by two actual cases:
a. An employee (who already used a wheelchair) was injured when he reached to answer the telephone while working at home. Coverage was found because he was required to answer the telephone as part of his official duties.
b. An employee was injured while walking downstairs at home to check her furnace, which was malfunctioning. Maintenance of the furnace was not a requirement of her official duties. Once she left her immediate work area, she removed herself from coverage under the FECA.
3. By extension of the rule described in item 2, a chronic illness that developed due to environmental exposure at home would not be covered under the FECA. The environment in an employee's home is not under the employer's control, and the "premises rule" that applies when an employee is on property owned or maintained by the employer is not relevant. The employee would be exposed to the home environment whether working for the government or not. Therefore, he or she would not be exposed to any risk inherent to employment while working at home.
4. Apart from alternative worksite programs, an employer may allow an employee who is recuperating from an illness to perform work at home. If the illness has resulted from a work-related injury, the work performed at home may be a light-duty job. The effect on workers' compensation benefits of returning to work at home is no different from that of returning to any other light-duty job. The employee is entitled to compensation for any loss of wage-earning capacity resulting from a compensable injury.
5. If an employee cannot continue to work at home because of injury-related residuals, he or she is entitled to compensation. This situation is no different from that of an employee who attempts to return to light duty on the employer's premises.
6. If an employee cannot continue to work at home because the home environment is not conducive to performance of his or her duties, the situation represents a withdrawal of light duty, since an employer cannot usually dictate an employee's home environment or require an employee to use personal resources to perform official duties.
7. If the employer can no longer provide the employee with work at home, the situation represents a withdrawal of light duty.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 98-09
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FECA BULLETIN NO. 98-10
Issue Date: June 29, 1998
Expiration Date: June 28, 1999
Subject: Bill Payment/BPS - Preparations for Changes to Pharmacy Bill Processing
Background: On approximately July 15, 1998, systems changes will be put in place which will change the way pharmacy bills are processed. These changes involve new forms and data requirements.
Currently, when a pharmacy bill is processed as a reimbursement to the claimant, it is not necessary to enter any of the provider information into the system. In some offices, particularly those in the eastern regions, a large proportion of pharmacy bills are submitted as claimant reimbursements. As a result, entries for many pharmacies in those areas are not present on the district office provider files.
When the changes go into place, provider information will be required on all pharmacy bills. The National Office is mailing notices to both claimants and pharmacies, to advise them of the upcoming changes. Copies of the letters which are being released are shown as Attachment 1 and Attachment 2. However, it is difficult to disseminate the information to the pharmacies involved in the claimant reimbursements, since payments have not been made directly to them, and they are not on the provider files.
Reference: Federal (FECA) Procedure Manual Chapter 5-0200.
Purpose: To notify District Offices of changes in billing form requirements, and to provide instructions for adding pharmacy providers to the provider files.
Applicability: All staff.
Action:
1. Effective immediately, the Universal Claim Form (see Attachment 3) is an acceptable form for submission of pharmacy bills. The form is not required until July 15, 1998. Note that there are different versions of the form, all of which are acceptable.
2. Effective immediately, the Form CA-915 (Attachment 4) may be used for claimant reimbursements, except for travel. The CA-915 is to be used along with the form required according to the provider type, i.e., HCFA-1500 for physicians, UB-92 for hospitals, Universal Billing Form for pharmacies, etc. The CA-915 is not a required form.
3. Effective immediately, when a claim for pharmacy reimbursement from a claimant is received, the following steps should be taken:
a. Perform a provider inquiry (option 08, FECS001 Query Menu), to determine whether the pharmacy is on the provider file. To do this, the tax identification number and zip code will be needed.
b. If the provider is already on the provider file, the bill should be processed as it usually would be.
c. If the provider is not on the provider file, the bill should be forwarded to the secure provider file update individual(s) for addition of the pharmacy to the provider file. This can be done either before or after the bill is keyed.
d. If 50 pharmacy bills are checked in this way and all of the pharmacies are on the provider file, it is not necessary to screen any more bills.
e. If the office finds that pharmacies are not on the provider file, they should continue to screen incoming pharmacy reimbursements, and update the provider file, until the volume of pharmacies not on the file has diminished to no more than one in ten of those screened.
f. Care should be taken in making provider file updates, that duplicate entries are not made.
4. Whenever a pharmacy provider (provider type F) is added to the provider file between June 8, 1998 and July 15, 1998, a copy of Attachment 1, "Important Notice for Pharmacy Providers" should be sent to the provider.
The National Office will be monitoring additions of pharmacy providers to the provider file.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
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FECA Bulletin 98-10 |
Attachment 1 |
NOTICE: NEW REQUIREMENTS FOR PHARMACY BILLS
This notice applies to medical bill payments made by the Office of Workers' Compensation Programs (OWCP), under the Federal Employees Compensation Act (FECA).
EFFECTIVE JULY 15, 1998 - NEW FORMS AND CODES
• Universal Billing Form will be required for all pharmacy bills, even for reimbursement to the injured employee. The form is to be completed by the pharmacy. A copy of the form is attached for your reference.
• For reimbursement to injured employees, a Form CA-915, claimant reimbursement form, will be preferred. This form is used in addition to the Universal Billing Form. A copy of the CA-915 form is attached.
• All claims for prescription payments must be coded using National Drug Council (NDC) codes, and also contain the prescription number, refill number, decimal quantity, date filled, and the tax identification number and full name and address of the pharmacy.
• Bills not submitted properly will be returned or denied.
EFFECTIVE JULY 15, 1998 - ELECTRONIC BILLING
• OWCP will be able to receive pharmacy bills from pharmacy providers electronically by electronic data interchange (EDI).
WHAT DOES THIS MEAN FOR THE FECA BENEFICIARY?
• Pharmacy bills will be processed faster.
• Direct billings from pharmacies involve less paperwork than reimbursements to injured employees. If your pharmacy is not already billing OWCP directly for medications prescribed for your work-related conditions, you may wish to discuss this matter with them. Many pharmacies are willing to bill OWCP directly.
• Electronic billing by pharmacies will eliminate paperwork, and be processed faster.
• You may begin to use the new forms immediately.
Pharmacies are also being sent information about these changes. You may wish to discuss these changes with your pharmacy. Pharmacies wishing to bill electronically should contact their clearinghouse.
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FECA Bulletin 98-10 |
Attachment 1 |
Back to Top of FECA Bulletin No. 98-10
|
FECA Bulletin 98-10 |
Attachment 2 |
IMPORTANT NOTICE FOR PHARMACY PROVIDERS
This notice applies to medical bill payments made by the Office of Workers' Compensation Programs (OWCP), under the Federal Employees Compensation Act (FECA), which provides workers' compensation coverage for civilian employees of the Federal government.
NEW FORMS AND CODING REQUIREMENTS - EFFECTIVE JULY 15, 1998
• Universal Billing Form will be required for all pharmacy bills, and is to be completed by the pharmacy.
• All claims for prescription payments must be coded using National Drug Council (NDC) codes, and also contain the prescription number, refill number, decimal quantity, date filled, and the tax identification number and full name and address of the pharmacy.
• Bills not submitted properly will be returned or denied.
ELECTRONIC BILLING - EFFECTIVE JULY 15, 1998
• OWCP will be able to receive pharmacy bills from pharmacy providers electronically by electronic data interchange (EDI).
• Contact your EDI clearinghouse for further information.
WHAT DOES THIS MEAN FOR PHARMACY PROVIDERS?
• Pharmacy bills will be processed faster.
• Electronic billing by pharmacies will eliminate paperwork, and thus be processed even faster.
• You may begin to use the Universal Claim Form immediately, if you do not already.
• If you do not routinely bill OWCP directly for pharmacy services, begin doing so. Injured employees prefer to do business with pharmacies which perform direct billing.
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FECA Bulletin 98-10 |
Attachment 2 |
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FECA Bulletin 98-10 |
Attachment 3 |
|
FECA Bulletin 98-10 |
Attachment 4 |
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FECA BULLETIN NO. 98-11
Issue Date: July 30, 1998
Expiration Date: July 29, 1999
Subject: Bill Payment/BPS - Bill Processing Modifications
Background: On approximately August 4, 1998, systems changes will be activated to encompass changes in several different areas.
Several data elements have been added for pharmacy bills (provider type F), to allow more complete automated editing, and to prepare for a pharmacy fee schedule. Many of the ADP programs have been modified and new programs added to accommodate these changes in pharmacy bills.
DFEC will start to receive and process bills received via electronic data interchange (EDI). Pharmacy bills will be the first bills received in this manner.
A standardized billing form is required as of July 15, 1998 for paper pharmacy bills (see FECA Bulletin 98-10). Bills not on the required form need to be returned for resubmission. In the past, a manual system has been used to return bills (sometimes referred to as "send-backs"). Often, no record of having received the bill was kept. Returned bill log and letter generation programs have been created to handle returned pharmacy bills. These programs should be used beginning July 22, 1998.
Bills received from vocational rehabilitation counselors (provider type U) will be coded using new DOL codes. In addition, rehabilitation services will be subject to editing based on authorized periods of service and authorized dollar amounts placed on the system.
Automated editing for nurse services will also be performed, using authorization parameters placed on the system.
These procedures are in effect for any bills processed after the installation of the changes. The procedures for returning pharmacy bills not on the correct for are in effect as of July 22, 1998.
Reference: Federal (FECA) Procedure Manual Chapters 5-0200, 5-0201, 5-0202, 5-0203, 5-0204, and 5-0205, FECA Bulletin 98-10, OWCP Bulletin 98-1.
Purpose: To notify District Offices of modifications to the bill processing system.
Applicability: All staff.
Actions:
A. Pharmacy Bills
1. Several new data elements are being used, most of which will be present on the pharmacy bill:
a. NDC code - National Drug Council code - an 11-digit code which represents a specific medication, made by a specific manufacturer, of a certain strength. A medication which is known by name, such as Tylenol (which comes in both prescription and non-prescription forms), may have several different NDC codes associated with it (211 in this instance). NDC codes are assigned by the National Drug Council.
b. Prescription number - a number of up to seven digits which is assigned to a prescription by the pharmacy. Most prescription numbers are six digits.
c. Refill number - a two-digit code which describes whether the medication was dispensed as a new prescription or as a refill of a previous prescription. Refill numbers go from 00 (new prescription) to 99 (99th refill).
d. Quantity - similar to units, but may be expressed as a decimal fraction for liquids. For pills or capsules, the quantity will be the number of pills dispensed. For liquids, quantity will be the volume dispensed, in milliliters (ml). For packaged items, such as aerosols or dose vials, the quantity is the number of packages. A quantity of eight digits is allowed for pharmaceuticals, five before the decimal point, and three after.
e. Prescriber ID - the last name of the physician who prescribed the medication.
2. As noted in FECA Bulletin 98-10, the tax identification number of the pharmacy is required for all pharmacy bills (provider type F), whether for direct payment to the pharmacy or reimbursement to the claimant.
3. New edits have been added to BILL552 to use the new data elements. These edits are summarized on pages 9-10. Complete bill resolution instructions for each new edit are being sent under separate cover, to be incorporated in the bill resolution job aid. These new pharmacy edits include editing for NDC code validity, and relationship of the medication to the accepted conditions in the case.
4. A therapeutic class (TC) code is associated with each NDC code. Therapeutic classes form fairly broad groupings. The relationship editing performed for pharmacy bills is based on the TC. Because NDC codes and their associated TCs change frequently (updates will be made monthly), a printed reference manual for prescription drugs is not practical. Two new query options have been added to both the FECS001 bill payment and query menus, for "NDC Query" and "Therapeutic Query" (see Paragraph C on page 5).
5. Duplicate checking for pharmacy bills is based upon case number, tax ID number, dates of service, prescription number and refill number. To prevent duplicate payments, it is critical that prescription numbers be data entered accurately.
6. Not all pharmacy charges that are submitted by pharmacies and claimants are for prescription drugs. Pharmacies also submit bills for over-the counter medications, supplies, durable medical equipment, and in some jurisdictions, taxes. Charges for over-the-counter medications, durable medical equipment, and supplies provided by pharmacies may be paid if they are prescribed (recommended) by a qualified physician for treatment of the work-related condition(s). Most over-the-counter medications do have NDC codes, but these may be difficult to obtain. Codes have been developed to accommodate non-prescription items. These codes are not to be used to process prescription drugs. They will be keyed in place of an NDC code, and should not have prescription or refill numbers. The codes must be shown on the bill. The codes are for Department of Labor use only, not for provider use.
DME - for durable medical equipment, such as a back brace
SUPPLY - for other supplies, such as ace bandages
OTC - for over-the-counter drugs for which an NDC is not available
TAXES - for taxes charged and billed. See FECA Circular 97-06. Most jurisdictions do not tax prescriptions.
7. Personnel should not attempt to provide NDC codes on behalf of pharmacies who submit bills without the codes.
B. EDI - Electronic Data Interchange (Pharmacy Only)
1. DFEC will receive and process electronic bills from pharmacies for prescription drugs only. These bills will be processed through intermediary clearinghouses. The bills will come into a central location in the National Office, go through some preliminary editing, primarily for validity of the case file number, and then be transmitted to the appropriate district office, where they will be loaded automatically into the bill tables. Electronic bills will exist only on the system.
2. A batch number assignment scheme has been developed for EDI pharmacy bills, as follows:
The first three characters will be EDF
The fourth character is a letter from A to L, which represents month 01-12.
The fifth character is a letter from A to Z, or number between 1 and 5, which represents the day of the month.
The sixth character is a letter between A and Z which represents the number of batches between 01 and 26.
3. Once the EDI bills are loaded into the bill tables on the Sequent, they will be edited by the system, similarly to paper bills that are data entered into the system.
4. BILL552 reports will be produced for the EDI batches (along with the keyed bills). The suspended bills will require resolution, in accordance with existing procedures.
5. Because EDI bills are submitted electronically, ability to change the data submitted is very limited. In bill resolution, the only data fields which may be accessed are those which contain data which is provided by DFEC, such as authorizing initials, bypass codes, ineligible amounts and ineligible codes, rx appeal code, and bill total (to be changed only when ineligible amounts and codes are used).
6. Billing addresses for EDI pharmacy bills are obtained from a central location, rather than the district office provider file. The address sequence number for EDI bills will be FD if the bill is for direct payment, and FR if the bill is for claimant reimbursement.
C. NDC Query and Therapeutic Class Query
1. Two new options have been added to the FECS001 bill payment and query menus. In the bill payment menu, Option 22 is NDC query, and option 21 is therapeutic (class) query.
2. Each NDC code is assigned a therapeutic class (TC) code. The TC code consists of 10 digits. The TC coding structure is hierarchical, in that the meaning of the digits becomes more specific, from left to right. The first two digits are the "Main Therapeutic Heading;" the second two, the "First Subcategory;" the third two, the "Second Subcategory;" and the last four, the "Unique or Primary Agent." For example, for the TC code 2404080020, the 24 represents "Cardiovascular Agents", the 04 represents "Cardiac Drugs", the 08 represents "Cardiac Glycosides", and the 0020 represents "Digitalis". All of these category descriptions are shown when a particular NDC or TC code is entered in the programs.
3. A print of the NDC code query screen and instructions for use are shown in Attachment 1.
4. A print of the TC query screen and instructions for use are shown in Attachment 2.
5. Pharmacies are required to bill using NDC codes. If the product name is not also provided (it is not required), NDC query can be used to determine the name and nature of the medication.
6. For both NDC and TC query, the relationships between the drug and diagnosed conditions (by ICD-9 codes) are shown in ranges in the lower half of the screen.
D. Returned Pharmacy Bill Logging and Letters
1. A new option 23, "Returned Bill Log Entry" has been added to the FECS001 bill payment menu.
2. When a pharmacy bill is being returned because it is not on the correct form (Universal Billing Form or reasonably similar form), whether for direct payment to the provider or reimbursement to the claimant, the bill should be entered on the "returned bill log" by designated personnel. The data entered includes:
a. Case Number
b. First three letters of claimant's last name
c. Direct payment flag (Y if provider is claiming payment, N if claimant is claiming reimbursement)
d. Provider tax ID number (required for direct payment; not required if claimant reimbursement, but should be entered if present)
e. Provider zip code
f. Provider sequence number (or cycle through)
g. Address OK? Flag for provider if direct pay, for claimant if not direct pay
h. Date bill received
i. Bill amount
j. Bill dates of service
k. A final OK? Prompt
3. A sequential serial number is assigned to each bill logged, which appears on the printed letter (see below).
4. Each day when returned bills are logged, BILL662 in the FECS002 Bill Payment menu should be run to generate cover letters for the returned bills. Attachment 3 shows a sample letter for pharmacy providers, and Attachment 4 shows a sample letter for claimants. The direct payment flag determines whether the letter is directed to the pharmacy or to the claimant. The letters will be printed in the order they were entered on the system. The bills being returned should be associated with the corresponding letter. The bills should then be mailed, using window envelopes.
5. Option 24, "Returned Bill Log Update" can be used to correct the date received, bill amount, or service from and to dates for a particular record, or to delete particular records. This option can also be used to query for returned bills on a particular case.
E. Changes to the Bill Payment Input Program
1. The bill payment input program is option 01 in the FECS001 bill payment menu.
2. The FECS user guide for the bill payment input program has been updated to include all of the changes, and is being provided under separate cover. A description of how the program has changed will accompany the user guide revision.
F. Changes to the Bill Resolution and Suspended Bill Query Screens
1. Bill resolution is option 10 under the FECS001 bill payment menu. Suspended bill query is option 18 under the FECS001 query menu and option 13 under the bill payment menu.
2. For EDI bills, access to the data fields under bill resolution will be limited as noted above in item B.5.
3. In the header screen, NABP, and PCC have been added. These are elements which apply only to EDI pharmacy bills, and are displayed for information purposes only. NABP is a unique identification number assigned to a pharmacy by the National Council of Pharmacy Drug Providers (NCPDP). PCC is a code identifying the payment cost center. This is used when more than one pharmacy uses a centralized payment center. For non-direct payments, "PHRM" has been removed from the label for the "PHRM/TRVL/MNT/TRNG REIMB:" flag, so that it now reads "TRVL/MNT/TRNG REIMB:".
4. In the line item screen, NDC, rx (prescription) number, refill number, prescriber, and rx appeal have been added. These are used for pharmacy bills only. For bills keyed in the office, the user will be able to correct these fields in bill resolution. For EDI bills, the user will not be able to alter these fields. In addition, the organization of the data on the screen has been modified to group all of the pharmacy elements together, and all of the non-pharmacy elements together.
G. Vocational Rehabilitation Services
1. Procedure codes are required for vocational rehabilitation counselor services (provider type U). Bills for provider type U cannot be paid without the codes. The codes are shown in Attachment 5.
2. A rehabilitation authorization program has been added to the FECS001 case management menu as option 39. The purpose of this new program was described in OWCP Bulletin 98-1, and instructions for use are found in Attachment 6.
3. Provider type U, V and W bills will be edited for dates of service being within the authorized period. Provider type U bills will be edited for total dollars not exceeding the amount authorized. These edits are summarized on pages 9-10. Full resolution instructions are provided under separate cover.
H. Contract Nurse Services
1. A nurse authorization program has been added to the FECS001 case management menu as option 40. When contract nurse services are authorized, the program should be accessed, and the authorized dates of service and the total maximum dollar amount authorized should be entered. Up to two date ranges for periods of authorization may be entered. Each authorization period may also be modified.
2. Access to the nurse authorization function should be limited to those individuals who authorize the services, or who have been given responsibility for entering authorizations from written documentation of the authorization.
3. New edits have been added for dates of service being within the authorized periods of time and total nurse costs being less than the dollar amount authorized. These edits are summarized on page 9. Use of the program is described in Attachment 7. Detailed procedures are being issued as an OWCP Bulletin.
I. Summary of New and Revised Edits
1. A package including an updated condensed edit listing, and EOB listing is being provided under separate cover.
2. Detailed edit sheets for all of the new edits are also being provided under separate cover. These should be inserted in the appropriate place in the bill resolution job aid.
The new and revised edits include the following:
201 - This is an existing edit for excluded providers. It has been modified to look for a record on the excluded provider file with a matching tax ID number if the bill is an EDI bill.
202 - This is an existing edit for providers suspended by the district office. The bill resolution instructions only have been changed, since for EDI bills, the tax ID number will not be keyed by DFEC.
314 - For pharmacy bills, edits for missing or invalid NDC code.
330 - For non-pharmacy bills, edit for decimal fraction units.
331 - For pharmacy bills, NDC code of TAXES has been used.
332 - For pharmacy bills, particular NDC code requires a manual review.
333 - For pharmacy bills, particular NDC code is not payable.
509 - For contract nurse bills, dollar total of nursing services exceeds the authorized dollar amount.
510 - For contract nurse bills, nursing services were not authorized.
520 - For contract nurse bills, dates of service on the bill are outside of the period of time authorized.
531 - For pharmacy bills, a code of DME, SUPPLY, or OTC was used, and the charge amount is greater than $25.00.
609 - For provider type U, dollar total of counselor services exceeds the authorized dollar amount.
610 - For provider types U, V, and W, services were not authorized.
620 - For provider types U, V, and W, dates of service on the bill are outside the period of time authorized.
734 - For pharmacy bills - therapeutic class is not payable for the accepted condition(s).
738 - For pharmacy bills, the relationship between the therapeutic class and the accepted condition(s) requires manual review.
744 - For pharmacy bills, there is an error in the range relationship table (this is an internal error, not a provider error).
746 - For pharmacy bills, the accepted condition is missing from the relationship table (this is an internal error, not a provider error).
Training on these procedures should be completed prior to August 4, 1998.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Attachments:
1 NDC Code Query
2 Therapeutic Query
3 Pharmacy Bill Return Letter
4 Claimant Pharmacy Reimbursement Return Letter
5 Vocational Rehabilitation Codes
6 Rehabilitation Authorization
7 Contract Nurse Authorization
Separate packages:
New edit sheets
Update of user guide for BILL051
Condensed edits and EOB messages
Attachment 1 National Drug Code Query (Link to Image)
Attachment 2 Therapeutic Class Query (Link to Image)
Back to Top of FECA Bulletin No. 98-11
Attachment 3 Pharmacy Bill Return Letter
U.S. DEPARTMENT OF LABOR
OFFICE OF WORKERS' COMPENSATION PROGRAMS
200 CONSTITUTION AVENUE
WASHINGTON DC 20001
DATE: 07/09/1998
ANDERSON DRUG STORE
100 HILL DR
BUILDING F
ROOM #1234
BALTIMORE MD 20750
|
RE: CLAIMANT NAME |
OWCP CLAIM NUMBER |
|
|
DATE RECEIVED |
SERVICE DATES |
BILL AMOUNT |
Dear Pharmacy Provider:
The attached bill, which claims payment for medical services provided to an injured employee under the Federal Employees' Compensation Act (FECA), is being returned to you for the following reason:
Claims for prescription drugs must be submitted on the Universal Drug Claim Form, and include the following elements:
1. Your full name and address
2. Your Federal tax identification number
3. The injured employee's name
4. The injured employee's OWCP claim number (shown above)
5. The prescribing physician's last name
6. National Drug Code (NDC) for each medication
7. Date each prescription was filled
8. Each prescription number and refill number
9. Quantity of each medication dispensed
10. Charge for each item
11. Total charge
Please resubmit your bill in accordance with the above instructions or via EDI (Electronic Data Interchange).
Thank you for your cooperation.
|
FECA Bulletin 98-11 |
Attachment 3 |
Back to Top of FECA Bulletin No. 98-11
Attachment 4 Claimant Pharmacy Reimbursement Return Letter
U.S. DEPARTMENT OF LABOR
OFFICE OF WORKERS' COMPENSATION PROGRAMS
200 CONSTITUTION AVENUE
WASHINGTON DC 20001
DATE: 07/09/1998
JANE DOE
300 MAIN STREET
GAITHERSBURG MD 20878
|
RE: OWCP CLAIM NUMBER |
PROVIDER NAME |
|
|
DATE RECEIVED |
SERVICE DATES |
BILL AMOUNT |
Dear FECA Claimant:
The attached bill, in which you claim reimbursement for pharmacy services provided under the Federal Employees' Compensation Act (FECA), is being returned to you for the following reason:
Claims for prescription drugs, whether for direct payment to the pharmacy or reimbursement to the employee, must be submitted on the universal Drug Claim Form. Your pharmacy should have this form and can complete it for you. The following information must be included on the forms:
1. Pharmacy's full name and address
2. Pharmacy's Federal tax identification number
3. The injured employee's name
4. The injured employee's OWCP claim number
5. The prescribing physician's last name
6. National Drug Code (NDC) for each medication
7. Date each prescription was filled
8. Each prescription number and refill number
9. Quantity of each medication dispensed
10. Charge for each item
11. Total charge
In addition, for reimbursement, proof of purchase, such as an itemized and dated receipt or a canceled check, is needed. You may wish to use form CA-915 (copy attached) to help organize your reimbursement claim.
Please resubmit your claim in accordance with the above instructions.
Thank you for your cooperation.
|
FECA Bulletin 98-11 |
Attachment 4 |
Back to Top of FECA Bulletin No. 98-11
Attachment 5
|
Code |
Description |
|---|---|
|
VR001 |
Professional time of RC, per hour - counseling, placement, monitoring, testing,transferable skills analysis,job seeking skills training - prior authorization required |
|
VR002 |
Non-professional time, by RC, or clerk/typist under the RC's supervision, per hour -travel, waiting - prior authorization required |
|
VR003 |
Testing or transferable skills analysis performed by other than RC (when RC has paid the vendor and submits to OWCP original receipt and bill for reimbursement) - prior authorization required |
|
VR004 |
Mileage associated with all travel - prior authorization required |
|
VR018 |
Long distance telephone calls, Parking, Tolls and other Itemized Expenses |
|
Bulletin 98-11 |
Attachment 5 |
Back to Top of FECA Bulletin No. 98-11
Attachment 6 Rehabilitation Authorization (Link to Image)
Attachment 7 Contract Nurse Authorization (Link to Image)
Back to Top of FECA Bulletin No. 98-11
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 98-12
Issue Date: September 21, 1998
Expiration Date: September 20, 1999
Subject: Codes--New QCM Code in Cases Where Claimant is Reemployed in Unclassified Job
Background: QCM procedures call for returning claimants to full time full duty wherever possible. This approach benefits both claimants and employing agencies, which can free up light duty positions for newly injured employees. Since the QCM procedures have been in effect, we have consistently urged claims staff to be vigilant with respect to claimants who are working only part time and/or at less than full duty, and to work toward returning such employees to full employment.
At the same time, the requirements for rating a claimant for LWEC have evolved in light of a group of cases from the Mare Island Naval Shipyard in California. Certain injured workers had been accommodated in light duty positions but were at risk from an impending RIF. A generic Industrial Trainee position was developed as transitional work leading to classified jobs. OWCP adjusted compensation based on the claimants' actual earnings while they participated in the program, but formal LWEC decisions were usually not issued. When a RIF in fact occurred, the targeted jobs were found to reasonably represent the claimants' WECs. However, the Branch of Hearings and Review properly found that claimants not actually reemployed in classified jobs could not be issued formal LWEC decisions.
These two developments have converged in certain cases where a claimant is reemployed in an unclassified job, either full or part time, with no indication that the hours or duties will increase. Such cases have had the benefit of QCM intervention, and no further QCM actions are necessary or feasible. Because their jobs are unclassified, the claimants must continue to be paid on the basis of actual earnings for the indefinite future. The current QCM coding scheme contains no code which properly addresses the status of such cases.
References: A description of QCM codes is found in PM 2-601.5, while the criteria for resolution of QCM cases are found in PM 2-600.12. Actual earnings ratings are addressed in PM 2-814.7.
Purpose: To discuss the use of a new QCM code in cases where the claimant is working in an unclassified job
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Rehabilitation Specialists, Staff Nurses, and Technical Assistants
Action:
1. A new QCM code, CNC [Closed - RTW (No LWEC; Non-Classified Position)], may be used when a claimant is working full time in an unclassified job. The code is not appropriate in cases where the claimant is working only part time, as such cases will still require additional QCM attention.
2. Cases coded CNC will show as resolutions on the CASE611 report. However, QCM status codes may continue to be entered as appropriate after the effective date of the CNC code.
3. A subsequent closure status must be entered if a formal decision is issued in the case, or if the claimant returns to the date of injury position or suffers a recurrence or new injury.
4. The CASE611 detail report will list those cases that are coded CNC with no subsequent closure code. Claims staff will need to reexamine each case in CNC status during the QCM tracking period, and at periodic intervals thereafter if necessary, to assess the employability of the claimant in a classified job and the feasibility of issuing a formal LWEC decision.
5. District office managers are responsible for ensuring that follow-up action is taken on any cases remaining in CNC status at the end of the QCM tracking period.
6. Code CNC is available for use effective immediately.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 98-12
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-01
Issue Date: October 1, 1996
Expiration Date: September 30, 1997
Subject: Comp Pay--Direct Deposit
Background: On July 26, 1996 the Treasury Department published interim regulations stating that, in general, Federal agencies are to use electronic funds transfer (direct deposit) when making payments to beneficiaries who first become eligible for benefits after that date. The regulations also note that by January 1, 1999, all federal payments are to be made by electronic funds transfer. This provision would include beneficiaries who were receiving benefits before July 26, 1996.
While we intend to comply with this regulation, we do not believe that payments to claimants who have not signed up for direct deposit should be delayed to obtain such authorization. However, district office staffs should encourage claimants to sign up for direct deposit to receive all payments, whether on the daily or periodic roll. Forms CA-7 and CA-1049 will be modified to request this information.
In August, the National Office advised all check recipients on the periodic roll that direct deposit is available and asked them to adopt this method of receipt, and many beneficiaries did so.
In the near future, we will publish further guidance concerning the effect of this regulation on the bill pay process.
Purpose: To describe the OWCP's policy concerning electronic transfer of funds and the actions needed to implement it more widely
Applicability: Claims Examiners, Senior Claims Examiners, Technical Assistants, Staff Nurses, Rehabilitation Specialists, Fiscal Staff, and Supervisors
Action:
1. When setting up a payment, the Claims Examiner must use the direct deposit address whenever possible. The authorization may already appear in the file, or it may be newly submitted.
2. The forms which may be used to sign up for direct deposit are the Direct Deposit Sign-Up Form (SF-1199A) and the Fast Start Direct Deposit Form (FMS 2231). Either is acceptable, but Form SF-1199A is preferable because the financial institution completes the check routing information, and because this form makes no reference to allotments. Form SF-1199A can be ordered from GPO using stock number 7540-01-058-0224 and control number 1199-207.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 97-01
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-02
Issue Date: October 15, 1996
Expiration Date: October 14, 1997
Subject: ADP - "Reengineered" Coding Scheme and Data Entry for the Quality Case Management (QCM) System.
Background: Commencing in January 1995 the QCM/Time Management Team began developing a plan to streamline the QCM tracking system. During the months since then the team proposed various changes focusing primarily on making QCM data entry more "user-friendly." With considerable group effort, including input from district office management and QCM users, and through discussions with National Office staff, the team put forth its final recommendations this past May. With only a few minor exceptions, the proposed changes have now been incorporated into the QCM system. Associated changes in the QCM reports and in the Disability Tracking system have also been implemented.
Reference: FECA Bulletin 93-10, issued July 28, 1993, FECA Bulletin 94-11, issued November 29, 1993, FECA Bulletin 94-14, issued January 20, 1994, FECA Bulletin 94-24, issued August 5, 1994 and FECA Bulletin 95-13, issued February 28, 1995.
Purpose: To notify all QCM users and DFEC managers of the revised coding scheme and system enhancements for the Quality Case Management and Disability Tracking functions on the Sequent system.
Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Rehabilitation Specialists, Staff Nurses, Fiscal Personnel, Technical Assistants and Systems Managers.
Action:
1. Under the new scheme there are now 27 mandatory and 46 optional QCM status codes available to users (see Attachment 1). The mandatory codes must be used in all cases, as appropriate, in order to properly track QCM actions and to accurately measure performance. Optional codes will have no significance in the measurement of performance. Also, individual optional codes may be designated "active" or "inactive" within each district office. Optional codes that are designated "inactive" will not be accessible to the users of the system.
2. In the QCM data entry screen (option 35 in the Case Management menu), the mandatory status codes will be listed in the pop-up window (ADD STATUS) under four activity headings. The "active" optional codes, if any, will appear under a fifth heading. The Page Up/Page Down keys may be used to move quickly between the code groups while the Up/Down arrow keys may be used to scroll through the entire list of codes.
3. A new date field (d18_track_date) has been added to the QCM header record. This date will be displayed as the "TRACK DT:" in place of the "DWLB:" in the QCM screens. In most cases this date will reflect the "Disab Date" for the Disability Tracking record associated with the QCM case. However, for cases where the claimant had returned to light duty work prior to the creation of the QCM record the "TRACK DT" will be the same as the QCM Start Date.
QCM performance will now be based on the Track Date rather than the Disab Date (DWLB). Accordingly, where the claimant is already working in a light duty capacity when the case comes under QCM the one-year and two-year tiers for resolving the case will run from the date the case drops into QCM rather than from the date the claimant stopped work.
4. The "QCM CE:" code displayed in the header will now reflect the responsible examiner (RCE) code value associated with each QCM record. The initial value for this field will automatically be copied from the CMF when a QCM record is created. Unless changed manually by the user, this code will remain on the QCM record even if the RCE code is subsequently changed in the CMF. No changes to this field will be permitted on closed QCM cases.
The QCM header has also been modified to allow for the entry of two lines (160 characters) of text.
5. In addition to the many optional QCM status codes which will not be discussed in detail (see Attachment 1), several mandatory status codes have been added. The current list of mandatory codes, including any changes in their descriptions and defined uses, are detailed below. The nine listed with an asterisk (*) are the "intervention" codes under the new scheme.
| Code | Description |
|---|---|
|
OIC* |
(Other Intervention by CE) This code is significantly re-defined as CE or SrCE contact with the claimant, agency or physician to discuss a return to work date and the availability of limited duty. The following qualifies for use of this code: |
|
|
a. Telephone contact with the claimant which includes at a minimum, a discussion about the anticipated return to work date (or return to regular work); what the present limitations are and why these limitations preclude any work whatsoever (or preclude return to the regular job), and; whether the employer has been contacted concerning the availability of limited duty. The conversation should be substantive and should serve as a reminder to the claimant of his/her responsibility to return to work. |
|
|
b. Telephone or written contact with the employer to discuss the availability of limited duty for the injured employee; to discuss the limitations, and; to solicit a job offer. The work restrictions should actually be available on the date of the conversation/letter. |
|
|
c. Telephone contact with the physician to discuss the reasons for the continuing disability; to request a work release, and; to request the anticipated date of release to regular duty. |
|
|
A conversation concerning bill payment, compensation payments or other case issues will not qualify for the use of this. Also, if OIC is used based upon a telephone call, the conversation must be fully documented. "OIC" should be pencilled on the corner of the qualifying CA-110, letter or other document for easy identification. This code may be used more than once on a given QCM record. |
|
QAP* |
(Questions to Attending Physician) This new code applies to the situation where the claims examiner releases a letter to the attending physician posing pointed questions regarding the extent and duration of disability. Simply requesting a current report from the attending physician will not be considered sufficient for use of this code. |
|
CON* |
(Conference Held) No change. |
|
MSI* |
(Secop Initiated) The status effective date is now defined as the date of the exam (a future date will be allowed). |
|
MRI* |
(Referee Exam Initiated) The status effective date is now defined as the date of the exam (a future date will be allowed). |
| Code | Description |
|---|---|
|
NFN* |
(Referred to Field Nurse) No change. |
|
NIN |
(Nurse Interrupt) This code, which was added last January, will be used in situations where the services of the nurse are interrupted but are expected to resume at a later date. An example of the use of this code is where the claimant undergoes surgery that will require a period of recovery during which nurse services are inappropriate. |
|
RRC* |
(Referred to Rehab Counselor) This new code will be used to indicate referral of the case to a rehabilitation counselor. |
|
RCL |
(Rehab Case Closed - No RTW) This new code applies to all cases closed by the rehabilitation specialist without a return to work. |
|
RLT* |
(Eventual Reduction via Rehab (Ltr Sent by CE)) No change. |
|
RTR* |
(In Approved OWCP Vocational Training) No change. |
| Code | Description |
|---|---|
|
PLP |
(Pre-QCM RTW Light Duty/Part Time) This code will apply to all situations where the claimant returns to part-time work prior to the case coming under QCM. |
|
PLF |
(Pre-QCM RTW Light Duty/Full Time) No change. |
|
NLP |
(RTW via Nurse; Light Duty/Part Time) This new code applies to all situations where the claimant returns to part-time work via the nurse. (This code may also be entered in cases that already have a PLP code. However, such an entry is proper only if the claimant's work hours are actually increased through the intervention of the nurse.) |
|
NLF |
(RTW via Nurse; Light Duty/Full Time) No change. |
|
RLP |
(RTW via Rehab; Light Duty/Part Time) This new code applies to all situations where the claimant returns to part-time work via rehab. (This code may also be entered in cases that already have a PLP code. However, such an entry is proper only if the claimant's work hours are actually increased through the intervention of the rehabilitation counselor.) |
|
RLF |
(RTW via Rehab; Light Duty/Full Time) No change. |
|
MLP |
(RTW via CE; Light Duty/Part Time) This new code applies to all situations where the claimant returns to part-time work other than through nurse intervention or rehabilitation services. However, there must be some identifiable intervention by the claims examiner, such as referral of the claimant for a second opinion evaluation, posing pointed questions to the attending physician regarding extent and duration of disability, or other intervention described under OIC above, in order to attribute the return to work to QCM and justify the use of this code. (This code may also be entered in cases that already have a PLP code. However, such an entry is proper only if the claimant's work hours are actually increased through the intervention of the claims examiner.) |
|
MLF |
(RTW via CE; Light Duty/Full Time) This new code applies to all situations where the claimant returns to light duty work on a full-time basis other than through nurse intervention or rehabilitation services. However, there must be some identifiable intervention by the claims examiner, such as referral of the claimant for a second opinion evaluation, posing pointed questions to the attending physician regarding extent and duration of disability, or other intervention described under OIC above, in order to attribute the return to work to QCM and justify the use of this code. |
| Code | Description |
|---|---|
|
CFF |
(Closed - RTW (DOI or Pre-established LWEC Job) Used in all cases where the claimant returns to full duty under QCM. |
|
CNL |
(Closed - RTW (Not DOI Job; 0% LWEC Decision)) No change. |
|
CCO |
(Closed - Comp Order No Disability) No change. |
|
CSA |
(Closed - Sanctions Imposed (or Comp Not Claimed)) In addition to designating a sanction decision, this code will now also be used in situations where the claimant elects OPM benefits or otherwise stops claiming compensation benefits. As with cases involving the imposition of sanctions, such cases are subject to reopening at the claimant's choosing. CSA is the only "successfully resolved" closure code where the case may be reopened by simply entering a later status code into the QCM record. With this "reopen" mechanism in place, QCM activity may continue to be tracked in cases where the sanctions are lifted or the claimant chooses to again receive compensation benefits. |
|
CAE |
(Closed - LWEC on Actual Earnings) No change. |
|
CLW |
(Closed - Constructed LWEC) No change. |
|
CRN |
(Recurrence/New Injury Following RTW Light Duty) This new code will be used in all cases where the claimant sustains a recurrence or a new injury while under QCM. Cases closed with this code will be scored as "resolved successfully" only where there exists an earlier status for a return to work attributable to QCM intervention (i.e., NLP, NLF, RLP, RLF, MLP, MLF). Where no such code exists the user will be prompted "OK to zero out this QCM record? Y/N:". If the user presses "Y" the CRN code will be added and case will automatically be set to category "0". Otherwise, the code entry will be aborted. |
|
CPN |
(Closed - Unable to Work (PN memo)) No change. |
6. As part of the implementation of the new coding scheme some existing QCM status records have been deleted and others have been converted using new status codes, with revised descriptions, to replace the old code values. For example, existing QCM status records with old code NFC (1st FN Contact w/CE date) or OIC (Initial Call to Claimant) have been deleted from the database. Existing records with status code NCR (Ret'd to CE - Rehab Recommended) or NCS (Ret'd to CE - Second Opinion Recommended), have been converted to the new optional code NCO (Nurse Case Closed - Claimant Cooperative).
Further conversion of existing records has occurred as follows:
PL4 or PL6 (Pre-QCM RTW Light Duty/...) Earliest record updated to new code PLP and any subsequent record deleted.
NL4 or NL6 (RTW via Nurse; Light Duty/...) Earliest record updated to new code NLP and any subsequent record deleted.
RL4 or RL6 (RTW via Rehab; Light Duty/...) Earliest record updated to new code RLP and any subsequent record deleted.
NFF (RTW via Nurse; Full Duty/Full Time) Updated to code CFF.
CRE (Closed - Pre-QCM RTW Light Duty; Recur/New Injury) Updated to new code CRN.
NCW (Recurrence/New Injury Following RTW Light Duty) Updated to new code CRN.
RRS (Referred to Rehab) Updated to new code RRC.
RS1 (RS Closed on Referral) Updated to new code RCL.
RS5 (Closed Other) Updated to new code RCL.
In addition to the deletion and/or conversion of records, four of the old status codes have been made optional: NSN - Referred to Staff Nurse; NCN - Nurse Case Closed - Claimant Not Cooperative; MSC - Secop Exam Completed; MRC - Referee Exam Completed. Existing records with these status codes have not been disturbed.
7. Users of the QCM system will note a number of changes in the data entry edits and screen messages displayed in particular circumstances. For example, the system will prevent the entry of a "resolved" status code (NLP, MLP, RLP, NLF, RLF, MLF, CFF, CNL, CCO, CSA, CAE, CLW, CPN) in a case where no prior "intervention" code exists. The message "Status Not Valid Without Prior Intervention Code" will be displayed in that situation. A similar edit will prevent the deletion of the only remaining "intervention" code if a "resolved" code exists.
8. The data entry edits in the Disability Tracking system (option 36 in the Case Management menu) have also been revised slightly. The edit that prevented users from entering a "D" (Denied) status on a record with an associated RTW code has been removed. Also, for any record that is associated with a QCM record that has been "zero-ed out", the user may not change the status from "A" to another value without deleting the associated QCM record. A prompt "Status change will cause deletion of associated QCM record. Proceed? Y/N" will be displayed and the user may abort the change by pressing "N".
9. Changes have been made to several reports to accommodate the new QCM coding scheme. The changes are as follows:
CASE630 - QCM TRACKING: This report has been dropped from the FECS menu.
CASE633 - QCM NO INTERVENTION: This report has been modified to list QCM cases that do not have one of the nine qualifying "intervention" codes.
CASE611 - QCM QUARTERLY REVIEW AND ANALYSIS: This report has been revised significantly.
- QCM cohorts will now be based upon the "TRACK DT" rather than the "DWLB" (see paragraph 3 above).
- The report will list counts only for the mandatory status codes. Accordingly, several rows have been deleted and others have been added to the report. Cases with only optional status codes will be counted as having "no status."
- For cohorts over one-year old, the upper part of the report will show "0" counts for codes that qualify as a successful resolution only during the first year (RLT, NLP, NLF, MLP, MLF, RLP, RLF). The lower part of the report has been expanded to list the counts for these codes in the over one-year old cohorts. With this change, the "RESOLVED TOTALS" will actually represent the sum of the individual code counts in the upper part of the report.
10. A new option (UPDATV36 - RE-SET OPTIONAL QCM CODES) has been added to the FECS004 menu under "CASE MANAGEMENT". Accessible by System Managers, this option will enable each office to "activate" or "deactivate" any or all of the optional QCM status codes, as desired. With the initial installation of these revised QCM programs and code tables, certain optional codes were "activated" as requested by the individual district offices.
Disposition: This Bulletin should be retained until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 -- Folioviews Groups A, B and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
Attachment 1 to FECA Bulletin 97-02
|
STATUS |
DESCRIPTION |
|---|---|
|
CLAIMS EXAMINER ACTIVITY STATUS CODES |
|
|
OIC |
Other Intervention by CE |
|
QAP |
Questions to Attending Physician |
|
CON |
Conference Held |
|
MSI |
Secop Initiated |
|
MRI |
Referee Exam Initiated |
|
NURSE/REHAB ACTIVITY STATUS CODES |
|
|
NFN |
Referred to Field Nurse |
|
NIN |
Nurse Interrupt |
|
RR |
Referred to Rehab Counselor |
|
RCL |
Rehab Case Closed - No RTW |
|
RLT |
Eventual Reduction via Rehab (Ltr Sent by CE) |
|
RTR |
In Approved OWCP Vocational Training |
|
WORK STATUS CODES |
|
|
PLP |
Pre-QCM RTW Light Duty/Part Time |
|
PLF |
Pre-QCM RTW Light Duty/Full Time |
|
NLP |
RTW via Nurse; Light Duty/Part Time |
|
NLF |
RTW via Nurse; Light Duty/Full Time |
|
MLP |
RTW via CE; Light Duty/Part Time |
|
MLF |
RTW via CE; Light Duty/Full Time |
|
RLP |
RTW via Rehab; Light Duty/Part Time |
|
RLF |
RTW via Rehab; Light Duty/Full Time |
|
CLOSURE STATUS CODES |
|
|
CFF |
Closed - RTW (DOI or Pre-established LWEC Job) |
|
CNL |
Closed - RTW (Not DOI Job; 0% LWEC Decision) |
|
CCO |
Closed - Comp Order No Disability |
|
CSA |
Closed - Sanctions Imposed (or Comp Not Claimed) |
|
CAE |
Closed - LWEC on Actual Earnings |
|
CLW |
Closed - Constructed LWEC |
|
CRN |
Recurrence/New Injury Following RTW Light Duty |
|
CPN |
Closed - Unable to Work (PN memo) |
|
PROCESS STATUS CODES (OPTIONAL) |
|
|
DEL |
Delayed Development |
|
IAE |
Interim Actual Earnings (No Formal LWEC) |
|
NFE |
Field Nurse Extension Granted |
|
JOL |
Suitable Job Offer Letter Issued |
|
MIN |
Medical Interruption of QCM Activity |
|
MRC |
Referee Exam Completed |
|
MRF |
Referee Exam Follow-up |
|
MSC |
Secop Exam Completed |
|
MSF |
Secop Exam Follow-up |
|
NCE |
Discussion of Case between CE and Nurse |
|
NCN |
Nurse Case Closed - Claimant Not Cooperative |
|
NCO |
Nurse Case Closed - Claimant Cooperative |
|
NRC |
Referred to CAP Nurse |
|
NSN |
Referred to Staff Nurse |
|
OPM |
OPM Elected (Use CSA Code to Close Case) |
|
Attachment 1 to FECA Bulletin 97-02 (continued) |
|
|
QCM STATUS CODES |
|
|
STATUS |
DESCRIPTION |
|
PROCESS STATUS CODES (OPTIONAL) (continued) |
|
|
PL4 |
Pre-QCM RTW Light Duty/4 hrs |
|
PL6 |
Pre-QCM RTW Light Duty/6 hrs |
|
NL4 |
RTW via Nurse; Light Duty/4 hrs |
|
NL6 |
RTW via Nurse; Light Duty/6 hrs |
|
ML4 |
RTW via CE; Light Duty/4 hrs |
|
ML6 |
RTW via CE; Light Duty/6 hrs |
|
PRL |
Pre-reduction Notice Letter Issued |
|
PTL |
Pre-termination Notice Letter Issued |
|
RHA |
Initial Interview Held |
|
RHC |
Returned to Claims Examiner |
|
RHD |
Plan Development |
|
RHE |
Employed |
|
RHG |
Assisted Re-employment Program |
|
RHI |
Rehab Plan in Place |
|
RHM |
Medical Rehabilitation |
|
RHN |
Placement Previous Employer - Without Other Srvcs |
|
RHP |
Placement New Employer |
|
RHQ |
Screened |
|
RHR |
Referred to RS |
|
RHS |
Self Employment |
|
RHT |
Training |
|
RHV |
Employed, Assisted Reemployment Prog; RC Follow Up |
|
RHW |
Placement Previous Employer - With Other Services |
|
RHX |
Services Interrupted |
|
RHZ |
Post Employment Services |
|
RDP |
Rehab Development Plan in Progress |
|
RWL |
Rehab Non-cooperation 30-day Warning Ltr |
|
SRE |
Referred to SrCE for Conference |
|
SUR |
Surgery Authorized |
|
TTD |
Continuing Total Disability per Secop/Referee |
|
TML |
10-month Letter Issued |
Back to Top of FECA Bulletin No. 97-02
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FECA BULLETIN NO. 97-03
Issue Date: October 15, 1996
Expiration Date: October 14, 1997
Subject: ADP - New Case Management File (CMF) Data Elements and New "Case Create" and "Case Change" Coding Requirements.
Background: When employing agencies do not to promptly submit injury notices and claim forms to OWCP, it often results in the initial rejection of medical bills and other claims that could otherwise be paid. To better serve claimants and to avoid unnecessary delays in issuing payments, we have been emphasizing to employing agencies the importance of submitting claims involving lost time and/or medical expenses to OWCP in a timely fashion. In order to monitor performance in this area, a new date field has been added to the CMF database. This field will be used during the "case create" process to record the date the employing agency receives the CA-1 or CA-2 claim form.
Other data elements have been added to the CMF to facilitate the identification of potential "dual benefits" cases, especially with respect to claimants employed under the Federal Employees' Retirement System (FERS). In addition, the CMF now includes data elements that will be used to record changes in the adjudication status of a case.
Reference: FECA Bulletin 95-23, issued August 28, 1995.
Purpose: To notify district offices of the new data entry requirements and screen display changes relating to the data elements that have been added to the CMF.
Applicability: Appropriate District Office and National Office personnel.
Action:
1. In the CASE CREATE screen (option 1 of the CASE MANAGEMENT menu) users will note a new data entry field labeled "Agency Received Date". The entry of a valid date in this field is required for any case being created based upon the receipt of form CA-1 or CA-2. A date in this field is optional for other form types.
Form CA-1: For cases being created from form CA-1 the date to be entered as the "Agency Received Date" should be the date listed in item 22 (Date notice received) of the form. If no date is listed in item 22 then, as a last resort, the date listed in item 11 (Date of this notice) should be used. The CA-1 form should be returned to the employing agency for completion if no date is entered in either of these items.
After entering the "Agency Received Date" the screen will display the prompt "ITEM 38 OF CA-1 INDICATES 'NO LOST TIME AND NO MEDICAL EXPENSE:'? Y/N". Depending upon whether this box is checked in item 38 the user should press "Y" or "N", as appropriate. If the user presses "Y" a special code will be entered in the CMF record so that these cases may be excluded from analyses of agency time-lag in submitting CA-1s.
Form CA-2: For cases being created from form CA-2 the date to be entered as the "Agency Received Date" should be the later of the date of the employee's signature (item 18) or the date listed in item 26 (Date employee first reported condition to supervisor). The CA-2 form should be returned to the employing agency for completion if no date is entered for either of these items.
2. In addition to the "Agency Received Date", users will note three new data fields in the CASE CHANGE screen (option 2 of the CASE MANAGEMENT menu).
SERVICE COMP DATE: If known, the claimant's Federal "service computation date" should be entered in this field.
OPM RETIREMENT NUMBER and OPM RETIREMENT DATE: For a claimant who is retired or is continuing in Federal service as a "reemployed annuitant", the retirement claim number and effective date, if known, should be entered in these fields.
These new data fields display also in the CASE SEARCH screen (option 2 of the QUERY menu.)
3. The STATUS/ACCEPTED COND screen (option 9 of the CASE MANAGEMENT menu) and the CASE STATUS INFORMATION screen (option 15 of the QUERY menu) will now display the "Short Form Reopen Date" for cases where this is applicable. These screens will also display up to three previous adjudication status codes and dates under the heading "Adjudication History". The "Initial", "Prior" and "Post Short Form" adjudication codes and dates will be displayed, as applicable.
The "Initial" adjudication data will be permanently recorded in the CMF only when an adjudication code is entered where none previously existed. This includes cases that are closed "short form" at the time of "case create".
The "Prior" adjudication data will be captured in the CMF record whenever a new adjudication status is entered in place of an existing code. This includes "short form" closure cases that are reopened. The "Prior" adjudication data will be overwritten in the CMF record whenever a new adjudication status is entered.
The "Post Short Form" adjudication data applies only to "short form" closure cases that have been reopened and are adjudicated after the implementation of these system changes. The adjudication code and date entered in such cases will be permanently recorded in the CMF record.
An automatic backfill of the "Initial" adjudication data has been performed for cases that are currently closed "short form" and for reopened "short form" closure cases that are still in "UD" status. Further automated backfill of this data will be accomplished at a later date using information contained in the central database (NCMF).
4. Two new data elements have also been added to the CMF to record the responsible examiner ID associated with the "initial" and "current" adjudication of cases. The "Initial Adj Resp Exam" data will be permanently recorded in the CMF when an adjudication code is entered on a case where none previously existed. This data field will remain blank for cases that are closed "short form". However, if a "short form" closure case is reopened, the "Initial Adj Resp Exam" data will be captured the first time that an adjudication code is entered on the case.
The "Current Adj Resp Exam" data will be recorded automatically in the CMF whenever an adjudication code is entered in a case. This data field will also remain blank for cases that are closed "short form".
Both the STATUS/ACCEPTED COND screen (option 9 of the CASE MANAGEMENT menu) and the CASE STATUS INFORMATION screen (option 15 of the QUERY menu) will display the "Initial Adj Resp Exam" and "Current Adj Resp Exam" codes.
5. The DEPARTMENT CHANGE option has been removed from the CASE MANAGEMENT menu. Changes to the table of valid agency chargeback codes (v12, Department Master) will be made only by the National Office.
6. In one final system change, the threshold for payment of medical bills in "short form" closure cases has been raised from $1,000 to $1,500. Users will note this new dollar figure in the REOPEN LT/NLT CLOSURE screen (option 10 of the CASE MANAGEMENT menu).
Disposition: This Bulletin should be retained until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 -- Folioviews Groups A, B and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists and Staff Nurses)
Back to Top of FECA Bulletin No. 97-03
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FECA BULLETIN NO. 97-04
Issue Date: October 23, 1996
Expiration Date: October 22, 1997
Subject: Comp Pay--Elimination of Short-Term Roll and Code PI Rehabilitation--Elimination of Code PV
Background: In 1991, the Federal employees' compensation program began using the short-term roll as part of its case management procedures. It was designed for cases where disability was not expected to exceed one year, to fill the perceived gap between the functions of the daily and periodic rolls.
At that time, the program had not developed the capacity to assign expiration dates in periodic roll cases, and it still required certification of routine daily roll payments, which were processed at several different work stations within the district office.
It was anticipated that use of the short-term roll would make clear to claimants that their disabilities were not expected to continue indefinitely, and that it would reduce the need to move the case among various work stations, thus allowing more rapid referrals for second opinion and referee evaluations. However, neither of these effects was fully realized, and when short-term payments expired, it was sometimes necessary to authorize further payments on an expedited basis.
The changes in daily and periodic roll processing and the problems which have arisen with the short-term roll have essentially rendered the short-term roll unnecessary. It is therefore being eliminated effective October 23. As of that date, cases currently coded PI will be recoded PR, but the expiration dates will remain the same.
This change will affect several letters in the Forms Correspondence System. Forms CA-1650 and CA-1651 are being removed from the system, and Form CA-1655 is being combined with Form CA-1049, which is being completely revised. Minor revisions are being made to Form CA-1656.
Also effective October 23, cases coded PV will be recoded PR. This change is being made mainly because the Rehabilitation Tracking System provides many other ways to monitor cases where the OWCP is providing vocational rehabilitation services.
The National Office will forward lists of recoded cases to each district office.
Purpose: To advise district office staff of the changes which will accompany elimination of the short-term roll
Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives, Supervisors, Technical Assistants, Rehabilitation Specialists, and Staff Nurses
Action:
1. Given the choice between placement on the periodic roll and continued daily roll payments, placement on the periodic roll should almost always be considered preferable.
2. Claims staff should use the periodic roll in place of the short-term roll by entering an expiration date which is carefully selected to reflect the circumstances of the case. It is assumed that expiration dates of at least six months to a year from the date of placement on the periodic roll will be needed in most cases given that it is OWCP's burden to terminate or reduce benefits absent a return to work when injury-related disability has ceased.
3. Claims staff should send Form CA-1049 to all claimants who will receive payments on the periodic roll, regardless of how long those payments are expected to continue.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 97-04
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FECA BULLETIN NO. 97-05
Issue Date: January 9, 1997
Expiration Date: January 8, 1998
SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1997.
PURPOSE: To provide the 1997 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1997.
APPLICABILITY: All appropriate personnel are to be made aware of the periods and "cut-off" dates for the ACPS periodic disability, death, and daily payrolls.
The production schedule for the DMS periodic reports is made available for the appropriate personnel. IT IS IMPERATIVE that this schedule be closely followed.
DISPOSITION: This bulletin should be retained in front of Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachments
Distribution: List No. 2--Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 97-05
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FECA BULLETIN NO. 97-06
Issue Date: January 30, 1997
Expiration Date: January 29, 1998
Subject: Fiscal--Updates of Cash Deposits and Cancelled Check Items into the BPS and ACPS History Files
Background: Audits conducted by the Office of the Inspector General show large year-end differences between the chargeback and SF-224, Statement of Transactions, net disbursements. The differences are caused mainly by untimely updates of cash deposits and cancelled check items into the BPS and ACPS History Files. This includes third party transactions.
The National Office is working with the Department of Treasury to develop an automated method for transmitting deposit transactions directly from the Lockbox Depository. The transactions would then be conveyed to each district office for update to the appropriate BPS or ACPS record. Until the automated method is available, however, these transactions will be controlled via the Cash Receipts Register or the Mailroom Cash Receipts Log, Form DL 1-301.
The chargeback year runs from July 1 through June 30, and the target date for all cash receipt transactions is June 15.
Purpose: To describe the steps needed to ensure that cash deposits and cancelled check items are updated in a timely manner
Applicability: Fiscal Staff, All Supervisors, and Technical Assistants
Action:
1. Each district office must develop a plan to ensure that all cash receipts and cancelled checks received through June 15 are entered into the BPS and ACPS History Files by that date, which is the cutoff date for running the chargeback report.
2. Third party refund transactions MUST be included in this process. Entering third party data into the Debt Management System (DMS) is not the same as updating the chargeback file. The DMS transaction simply records the refund amount for the purposes of completing Schedule 9 (report from the Department of Labor to the Department of Treasury).
3. The Cash Receipts Register must be annotated as each transaction is updated in the BPS or ACPS history file. Since cancelled check items are not recorded on Form DL 1-301, the district office must maintain records to verify that history files have been updated. The manner in which the district office maintains these records is discretionary. However, each district office must be able to produce evidence that the history files have been updated, to include the date of the entries.
4. Each office must submit a brief report describing its plan for implementation, including the projected date of implementation, which should be no later than April 1. The report should be sent to Ken Siglin via e-mail (kls@fenix2) no later than April 15.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 4--Folioviews Groups B and D
(Fiscal Officers, Benefit Payroll Clerks and Assistants, All Supervisors, Systems Managers, Technical Assistants)
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FECA BULLETIN NO. 97-07
Issue Date: January 6, 1997
Expiration Date: January 5, 1998
Subject: Compensation Pay: Compensation Rate Changes Effective January 1997
Background: In November 1996, the President signed an Executive Order implementing a salary increase of 2.30 percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the 2.30 percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 1997.
Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The new rates will be effective with the first compensation payroll period beginning on or after January 1, 1997. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $92,161 per annum.
The minimum increase specified in this Bulletin is applicable to Postal employees.
The effect on 5 U.S.C. 8112 is as follows:
|
Effective January 5, 1997 |
Minimum |
Maximum |
|---|---|---|
|
Monthly |
$1,186.92 |
$5,760.06 |
|
Weekly |
205.43 |
1,329.25 |
|
Daily(5-day week) |
41.09 |
265.85 |
The basis for the minimum compensation rates is the salary of $14,243 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $92,161 per annum (GS-15, Step 10).
The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,186.92, effective January 5, 1997. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $5,760.06 per month.
Applicability: Appropriate National and District Office personnel.
Reference: Memorandum For Directors of Personnel (CPM 96-14), dated November 22, 1996; and the attachment for the 1997 General Schedule.
Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustments Dates.
a. As the effective date of the adjustment is January 5, 1997, there will be no supplemental payroll necessary for the periodic disability and death payrolls.
b. The new minimum/maximum compensation rates will be available in ACPS on or about January 24, 1997.
2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 1997. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.
3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows (these forms will be reproduced after March 1, 1997):
|
CA-842 |
|||||
|
1/05/97 |
41.09-61.64 |
205.43-308.14 |
41.09 |
205.43 |
1,186.92 |
|
CA-843 |
|||||
|
1/05/97 |
265.85 |
1,329.25 |
(5,317.00) |
5,760.06 |
|
4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.
Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 97-07
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FECA BULLETIN NO. 97-08
Issue Date: March 1, 1997
Expiration Date: February 28, 1998
Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1997
Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1997.
1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 3.3 percent.
2. The increase is effective March 1, 1997, and is applicable where disability or death occurred before March 1, 1996.
3. The new base month is December 1996.
4. The maximum compensation rates which must not be exceeded are the following:
| Rate | Time |
|---|---|
|
$ 5,760.06 |
per month |
|
1,329.25 |
per week |
|
5,317.00 |
each four weeks |
|
265.85 |
per day (for a 5-day week) |
Applicability: Appropriate National Office and District Office personnel.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.
Action: On or about February 21, 1997, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustment Dates.
a. The periodic disability and death supplemental payrolls for CPI adjustments will cover the period March 1, 1997 only, with the new cycle effective March 2, 1997.
b. The supplemental check date for the periodic disability and death payrolls will be March 18, 1997. Please note: payments of less than $1.00 will not be issued.
2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 21, 1997, daily roll payment cases requiring the new CPI should be held for data entry until that date.
3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information. (These forms will be reproduced within the next month or so.)
4. Forms.
a. Form CA-837, Notice to Payee, will be sent to the payees on the periodic disability and death payrolls. The notice will be sent to the payees from the National Office. The CA-837 will be addressed using the ACPS Correspondence Address File. PLEASE be sure to maintain the address file as you do with the Payee Address File and the CMF. PLEASE remember that an address change to the CMF DOES NOT automatically change the ACPS check address or correspondence address. ACPS must be accessed and the enter key must be depressed through the address areas. Be watchful for those payments being sent via Direct Deposit.
b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.
c. CP-140 will be printed for each case adjusted. These should be drop filed in the case file.
Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)
Back to Top of FECA Bulletin No. 97-08
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FECA BULLETIN NO. 97-09
Issue Date: February 3, 1997
Expiration Date: February 2, 1998
Subject: Dual Benefits - Deduction from FECA benefits of Social Security Benefits "Attributable to Federal Service" in FERS cases.
Background: Retirement benefits under the Federal Employees' Retirement System (FERS) are considered dual benefits just like the Civil Service Retirement System (CSRS) benefits. Because FERS benefits include SSA death and old age benefits, however, they are treated differently. While there have been very few Federal employees eligible for retirement under FERS until recently, the number is beginning to grow. This bulletin explains how FERS retirement benefits affect FECA payments and what the CE must do to prevent payment of dual benefits.
WHAT IS THE FERS DUAL BENEFIT?
FERS, which took effect on January 1, 1987, is a mandatory replacement for CSRS and all employees first hired on or after January 1, 1982 are covered under FERS. CSRS employees were offered the opportunity to switch to FERS during an open season in 1987.
The FERS benefit package consists of three basic components, FERS basic benefits paid by OPM, the Thrift Savings Plan, and Social Security. Claimants elect between FECA benefits and the FERS basic benefit from OPM in the same manner as they elect between FECA benefits and CSRS benefits. There is no bar to concurrent receipt of the proceeds of the Thrift Savings Plan and FECA benefits. It is the SSA program which requires the most significant changes by OWCP in how it deals with retirement benefits.
FECA benefits have to be adjusted for the FERS portion of SSA benefits. The portion of the SSA benefit earned as a Federal employee is part of the FERS retirement package, and the receipt of FECA benefits and Federal retirement benefits concurrently is a prohibited dual benefit. 5 USC 8116(d)(2) requires that disability and death benefits paid under the FECA be reduced by the amount of any Social Security (Title II) old age or death benefits paid that are attributable to the Federal service of the employee. Unlike CSRS or FERS OPM benefits, however, this is not an election, but a deduction from FECA benefits payable. The beneficiary continues to receive their full SSA benefit.
There are general exceptions to the dual benefits deduction. The two major ones are: 1) schedule awards, as with CSRS retirement benefits, FERS retirement benefits paid by OPM or SSA can be paid concurrently with a schedule award, without any deduction from FECA benefits; 2) The deduction from FECA benefits does not apply to SSA disability benefits (SSA, not OWCP, makes a deduction from SSA disability benefits for FECA benefits paid).
HOW TO RECOGNIZE POTENTIAL FERS SSA DUAL BENEFIT CASES
In Disability Cases: The possibility of FERS SSA dual benefits exists where:
1. The claimant is at least 62 years old, and
2. The claimant had FERS retirement coverage during any of his or her Federal employment, and
3. The claimant is paid benefits based on age by SSA.
Claimants between 62 and 65 may be eligible for both SSA disability and SSA death benefits. If so, they may elect the more advantageous. If they elect disability, there is no FECA offset. At age 65, SSA disability benefits automatically convert to SSA old age retirement benefits. Therefore, all SSA retirees age 65 or older, who are covered by FERS, are subject to the FERS offset.
In Death Cases: The potential for FERS SSA dual benefits exists where:
1. The deceased employee had FERS retirement coverage during any of his or her Federal employment, and
2. There are dependent children, or
3. There is a spouse who either, 1) has in their care a child under the age of 16, 2) is 50 years old and disabled, or 3) is 60 years old.
Recognizing a FERS dual benefits situation may be difficult. Unlike CSRS retirement, OPM may not be aware of an individual receiving SSA benefits based on Federal employment, since applications for and entitlement to SSA benefits and OPM benefits are not dependent upon one another. OPM is not advised that a FERS employee has or has not applied for SSA benefits. Where a CSA number has been assigned, however, the CSA or CSF number is the easiest way to recognize FERS cases. The CSA number for all FERS retirement cases begins with 8 million. All FERS death cases have a 7 million CSF number.
Forms CA-1, CA-2, CA-5 and CA-5b are currently being revised to ask for the employee's retirement plan and whether a claim has been filed for SSA benefits.
HOW TO CALCULATE THE OFFSET OF SSA BENEFITS "ATTRIBUTABLE TO FEDERAL SERVICE":
Only that portion of SSA benefit "based on Federal Service" is deducted from the FECA benefits. This section explains how OWCP calculates what that portion is.
SSA benefits are computed based on the number of years of employment and the amount of earnings. To be eligible for SSA benefits, an employee must have a minimum number of quarters of employment (usually 40 quarters or 10 years) during which contributions were made to the Social Security System. OWCP has defined the portion of SSA benefits "ATTRIBUTABLE TO FEDERAL SERVICE", which must therefore be deducted from FECA benefits, as the difference between the beneficiary's actual SSA benefit and a hypothetical SSA benefit computed without the Federal earnings, assuming that the employee had the required number of quarters for SSA benefits.
Where a claimant has received SSA benefits, OWCP will obtain information from SSA on the amount of the claimant's SSA benefits beginning with the date of eligibility to FECA benefits. SSA will provide the actual amount of SSA benefits received by the claimant/beneficiaries. SSA will also provide a hypothetical SSA benefit computed without the FERS covered earnings. OWCP will then deduct the hypothetical benefit from the actual benefit to determine the amount of benefits which are "attributable to Federal Service". That amount is deducted from the FECA benefit to obtain the amount of compensation payable.
EXAMPLE: The claimant is entitled to $900.00 per month in FECA benefits. The actual Social Security benefit is $500 per month. The "hypothetical" SSA benefit is $300 per month.
$500 - $300 = $200 (the amount deducted from FECA benefits)
$900 - $200 = $700 (FECA benefits payable)
The claimant would be entitled to keep the entire $500 per month from SSA but would have to elect between the $700 per month FECA benefits and the full OPM retirement benefit. (Any Thrift Savings benefit is not considered a dual benefit.)
OTHER ISSUES RELATING TO CALCULATION OF BENEFITS
COLAs: All Social Security beneficiaries receive COLAs effective the 1st of December each year, regardless of when they were put on the rolls. A beneficiary who is first eligible for SSA benefits in November, receives the full COLA in December. Effective December 1 each year, all deductions for FERS SSA dual benefits will be increased by the percentage of the SSA COLA. The FECA CPI, effective March 1, will be added to the total amount of FECA benefits, before the FERS SSA deduction.
There are several issues related to the deduction of the FERS SSA benefit from FECA benefits which apply primarily to death and LWEC cases. In rare instances, they could apply to any claim. Guidelines for handling those issues are outlined in the addendum to this bulletin. The addendum should be kept with the bulletin and used as a reference for all death and LWEC cases.
Purpose: To provide procedures for making proper FERS SSA deductions from FECA benefits in cases which are covered under FERS and are eligible for SSA old age or death benefits.
Applicability: All claims and fiscal staff.
Reference: 5 USC 8116(d); title II of the Social Security Act
Action:
1. When it is determined that FECA benefits are payable, determine if there is a potential for FERS SSA dual benefits, using the criteria outlined in the background.
2. Where the claimant in a disability case is under 62 years old, place a call up on the case for the 62nd birthday.
In a death case, where the spouse is under 60 years old and has no children under 16, place a call-up for the 60th birthday.
Advise these claimants that they must notify OWCP at once upon applying for SSA old age or spousal death benefits.
3. Where there is a possibility of FERS SSA dual benefits, complete the FERS SSA Dual Benefits Form attached to this bulletin. This form should be photocopied in each district office. It will also be emailed to all District Directors for distribution to their staff.
FECA claims examiners complete the header information in all claims. Print your name, phone number and FAX number clearly in the "FROM" section. At the present time, Bill Hilton at SSA is performing the necessary computations for OWCP. FAX the form "TO" him at (410)966-9214. His phone number is (410)965-2468. The National Office will provide updates of the SSA contact. Check whether you are requesting an initial computation or a recomputation.
OWCP then completes the left side of the form. In Part I, provide the name, SSN, Date of Birth, and Date of Death (if applicable) of the employee. Provide the dates of FERS covered employment. It can be stated in years (e.g. 1981 - 1992). If the date FERS coverage began (either the date FERS covered employment began, or the date of the FERS election) is not available, use 1981. The computation date is the date that FECA benefits are payable.
Complete the name, DOB, SSN (if available) and relationship in item II for all survivors claiming benefits in death cases.
Provide any relevant remarks not covered by this form in item III.
FAX the completed form to SSA at (410) 966-9214, attention: Bill Hilton.
4. When a completed form is returned by SSA indicating that the claimant is not receiving SSA benefits, no further action is necessary at that time. If it is a long term disability case, however, the periodic review should include checking to make sure that SSA benefits have not been initiated since the last review.
When the form indicates that the claimant is in receipt of SSA benefits, subtract the "SSA rate W/O FERS" from the "SSA rate W/FERS" (as indicated on the form). The result is the FERS SSA dual benefit. Subtract the FERS SSA dual benefit from the FECA benefits payable. Perform this computation for each date the benefit amount was revised by either OWCP or SSA, for each beneficiary in the case.
Place a memorandum in the file explaining the claimant's entitlement, and the computation of benefits. A sample memorandum is attached.
5. Where the claimant is entitled to both OPM benefits, including any OPM lump sum death benefit, and FECA benefits, provide the claimant with an election between OPM benefits and FECA benefits, which identifies the full FECA amount, the FERS SSA dual benefit deduction and the amount of FECA benefits payable after the deduction.
With the election, provide the claimant with an explanation of how the FECA benefits were computed. Direct the claimant to address any questions related to Social Security's computations to the local Social Security office. A sample letter is attached for your reference. You may modify this to the circumstances in the case. You could also send the CA-1102 or CA-1103, and include a separate letter of explanation. Make sure that each claimant receives an independent election in a death case.
6. When a claimant elects FECA benefits, coordinate the transfer from OPM benefits and release appropriate correspondence such as Form CA-1049 or CA-180 according to current procedures. These form letters have been revised to advise claimants of the FERS SSA dual benefit deduction.
7. When initiating an ACPS payment in ANY FERS case, answer "Y" to the new system prompt, "FERS SSA Offset? [Y/N], even if there is no current FERS SSA dual benefit. (This will be available in ACPS in late January 1997.)
The following prompt will then appear, "FERS OFFSET AMOUNT". If there is a FERS SSA dual benefit deduction, enter the amount to be deducted from the full FECA benefit. The system will then make the deduction. If there is no current FERS SSA deduction, press "ENTER". This will fill the field with zero.
This will provide a unique identifier for FERS cases and aid in COLA adjustments, tracking and matching.
ACPS will adjust the FERS SSA deduction effective every December 1 with the SSA COLA. In the example provided in the background, the COLA would be added to the $200 deduction.
The FECA CPI will be added to the full FECA benefit, before any deductions, as with current procedures.
8. Some district offices have existing records with an established AR for the FERS off-set. It is necessary for these records to be entered in the new ACPS screen, when available. After entry in the new FERS screen, please be sure the AR is deleted.
9. If there is any adjustment to SSA benefits because of earnings (See addendum. SSA should indicate this in Part III, Remarks, on the form), call up for May 1 to ask SSA to update the computations. Complete and FAX another form. When it is received, adjust ongoing benefits according to the information provided. Provide a letter of explanation to the claimant. A sample is attached.
In addition, follow current procedures for actions appropriate to the receipt of earnings information.
Disposition: This Bulletin is to be retained in Chapter 2-1000, Dual Benefits, of the FECA Procedure Manual, until revised or incorporated into the existing procedures.
Training should be conducted in each District Office on these procedures. Please report to me that the training has been conducted within 60 days of receipt of this bulletin. Any questions regarding these procedures should be addressed to Cecile Moran (202) 219-8461.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 Folioviews Groups A and B (Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
ADDENDUM: FERS SSA DUAL BENEFITS FOR DEATH AND LWEC CASES
WITHHOLDING OF SSA BENEFITS FOR EARNINGS: SSA computes an individual's entitlement as a yearly amount. When an individual under the age of 70 earns more than an amount established by SSA, while otherwise entitled to SSA benefits, SSA will withhold benefits for a period of time. There is no SSA earnings withholding after age 70. Before the start of a calendar year, beneficiaries are required to estimate their earnings for the coming year. Based on that estimate, the entire SSA benefit check is withheld, beginning January 1, until the excess earnings withholding is met. If part of a check is required to complete the withholding, the entire check is withheld.
In the middle of the year, SSA beneficiaries are asked to update the earnings estimate. They are also asked to advise SSA at such time as their earnings exceed their estimate. The SSA withholding period may be adjusted based on the earnings updates. After the year has ended, the beneficiary must report to SSA the actual amount of earnings for the year.
Any balance due the beneficiary by SSA at the end of the year is paid at the end of the year. If, at the end of the year, insufficient funds have been withheld to fully cover the earnings, the balance owed becomes an overpayment, subject to due process overpayment procedures. If, after due process has been followed, entitlement to SSA continues, the overpayment will likely be withheld from continuing benefits.
For example, a beneficiary estimates earnings for 1995, and SSA computes the amount of benefits that must be withheld based on that estimate to be $2,500. The individual is entitled to $500.00 per month in SSA benefits. Monthly payments, beginning January, 1995 are withheld until the amount of excess earnings is withheld. In this case, the total withholding will be met with the May check. The beneficiary will receive nothing from SSA through May. They will receive their full check for June and July. Based on information provided by the beneficiary on the mid-year mailer, SSA, during July, then recomputes the earnings withholding to be $2,900. The entire August check is then withheld to cover the additional $400.00.
By April 15, 1996, the beneficiary must report actual earnings during 1995. If, based on this report, SSA recomputes earnings withholding for 1995 to be $3,300, the beneficiary has an overpayment of $300 (remember the entire $500 was withheld for Aug). If, instead, the final computation of earnings withholding remains $2,900, the extra $100.00 will be paid to the beneficiary.
During months that the claimant is not receiving any SSA benefits due to earnings withholdings, they are entitled to their full FECA benefit. During months that they receive their full SSA check, the full FERS deduction of FECA benefits applies. Where SSA benefits are withheld fully or in part to collect an overpayment, the claimant will have to notify OWCP and request any resulting adjustment to the FERS deduction from FECA benefits.
Where the beneficiary's actual earnings are greater than the estimate, the result would be a decrease in the SSA benefits. A lower amount of SSA benefits results in a smaller deduction from FECA. In these cases, there would be no excess FECA benefits paid. There may by additional retroactive FECA benefits due based on the recomputation of SSA benefits.
SSA will provide pertinent information regarding any withholding for earnings in the comments section when they complete a benefit computation form for FECA. It is important that FECA claims examiners be aware of these SSA procedures so that they can follow up on earnings withholdings and correctly compute the FERS deduction in these cases.
Keep in mind that earnings reported by SSA could also be relevant to the cliamant's earning capacity in a disability case.
OVERPAYMENTS: Where timely notification of a benefit adjustment is received from SSA or the claimant, an immediate adjustment can be made to FECA benefits. Where OWCP does not learn until after the fact that a claimant's SSA benefits have commenced or increased, an overpayment of FECA benefits will be declared. Usually, prior notification to the claimant to advise OWCP of changes in SSA benefits, and the claimant's failure to provide such advice, will be sufficient to find the claimant "not without fault" in the occurrence of the overpayment.
THE DEDUCTION FROM FECA BENEFITS ONLY APPLIES TO SSA BENEFITS ACTUALLY RECEIVED: OWCP has interpreted the phrase "in the case of benefits received", in 5 USC 8116(d)(2), to mean that only benefits actually received by the claimant from SSA are subject to deduction from FECA benefits. If a claimant is potentially eligible for SSA benefits, but has not received anything, there is no deduction. If SSA benefits are reduced because of earnings or other adjustments, the deduction from FECA benefits is based on the actual SSA benefit received. If benefits are received by one individual on behalf of another, the benefit is considered to be received by the beneficiary, not the individual who receives the check.
MONTHLY MAXIMUM OF SSA BENEFITS IN DEATH CASES: Total SSA survivor benefits are limited by a monthly maximum. In some cases, where there is more than one eligible survivor, each survivor's benefit is reduced so that the total benefit paid does not exceed the monthly maximum. Where there are fewer beneficiaries, each beneficiary receives a larger portion.
WITHDRAWAL OR REFUSAL OF SSA BENEFITS: An individual may either withdraw their application for SSA benefits or decline to apply for benefits. Withdrawal nullifies entitlement. The beneficiary has to repay any benefits paid. If a beneficiary in a death case withdraws their application or declines to apply for benefits, the other eligible survivors will be paid as if that beneficiary does not exist. If a person declines benefits and then applies, the benefits are computed prospectively considering all of the entitled beneficiaries.
A widow with children, for example, could decline to apply for SSA benefits on her own behalf and still collect the same monthly maximum of SSA benefits for her children as if she accepted benefits for herself. Since the widow is not receiving any SSA benefits, OWCP will not make any SSA FERS deduction from her FECA benefits. OWCP will make the FERS SSA deduction for the children's FECA benefits only. The result may be that the widow can collect more from the combined programs than if she accepted SSA benefits on her own behalf. The law does not prohibit this.
Back to Top of FECA Bulletin No. 97-09
ATTACHMENT 1
FERS SSA DUAL BENEFITS CALCULATIONS FAX TRANSMITTAL NO. OF PAGES
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FROM: |
TO: |
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OFFICE OF WORKERS' COMPENSATION PROGRAMS |
SOCIAL SECURITY ADMINISTRATION |
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PHONE NUMBER: |
PHONE NUMBER: |
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FAX NUMBER: |
FAX NUMBER: |
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INITIAL |
RECOMPUTATION |
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THIS SIDE TO BE COMPLETED BY OWCP |
THIS SIDE TO BE COMPLETED BY SSA |
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I. EMPLOYEE/ANNUITANT |
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EFF DATE SSA RATE |
SSA RATE |
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DATE OF BIRTH |
DATE OF DEATH |
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FERS $$ PERIOD |
COMPUTATION DATE |
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II. SURVIVORS |
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ENTITLED EFF DATE |
SSA RATE SSA RATE |
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YES NO |
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SSN |
RELATIONSHIP |
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ENTITLED EFF DATE |
SSA RATE SSA RATE |
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YES NO |
RELATIONSHIP |
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ENTITLED EFF DATE |
SSA RATE SSA RATE |
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YES NO |
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SSN |
RELATIONSHIP |
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II. REMARKS:
NAME OF PERSON COMPLETING THE FORM FOR SSA
DATE FORM COMPLETED BY SSA
Back to Top of FECA Bulletin No. 97-09
ATTACHMENT 2
Memorandum to File
JOHN DOE, A00-********
This is a FERS SSA dual benefits case. The Office is required to deduct from FECA benefits that portion of Social Security benefits attributable to Federal Service. The widow has withdrawn her application for SSA benefits. Therefore, she is entitled to the full FECA benefit on her own behalf, with no deduction.
For the children, their SSA benefit is $588.00 per month each effective 9/25/94. Effective 12/1/94, their SSA benefit was increased to $603.00 each per month. In determining that portion of the SSA benefit attributable to Federal Service, SSA computed the amount of SSA benefit to which the children would be entitled, if the deceased never had FERS covered service, assuming that he died fully insured under the SSA system. (They deleted FERS covered earnings from the computation. There was some part time Federal service which was covered by SSA and not covered under any Federal retirement system. Earnings from this service were not deducted.)
The result was that the children would have been entitled to $327.00 each as of 9/25/94, and $336.00 each as of 12/1/94.
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$588.00 |
$603.00 |
Therefore, effective 9/25/94, the FERS SSA dual benefit deduction for each child from their FECA benefit is $261.00. Effective 12/1/94, the deduction is $267.00.
The FECA benefit for each child at 15% of $2547.25 per month is $382.09.
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$382.09 |
$382.09 |
Effective December 1 of each year, the National Office will increase the FERS SSA dual benefits deduction by the percentage of the SSA COLA. In March, 1996, when the CPI is applied to the FECA benefit, it should be applied to the total FECA benefit ($382.09).
CLAIMS EXAMINER
DATE:
Back to Top of FECA Bulletin No. 97-09
ATTACHMENT 3
|
Mrs. John Doe |
File Number: A00-000000 |
Dear **************,
I deeply regret your loss, and hope that I can be of some assistance in providing you with benefits to which you and your children are entitled on behalf of your husband's death.
Enclosed please find election forms for yourself and your two children, for you to elect between the compensation benefits payable to you as survivors under the Federal Employees' Compensation Act (FECA), and benefits payable to you by the Office of Personnel Management (OPM). Each of you is entitled to an independent election of the benefits you consider most advantageous, and you should complete and submit both originals for each of you to me at:
US Department of Labor, OWCP
District Office Address
***********************
***********************
FECA benefits and OPM benefits (including any lump sum death benefit provided under the FERS) are not payable for the same period of time. You are entitled to FECA benefits effective 9/25/93. If you elect FECA benefits, you may receive concurrently benefits from the Thrift Savings Fund and survivor benefits provided by the Social Security Act with the following exception.
5 USC 8116(d)(2) requires that compensation benefits be reduced by the portion of Social Security (SSA) benefits based on age or death that are attributable to Federal Service. Because you are receiving SSA benefits based on the Federal Service of an employee, your compensation benefits are reduced by the amount of Social Security benefits attributable to your husband's Federal service. Any questions related to SSA's computation of benefits should be addressed to your local SSA office.
If you elect compensation benefits, we will calculate the amount of compensation due from 9/25/93 to the present. Any benefits paid to you by OPM will be reimbursed to them from the compensation due, and any remaining balance will be paid to you. If you receive a lump sum death benefit from OPM under FERS, compensation due will be paid to OPM and no benefits will be paid to you until OPM has been fully reimbursed.
Your entitlement to FECA benefits is outlined below. FECA benefits are paid every 4 weeks, but the monthly amount is also shown for ease of comparison. Effective with the first periodic roll period following December 1 of each year, your compensation payment will be adjusted because of the cost of living increase granted to SSA beneficiaries.
| Person |
FECA |
SSA DEDUCTION |
MONTHLY |
4 WEEKLY |
|---|---|---|---|---|
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Debra: |
$1146.26 |
00 |
$1146.26 |
$1058.08 |
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Shannon: |
382.09 |
$261.00 |
121.09 |
111.78 |
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Cathy: |
382.09 |
261.00 |
121.09 |
111.78 |
|
Total: |
$1910.44 |
522.00 |
$1388.44 |
$1281.64 |
| Person |
FECA |
SSA DEDUCTION |
MONTHLY |
4 WEEKLY |
|---|---|---|---|---|
|
Debra: |
$1146.26 |
00 |
$1146.26 |
$1058.08 |
|
Shannon: |
382.09 |
267 |
115.09 |
106.24 |
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Cathy: |
382.09 |
267 |
115.09 |
106.24 |
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Total: |
$1910.44 |
534 |
1376.44 |
1270.56 |
**** Use the following paragraph in situations where the spouse is not receiving benefits on his or her own behalf, or where the claimant has not yet met the requirements for SSA benefits. ****
(At such time as you apply for Social Security benefits, the appropriate deduction would apply to your FECA benefit. It is your responsibility to advise this office immediately if you should apply for SSA benefits.)
If you have any questions about this election, or if I can be of any assistance, please contact me on (your phone number).
Sincerely,
******************
Claims Examiner
cc: Agency
Claimant
***************
***************
Dear Claimant,
You were advised by letter of 00/00/00 that your FECA benefits had to be reduced by the portion of SSA old age or death benefits attributable to the FERS covered Federal Service of the employee.
Effective 01/01/96 your SSA benefits were adjusted to $550 per month. Your SSA benefits without the FERS covered Federal service would be $325 per month effective 01/01/96. As of 01/01/96, therefore, the amount of FERS SSA dual benefits which must be deducted from your FECA benefits is $225 per month, or $207.69 per 4 weeks. Your FECA benefits will be adjusted accordingly effective with your check dated 03/01/96.
Since OWCP only deducted $200 per month, or $184.62 per 4 weeks for the period January 1, 1996 through March 1, 1996, you have been overpaid in the amount of $50.00. Please remit a check in this amount at your earliest convenience.
If you have any questions about your SSA dual benefits deduction, please do not hesitate to contact me.
Sincerely,
NAME
Claims Examiner
Phone Number
***Please note: you must also release the standard overpayment letters***
Back to Top of FECA Bulletin No. 97-09
ATTTACHMENT 4
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File No. A14-000000 |
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Employee SSN: ***-**-**** |
Employee DOB: 00/00/54 |
Under the provisions of 5 U.S.C. 8101 et seq. (Federal Employees' Compensation Act), the OWCP makes the following
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FOR WHOM PAID |
RELATION |
FOUR |
FOUR |
HEALTH |
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|---|---|---|---|---|---|
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Debra |
wife |
$2351.31 |
45 |
1058.08 |
184.42 |
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Shannon |
daughter |
2351.31 |
15 |
352.70 |
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|
Cathy |
daughter |
2351.31 |
15 |
352.70 |
|
|
$1763.48 |
|||||
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492.92 |
|||||
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1270.56 |
When an employee is covered under the Federal Employees' Retirement System (FERS), Social Security benefits payable to their beneficiaries, which are attributable to the employees' Federal Service, are deducted from FECA benefits (FERS SSA deduction). Each of your daughters are in receipt of Social Security benefits, a portion of which is attributable to the employees' Federal Service. Effective September 25, 1993, the amount of the FERS SSA deduction is $261.00 per month, or $240.92 per 4 weeks, per child. As of December 1, 1993, the FERS SSA deduction is $267.00 per month, or $246.46 per 4 weeks per child. As of December 1, 1993, the FECA benefits payable are $1270.56, minus health benefits of $184.42, for a net of $1086.14.
Your first check and the period covered: $15,361.31 9/25/93 to 10/15/94.
Your continuing four-weekly checks will be: $1,086.14. Effective with the first periodic roll period following December 1 of each year, your compensation payment will be adjusted because of the cost of living increase granted to SSA beneficiaries.
If, at some future time, you apply for Social Security benefits on your own behalf, you must advise this office immediately, so that we may coordinate the appropriate adjustment to your benefits with SSA.
By Order of the Director
Office of Workers' Compensation Programs
Claims Examiner
Enclosures: EN0180-0388, EN0180-0992, ENAPPA-0489/CA0180
cc: Attorney , OPM, Agency, file
Back to Top of FECA Bulletin No. 97-09
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-10
Issue Date: February 15, 1997
Expiration Date: February 14, 1998
Subject: Case Doubling
Background: The existing procedures for case doubling, found in the Federal (FECA) Procedure Manual at Chapter 2-400.8, state, "Doubling of case files should be avoided if possible." This reluctance to double cases has led to some very difficult situations with respect to cases before the Employees' Compensation Appeals Board, payment of medical bills, correct adjudication of claims, and providing excellent customer service to claimants. In addition, differences in doubling practices among and within the district offices have led to disagreements.
Case doubling is now encouraged where certain criteria are met. In general, the oldest case will be the master case. As of July 5, 1996, the CASE632 report, "Claimant New and Prior Injuries Report," is produced automatically whenever CASE615 (Case Create) is run. All CASE632 reports must be reviewed and appropriate cases doubled.
Reference: Federal (FECA) Procedure Manual, Chapters 1-300.6 and 2-400.8.
Purpose: To describe new guidelines and procedures for case doubling.
Applicability: District Directors, Systems Managers, All Supervisors, Claims, Fiscal, Bill Resolution, Mail Room and ADP staff.
Action:
1. When an employee has sustained more than one injury, it is often necessary to incorporate all of the records in one case folder. The case records are kept separately but travel under one claim number, which is known as the "master file". The subsidiary and master files are cross-referenced in the FECS data base. Each case file is assigned a status code, as follows:
| Code | Description |
|---|---|
|
I |
independent (neither a master or subsidiary file) |
|
M |
master file |
|
S |
subsidiary file |
2. Cases should be doubled where correct adjudication of the issues depends on cross-reference between files. Cases meeting one of the following tests must be doubled:
a. A new injury case is reported for an employee who has filed a previous injury claim for a similar condition or the same part of the body. An example would be where a claimant has an existing case for a back strain and submits a new claim for a herniated lumbar disc.
b. Two or more separate injuries (not recurrences) have been sustained on the same date.
c. Adjudication or other processing of a case will require frequent reference to another case which is not for a similar condition or the same part of the body. An example would be where an individual who has an existing claim for carpal tunnel syndrome files a new claim for a mental condition which has overlapping disability periods. If only a few such references will be needed, the cases should not be doubled. Cases of this nature include:
1. cases in which problems arise keeping the cases straight for bill pay and/or mail purposes, such as when the same physician is treating the claimant for more than one injury;
2. cases with overlapping periods of disability; and
3. cases which should be handled by a single individual to ensure consistency and fairness.
3. The responsible claims examiner (CE) will be responsible for reviewing newly created cases for potential doubling and making doubling recommendations. The District Director or one or more designees will be responsible for approving case doublings and settling any disputes about whether cases should be doubled and which case file number should be the master file number. Unit claims managers may be designated reviewers.
4. Each day in which cases are created and CASE615 is run, a CASE632, "Claimant New and Prior Injuries Report" will be produced as well. This report shows all cases already existing for a claimant. Each page of the report should be placed in the corresponding newly created case file. If a case contains such a report, it must be forwarded to the responsible CE, even if it is a short-form closure case. The responsible CE will examine the list for each case in which a list appears and determine whether doubling is indicated. If needed, the other cases listed on the report may be pulled for the CE. The CASE632 report should be filed just above the CA-1 or CA-2. If the cases are to be doubled, the responsible CE should forward a request for case doubling to the designated reviewer, along with the cases. If the reviewer approves the case doubling, the cases should then be forwarded to the mail room.
5. If the CE notes, while examining a case file, that there are other injuries that may have bearing on the case at hand, the CE should request the other case file or files by completing Form CA-33. If the cases meet one of the criteria noted above, the CE should request that they be doubled. Such a request, which may be made by informal (handwritten) memo, should show the case file numbers, the master case file number, the reason for doubling, the CE's initials, and the date. The designated reviewer should approve the request before it is sent to the mail room.
6. When cases are forwarded to the mail room for doubling, the mail room should physically combine the cases into the master file jacket. The subsidiary case file numbers should be written on the front top center of the master file jacket. The subsidiary file jackets should be filed in the file room, with an annotation of the master file number. The spindles for the cases should remain separate, even though they are contained within the same jacket. The master file number should be written on the CA-800(s) of the subsidiary case(s). If any subsidiary case is inactive, as defined in item 10(a) below, the CA-800 will be spindled down. If the doubled file is too thick for the folder, it should be divided in accordance with FECA Procedure Manual Chapter 1-500.8. All of the inactive subsidiary cases should be placed in the A part of the file.
7. Once the cases have been physically doubled, the file should be forwarded to the ADP section for doubling on the FEC System. This is accomplished by using the Double/Undouble option under the FECS001 Case Management menu. After the cases have been doubled on the system, the memo which authorized the doubling should be initialed and filed down in the master file.
8. If cases are not doubled, but some cross-reference may be needed, and there is no CASE632 report in the file, related cases should be noted on Form CA-18. Medical and other evidence from other injuries may be copied, annotated to show the source, and added to the file. This would primarily be applicable to cases closed for more than 2 years which were accepted for minor conditions, and "automatic" closures more than 2 years old.
9. Cases should be doubled at the first indication that doubling is needed.
10. The master case file number should generally be the oldest (by file number) case in the office. The claims examiner who is responsible for the master case file will also be responsible for all of the subsidiary files. Changing claims examiners when a new claim is filed should be avoided. Subsequent related cases will be doubled into the existing master case file.
(a) Whether a case is open or closed will have little bearing on the doubling decision. However, a case that has been closed for at least two years and has not involved medical payments for two years is considered to be inactive, and will generally not be the master case file.
(b) Cases that have to be retrieved from the records center will generally not be the master case file.
(c) Cases that already have a master number will not be undoubled and redoubled under another master case file number. This is true even if compensation payments are being made under a subsidiary case file number, but not under the master case file number.
11. A subsidiary case is not necessarily an inactive case. Subsidiary cases may be in an open status. The status of the case should reflect the situation at hand. If a subsidiary case is open, it should also have appropriate call-ups in place.
12. When case files are doubled, a letter should be sent to the claimant, the employer, the treating physicians, authorized representatives, and other interested parties, informing them of the doubling, and instructing them as to which case file number to use for inquiries, medical bills, and compensation claims.
13. If the accepted conditions in doubled cases are the same, the employing agency is the same, and there is no third party involvement, bills should be paid using the master file number (if that is an open case). However, where accepted conditions among doubled cases are dissimilar, or employers have changed, or third party liability is involved, care should be taken to make bill payments under the appropriate case file number.
14. When doubled cases are retired, both the master and all of the subsidiary case files must be retired.
Training for all personnel affected by these changes should be conducted no later than March 31, 1997. Compliance with these new procedures will be evaluated as part of the accountability review process.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 97-10
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-11
Issue Date: February 24, 1997
Expiration Date: February 23, 1998
Subject: District Office Use of Nurses Providing Telephonic Services
Background: To enhance the opportunities for the medical recovery and successful return to work of injured Federal workers, OWCP implemented two nurse intervention pilots from 1989 to 1991.
The first pilot, the Early Nurse Intervention Project, was implemented in three district offices and involved face-to-face contact of nurses in the local area (field) under contract to OWCP with claimants, health care providers, and employing agencies. These nurses were managed by designated office staff, usually a senior claims examiner, who served as a liaison between CEs in the office and the nurses. In contrast, the second pilot, Claimant Advocate Project (CAP) was strictly a telephone intervention. Nurses under contract to OWCP came into the district office and contacted claimants, treating physicians, and agency personnel. As in the first pilot, there was a staff member who coordinated the services of these nurses in each district office. Both pilots were effective in reducing compensation costs and enhancing the return to work. In addition, both demonstrated a high degree of satisfaction among participating claimants, agencies, district office staff and medical providers.
The face-to-face nurse intervention served as the model for the nurse intervention process included in the QCM procedures and was implemented nationally in 1993. However, the nurse providing telephonic case management offers several features that expand the district offices' ability to handle workloads. Some of these are: (1) it reduces the need for nurses in rural or geographically isolated areas, (2) it enables each nurse to handle a larger number of cases efficiently, (3) it is a relatively low-cost form of intervention. In implementing this program, district offices must be aware of the guidelines set forth below.
Purpose: This bulletin will provide guidelines and procedures for the use of nurses (telephonic) in the district offices.
Reference: OWCP Bulletin No. 91-2; Federal (FECA) Procedure Manual Chapter 3-200; OWCP Bulletin No. 93-6.
Applicability: Regional Directors, OWCP; District Directors, FEC; Staff Nurses and Claims Examiners
Action:
District offices implementing this type of intervention need to establish the number of nurses necessary to handle those cases subject to telephone intervention. In addition, district offices need to develop referral and reporting procedures which meet QCM time limits, privacy requirements and a process for the tracking and monitoring of cases by the Staff Nurse (SN). This includes the accurate coding of telephone intervention milestones in the QCM screen for tracking purposes.
Nurses performing telephonic intervention must be certified by OWCP and their recruitment, selection and certification must be in keeping with the process described in FECA PM, Chapter 3-202. Nurses selected for telephonic intervention must sign a Memorandum of Agreement (MOA) unique to telephone intervention. Should one of these nurses, elect to perform face-to-face work as a field nurse (or vice versa) he/she has to sign an appropriate MOA. Further, a nurse cannot perform both types of intervention at the same time. Any cases in an open status have to be transferred to other nurses before the nurse in question can change his/her duties and designation. Irrespective of where the telephonic intervention is conducted, contract nurses must hold valid licenses in the states where their assigned claimants reside.
All nurses providing telephonic services must establish their own work site (e.g. home, office) and cannot work out of the district office. They may come into the office as necessary to obtain or drop off documents and for other administrative purposes. While in the office, the nurse may interact with claims staff. They may also have access to the telephone, computers and copying machines in the office for administrative convenience, but are otherwise responsible for furnishing their own supplies and materials
The duties of the nurses providing telephone services should be identical to those of the field nurse. Both assist the CE in the medical management of compensation cases to bring about the return to work on a full-time, part-time or light duty basis. Nurses may also be asked to review the medical management of long term disability cases for the purpose of coordinating proper medical treatment and reducing residuals. Although nurses may offer medical guidance and input in a case, they cannot perform functions principally performed by a claims examiner such as: preparing statements of accepted facts (SOAF) or questions for a second opinion or referee physician. Further, the nurses' functions are limited to the individual cases assigned to them for medical management, and they may not perform certain duties such as scheduling second opinion examinations and handling medical authorization requests on an office-wide scale.
5. The SN provides general instructions and guidelines to accomplish the return to work goal. However, once a case is assigned, the nurse (telephonic) does not receive direct and continuing supervision. Performance is evaluated on the outcome of cases and on the timeliness and quality of services. Telephone intervention can have successful outcomes in cases with widely different diagnoses, length of disability, and/or demographic characteristics. However, because of its total dependence on oral communication at a distance, it may not be as efficacious as the face-to-face approach in some instances. To maximize results and to observe QCM time frames, a limit of 60 days should be applied to this intervention. However, in cases where there is a return to work (or return to work is imminent) within the 60 day period the nurse (telephonic) can provide the necessary follow-up. The CE may also allow extensions in special circumstances, such as when there are no available field nurses in the claimant's vicinity or when the nurse(telephonic) possesses language or professional skills that are necessary for the successful management of the case. Absent these circumstances, after 60 days the case should be transferred to a field nurse who will perform face-to-face intervention. An earlier transfer to a field nurse can occur if the nurse identifies factors which may render telephone intervention unsuitable. Some of these are: (a) claimants with problems in oral communication, (b) treating physicians who traditionally support total and prolonged disability for relatively benign conditions, (c) claimants with multiple, severe disabilities or with multiple recurrences of the accepted condition. In non-QCM cases, time limits for telephone intervention are the same as for face-to-face intervention: a total of 120-180 days.
Reimbursement to a nurse providing telephonic services cannot exceed $50,000. Any nurse who reaches this amount must not be assigned further work for the balance of the contract year. This reimbursement excludes all long distance telephone and FAX charges. These services are billed under the NIPTC code. Reimbursement for the services of the nurse (telephone) will follow the same requirements as for the field nurse namely the services provided must be case specific, a brief summary of the contacts made must be included, bills must submitted on the HCFA-1500 form and only the following unique telephonic codes must be used.
NCA00 - Telephonic nurse intervention, administrative - increments of time less than 1 hr.
NCA01 - Telephonic nurse intervention, administrative - 1 hr. increments of time.
NCP00 - Telephonic nurse intervention, professional services increments of time less than 1 hr.
NCP01 - Telephonic nurse intervention, professional services 1 hr.increments of time.
Do not use the field nurse (NIP) codes with the exception of the long distance telephone call code NIPTC for telephonic (CAP) nurse services.
Disposition: Retain until the expiration date or until superseded.
THOMAS M. MARKEY
Director for Federal Employees'
Compensation
Attachments
Distribution: List No.1--Folioviews Groups A and D, (Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
MEMORANDUM OF AGREEMENT
I. Introduction
The functional rehabilitation and return to work of injured workers are primary goals of the Federal Employees' Compensation Program. This agreement provides for early intervention by nurses to affect the extent and duration of disability or to improve medical management in cases where the length of disability is prolonged or uncertain. Examples include: back sprain/strain, neck or shoulder sprain/strain, knee injuries and carpal tunnel syndrome.
II. Services to be Provided
The following services will be performed by the contract nurse: (1) communicate directly with injured workers and their families to explain and monitor medical treatment and progress; (2) identify and pursue as needed more active treatment or more active participation by the injured worker; (3) as requested by the claims examiner, obtain concrete work limitations; (4) when applicable, arrange for on-site visits to the work place; (5) communicate directly with physicians about light duty opportunities and other issues; and (6) initiate return to work programs with the employee, agency and treating physician. All these interventions are conducted telephonically.
III. Reports
For any case referred to the nurse, a written management plan based on the nurse's initial telephone interview with the claimant must be submitted. Additional data elements will also be required in this management plan and will be discussed with the nurse during the training. Brief updates of the claimants medical condition, the goals reached or missed must also be submitted. Each district office will determine the desired frequency of these reports.
IV. Method of Billing and Payment
Reimbursement for the contract nurse's services will be made by charging individual case files worked. These services are considered to be prompt pay bills which will require the use of a separate HCFA-1500 form on each claimant's case.
V. Reimbursement Rate
There is a maximum time limit per case which may be authorized for these services. Duration of nurse services should not exceed sixty (60) days. Any plan for more than this time, must receive authorization by a claims examiner. There is a yearly reimbursement maximum of no more than $50,000 in a given fiscal year.
In those cases when a company will be billing for the nurse's services, the special disclaimer below needs to be signed by the individual nurse.
I hereby authorize (name of company) to act as my agent to bill and receive payment for any services I render under this contract, and I hereby release the U.S. Department of Labor, and the Employees'Compensation Program from any and all losses which I may suffer as a result of my using (name of company) as my billing and payment agent.
Nurse's signature................................................
Date ..................
VI. Security of Case Files
The contract nurse agrees to maintain the confidentiality of all records, reports, documents and case files developed or generated as part of this intervention effort in accordance with the Privacy Act of 1974 (5 U.S.C. 552a), and regulations promulgated by the Department of Labor to implement that statute (29 CFR Part 70a).
VII. Principles of Ethical Conduct
I understand that, the ethics rules (29 CFR Part O) and laws which apply to government employment may also apply to me. This includes the general prohibition against benefiting, through decision, approval, the recommendation, rendering of advice, or otherwise, in any particular matter in which a spouse, minor child, partner, organization in which you are serving as an officer, director, trustee, partner or employee or any person or organization with whom he is negotiating or has any arrangement concerning prospective employment or has a financial interest.
VIII. Termination
This agreement may be cancelled by either party upon thirty (30) days' written notice.
|
--------------------------------- |
---------------------------------- |
|
Date --------------------- |
Date --------------------- |
|
Expiration Date of Contract |
|
|
---------------------------- |
Address |
Employment Identification Number (EIN) or the number under which payments should be reported to the Internal Revenue Service
State(s) in which licensed:
State Board
License Number:
Expiration Date :
Back to Top of FECA Bulletin No. 97-11
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-12
Issue Date: April 10, 1997
Expiration Date: April 9, 1998
Subject: February 1997 DFEC/OPM Computer Match
Background: Another DFEC/OPM computer match, designed to identify possible occurrences of prohibited concurrent dual benefit payment, was completed last month using the data for the February 1, 1997 periodic roll cycle. The data shared with OPM again included the death roll, and excluded schedule award cases. 110 cases survived the manual and automated screening processes employed by OPM. The last DFEC/OPM Computer Match was conducted in September 1995.
With its advance copy of this bulletin, each District Office will receive a computer printout of the cases under its jurisdiction which should be screened, followed and reported on in accordance with the procedures described in FECA Bulletin 96-4 and again specified below. The presence of a case on the list should indicate that benefits were being paid by both DFEC and OPM on February 1, 1997, in apparent violation of the dual benefit prohibitions.
For this, and future matches, we will continue to follow the procedures used in the past; that is, OPM and the responsible District Offices will directly converse and correspond in order to resolve the hits. The District Offices will continue to have National Office reporting requirements, as detailed below. However, any problems that arise with OPM, or with any other aspect of processing the match hits, should be raised with Alex Senecal (202) 219-8461 for resolution. Telephone inquiries to OPM should be directed to Eugene Wooldridge at (202) 606-0228 (or 606-0232). Written inquiries or other correspondence should be directed to the Office of Personnel Management, Retirement Inspection Branch, P.O. Box 7174, Room 2309, Washington, D.C. 20044-7174, Attention: Eugene Wooldridge.
Purpose: To inform District Offices of the procedures for follow-up review and reporting requirements concerning the "hits" identified in the February 1997 DFEC/OPM match, and to reiterate continuing reporting requirements for the previous OPM matches.
Applicability: District Directors, Assistant District Directors.
Action: Each District Office with one or more cases appearing as hits from this match will receive a copy of a computer printout detailing the information on those cases, in a combined listing of disability and death cases. (On this printout the OPM Claim Number begins with "A" for disability cases and begins with "F" for death cases. Also, if the first digit of the OPM Claim Number is 7 or 8 then benefits are being paid under FERS rather than CSRS.) In addition, individual "hit sheets" completed by OPM are in the process of being mailed directly to the District Offices by OPM. Please note that the field identified on the printouts as "OWCP Gross" is actually the FECA 28 day payment amount converted to a 30 day equivalent for easy comparison purposes. The "OWCP Net" field is the actual 28-day gross compensation amount paid.
1. Immediately pull and review each disability (OPM "A" prefix) case listed in which the OPM gross payment amount exceeds the FECA gross payment amount. (For these cases the OPM amount is underlined on the printout.) If a review of the case confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
2. Review the remaining disability cases (those where FECA benefits exceed OPM benefits), and the death (OPM "F" prefix) cases (as detailed below). In the disability cases where FECA benefits are greater, OPM will seek the election and return a copy of the election along with a completed OPM "hit sheet" to DFEC.
3. In death/survivor cases (OPM "F" prefix), an informed election must be made before either benefit is terminated. Please remember that split elections can be made. In fact, several de facto split elections were discovered during previous matches; that is, there appeared to be dual benefits situations when in fact different beneficiaries were receiving OPM and FECA benefits. In other cases split elections have been made as a result of the matches. It is important that truly informed elections are made in these cases. During the 3rd match you were advised of our revised policy regarding the revocability of elections in death cases. That change was formalized by revision to the regulations. However, OPM maintains that survivor elections are irrevocable; that is, that once an election of FECA benefits is made, the beneficiary may not subsequently elect OPM benefits, unless the FECA entitlement is later determined to have been mistaken, or there is a third-party credit absorption.
Therefore, included in the information provided to a beneficiary in order for him/her to make an informed election should be a statement that an election of OPM benefits can later be changed to elect FECA benefits, but that the reverse is not possible. In addition, an informed election should be based on a comparison of each beneficiary's benefits. Where the total converted gross FECA benefit is greater than the total OPM benefit, OPM will obtain the election of benefits and return a copy of the election along with a copy of the OPM "hit sheet" to DFEC.
Where the total OPM benefit exceeds the total converted gross FECA benefit and the review of the file confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
4. In any case which results in a DFEC overpayment, the District Office should take immediate action in accordance with the overpayment procedures specified in Part 6 of the Procedure Manual.
5. Each DFEC overpayment case should be reviewed in order to determine whether the usual notifications concerning the prohibition against receiving concurrent retirement and compensation payments have been made. If so, the assumption must be made that the claimant is not without fault when such an overpayment occurs. Thus, except where this assumption is overcome by the evidence in the case file, a CA-2201 should be released immediately. Examiners are reminded that the supporting memorandum should explicitly detail the notification made.
6. When the appropriate overpayment letter is released, a 30-day call-up should be placed in the file. As soon as possible after a final decision has been released, administrative offset should be requested from OPM.
7. Initial review of all the listed cases should be completed and a report submitted by May 9, 1997, and quarterly thereafter until each "hit" is resolved. This review should confirm or refute the information supplied, the receipt of dual benefits and, where receipt of dual benefits is confirmed, determine whether or not there is an election of benefits on file. Each report must include, as appropriate:
a. The FECA case number and beneficiary name for each listing.
b. For death cases, the name, date of birth and relationship to the decedent should be listed for each eligible beneficiary.
c. Periods for which FECA benefits have been paid (specify schedule award periods).
d. Was the payment of dual benefits discovered through this match? (yes/no)
e. Is there an election on file? (yes/no) If yes, a copy of the election letter should be attached.
f. Have compensation payments been terminated? If so, effective on what date?
g. Is there an overpayment of compensation? (yes/no)
h. Is DFEC responsible for recovery?
i. What is the amount of the OPM overpayment?
j. What is the amount of the FECA overpayment transferred to the Accounts Receivable ledger?
k. Dates of subsequent due process and collection actions, including issuance of overpayment letters, final decision, release of SF-2805 to OPM requesting offset, etc. (Note: The current version of the SF-2805, Revised October 1988, should be used.)
Follow-up reporting for this match and for unresolved cases from prior matches should continue quarterly (by the 15th day of the first month of each quarter, i.e., 7/15, 10/15, 1/15, 4/15) until final resolution of the matter, until, for example, either the debt has been collected in full, a repayment schedule has been established and met at least once, or the account is otherwise closed. The final report should describe the repayment plan and/or date of payment. For example, the final report should show that a CA-2201 was issued on July 7, 1997; a final decision was issued on August 11, 1997 finding an overpayment of $2000; an SF-2805 was issued on September 22, 1997; the first payment of $200 was received from OPM on December 1, 1997; the debt will be recovered by October 1998. (Note: For OPM debts, reporting may cease once the OPM overpayment amount has been reported. You no longer need to report any actions on OPM debts beyond this point.)
Disposition: This Bulletin should be retained until all actions have been completed.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 6
(Regional Directors, District Directors, Assistant District Directors, Chiefs of Operations, Systems Managers, Technical Assistants and National Office Staff)
Back to Top of FECA Bulletin No. 97-12
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-13
Issue Date: June 5, 1997
Expiration Date: June 4, 1998
Subject: Contract Observers on Vessels
Background: Public Law 104-297, enacted on October 11, 1996, provides that observers on vessels who are under contract to carry out responsibilities under the Magnuson-Stevens Fishery Conservation and Management Act or the Marine Mammal Protection Act of 1972 shall be deemed to be Federal employees for the purpose of compensation under the Federal Employees' Compensation Act.
Contract observers are employed in private industry to carry out the requirements of these Acts, which are under the jurisdiction of the Department of Commerce. Since these individuals are not Federal employees, the Department of Commerce will not be charged back for these cases, and will not be directly involved in the claims process.
Because we anticipate that these cases will present unusual issues, they must be handled in one location.
Reference: P.L. 104-297, Section 204; Federal (FECA) Procedure Manual, Chapters 1-0100.5 and 2-0802.
Purpose: To alert district offices to the possibility of receiving claims from a new group of individuals.
Applicability: District Directors, Systems Managers, All Supervisors, Claims, Mail Room, and Case Create staff.
Action: All claims from contract observers and their survivors will be forwarded to the National Operations Office (District 25) without jacketing. They will be assigned case file numbers with an OB- prefix, and will be retained in the National Operations Office.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
Back to Top of FECA Bulletin No. 97-13
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FECA BULLETIN NO. 97-14
Issue Date: July 14, 1997
Expiration Date: July 13, 1998
Subject: Bill Pay--Travel Expenses
Background: Recent changes in travel regulations for federal employees have prompted National Office staff to reevaluate how FECA claimants should be reimbursed in connection with travel to obtain medical examination, treatment, appliances and supplies.
Consistent with the new regulations, claimants will no longer be reimbursed for meals obtained during periods of travel lasting 12 hours or less. Where the period of travel lasts between 12 and 24 hours, the claimant will be authorized actual expenses up to 3/4 of the per diem rate for the locality of travel based on reasonable charges. Where the period of travel is a full 24 hour day, the claimant will be authorized actual expenses up to the entire per diem rate for the locality of travel.
National Office staff will advise employing agencies of these changes through a notice on the Internet and at the next Interagency Meeting.
Reference: FECA Procedure Manual Chapters 3-500.10 and 5-204.8
Purpose: To provide guidance in evaluating claims for reimbursement of travel expenses
Applicability: Claims Examiners, Bill Resolution Staff, Technical Assistants, Staff Nurses, Rehabilitation Specialists, and Supervisors
Action:
1. When authorizing travel, claims staff should advise the claimant of the applicable rule, based on the likely period of travel, as stated above in the second paragraph under "Background".
2. Bill resolution staff should deny payment for meals and incidental expenses for travel lasting less than 12 hours. Ineligible amount code H (disallowed travel expenses) may be used to disallow a portion of a travel claim.
3. Claimants are still required to submit receipts for hotels. Bill resolution staff should reimburse claimants for meals in the same fashion as federal employees are while on official government travel. That is, 3/4 of the per diem rate on the first and last day of travel and full per diem rate for travel on any other days of the trip. With this there is no requirement for meal receipts.
4. To obtain per diem rates, claims and bill resolution staff may consult "Temporary Duty Guide for Department of Labor Employees", Publication No. 7. This booklet, which is revised each year, is available from OASAM.
5. Claimants must also continue to submit receipts for taxicabs, regardless of the amount, because the use of a taxicab is based on medical need.
6. These provisions are effective for all travel undertaken on or after the date of this bulletin.
7. Form CA-77 has been revised, and a copy is attached.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 97-14
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 97-15
Issue Date: September 5, 1997
Expiration Date: September 4, 1998
Subject: Felony Imprisonment Cases—-Reporting Requirements
Background: Public Law 103-333, enacted on September 30, 1994, amended the FECA by adding a new section 5 U.S.C. 8148, which provides for (a) the termination of benefits payable to beneficiaries who have been convicted of defrauding the program, and (b) the suspension of benefits payable to beneficiaries imprisoned as a result of felony conviction.
FECA Bulletin 95-5 originally reported this amendment; it has since been incorporated into the Federal (FECA) Procedure Manual at 2-1400.12. Also provided were instructions for reporting suspensions to Don Frederick of the National Office so that savings from the enactment of this amendment could be monitored. A requirement was not created, however, for reporting when a claimant whose compensation had been suspended under this provision was released from prison and again entitled to compensation. This has resulted in the potential for overstatement of savings.
Purpose: To alert district offices of the requirement that resumption of benefits previously suspended due to felony imprisonment must be immediately reported to the National Office, and to alert district office staff of the new contact person, Sheila Baker.
Applicability: District Directors, Assistant District Directors, Claims staff.
Action: Any claim where compensation has been suspended due to felony imprisonment should continue to be immediately reported to Sheila Baker at the National Office. Ms. Baker should also be promptly notified when the imprisonment ends and compensation resumes.
Disposition: Retain until incorporated in the Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1—-Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 97-15
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FECA BULLETIN NO. 96-01
Issue Date: October 5, 1995
Expiration Date: October 4, 1996
Subject: Codes--Nature of Injury Codes in Cases for Occupational Illness
Background: Until now, the Office of Workers' Compensation Programs (OWCP) has had one set of time frames for adjudicating claims for occupational illness. After some study, it has become clear that certain kinds of occupational illness cases can be adjudicated in much less time than is currently allowed.
Therefore, a second standard for occupational illness cases has been developed. Some groups of cases should now be routinely adjudicated within 90 days, whereas other groups should continue to be adjudicated within 180 days.
So that claims examiners will know which cases are to be adjudicated within 90 days and which cases are to be adjudicated within 180 days, each case must now have a Nature of Injury code which shows exactly what kind of injury is involved. For this reason, code "D9" can no longer be used.
Also, new codes were needed since certain diseases, such as eye strain, inguinal hernia, Lyme disease, and dental problems were not included in the previous list of codes. Such codes have been developed, and a list of all codes to be used effective the date of this bulletin is attached.
Purpose: To instruct Case Create Clerks in proper coding of nature of injury in occupational illness claims
Applicability: All Supervisors, Mail and File Personnel
Action:
1. When coding incoming cases, Case Create Clerks should use the attached list to identify the nature of injury. The code "D9" should no longer be used.
2. If the nature of injury does not appear on the list, or if it is not clear what code should be used, the Case Create Clerk should consult the claims staff member designated by district office management for guidance.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution:List No. 5--Folioviews Groups C and D
(All Supervisors, Index and Files Personnel, Systems Managers, and Technical Assistants)
Attachment to FECA Bulletin 96-01
|
CODE |
DEFINITION |
|---|---|
|
TA |
Amputation |
|
TB |
Back strain |
|
TC |
Contusion; bruise; abrasion |
|
TD |
Dislocation |
|
TE |
Exposure (including frostbite, heat stroke/exhaustion) |
|
TF |
Fracture |
|
TH |
Hernia (inguinal) |
|
TJ |
Crush injury |
|
TK |
Concussion |
|
TL |
Laceration; cut |
|
TP |
Puncture (not insect bite) |
|
TS |
Strain (not back) |
|
TT |
Tooth injury |
|
TU |
Burn, scald, sunburn |
|
TV |
Foreign body in eye |
|
TY |
Insect bite |
|
TI |
Traumatic skin diseases/conditions, including dermatitis |
|
TR |
Traumatic respiratory disease |
|
TQ |
Traumatic food poisoning |
|
TW |
Traumatic tuberculosis |
|
TX |
Traumatic virological/infective/parasitic diseases |
|
T1 |
Traumatic cerebral vascular condition; stroke |
|
T2 |
Traumatic hearing loss |
|
T3 |
Traumatic heart condition |
|
T4 |
Traumatic mental disorder; stress; nervous condition |
|
T8 |
Traumatic injury - unclass. (except disease, illness) |
|
|
|
|
(G ) |
Gastrointestinal |
|
|
|
|
GH |
Hiatal, umbilical or ventral hernia |
|
GU |
Ulcer |
|
G9 |
Gastrointestinal, not otherwise classified |
|
|
|
|
(S ) |
Skin Disease or Condition |
|
|
|
|
SB |
Biological (including poison ivy, poison oak) |
|
SC |
Chemical |
|
SL |
Skin lesion (including blister, bunion, callus and corn) |
|
S9 |
Dermatitis, not otherwise classified |
|
|
|
|
(M ) |
Musculoskeletal and Connective Tissue |
|
|
|
|
MA |
Arthritis |
|
MB |
Back or neck strain, sprain |
|
MC |
Carpal Tunnel Syndrome |
|
MD |
Degenerative Disc Disease; spondylosis; spondylitis |
|
MI |
Inflammatory Disease (including bursitis, tendinitis) |
|
MK |
Chondromalacia |
|
M9 |
Musculoskeletal condition, not otherwise classified |
|
|
|
|
* Injury or condition must be caused by a specific incident or event which occurred during a single work day or shift. |
|
|
|
|
|
CODE |
DEFINITION |
|
(R ) |
Respiratory Disease |
|
|
|
|
RA |
Asbestosis |
|
RB |
Bronchitis, asthma |
|
RE |
Emphysema |
|
RP |
Pneumoconiosis (Black Lung) |
|
RR |
Reaction to smoke, fumes, chemicals |
|
RS |
Silicosis |
|
R9 |
Respiratory disease, not otherwise classified |
|
|
|
|
(V ) |
Virological, Infective and Parasitic Diseases |
|
|
|
|
VA |
Acquired Immune Deficiency Syndrome (AIDS) and HIV |
|
VB |
Brucellosis |
|
VC |
Valley Fever (Coccidioidomycosis) |
|
VH |
Hepatitis |
|
VL |
Lyme Disease |
|
VM |
Malaria |
|
VP |
Parasitic Diseases |
|
VR |
Rocky Mountain Spotted Fever |
|
VS |
Staphylococcus |
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VT |
Tuberculosis |
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V9 |
Virological/Infective/Parasitic, not otherwise classified |
|
|
|
|
(C ) |
Cardiovascular/Circulatory |
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CA |
Angina |
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CB |
Blood Disorder |
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CH |
Hypertension |
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CM |
Myocardial Infarction (Heart Attack) |
|
CP |
Phlebitis; varicose veins |
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CS |
Stroke; cerebral vascular condition |
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C9 |
Cardiovascular/circulatory, not otherwise classified |
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(O ) |
Occupational disease, non-complex |
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OF |
Food poisoning |
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OG |
Tooth and gum-related problems |
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OL |
Inguinal Hernia |
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OP |
Pregnancy (Peace Corps only) |
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(D ) |
Other Disability, Occupational |
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DH |
Hearing loss |
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DI |
Vision/sight loss |
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DM |
Mental disorder; emotional condition; nervous condition |
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DN |
Nerve injury, incl. paralysis, after exposure to toxins |
|
DR |
Radiation |
|
DT |
Tumors and other cancer-related conditions |
Back to Top of FECA Bulletin No. 96-01
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-02
Issue Date: November 5, 1995
Expiration Date: November 4, 1996
Subject: Dual Benefits--Severance and Separation Pay
Background: Employing agencies may grant severance pay to employees who are involuntarily separated as part of a reduction in force (RIF). Severance pay represents a certain number of weeks worth of salary or wages, and it is usually computed as a lump sum.
Employing agencies may also offer separation pay ("buyouts") to encourage employees to leave Federal employment voluntarily. For example, the U.S. Postal Service offered a six-month lump-sum payment as part of its Special Retirement Option, as described in FECA Bulletin No. 93-1.
We have received many questions about entitlement to compensation during periods covered by severance or separation pay. The purpose of this bulletin is to explain which payments constitute dual benefits under the FECA and the actions which district office staff should take when a claimant receives one of these forms of payment. (Determining loss of wage-earning capacity (LWEC) under these circumstances is addressed in FECA Procedure Manual Chapter 2-1500.9.)
Severance pay was first authorized by the Federal Employees' Salary Act of 1965 (Pub. Law 89-301, since codified at 5 U.S.C. 5595). Under this statute, severance pay could not be paid "concurrently with salary or on account of the death of another person." FECA Program Memorandum 55, dated January 24, 1968, interpreted the phrase "concurrently with salary" to allow payment of severance pay to claimants receiving benefits for LWEC, since the severance pay is calculated on the basis of the salary only, and does not take claimants' LWEC payments into consideration. Also, a schedule award may be paid concurrently.
Health benefits and optional life insurance coverage may continue during the period of severance pay as long as the OWCP eventually makes appropriate payments for the time period covered by the severance pay to the Office of Personnel Management (OPM).
Separation pay is offered in different forms by different agencies. Sometimes it is defined as a number of weeks of pay, and other times as a specific amount of money. How separation pay is defined is determined by the law governing the operations of the agency in question. For example, in 1992 the Postal Service calculated its payments as six months of the employee's base pay, while the Department of Defense, beginning in 1993, used the amount of severance pay to which the individual would have been entitled, or $25,000, whichever was less. The method of offset differs somewhat according to how the separation pay is defined (see below).
Reference: 5 U.S.C. 8116; FECA Program Memorandum 55
Purpose: To provide instructions for payment of compensation, deductions for health benefits and optional life insurance, and later claims for compensation in cases involving severance and separation pay.
Applicability: Claims Examiners, Senior Claims Examiners, All Supervisors, Technical Assistants, Staff Nurses, Rehabilitation Specialists, and Fiscal Officers in the district offices; and Hearing Representatives
Action:
1. Nature of Payment. Before attempting to address entitlement to benefits, it will be necessary to determine whether severance pay or separation pay is at issue. The employing agency should provide this information. If there is any doubt, request a copy of the pertinent law (or at least a citation to it). If the nature of the payment remains unclear after correspondence or discussion with the employing agency, the Supervisory Claims Examiner or higher-level manager should contact the National Office for further guidance.
The employing agency should also submit a copy of the claimant's acceptance of the offer of separation pay and severance pay (if applicable) and the separation or retirement papers themselves.
Some employees may be entitled to both severance and separation pay. If the separation pay is based on a specific sum of money, address separation pay first (see item 3 below). Otherwise, the two types of payment may be addressed in either order.
2. Severance Pay.
a. Section 5 U.S.C. 5595(c), which governs severance pay, states as follows:
(c) Severance pay consists of--
(1) a basic severance allowance computed on the basis of 1 week's basic pay at the rate received immediately before separation for each year of civilian service up to and including 10 years for which severance pay has not been received under this or any other authority and 2 weeks' basic pay at that rate for each year of civilian service beyond 10 years for which severance pay has not been received under this or any other authority; and
(2) an age adjustment allowance computed on the basis of 10 percent of the total basic severance allowance for each year by which the age of the recipient exceeds 40 years at the time of separation.
Total severance pay under this section may not exceed 1 year's pay at the rate received immediately before separation. For the purpose of this subsection, "basic pay" includes premium pay under section 5545(c)(1) of this title.
b. Claimants are not entitled to compensation payments for temporary total disability (TTD) during the period covered by the severance pay. For example, if a claimant receives 13 weeks worth of severance pay, compensation is not payable until the fourteenth week.
The employing agency will need to advise the OWCP of the total dollar amount of severance pay and the date of separation or retirement.
c. Compensation payments should be suspended for the period in question, effective the date of separation or retirement, by 100% offset for the number of weeks (not the amount of money) which the severance pay represents. The total amount of the severance pay should be divided by the salary used to compute it to determine the number of weeks for which compensation payments should be suspended. The employee will not be entitled to compensation payments at least through the end of that period.
d. Where the OWCP finds out after the fact that severance payments were made to a claimant for the same period that compensation was paid, an overpayment must be declared and the usual due process rights provided.
e. Compensation for a schedule award may be paid concurrently with severance pay. Also, medical benefits continue to be payable.
f. Severance pay may also be paid concurrently with compensation for LWEC. The basis for allowing concurrent payment for LWEC is that the amount of severance pay is based on the employee's reduced salary, not OWCP's payments for LWEC. If an employee who is receiving compensation for LWEC receives severance pay and then retires, an election of benefits will be required at the time of retirement.
3. Separation Pay Based on Period of Time.
a. The entitlement to benefits is as described for those entitled to severance pay (items 1a-1c above). That is, the claimant may not receive compensation for TTD, but may receive compensation for a schedule award or LWEC based on a given number of weeks of compensation at the current rate of salary (i.e., the salary as reduced to reflect the claimant's LWEC) concurrently with separation pay.
b. Provisions for offset and overpayments are also as noted above for severance pay. A claimant who was receiving compensation for TTD should be advised that payment of these benefits will cease immediately because he or she has elected to receive separation pay and severance pay (if applicable).
4. Separation Pay Based on Amount of Money.
a. The entitlement to benefits is as follows: a claimant may not concurrently receive payment for TTD or LWEC, but may receive payment for a schedule award. The reason for the difference in policy with respect to payments for LWEC is that, under 5 U.S.C. 8116 (a), lump-sum separation payments are not included in the categories of payments which may be made concurrently with compensation payments (except, of course, for schedule awards). As with other kinds of severance and separation payments, medical benefits continue to be payable.
b. The employing agency should advise the OWCP of the total dollar amount of separation pay and the date of separation or retirement. This amount should be applied to the amount of compensation for wage loss on a dollar-for-dollar basis. The claimant should be advised of the approximate time the offset will end; the estimate may be affected by application of cost-of-living increases, etc.
5. Health Benefits and Optional Life Insurance.
a. For claimants with health benefits and/or optional life insurance coverage, compensation should be suspended at the net rather than the gross amount to allow OWCP to collect the appropriate deduction(s) and forward them to OPM. Form CA-25 should be completed so that only the amounts of deductions for health benefits and/or optional life insurance are payable. The amounts are payable to OPM. If compensation payments are suspended at the gross rate, it will be necessary to contact the claimant to arrange for payment of the premiums for the period in question.
b. The agency will transfer the health benefits enrollment to OWCP effective the date that employment ceases. The claimant is responsible only for his or her own share of the premiums.
c. Claims and Fiscal personnel may receive inquiries concerning entitlement to continuation of health benefits coverage under the Temporary Continuation of Coverage (TCC) program. This program allows employees who have been involuntarily separated to continue their coverage for a short period of time. The TCC program will not allow the enrollment of an individual who is entitled to compensation, and it will terminate any existing enrollment of a person entitled to either of these benefits.
6. Claims for Additional Compensation.
a. If a schedule award ends during the period covered by the separation or severance payment, the employee may claim additional compensation for disability (see subparagraph b below). If the claimant was not receiving compensation for disability before the schedule award, he or she would not be entitled to receive compensation afterwards unless it could be shown that the medical condition had worsened to the point that it disabled him or her from the regular or limited duty job performed before separation. Should entitlement to additional compensation be established, the employee will need to elect between OWCP and retirement benefits (if eligible).
b. A separated employee who was not receiving compensation at the time of separation because of placement in a modified job with no loss of pay will not be entitled to further compensation at the end of the period covered by separation or severance pay solely because the modified job is no longer available. A claimant who has returned to duty, whether regular or light, has the burden of proof to show that injury-related disability had worsened to the point that he or she is now disabled for the limited duty position (see Terry L. Hedman, 38 ECAB 222).
c. Benefits will not necessarily be reinstated in cases where the employee shows that the condition has worsened, since he or she might have been able to continue performing the modified job even if the condition worsened. Therefore, where a formal LWEC decision has not been issued, the employing agency should be asked to submit a description of the employee's job duties, including the physical requirements, at the time of separation. With this evidence, it will be possible to determine if the employee has any further entitlement to compensation.
d. An employee who establishes that his or her accepted condition worsened to the point of being unable to perform a modified job will be required to make an election of benefits, if eligible for retirement, since he or she has been formally separated. An employee who elects OWCP benefits should receive compensation for TTD and be considered for referral for vocational rehabilitation services to explore reemployment in another job.
e. Employees working part time, or working full time but at lower rates of pay, will be entitled to continue receiving compensation at the end of the period covered by separation or severance pay at the LWEC rate, if injury-related disability continues and they elect OWCP benefits in favor of retirement benefits. Should a recurrence be claimed, it will be their burden to show that injury-related disability has worsened (see question 6 above).
f. An employee who was performing regular duty at the time of separation would be entitled to receive compensation only if a true recurrence of disability were established (see subparagraph b above).
g. An employee who accepts separation pay and then changes his or her mind may not receive compensation for the duration of entitlement to separation pay or severance pay (if applicable). After that time, a claimant who remains entitled to benefits on the basis of total disability or LWEC when separated, and who contacts OWCP seeking compensation, will be offered an election of benefits.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 --Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 96-02
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-03
Issue Date: November 30, 1995
Expiration Date: November 29, 1996
Subject: Excluded Provider Changes
Background: The National Office has in the past maintained a data file of medical providers which were excluded under the FECA program. The source of most of these exclusions was the Department of Health and Human Services, Office of the Inspector General (HHS OIG). These exclusions make up most of the so-called automatic exclusions. In addition, district offices have regulatory authority to exclude medical providers for a variety of reasons. These inhouse exclusions comprise most of the so-called non-automatic exclusions.
Formerly, all updates to the National Office excluded provider file were made manually. Periodically, updated reports of excluded providers were sent to district offices and were also made available to Federal employers for their use in authorizing medical treatment. When updates were made to the National Office data file, the geographically appropriate district offices were also informed, so that the provider payment flag on the local Sequent provider file (v46) could be set to N for "no".
Major changes have been made to the ADP systems portion of the excluded provider process. A new excluded provider data file has been created at National Office (m41). This file has a different format from the previous data files. The m41 file will be updated automatically from data provided by the HHS OIG. The m41 file can also be updated manually, to allow for exclusions from other sources, including the inhouse non-automatic exclusions.
A new data file at the district office Sequents (v41) is an extract of the m41 file. The v41 file will be updated periodically. Whenever the v41 file is updated, the records in that file will be compared to the records on the office's existing v46 file (provider file), using the tax identification numbers. If a match is found, the v46 file record will be flagged as an excluded provider (the excluded provider flag will be Y for "yes"). In addition, whenever a new provider is added to the provider file, the provider update program checks tax identification number against the v41 file to determine whether that provider has been excluded, and if a match is found, the v46 exclusion flag is set to Y. A message concerning the exclusion status of the provider appears at the top of the provider update screen.
The new excluded provider flag is in addition to and does not replace the existing v46 payment flag, which is set by the district office, and is Y for "yes" if the provider is payable. District offices also have the ability to query the v41 (excluded provider) file, using either a tax identification number or a last name. Within a short time, district offices will also be able to run reports of the records in the v41 file.
A new edit has been added to the BILL552 process which is based on the provider exclusion flag in v46.
Reference: 20 C.F.R. Chapter 10, Subpart F; Federal (FECA) Procedure Manual Chapter 3-800, Exclusion of Medical Providers.
Purpose: To inform offices of changes to the excluded provider process, and provide revised procedures.
Applicability: Regional Directors, District Directors, Systems Managers, District Medical Advisors, Claims and Bill Resolution staff, and individuals responsible for secure provider file updates in the district offices.
Action:
1. Updates to the v41 file (excluded providers) will be performed promptly by the operations staff. Whenever v41 updates are done, a new excluded provider report (BILL610) will be run and be made available to district office staff. (Note that the report is not yet available, but will be shortly.)
2. When providers are added to the provider file (v46) by the authorized individual(s) responsible for security input, a check against the v41 file (using the tax identification number) will be made automatically by the system. A message appears on the BILL005 (provider master file update) screen stating whether the provider is excluded or not, based upon the v41 data. In addition to the automated check, an on-line excluded provider query must be performed, using the provider's last name, to determine whether the provider is excluded. Excluded provider query is option 19 on the FECS001 bill payment menu and option 24 under the FECS001 query menu. A copy of the screen is shown as Attachment 1. This action is necessary because providers may use different tax identification numbers, and the information from the HHS OIG contains Social Security Numbers, rather than Employer Identification Numbers. For organizations, the first word of the organization should be used to query. A flow may be set up between FECS001 bill payment menu options 19 (excluded provider query) and 5 (provider update). In place of the on-line query, once it is available, the latest excluded provider report may be checked to determine whether the name of the provider appears on the report, and has been excluded. If the provider is present in the on-line query or on the excluded provider report, but was not identified as an excluded provider in the provider update screen, the district office payment flag should be set to N for "no" when the provider is added to v46 (provider file), and the National Office notified.
3. Offices will continue to flag a v46 provider record for non-payment when an inhouse or non-automatic exclusion is made. The Director for FEC will also be informed, preferably by memorandum. The National Office will then add the provider to the m41 table, and the local v41 exclusion flag should be set to Y automatically the next time a v41 update is done. After the v41 flag has been set to Y, the district office may change the v46 payment flag to Y.
4. A new bill processing system edit 201 is based upon the new v46 exclusion flag. If the exclusion flag is Y for a provider, and a bill from that provider is data entered and edited by the BILL552 process, edit 201 will fail. Edit 201 failure results in suspension of the bill for manual review. The resolver should check the excluded provider query (or report) to ensure that the excluded provider's name matches the name on the bill. Complete instructions for resolving edit 201 failures are contained in Attachment 2. This attachment should be inserted in the thick BPS edit by edit resolution job aid.
5. The description and resolution instructions for BPS edit 202 have been modified slightly to reflect the differences between edits 201 and 202. The modified information is contained in Attachment 3. This modified sheet should be substituted for the existing edit 202 sheet in the thick BPS edit by edit resolution job aid.
6. E-mail containing Attachments 2 and 3, as well as an updated condensed edit listing, and EOB listing has been sent to each office.
7. Each office should continue to keep a written file of actions taken with respect to non-automatic exclusion of providers.
8. Any problems or inaccuracies noted with respect to the v46 exclusion flags or v41 records should be brought to the attention of the Director for FEC. An example of such a problem would be if a provider was shown as excluded on the system, but provided documentation that the exclusion had been rescinded or was in error.
9. It should be noted that the excluded provider file includes a large number of providers for whom no tax identification number was provided. These providers, which include organizations as well as individuals, are being placed on the excluded provider file and may be viewed through a name query. Because of variances in name formats, the entire name for these providers is placed in the last name field.
10. Excluded provider information is also used by Federal agencies when they authorize medical treatment for injuries covered under the FECA. The excluded provider report should be made available to employing agencies upon request. The National Office also provides excluded provider information to employing agencies on a periodic basis, either by report or diskette.
Training for all personnel affected by these changes should be conducted no later than November 30, 1995.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
|
EXCLUDED PROVIDER QUERY SCREEN |
||
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PAYEE NO: 123456789 |
LAST NAME: JONES |
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PAYEE NAME: |
FIRST: JOHN |
MI: J |
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ADDR: 123 MAIN STREET |
||
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CITY: ANYWHERE |
ST: DC |
ZIP: 20210 |
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SANCTION DATE: 09/21/1995 |
NOTIFY DATE: 09/01/1995│ |
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SOURCE OF EXCLUSION: H - HHS |
||
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NEXT RECORD [Y/N] |
||
This is what the screen would look like if a query were performed using the last name of Jones. The user is able to view all of the records which contain "JONES" in the last name field by responding "Y" for "yes" to the NEXT RECORD prompt.
|
FECA Bulletin 96-3 |
Attachment 1 |
Back to Top of FECA Bulletin No. 96-03
MEDICAL BILL SYSTEM
EDITS
EDIT NO. 201H
ERROR DESCRIPTION: PROVIDER EXCLUDED UNDER FECA
EDIT DESCRIPTION:BILL TIN MATCHES THAT OF A RECORD ON THE PROVIDER FILE WITH V46_EXCLUDE_FLAG OF Y (FOR YES).
SUSPEND/DENY: S
OVERRIDE: Y
EOB: Payments to this provider are excluded under Federal Regulations 20 C.F.R. Part 10, Subpart F.
PRIORITY: 1
BILL RESOLUTION:
1. Verify that the TIN (tax identification number) was keyed correctly. Correct any errors.
2. If the TIN was keyed correctly, verify that this particular provider has been excluded by querying provider exclusions, preferably on-line, and matching the name of the provider. This flag is activated by the national office. The flag is set to Y when the provider has been excluded automatically from participation in FECA. These flags are updated periodically.
3. If the provider has been formally excluded from participation in FECA, deny bill with EOB 201 (above), unless a CA-16 authorization was issued to the excluded provider. If a CA-16 authorization was issued, the bill should be paid by overriding the edit. The CE is responsible for rescinding the CA-16 authorization. If this particular provider has not been excluded, but shares a tax identification number with an excluded provider, the edit failure may be overridden.
4. If it appears that the exclusion flag is in error, national office should be contacted.
|
FECA Bulletin 96-3 |
Attachment 2 |
Back to Top of FECA Bulletin No. 96-03
MEDICAL BILL SYSTEM
EDITS
EDIT NO. 202H
ERROR DESCRIPTION: PROVIDER SUSPENDED OR UNDER REVIEW
EDIT DESCRIPTION:BILL TIN MATCHES THAT OF A RECORD ON THE PROVIDER FILE WITH V46_PAYMENT_FLAG OF N (FOR NO).
SUSPEND/DENY: S
OVERRIDE: Y
EOB: Payments to this provider are excluded under Federal Regulations 20 C.F.R. Part 10, Subpart F.
PRIORITY: 1
BILL RESOLUTION:
1. Verify that the TIN (tax identification number) was keyed correctly. Correct any errors.
2. If the TIN was keyed correctly, determine why the provider file payment flag has been set to no. This flag is activated by the district office. The flag may have been set because of a non-automatic exclusion, or a need to review all of this provider's bills. The systems manager or other office manager should maintain information on these providers.
3. If the provider has been formally excluded from participation in FECA, deny bill with EOB 202 (above), unless a CA-16 authorization was issued to the excluded provider. If a CA-16 authorization was issued, the bill should be paid by overriding the edit. The CE is responsible for rescinding the CA-16 authorization.
4. If the flag has been activated with the purpose of reviewing services rendered by the particular provider, the bills should be reviewed by the CE. If the services are approved for payment the edit is overridden. Non-reimbursable services are denied with an appropriate EOB.
|
FECA Bulletin 96-3 |
Attachment 3 |
Back to Top of FECA Bulletin No. 96-03
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-04
Issue Date: January 25, 1996
Expiration Date: January 24, 1997
Subject: September 1995 DFEC/OPM Computer Match
Background: Another DFEC/OPM computer match, designed to identify possible occurrences of prohibited concurrent dual benefit payment, was completed in September using the data for the August 19, 1995 periodic roll cycle. The data shared with OPM again included the death roll, and excluded schedule award cases. 55 cases survived the manual and automated screening processes employed by OPM.
With its advance copy of this bulletin, each District Office will receive a computer printout of the cases under its jurisdiction which should be screened, followed and reported on in accordance with the procedures described in FECA Bulletin 95-22 and again specified below. The presence of a case on the list should indicate that benefits were being paid by both DFEC and OPM on August 19, 1995, in apparent violation of the dual benefit prohibitions. (Note: The Boston, Philadelphia and Kansas City District Offices had no "hits" from this match.)
For this, and future matches, we will continue the procedures used for the past few years; that is, OPM and the responsible District Offices will directly converse and correspond in order to resolve the hits. The District Offices will continue to have National Office reporting requirements, as detailed below. However, any problems that arise with OPM, or with any other aspect of processing the match hits, should be raised with Alex Senecal (202) 219-8461 for resolution. Telephone inquiries to OPM should be directed to Jim Najjar at (202) 606-0235 (or 0232). Written inquiries or other correspondence should be directed to the Office of Personnel Management, Program Integrity Section, P.O. Box 7174, Room 2309, Washington, D.C. 20044, Attention: Jim Najjar.
Purpose: To inform District Offices of the procedures for follow-up review and reporting requirements concerning the "hits" identified in the September 1995 DFEC/OPM match, and to reiterate continuing reporting requirements for the previous OPM matches.
Applicability: District Directors, Assistant District Directors.
Action: Each District Office with one or more cases appearing as hits from this match will receive a copy of a computer printout detailing the information on those cases, in a combined listing of disability and death cases. (On this printout the OPM Claim Number begins with "A" for disability cases and begins with "F" for death cases. Also, if the first digit of the OPM Claim Number is 7 or 8 then benefits are being paid under FERS rather than CSRS.) In addition, "hit sheets" completed by OPM should have already been mailed directly to the District Offices by OPM. Please note that the field identified on the printouts as "OWCP Gross" is actually the FECA 28 day payment amount converted to a 30 day equivalent for easy comparison purposes. The "OWCP Net" field is the actual 28-day gross compensation amount paid.
FB 96-04 September 1995 DFEC/OPM Computer Match
1. Immediately pull and review each disability (OPM "A" prefix) case listed in which the OPM gross payment amount exceeds the FECA gross payment amount. (For these cases the OPM amount is underlined on the printout.) If a review of the case confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
2. Review the remaining disability cases (those where FECA benefits exceed OPM benefits), and the death (OPM "F" prefix) cases (as detailed below). In the disability cases where FECA benefits are greater, OPM will seek the election and return a copy of the election along with a completed OPM "hit sheet" to DFEC.
3. In death/survivor cases (OPM "F" prefix), an informed election must be made before either benefit is terminated. Please remember that split elections can be made. In fact, several de facto split elections were discovered during previous matches; that is, there appeared to be dual benefits situations when in fact different beneficiaries were receiving OPM and FECA benefits. In other cases split elections have been made as a result of the matches. It is important that truly informed elections are made in these cases. During the 3rd match you were advised of our revised policy regarding the revocability of elections in death cases. That change was formalized by revision to the regulations. However, OPM maintains that survivor elections are irrevocable; that is, that once an election of FECA benefits is made, the beneficiary may not subsequently elect OPM benefits, unless the FECA entitlement is later determined to have been mistaken, or there is a third-party credit absorption.
Therefore, included in the information provided to a beneficiary in order for him/her to make an informed election should be a statement that an election of OPM benefits can later be changed to elect FECA benefits, but that the reverse is not possible. In addition, an informed election should be based on a comparison of each beneficiary's benefits. Where the total converted gross FECA benefit is greater than the total OPM benefit, OPM will obtain the election of benefits and return a copy of the election along with a copy of the OPM "hit sheet" to DFEC.
Where the total OPM benefit exceeds the total converted gross FECA benefit and the review of the file confirms that the claimant is, in fact, in receipt of prohibited dual benefits, then action should be taken immediately to obtain an election from the claimant. If the receipt of dual benefits was discovered as a result of this computer match, the claimant should be advised of this. The claimant should be advised that the benefit not elected will be terminated and that he or she may dispute the dual benefit finding and proposed action. The claimant will be given 30 days to complete and return an election of benefits form. Upon receipt of the completed election form, the benefit not elected is to be terminated as soon as possible. A copy of the election form is to be returned to OPM along with a copy of the supplemental "hit sheet." If the claimant fails to make an election or to dispute the dual benefit finding within the 30 day period, the claimant should be removed from the compensation rolls as soon as possible.
4. In any case which results in a DFEC overpayment, the District Office should take immediate action in accordance with the overpayment procedures specified in Part 6 of the Procedure Manual.
5. Each DFEC overpayment case should be reviewed in order to determine whether the usual notifications concerning the prohibition against receiving concurrent retirement and compensation payments have been made. If so, the assumption must be made that the claimant is not without fault when such an overpayment occurs. Thus, except where this assumption is overcome by the evidence in the case file, a CA-2201 should be released immediately. Examiners are reminded that the supporting memorandum should explicitly detail the notification made.
6. When the appropriate overpayment letter is released, a 30-day call-up should be placed in the file. As soon as possible after a final decision has been released, administrative offset should be requested from OPM.
7. Initial review of all the listed cases should be completed and a report submitted by January 15, 1995, and quarterly thereafter until each "hit" is resolved. This review should confirm or refute the information supplied, the receipt of dual benefits and, where receipt of dual benefits is confirmed, determine whether or not there is an election of benefits on file. Each report must include, as appropriate:
a. The FECA case number and beneficiary name for each listing.
b. For death cases, the name, date of birth and relationship to the decedent should be listed for each eligible beneficiary.
c. Periods for which FECA benefits have been paid (specify schedule award periods).
d. Was the payment of dual benefits discovered through this match? (yes/no)
e. Is there an election on file? (yes/no) If yes, a copy of the election letter should be attached.
f. Have compensation payments been terminated? If so, effective on what date?
g. Is there an overpayment of compensation? (yes/no)
h. Is DFEC responsible for recovery?
i. What is the amount of the OPM overpayment?
j. What is the amount of the FECA overpayment transferred to the Accounts Receivable ledger?
k. Dates of subsequent due process and collection actions, including issuance of overpayment letters, final decision, release of SF-2805 to OPM requesting offset, etc. (Note: The current version of the SF-2805, Revised October 1988, should be used.)
Follow-up reporting for this match and for unresolved cases from prior matches should continue quarterly (by the 15th day of the first month of each quarter, i.e., 4/15, 7/15, 10/15, 1/15) until final resolution of the matter, until, for example, either the debt has been collected in full, a repayment schedule has been established and met at least once, or the account is otherwise closed. The final report should describe the repayment plan and/or date of payment. For example, the final report should show that a CA-2201 was issued on March 6, 1996; a final decision was issued on April 10, 1996 finding an overpayment of $2000; an SF-2805 was issued on May 20, 1996; the first payment of $200 was received from OPM on August 1, 1996; the debt will be recovered by June 1997. (Note: For OPM debts, reporting may cease once the OPM overpayment amount has been reported. You no longer need to report any actions on OPM debts beyond this point.)
Disposition: This Bulletin should be retained until all actions have been completed.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 6
(Regional Directors, District Directors, Assistant District Directors, Systems Managers, Technical Assistants and National Office Staff)
Back to Top of FECA Bulletin No. 96-04
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-05
Issue Date: December 15, 1995
Expiration Date: January 4, 1997
SUBJECT: ADP - Automated Compensation Payment System (ACPS) and Debt Management System (DMS) Report Schedule - 1996.
PURPOSE: To provide the 1996 schedule for processing the periodic disability and death payrolls under the ACPS and the DMS weekly and monthly reports for calendar year 1996.
APPLICABILITY: All appropriate personnel are to be made aware of the periods and "cut-off" dates for the ACPS periodic disability, death, and daily payrolls.
The production schedule for the DMS periodic reports is made available for the appropriate personnel. IT IS IMPERATIVE that this schedule be closely followed.
DISPOSITION: This bulletin should be retained in front of Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachments
Distribution: List No. 2--Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
|
CHECK |
PERIOD |
BI-WEEKLY PAY PERIODS |
DISTRICT OFFICE |
N.O. CHK OF |
|---|---|---|---|---|
|
1 |
01/07/96-02/03/96 |
01/07/96 - 01/20/96 |
01/24/96 |
01/26/96 |
|
2 |
02/04/96-03/02/96 |
02/04/96 - 02/17/96 |
02/21/96 |
02/23/95 |
|
3 |
03/03/96-03/30/96 |
03/03/96 - 03/16/96 |
03/20/96 |
03/22/96 |
|
4 |
03/31/96-04/27/96 |
03/31/96 - 04/13/96 |
04/17/96 |
04/19/96 |
|
5 |
04/28/96-05/25/96 |
04/28/96 - 05/11/96 |
05/15/96 |
05/17/96 |
|
6 |
05/26/96-06/22/96 |
O5/26/96 - 06/08/96 |
06/12/96 |
06/14/96 |
|
7 |
06/23/96-07/20/96 |
06/23/96 - 07/06/96 |
07/10/96 |
07/12/96 |
|
8 |
07/21/96-08/17/96 |
07/21/96 - 08/03/96 |
08/07/96 |
08/09/96 |
|
9 |
08/18/96-09/14/96 |
08/18/96 - 08/31/96 |
09/04/96 |
09/06/96 |
|
10 |
09/15/96-10/12/96 |
09/15/96 - 09/28/96 |
10/02/96 |
10/04/96 |
|
11 |
10/13/96-11/09/96 |
10/13/96 - 10/26/96 |
10/30/96 |
11/01/96 |
|
12 |
11/10/96-12/07/96 |
11/10/96 - 11/23/96 |
11/27/96 |
11/29/96 |
|
13 |
12/08/96-01/04/97 |
12/08/96 - 12/21/96 |
12/24/96 |
12/27/96 |
|
*ENDING PERIOD IS THE CHECK DATE |
||||
|
DATE OF CHECK |
DISTRICT OFFICE CUT-OFF DATE |
N.O. CHECK TAPE |
|---|---|---|
|
EACH FRIDAY** |
PREVIOUS TUESDAY |
PREVIOUS WEDNESDAY |
|
**FOR EFT PAYMENTS, EACH FRIDAY |
||
| Date | Report |
|---|---|
|
12/22/1995 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/16/1995 -12/22/1995) |
|
12/29/1995 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/23/1995 -12/29/1995) |
|
01/02/1996 |
MONTH END PROCESSING (12/31/1995) |
|
O1/05/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
01/08/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/30/1995 -01/05/1996) |
|
01/16/1996 |
WEERLY CASH RECEIPTS/INTEREST REPORT (01/06/1996 -01/12/1996) |
|
01/22/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/13/1996 -01/19/1996) |
|
01/29/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/20/1996 -01/26/1996) |
|
01/31/1996 |
MONTH END PROCESSING (01/31/1996) |
|
02/05/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/27/1996 -02/02/1996) |
|
02/05/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
02/12/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/03/1996 -02/09/1996) |
|
02/20/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/10/1996 -02/16/1996) |
|
02/26/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/17/1996 -02/23/1996) |
|
02/29/1996 |
MONTH END PROCESSING (02/29/1996) |
|
03/04/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
03/04/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (02/24/1996 -03/01/1996) |
|
03/11/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/02/1996 -03/08/1996) |
|
03/18/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/09/1996 -03/15/1996) |
|
03/25/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/16/1996 -03/22/1996) |
|
03/27/1996**** |
SPECIAL ACPS/DMS DEBT NUMBER MATCH**** |
|
03/31/1996 |
MONTH END PROCESSING (03/31/1996) |
|
04/01/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/23/1996 -03/29/1996) |
|
04/08/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (03/30/1996 -04/05/1996) |
|
04/15/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/06/1996 -04/12/1996) |
|
04/22/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/13/1996 -04/19/1996) |
|
04/26/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
04/29/1996 |
WEERLY CASH RECEIPTS/INTEREST REPORT (04/20/1996 -04/26/1996) |
|
04/30/1996 |
MONTH END PROCESSING (04/30/1996) |
|
05/06/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (04/27/1996 -05/03/1996) |
|
05/13/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/04/1996 -05/10/1996) |
|
05/20/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/11/1996 -05/17/1996) |
|
05/24/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
05/28/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/18/1996 -05/24/1996) |
|
05/31/1996 |
MONTH END PROCESSING (05/31/1996) |
|
06/03/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (05/25/1996 -05/31/1996) |
|
06/10/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/01/1996 -06/07/1996) |
|
06/17/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/08/1996 -06/14/1996) |
|
06/21/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
06/24/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/15/1996 -06/21/1996) |
|
06/28/1996 |
MONTH END PROCESSING (06/30/1996) |
|
07/01/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/22/1995 -06/28/1996) |
|
07/08/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (06/29/1996 -07/05/1996) |
|
07/15/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/06/1996 -07/12/1996) |
|
07/19/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
07/22/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/13/1996 -07/19/1996) |
|
07/29/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/20/1996 -07/26/1996) |
|
07/31/1996 |
MONTH END PROCESSING (07/31/1996) |
|
08/05/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (07/27/1996 -08/02/1996) |
|
08/12/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/03/1996 -08/09/1996) |
|
08/16/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
08/19/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/10/1996 -08/16/1996) |
|
08/26/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/17/1996 -08/23/1996) |
|
08/30/1996 |
MONTH END PROCESSING (08/31/1996) |
|
09/03/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/24/1996 -08/30/1996) |
|
09/09/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (08/31/1996 -09/06/1996) |
|
09/13/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
09/16/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/07/1996 -09/13/1996) |
|
09/23/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/14/1996 -09/20/1996) |
|
09/30/1996 |
MONTH END PROCESSING (09/30/1995) |
|
10/01/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/21/1996 -09/27/1996) |
|
10/07/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (09/28/1996 -10/04/1996) |
|
10/11/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
10/15/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/05/1996 -10/11/1996) |
|
10/21/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/12/1996 -10/18/1996) |
|
10/28/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/19/1996 -10/25/1996) |
|
10/31/1996 |
MONTH END PROCESSING (10/31/1996) |
|
11/04/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (10/26/1996 -11/01/1996) |
|
11/08/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
11/12/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/02/1996 -11/08/1996) |
|
11/18/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/09/1996 -11/15/1996) |
|
11/25/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/16/1996 -11/22/1996) |
|
11/29/1996 |
MONTH END PROCESSING (11/30/1996) |
|
12/02/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/23/1996 -11/29/1996) |
|
12/06/1996 |
ACPS/DMS DEBT NUMBER MATCH |
|
12/09/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (11/30/1996 -12/06/1996) |
|
12/16/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/07/1996 -12/13/1996) |
|
12/23/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/14/1996 -12/20/1996) |
|
12/30/1996 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/21/1996 -12/27/1996) |
|
12/31/1996 |
MONTH END PROCESSING (12/31/1996) |
|
01/03/1997 |
ACPS/DMS DEBT NUMBER MATCH |
|
01/06/1997 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (12/28/1996 -01/03/1997) |
|
01/13/1997 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/04/1997 -01/10/1997) |
|
01/21/1997 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/11/1997 -01/17/1997) |
|
01/27/1997 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/18/1997 -01/24/1997) |
|
01/31/1997 |
MONTH END PROCESSING (01/31/1997) |
|
02/03/1997 |
WEEKLY CASH RECEIPTS/INTEREST REPORT (01/25/1996 -01/31/1997) |
Back to Top of FECA Bulletin No. 96-05
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-06
Issue Date: January 29, 1996
Expiration Date: January 27, 1997
Subject: Case Management--Role of Registered Nurses in QCM Cases
Background: The Federal Employees' Compensation program has had two years of experience in using the services of registered nurses to assist in medical management of disability claims and help claimants return to work. Staff Nurses and Field Nurses have identified several policies which affect their ability to bring claimants back to work at their fullest potential. Also, district office and national office staff have been discussing the nurses' role during the 60-day period after the claimants' return to work, especially in light of the downsizing of the Federal government. Among the foremost issues raised are follow-up by the nurse after return to light duty, the effects of surgery, and other kinds of medical situations which may develop.
Until now, the focus of the 60-day return-to-work period has been to ensure that the claimant remains on the job. Where the job is other than full-time full duty, we have not emphasized the need to increase the number of hours of work, or to help the claimant progress from light to full duty. In the period just after return to work, the nurse should remain involved to help the claimant reach higher levels of physical capacity, resulting wherever possible in return to full-time full duty. Toward this end, Claims Examiners (CEs) will now be able to extend the nurses' time beyond the usual 60-day follow up when return to full(er) duty is imminent.
At the same time, it is also clear that delays in returning to work or problems in remaining at work may be caused by other medical conditions, either work-related or not. Nurses sometimes continue working on such cases, but by the time the claimant has recovered from the concurrent condition or surgery and return to work has again become a viable goal, the nurses have often exceeded their allotted 120 days. To remedy this situation, we are instituting an interrupted status for nurse services.
References: FECA PM Chapters 2-600 and 3-201; OWCP Bulletin Nos. 91-2 and 93-6; MEDGUIDE Chapter 1
Purpose: To describe when extensions and interruptions of the Field Nurse's time may be warranted, and the actions which Staff Nurses, Field Nurses and Claims Examiners should take
Applicability: All Claims Examiners, Supervisors, Staff Nurses, Rehabilitation Specialists, and Technical Assistants
Action: Nurse intervention can result in various outcomes. If the intervention progresses along the normal course, the expected result is that the claimant returns to work within 120-180 days. Action items have been grouped by topic for ease of reference.
LIGHT/PART-TIME DUTY
1. Field Nurses (FNs) should stress to claimants the need to return to maximum functioning and work potential. Return to light duty should be considered just the first step in helping claimants reach their maximum abilities. After the claimant has returned to work, the FN should continue to pursue increases in work tolerance limitations and obtain descriptions of them on Form OWCP-5 at periodic intervals if the claimant does not return to full-time full duty. These attempts should be made at approximately two to three week intervals unless the facts of the case suggest a different plan.
2. After the 60-day follow-up period ends, the FN may continue to work toward full-time full duty if the medical evidence shows that such an outcome is likely. The FN and the Staff Nurse (SN) should recommend additional time in increments of no more than 30 days each, up to a total of 60 days. The Claims Examiner (CE) must authorize each increment.
3. In authorizing the extension, the CE must note on the Form CA-110 (or other form; see Attachment 1 for a sample) the goals of continued intervention, the steps the CE has directed the FN to take, and the time frame for performing the work. The goals should be consistent with the medical evidence of record, and they must be specific, i.e., framed as a stated number of hours within a stated time frame. The CE should also advise the SN of the extension. See Attachment 2 for a sample tracking sheet, which should be maintained in the case file.
SURGERY AND OTHER MEDICAL ISSUES
4. Return to work may be delayed by the need to obtain a second opinion evaluation. The FN may help the CE or Medical Management Assistant to identify physicians who can perform such examinations on an expedited basis.
5. Return to work may be delayed or interrupted by other medical conditions (work-related or not), by pregnancy, or by surgery. The chart below lists some common surgical procedures and their usual recovery times. As with the medical matrices contained in MEDGUIDE, this information is meant to serve as guidance, not the last word in determining a return to work date.
|
FB 96-06 Case Management--Role of Registered Nurses in QCM Cases |
|||
|
TTT |
TYPE OF SURGERY |
PROCEDURE |
EXTENSION |
|
A. Simple, |
Endoscopies, |
30 day extension, |
|
|
B. Moderately |
Discectomies |
60 day extension, |
|
|
C. Very complex |
Multiple fusions, |
Work with claimant |
|
In general, the simple procedures should require no more than 8-10 hours of professional nurse services within the 30-day period. The moderately complex procedures will require about 12-16 hours of services within the 60-day period. Since the complex procedures will typically result in work limitations which may warrant referral for vocational rehabilitation services, the FN should work toward stabilizing the claimant's condition and obtaining Form OWCP-5 in these cases.
6. For a concurrent non-work-related condition, or surgery (whether work-related or not), the SN should determine whether continued FN services will likely be needed within six months.
If so, and the CE concurs, the SN should place the case in interrupted status until the time of expected recovery. (Interrupted status, rather than an extension, is appropriate since the claimant would require little or no active involvement by the FN during this time.)
The FN may not unilaterally interrupt services, and the CE's approval is necessary because any interruption will affect the one-year time frame for resolving the case. Interrupted status should not continue longer than six months. The status code "NIN" (Nurse Interrupt) has been added to the QCM tracking system and is available for immediate use. The Nurse/Rehabilitation Tracking System (N/RTS) will also be modified to accommodate entry of an interrupt status code.
7. During the interruption, the FN should stay in touch with the claimant to monitor medical issues and maintain a focus on return to work. If surgery is involved, the FN will typically review the attending physician's orders with the claimant after surgery and monitor the claimant's course at home. Also, the FN may discuss the post-operative plan with the physician by telephone and monitor the claimant's compliance with these orders. The RN may perform these services up to five hours per month.
MANAGEMENT BY CLAIMS EXAMINERS
8. The CE must assess the medical evidence carefully and use judgment to determine the continuing benefit of the FN's services. For instance, if the medical evidence states that the claimant will be able to work eight hours per day within a month, the situation is straightforward, and the CE may authorize another 30 days of FN services. However, if the claimant has reached a plateau and is unlikely to improve, nurse services should be terminated.
9. Timely responses to telephone calls from FNs are crucial to successful case management. Interventions, whether by telephone or in writing, do not necessarily need to be long and involved. Brief but timely inquiries and reminders to physicians, employing agencies, and RNs are often very effective.
10. The claimant may progress from light to full duty or from four to six or eight hours of work a day, then claim a recurrence of total disability or a relapse which returns the claimant to light duty status or fewer hours of work per day. In addition to developing the claim for recurrence, the CE will need to decide whether the FN should continue to work with the claimant, or whether referral for vocational rehabilitation services is needed. This decision should be based on whether return to work with the Federal employing agency remains feasible, the length of time since the original injury, and the degree of disability.
REFERRAL FOR VOCATIONAL REHABILITATION SERVICES
11. In cases where at 120 days (or sooner) the FN cannot identify any potential for return to the previous employment, the FN must obtain a good description of work tolerance limitations using Form OWCP-5 and then recommend referral for vocational rehabilitation services if there is any ability to work. The FN may also recommend a second opinion examination. The SN may complete Form OWCP-14 to refer the case for vocational rehabilitation services, but may not sign the form. The actual referral remains the CE's responsibility.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
REQUEST FOR EXTENSION OF FIELD RN SERVICES
CLAIMANT NAME:__________________________________
FILE NUMBER:_____________________
NO. OF DAYS REQUESTED:___________
REASON FOR EXTENSION:____________
Change of attending physician
Released to light duty
Monitor RTW full time full duty
FIELD RN INTENDS TO ACCOMPLISH:
CE AUTHORIZATION:________________________________
DATE:__________________________
FIELD RN:_________________________________________
TELEPHONE NO:__________________
FAX NO:________________________
Attachment 1
Back to Top of FECA Bulletin No. 96-06
PLANNING CHART FOR QCM CASES
|
Claimant Name |
DOB |
DOI |
File Number |
|
|
Accepted Condition(s)
|
ICD-9 Codes
|
|
||
|
Date Wage
|
10 Month Letter/
|
Reinstatement
|
||
|
Date RN
|
Status at 120 Days |
|||
|
RN Services
|
Date/How Long
|
Reason
|
| Interrupted |
|
|
Date/How Long
|
Reason
|
|||
|
Date/How Long
|
Reason
|
|||
|
RN Services |
Date/How Long
|
Reason
|
||
|
Date/How Long
|
Reason
|
|||
|
Date/How Long
|
Reason
|
|||
For interruptions and extensions which will exceed the date of the 10 month letter, the SCE must initial concurrence with the time frame
Attachment 2
Back to Top of FECA Bulletin No. 96-06
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-07
Issue Date: January 7, 1996
Expiration Date: January 4, 1997
Subject: Compensation Pay: Compensation Rate Changes Effective January 1996.
Background: In December 1995, the President signed an Executive Order implementing a salary increase of two percent in the basic pay for the General Schedule. The applicability under 5 U.S.C. 8112 only applies to the two percent increase in the basic General Schedule. Any additional increase for locality-based pay is excluded. The adjustment is effective the first pay period after January 1, 1996.
Purpose: To inform the appropriate personnel of the increased minimum/maximum compensation rates, and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The new rates will be effective with the first compensation payroll period beginning on or after January 1, 1996. The new maximum compensation rate payable is based on the scheduled salary of a GS-15, Step 10, which is now $90,090 per annum.
The minimum increase specified in this Bulletin is applicable to Postal employees.
The effect on 5 U.S.C. 8112 is as follows:
|
Effective January 7, 1996 |
Minimum |
Maximum |
|---|---|---|
|
Monthly |
$1,160.25 |
$5,630.63 |
|
Weekly |
200.81 |
1,299.38 |
|
Daily (5-day week) |
40.16 |
259.88 |
The basis for the minimum compensation rates is the salary of $13,923 per annum (GS-2, Step 1) and the basis for the maximum compensation rates is $90,090 per annum (GS-15, Step 10). The effect on 5 U.S.C. 8133(e) is to increase the minimum monthly pay on which compensation for death is computed to $1,160.25, effective January 7, 1996. The maximum monthly compensation as provided by 5 U.S.C. 8133(e)(2) is increased to $5,630.63 per month.
Applicability: Appropriate National and District Office personnel.
Reference: Memorandum For Directors of Personnel (CPM 95-10), dated December 29, 1995; and the attachment for the 1996 General Schedule.
Action: ACPS will update the periodic disability and death payrolls. Any cases with gross overrides will not have a supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustments Dates.
a. As the effective date of the adjustment is January 7, 1996, there will be no supplemental payroll necessary for the periodic disability and death payrolls.
b. The new minimum/maximum compensation rates will be available in ACPS on or about January 26, 1996.
2. Adjustment of Daily Roll Payments. Since the salary adjustments are not retroactive, it is assumed that all Federal agencies will have ample time to receive and report the new pay rates on claims for compensation filed on or after January 1, 1996. Therefore, it will not be necessary to review any daily roll payments unless an inquiry is received. If an inquiry is received, verification of the pay rate must be secured from the employing establishment.
3. Minimum and Maximum Adjustment Listings. Form CA-842, Minimum Compensation Pay Rates, and Form CA-843, Maximum Compensation Rates, should be annotated with the new rate information as follows (later this year these forms will be reproduced):
|
CA-842 |
|||||
|
1/07/96 |
40.16-60.24 |
200.81-301.22 |
40.16 |
200.81 |
1,160.25 |
|
CA-843 |
|||||
|
1/07/96 |
259.88 |
1,299.38 |
(5,197.52) |
5,630.63 |
|
4. Forms. CP-150, Minimum/Maximum Compensation, will be generated for each case adjusted. Notices to payees receiving an adjustment in their compensation will be sent from the National Office. Form CA-839, Notice of Increase in Compensation Award, will be utilized for this purpose. Manual adjustments necessary because of gross overrides should be made on Forms CA-24 or CA-25 with a notice sent to the payee by the District Office.
Disposition: This bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 96-07
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-08
Issue Date: March 1, 1996
Expiration Date: February 28, 1997
Subject: Comp Pay/ACPS - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 1996.
Purpose: To furnish instructions for implementing the CPI adjustments of March 1, 1996.
1. The new CPI increase, adjusted to the nearest one-tenth of one percent, is 2.5 percent.
2. The increase is effective March 1, 1996, and is applicable where disability or death occurred before March 1, 1995.
3. The new base month is December 1995.
4. The maximum compensation rates which must not be exceeded are the following:
$ 5,630.63 per month
1,299.38 per week
5,197.52 each four weeks
259.88 per day (for a 5-day week)
Applicability: Appropriate National Office and District Office personnel.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981.
Action: On or about February 23, 1996, both the periodic disability and death payrolls will be updated in ACPS. If there are any cases with gross overrides, there will be no supplemental record created. Thus, the cases with gross overrides must be reviewed to determine if CPI adjustments are necessary. If adjustment is necessary, a manual calculation will be required.
1. Adjustment Dates.
a. The periodic disability and death supplemental payrolls for CPI adjustments will cover the period March 1 through March 2, 1996, with the new cycle effective March 3, 1996.
b. The supplemental check date for the periodic disability and death payrolls will be March 19, 1996.
2. Adjustments of Daily Roll Payments. Since the CPI will not be in ACPS until February 23, 1996, daily roll payment cases requiring the new CPI should be held for data entry until that date.
3. CPI, Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated with the new information.
4. Forms.
a. Form CA-837, Notice to Payee, will be sent to the payees on the periodic disability and death payrolls. The notice will be sent to the payees from the National Office. The CA-837 will be addressed using the ACPS Correspondence Address File. PLEASE be sure to maintain the address file as you do with the Payee Address File and the CMF. PLEASE remember that an address change to the CMF DOES NOT automatically change the ACPS check address or correspondence address. ACPS must be accessed and the enter key must be depressed through the address areas. Be watchful for those payments being sent via Direct Deposit.
b. Any manual adjustments necessary because of gross overrides in cases should be made on Form CA-24 or CA-25. A notice to the payee should be sent from the district office.
c. CP-140 will be printed for each case adjusted. These should be drop filed in the case file.
Disposition: This Bulletin is to be retained in Part 5, Benefit Payments, Federal (FECA) Procedure Manual, until further notice or the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 --Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisors, Fiscal Personnel, Systems Managers, Technical Assistants, and Rehabilitation Specialists)
Back to Top of FECA Bulletin No. 96-08
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-09
Issue Date: June 17, 1996
Expiration Date: June 17, 1997
Subject: Occupational Rehabilitation Programs (ORPs)
Background: There are a great variety of rehabilitation services available to help the injured worker return to work, and to expedite that process through the use of abbreviated workdays or altered job duties. As a group, these services, which were previously known as work hardening or work conditioning, are now defined as Occupational Rehabilitation Programs (ORPs). Although some report significant successes, professionals in rehabilitation concur that the lack of standards in this area make it difficult to identify programs with positive outcomes and reasonable cost.
The substantial increase in the length and cost of such services over the past year has prompted inquiry about their quality, appropriateness, and outcomes. Moreover, these services constitute a workload for district offices. The lack of a coding scheme often results in inappropriate denials, suspensions and fee reductions. Conversely, the lack of codes prevents the application of cost controls. To encourage the use of effective services and to prevent abuse, OWCP has developed guidelines for the authorization and reimbursement of occupational rehabilitation services. These guidelines are intended to aid as a resource for: (1) the selection of claimants who would benefit from these services, (2) the identification of programs that are effective and cost efficient, (3) setting limitations on the length and cost of ORPs, (4) providing methods for monitoring ORPs, and (5) establishing a means to measure program outcomes.
Purpose: To transmit guidelines for the authorization and reimbursement of Occupational Rehabilitation Programs (ORPs).
Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives, Supervisors, Technical Assistants, Rehabilitation Specialists, Staff Nurses, Bill Resolution Staff.
Action:
1. Identification of cases which could benefit from these services may arise from various sources:
(a) CEs refer the following cases to the Rehabilitation Specialist for an ORP assessment:
i. cases in which a health care provider has recommended rehabilitation, unless the claimant has already returned to full regular duty,
ii. QCM cases in which the Field Nurse (FN) period has been exhausted but the claimant has not returned to work, and has been determined to have moderate to high physical limitations/deconditioning, or has not had an assessment of physical limitations.
(b) The RS initiates an ORP placement and notifies the responsible CE in any case already open for vocational rehabilitation which, in his or her opinion, may benefit from this type of service.
2. The RS reviews these cases and verifies that they meet the criteria detailed in Chapters 1-2 of the attached Guidelines.
3. Cases referred by the CE that meet the basic criteria are opened for rehabilitation. To open these cases, the RS introduces the appropriate case information in the RTS, using status M (medical rehabilitation), assigns a Rehabilitation Counselor (RC), and selects an ORP facility that meets the provider criteria and is as close as possible tot he claimant's residence. If the case is already in an open rehabilitation status, the RS changes the status to M.
4. The RS refers the case to a RC for a screening interview and the scheduling of a Functional Capacity Evaluation (FCE) to determine the type and character of the ORP most suited to the claimant's needs. As usual, the RS forwards pertinent claim documentation, and a completed Form OWCP-35A to the RC. A Form OWCP-3 with detailed instructions relating to the ORP is also forwarded, accompanied by a completed authorization form for a Functional Capacity Evaluation with an Occupational Rehabilitation Plan (Table I). A maximum of three (3) months and twelve (12) professional hours are allowed for this status.
5. The RC assigned to the case previews the pertinent documentation and performs the claimant interview and categorizes the claimant as a potential candidate for a Return to Work (RTW) or a Work Readiness (WR) ORP in keeping with the criteria set forth in Chapters 2 and 3. The RC schedules a Functional Capacity Evaluation (FCE) in the selected facility and:
(a) Transmits all available information regarding job availability job description(s), the current work tolerance of the claimant and other relevant work site considerations,
(b) advises the facility of the purpose of the FCE, report requirements, and the necessity for a detailed description of any recommended ORP, including treatment schedules and cost,
(c) communicates timeliness requirements and instructions for billing, and sends a copy of the ORP-FCE authorization form (Table I).
6. Once the FCE is completed, the RC forwards the facility report with his or her own brief report, which should contain recommendations for actions. Based on these documents, and using the criteria detailed in Chapter 3, the RS selects and authorizes the appropriate ORP "class" for the claimant. He or she advises the facility and the RC of the types and number of services authorized. Tables II or III should be used for this purpose. Additionally, the RS or RC provides instructions on billing procedures and requirements, and informs the facility about the applicable price maxima.
7. The RS or another DO staff enters the authorization for the ORP in the "notes" section of the Claimant Management File (CMF). To ensure the accurate processing of facility bills, the following information must be included: the approved ORP category (RTW vs. WR) and class, the date range for the approved services. If additional services, such as work-site visits, or the use of modifiers are approved, a notation to this effect must be also included (See Guidelines, Chapter 4).
8. Once the particular program has been authorized and the claimant is enrolled in the ORP, the treating physician, employer (when available), the RC and the CE are notified using a Form OWCP-3.
9. The RC continues to act as a liaison with the ORP facility and he or she works with the claimant to ensure attendance and to resolve issues that arise during the ORP which may interfere with the completion of the program. Medical or other issues which could delay or terminate the ORP, such as the appearance of non-work related conditions, recurrences, complaints of high levels of pain, etc. have to be reported immediately to the RS and CE.
10. The RC provides reports as established in the district office, including a brief summary of the ORP activities, the progress of the claimant, problems awaiting resolution, and expected completion date. All request for extension of services or the provision of additional services such as work-site visits, follow-up treatments and the use of modifiers, should be reviewed and decisioned by the RS.
11. The RC must notify the RS immediately when an ORP is completed and he or she forwards the ORP final report to the RS as soon as this document is available. As a response, the RS changes the status to W, Placement Previous Employer with Services, to P, Placement New Employer, or to T, Training, as warranted in the particular case. The RS transmits this change and further instructions to the RC using a Form OWCP-3.
12. In instances where the results of the ORP indicate that the claimant is not able to perform the duties of the previous employment or the targeted jobs, the RS may place the case in D, Plan Development, with the concurrence of the CE to consider other rehabilitation solutions. In instances where the result of the ORP indicate that the claimant is able to perform the duties of the date of injury job, the RS should notify the CE immediately. Alternatively, the RS may select other options (eg. recommend the application of sanctions or the performance of a second opinion) and forwards the case to the CE.
13. When the ORP is interrupted before completion, the RC notifies the RS immediately, carefully detailing the reason(s) for the interruption. The RS communicates this fact to the CE and recommends an appropriate course of action based on the circumstances of the case. He or she also includes mention of this event in the CMF "NOTES", and change the approved last date of service to coincide with the date of the interruption.
14. Processing of ORP Facility Bills.
(a) Bills from an ORP facility that is providing authorized services are "prompt pay" bills.
(b) Facilities should submit a single global bill at the end of the ORP on a Form HCFA-1500 or UB-92. The bill should contain all the data elements required to process bills through the automated bill processing system, including: the claimant's name, address, and claim file number; and the provider's name, address, and EIN. In addition, the provider must include the pertinent OWCP ORP codes, with the corresponding units (hours), the amount billed code, and the total amount of the bill.
(c) Because these bills will contain unique alphanumeric codes, they can be identified and batched together prior to data entry. Once data entered, the bill lines will fail Error Code 302, and manual resolution will be required to process them to completion. To resolve these suspensions, the designated district office staff should access the CMF "Notes" and verify whether an ORP has been authorized. If so, the codes on the bill are matched against the ORP category (RTW vs. WR) and "class", and the dates of services on the bill are matched against the authorization period present in the "Notes". If a line meets the above conditions, the edit failure is overridden.
(d) If a line does not meet the above condition, the bill resolver forwards the bill to the district office staff responsible for the resolution of problematic rehabilitation bills. This other staff consult with the RS and the facility as necessary and take appropriate action.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1
(Claims Examiners, All Supervisors, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Attachment
Back to Top of FECA Bulletin No. 96-09
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-10
Issue Date: May 9, 1996
Expiration Date: May 8, 1997
Subject: Adjudication of Claims: Use of Incorrect Form
Background: In examining cases received in the Branch of Hearings and Review, National Office staff have increasingly noticed that claims are sometimes denied because they are filed on the incorrect form, without substantive development. For example, Form CA-1 may be submitted to claim a recurrence, or Form CA-2a may be submitted for another episode of a condition for which a Form CA-2 is already on file. (With respect to the latter instance, see FECA PM Chapter 1500.3b(2)(e), which states that a new claim need not be filed.)
Submission of an incorrect form is only a technical error, and it is improper to deny a case simply because the claimant has not submitted the correct form. The case should be developed and adjudicated on the basis of the evidence submitted. Moreover, to the extent possible, the same Claims Examiner should handle all claims involving the same part of the body for a given claimant.
Reference: FECA PM Chapters 2-400.8, 2-800.4 and 2-1500.3
Purpose: To describe actions to be taken when an injury, illness or recurrence of disability is claimed using an incorrect form
Applicability: All Claims Examiners, Supervisors, and Technical Assistants
Action:
1. As indicated in FECA PM 2-800.4, if a Form CA-1, Form CA-2 or Form CA-2a is incorrectly submitted in place of another form, the Claims Examiner (CE) should develop the claim based on the facts at hand. The development letter should include a request that the claimant complete the proper form, and the CE should include a blank copy of the proper form with the current claim number written in large letters on the top of the form.
2. The CE should not deny the case on the basis of the form filed, even if the case is technically in posture for denial. For instance, if Form CA-1 is received and Form CA-2 is actually required, the CE should not deny the case on the basis that fact of injury is not established.
3. However, if Form CA-1 has been submitted in error, it may be necessary to deny payment of continuation of pay. This action may be taken in conjunction with the development letter. 4. When the requested Form CA-1 or CA-2 has been received, the Case Management Record should be changed to reflect the correct form, so that the adjudication time frame for the case will be accurate. A case previously entered into the Disability Tracking System in error should be removed. Similarly, if Form CA-2a was requested and received, the case should be entered into the Disability Tracking System.
5. The CE should evaluate the evidence as a whole as it pertains to a given part of the body. To do so, case doubling may be necessary. FECA PM 2-400.8 describes the current criteria for doubling cases, which are being modified to include the following situations:
a. A new injury is reported for an employee who has filed a previous injury claim for a similar condition;
b. Two or more separate injuries (not recurrences) occurred on the same date.
c. Adjudication or other processing of a case will require frequent reference to an earlier case for a dissimilar condition. Cases of this nature include those where problems arise with bill pay and/or mail placement, such as when the same physician is treating the claimant for more than one injury; and those with overlapping periods of disability.
Cases should be doubled as soon as they are identified as proper to double. Changes of responsible CE should be avoided if possible.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 96-10
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-11
Issue Date: July 9, 1996
Expiration Date: July 8, 1997
Subject: Compensation - Revised Leave Buy-Back Procedures
Background: In February 1995, a team of OWCP employees met in Washington D.C. to reinvent the current leave buy back (LBB) procedures.
Surveys of OWCP employees indicated that the existing LBB process was cumbersome and time-consuming for claims examiners, and often confusing for both injured workers and federal employing agency staff. In addition, data shows that only about one-half of claimants elect to repurchase their leave after the CA-1207 is issued and they become aware of the additional payment the agency requires beyond the amount of their FECA entitlement.
A decision was made to simplify the current procedures from a two step process to a one step process, with the CE issuing an immediate payment (instead of a CA-1207) where possible.
Two new forms, a Time Analysis Form (CA-7a) and a Worksheet/ Certification and Election Form (CA-7b), have been developed to be filed with Form CA-7 in LBB claims. The new form CA-7a is to be used when leave dates are intermittent or when more than one continuous period of leave is claimed. The CA-7b fully explains the process to the claimant and allows an estimate of the FECA entitlement. It requires the employing agency to advise the employee of the amount required by the agency to reinstate the leave in question and to agree to the process in advance of submission of the form. Based on past experience with non-returned EN-1207s, many claimants will decide at this point not to file the claim when they become aware of the balance they must pay to have their leave restored.
The revised CA-7 claim form refers the claimant to new forms CA-7a if time was lost for intermittent hours or days and CA-7b for leave repurchase. These forms are supplements to the CA-7 and a CA-7 must be submitted as part of the claim. If the claim is incomplete, it may be returned to the employer for completion and tracking is not required, as with current practice.
Unless there is a significant variance between the agency estimate of FECA entitlement and the actual entitlement, the LBB claim can be paid immediately upon receipt of the completed claim providing the medical evidence supports injury related time loss for each date claimed. A significant variance exists where the estimated entitlement is more than 10% above the actual entitlement. If there is a significant variance between the agency estimate and the CE's calculation and supporting medical evidence has been provided for all hours claimed, the CE advises the claimant of this via CA-1207 and requires return of a signed EN-1207 election before the claim is paid. If there is a 10% variance and medical evidence has not been provided for some or all of the hours claimed, the CE will develop the medical status before proceeding further. Please see item 7 under "Action" for a more detailed explanation.
If the estimated entitlement was calculated accurately but there is insufficient medical evidence to support all hours claimed, the CE will process the claim for the verified hours.
ACPS will be updated to include a relationship code "LB" which will automatically generate the correct agency payee address for leave buy back. The claims examiner will have the option of automatic or manual generation of a revised Form Letter CA-1208. If the claim is payable as presented, the automatically generated CA-1208 will be used. If only a portion of the claim is payable, the CE will generate a manual version of the CA-1208 (designated CA-1208a) and enter text concerning the unpaid periods.
The CA-7b instructions request the claimant to submit the LBB claim within one year of the date the leave was used or the claim was accepted, whichever is later. While the CA-7b instructions are designed to encourage more timely submission, claims older than one year cannot be denied on that basis.
The CA-7b instructions also request that claims be submitted for a minimum of ten hours of leave unless no further claims are anticipated. This is intended to reduce the frequency of claims and time required for processing by both the agency and OWCP.
This revised LBB process enables the examiner to resolve most LBB claims to conclusion upon initial submission, even where payment is not made for all dates claimed.
Copies of the new CA-7a, CA-7b, CA-1207, CA-1208, and CA-1208a form letters are attached.
Purpose: To provide instructions for implementing streamlined leave buy-back processing.
Applicability: Claims examiners, Supervisors, Systems Managers, Technical assistants, Fiscal Personnel, and other appropriate staff of the National and District Offices, and the Branch of Hearings and Review.
Reference: 20 CFR 10.310, Buy back of annual or sick leave Federal (FECA) Procedure Manual, Chap 2-901 (13) Comptroller General decision B-112786, January 26, 1953
Action: Each office Systems Manager or other designated staff will enter specific agency addresses for LBB payments into a new LBB address maintenance table.
Effective August 1, 1996, except as noted in paragraph 8 (below), LBB claims will be processed as follows:
1. On receipt of the agency certified LBB claim (CA-7, CA-7a, CA-7b) mailroom staff will key it into the TPCUP system and deliver it to the office designated location.
2. The CE will review the claim to insure it is complete. If the claim is incomplete or unsigned, the CE will return the claim for completion. The CE will advise the claimant by letter as to what was missing and document the case file with a copy of the letter. Returned claims do not have to be tracked and can be deleted from TPCUP as with current practice.
3. When the FECA District Office receives the package, the CE will first review the estimate of FECA entitlement on the CA-7b. If the estimate of entitlement is within 10% of the amount determined to be accurate by the CE, the CE proceeds to review the supporting medical evidence.
For example, let us assume that the agency has estimated FECA entitlement to be $1500 for 100 hours of leave use. The CE, using the correct pay rate and compensation rate, determines the correct amount to be $1470 for those hours. Since the agency's estimate is less than 10% above the correct amount, the CE will proceed to evaluate the medical evidence.
4. If the claim is payable for all hours claimed, the CE will round the total number of hours payable to the nearest whole hour, key the payment using relationship code "LB", and obtain payment certification. Entry of the relationship code "LB" will cause the payment to be made to the agency address designated for LBB payments (this may be the same as the agency correspondence address). Answer "yes" to the system prompt for automatic generation of the CA-1208. This action will automatically generate the revised form letter CA-1208 to the claimant and agency showing that the claim was accepted in full with the inclusive dates and amount of the payment made. The CA-1208 will not have to be signed by the CE and can be mailed by other staff.
In rare situations, the total FECA entitlement will exceed the amount owed by the claimant to the employing agency. In these instances, the employing agency will pay the claimant any balance due.
5. Where there is medical support for some but not all of the hours claimed, the CE will key a payment for the approved hours.
Using the example in 3 (above), if medical evidence only supports 80 of the 100 hours claimed, the CE will key the payment for the 80 approved hours, and will manually generate Form Letter CA-1208a. Even though we are not paying all of the hours claimed, payment can be made because the amount actually paid will be proportionately the exact same percentage of the agency estimate of FECA benefits.
The Letter CA-1208a will show the total number of hours approved and the inclusive dates, with a freeflow entry explaining any additional hours not approved for payment. The CE will enter a TPCUP "D1" code. This will close out OWCP processing of that particular leave buy back claim. If the claimant is able to obtain medical support for the unpaid hours, he/she may initiate a new leave buy back claim specifically for those hours.
6. If medical evidence received is insufficient to support payment of the hours claimed, the CE will defer a decision on the claim. The claimant will be advised in writing of the deficiency of the claim and given 30 days to provide the supporting evidence.
If medical evidence is received in response to the request, the CE will evaluate it and proceed as outlined in paragraph 4 or 5 above.
If no medical evidence is received or if the evidence is not sufficient to establish entitlement for any of the hours, the CE will deny the leave buy back claim by formal decision.
7. If the employing agency's estimate of FECA entitlement differs from the CE's calculation of the correct amount by more than 10%, the CE will review the medical evidence before proceeding further.
Using the example in 3 with the agency estimate of $1500, let us assume that the CE determines the correct amount of FECA entitlement to be $1250 for the hours claimed. Since this is a variance of more than 10%, the CE will proceed as shown below after evaluating the medical evidence.
If there is medical evidence for all hours claimed, the CE will issue a letter CA-1207 showing the correct entitlement amount. If the claimant still wishes to pursue leave repurchase, he/she will then complete his/her portion of the enclosure EN-1207 and return it to the employing agency. If the parties reach an agreement on restoration of leave, the agency will complete its portion of the EN-1207 and forward the completed form to OWCP. The CE will then issue a compensation payment to the agency and release letter CA-1208 to the claimant, with a copy to the agency.
Where the medical evidence is insufficient to support all of the hours claimed, the CE will defer payment of the claim and send the claimant a narrative letter requesting additional medical documentation. The CE may also contact the employer if there is a question as to the correct pay rate to be used.
If there is no medical evidence to support any of the hours claimed, the CE will deny the leave buy back claim by formal decision.
8. District offices will use the old procedures to process LBB claims filed with the employing agency in the old format prior to 10/1/96, and will not require these to be resubmitted in the new format. The old form CA-1207 has been modified to advise parties of the new process and has been renumbered as CA-1206, and will be used to process these old claims.
9. All District Offices will conduct training on this bulletin prior to August 1, 1996. Please address any questions on any of this material to Cecile Moran (202) 219-8461 or email cmf@fenix2.
Disposition: Retain until incorporated in Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2 - Folioviews Groups A and D
(Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
DRAFT////////////////////////DRAFT/////////////////DRAFT
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Month 9, 1999 |
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File Number: 99999999 |
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claimant name/address |
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Dear FIRSTNAME M. LASTNAME:
Your claim for compensation to repurchase leave for the period indicated below has been approved in full.
This payment is based on your weekly salary of ($ ENTERED BY SEQUENT), as of (effective date of payrate used, ENTERED BY SEQUENT). This is paid at the rate of (the without dependents rate of 66 2/3rds, OR 75%, as you have one or more dependents - ENTERED BY SEQUENT).
The amount of compensation paid and the period covered are shown below. The full FECA payment has been made directly to your employing agency at the address below. If you have not already done so, you must make arrangements with your employing agency to pay any balance due for the repurchase of your leave. If your FECA entitlement exceeds the total amount required by your agency, your agency will pay you any balance due.
FECA compensation paid: $ (ENTERED BY SEQUENT)
Period covered by payment: 00/00/0000 to 00/00/0000 (ENTERED BY SEQUENT)
Sincerely,
Fname M. Lname
Claims Examiner
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Month 9, 1999 |
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File Number: 99999999 |
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claimant name/address |
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Dear FIRSTNAME M. LASTNAME:
Your claim for compensation to repurchase leave for the period indicated below has been approved in part.
This partial payment is based on your weekly salary of ($ entered by CE), as of (effective date of payrate used, entered by CE). This is paid at the rate of (the without dependents rate of 66 2/3rds, OR 75%, as you have one or more dependents - entered by CE).
The amount of compensation paid and the period covered are shown below. The FECA payment has been made directly to your employing agency at the address below. If you have not already done so, you must make arrangements with your employing agency to pay any balance due for the approved period. If your FECA entitlement exceeds the total amount required by your agency for the approved period, your agency will pay you any balance due.
FECA compensation paid: $ (entered by CE)
Period covered by payment: 00/00/0000 to 00/00/0000 (entered by CE)
We are unable to approve payment for the following dates and/or number of hours for the reasons stated:
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If you wish to pursue a claim for the unpaid time, please submit a new claim for the balance along with medical or other evidence relating to the reason for non payment.
Sincerely,
Fname M. Lname
Claims Examiner
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Month 9, 1999 |
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File Number: 99999999 |
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claimant name/address |
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Dear FIRSTNAME M. LASTNAME:
This refers to your claim for compensation for leave buyback for the period (to/from dates manually entered by CE).
Your agency's estimate of your FECA entitlement exceeded your actual entitlement by more than 10% Therefore, we must advise you of your actual entitlement, and require your election as whether you desire to pursue your claim since you must pay a greater amount to your employing agency than originally estimated.
Your actual entitlement is calculated as follows:
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a. Weekly pay rate as of (DOI, DDB, DOR as entered manually by CE) |
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b. Above weekly pay times either 2/3 (if no dependents) or |
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c. Number of leave hours approved for buyback |
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d. Total hours worked per week (see CA 7b, item F) |
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e. TOTAL actual FECA entitlement (B above times C above |
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Calculation for payment due to employing agency by employee |
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1. Total amount required by your agency to recredit leave |
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2. Actual FECA entitlement in (e) above |
$______ |
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3. Amount you owe your agency Item (1) LESS item (2) |
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If you desire to proceed with you claim, please complete the staement below, give a copy to your agency, and return the original to us. We will assume you do not desire to pursue your claim if your signed statement is not returned to us.
Sincerely,
Fname M. Lname
Claims Examiner
TO OWCP: I desire to proceed with my claim, and have made arangements to refund all leave pay received.
Signed_______________________________ Date___________________
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EMPLOYEE STATEMENT - Please carefully read instructions on reverse |
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From ___/___/___ To ___/___/___ |
for LWOP _________________ |
||||||
|
for leave buyback __________
|
|||||||
6. In "Type Leave" column use codes "S"=sick, "A"=annual, "O"=other If compensation is claimed for date, indicate "Yes" in "COMP claimed" column.
|
DATES |
COMP |
NUMBER OF HOURS |
TYPE |
Reason For Leave Use/Remarks |
|||
|
LWOP |
Worked |
Ho1 |
LVE |
||||
|
TOTALS |
|||||||
|
Signature of Claimant |
Date Signed |
|
__________________________________________________________________________________
|
|
|
__________________________________ |
__________________________________ |
CA-7a
INSTRUCTIONS FOR COMPLETING FORM CA-7A
LEAVE ANALYSIS
GENERAL: This form is used when claiming FECA compensation, including for repurchase of paid leave. It must be used when claiming compensation for more than one consecutive period of leave.
INSTRUCTIONS FOR EMPLOYEE:
Blocks 1, 2 and 3 are self-explanatory.
Block 4:indicate beginning and ending dates covered by this form. These must be the same as on forms CA-7 and CA-7b.
Block 5:if claiming compensation for any dates detailed in block 5, state total number of hours claimed for leave without pay and total number of hours of leave. This should be at least 10 hours unless this is your final claim.
Block 6:
1st Column: Show full date
2nd Column: For each date noted in column 1, state Y if you are claiming compensation for that date and N of you are not.
3rd, 4th, 5th and 6th columns: Show the number of hours of LWOP, number of hours worked, paid holiday hours, and number of hours of paid leave.
7th Column: Using the legend provided, indicate the type of leave used.
8th Column: State the reason you were off work. For each date for which compensation is claimed, there must be medical evidence supporting entitlement.
SIGN AND DATE FORM AND SUBMIT TO THE APPROPRIATE AGENCY OFFICIAL.
INSTRUCTIONS FOR EMPLOYING AGENCY
Block 7: Verify accuracy of hours and status for each date listed. If challenging entitlement for any date, attempt to resolve discrepancies prior to submitting the claim to OWCP. If discrepancy cannot be resolved, indicate the specific basis for the challenge in the space provided.
Back to Top of FECA Bulletin No. 96-11
|
LBB WORKSHEET/CERTIFICATION AND ELECTION FORM |
||||||
|
A. Name of Employee: |
Last |
First |
Middle |
B. OWCP File No. |
||
|
C. Social Sec. No. |
||||||
|
D. Period for which compensation is claimed to repurchase leave |
||||||
|
--------------------------------------------------------------- |
||||||
|
A. WEEKLY BASE PAYRATE (excluding overtime) |
||||||
|
o Date of Injury |
___/___/___ |
$_____ |
||||
|
o Date Stopped Work |
___/___/___ |
$_____ |
||||
|
o Date of Recurrence |
___/___/___ |
$_____ |
||||
|
Enter the greatest amount & the effective date of |
1. __________ __________ |
|||||
|
___ /___/___ |
||||||
|
B. ADDITIONS TO BASE PAY: If employee works a regular schedule, state the amount earned weekly. If irregular schedule, state amount earned 1 year prior to date entered on line 1 ö by 52. |
||||||
|
o Night Differential |
2. _________ |
|||||
|
o Sunday Premium |
3. _________ |
|||||
|
o Subsistence/Quarters |
4. _________ |
|||||
|
o Other (specify)
|
5. _________ |
|||||
|
C. TOTAL WEEKLY PAYRATE (Add lines 1 thru 5) |
6. _________ |
|||||
|
D. COMPENSATION RATE (Circle either 2/3 or 3/4) |
7. 2/3 3/4 |
|||||
|
E. TOTAL HOURS CLAIMED ON CA-7a |
8. _________ |
|||||
|
F. TOTAL HOURS WORKED PER WEEK |
9. _________ |
|||||
|
G. FORMULA (FOR FECA ENTITLEMENT) |
||||||
|
$__________ X |
__________ X |
_________-- |
__________ = |
10. $ _______ |
||
|
II. AGENCY CERTIFICATION: |
||||||
|
H. Total amount due agency to repurchase leave |
11. $ _________ |
|||||
|
I. Estimate of FECA entitlement (See Line 10) |
12. $ _________ |
|||||
|
J. Balance due Agency from Employee |
13. $ _________ |
|||||
|
I hereby certify that the above is consistent with agency payroll records. |
||||||
|
The employing agency agrees to allow the employee to repurchase his/her leave. Leave records will be, or have been, changed from "Leave With Pay" to "Leave Without Pay" for the period shown on the leave analysis. |
||||||
|
I further certify that if this claim is signed by the employee, the employee has made arrangements to pay the agency the balance between the total amount the agency requires to recredit leave and the amount of the FECA entitlement. |
||||||
|
___________________________________ |
_________________________ |
|||||
|
Phone No:_________________________ |
Date Signed______________ |
|||||
|
Employing Agency Address for Check |
_______________________________ |
|||||
|
III. EMPLOYEE CLAIM |
||||||
|
____ K. I hereby elect NOT to repurchase the leave used at this time. |
||||||
|
____ L. I hereby elect FECA compensation to repurchase leave used for medical care or disability resulting from my job-related injury or condition. I understand that I am responsible for paying my agency the difference between the FECA entitlement and the amount my agency requires to restore my leave, and have done or made arrangements for this. I understand that if my actual entitlement to FECA compensation is within 10% of the amount estimated above, OWCP will process the leave buy back. If the payrate used in the worksheet above is within 10% of the payrate determined by FECA, and less than the full period claimed is approved, OWCP will process payment for the approved period. |
||||||
|
____________________________________________ |
_______________________ |
|||||
Back to Top of FECA Bulletin No. 96-11
INSTRUCTIONS FOR FORM CA-7B, LEAVE BUY BACK WORKSHEET
This form is intended to accompany Form CA-7, Claim for Compensation, when the employee is claiming leave buy back.
THINGS TO KNOW ABOUT LEAVE BUY BACK: When an employee uses their sick or annual leave to cover an injury-related absence from work, they may elect to receive compensation instead. Compensation is paid at 2/3 of the employee's base pay if there are no eligible dependents, or at 3/4 with 1 or more dependents. The agency pays leave at 100% of salary. In order for leave to be reinstated, the employee must refund to the agency the difference between the compensation entitlement and the total amount of leave paid by the agency.
The employee's pay status must be changed to LWOP in order for compensation to be paid. Leave is not earned while in LWOP. Also, contributions to the Thrift Savings Plan (TSP) are not made during LWOP. Therefore, the repurchase of leave may result in a reduction in an employee's leave and/or TSP balance. Consult your personnel office to learn how the change to LWOP would effect you.
When a Leave Buy Back (LBB) payment is made during the same year that leave is used, the employee's earnings are reduced by the amount repaid, and tax is not paid for the compensation received. Where leave repurchase is not completed during the same year in which leave is used, the employee may not adjust their prior year tax form. They may only claim the amount of leave paid as an employee expense, if they itemize deductions. Further questions regarding tax implications of LBB should be addressed to the IRS.
A claimant may not repurchase leave used during a period they were eligible for COP.
When disability does not exceed 14 days beyond the COP period, 3 day LWOP must be charged before compensation can be paid. If leave was used for this period, compensation can not be paid for the 3 days, but the claimant will have to pay back leave paid during the 3 days to repurchase the leave.
INSTRUCTIONS TO THE EMPLOYEE:
Please submit a claim for a minimum of 10 hours unless no further claim is anticipated. Medical documentation must be provided for all dates claimed.
1. Complete the Form Ca-7 for the dates claimed. Where more than one continuous period of leave is claimed, complete From CA-7a following the instructions for completing that form.
2. Submit the completed CA-7, CA-7a, if appropriate, and medical documentation for all dates claimed, to your agency official. If there are discrepancies, try to reconcile the difference with your agency official prior to submission of the claim.
3. The agency official will provide you with an estimate of worker's compensation benefits due, the total amount owed the agency in order for the leave to be restored, and the amount you must pay the agency. Using this information, determine whether you wish to repurchase your leave, and check the appropriate block. If you choose to repurchase the leave, you will be required to pay to the agency the difference between the compensation due and the amount owed to the agency.
a) If the total amount of FECA benefits estimated by the agency is not more than 10% above the amount determined by OWCP to be accurate, OWCP will process a payment for all hours supported by medical evidence. If medical evidence supports some, but not all of the hours claimed, payment will be made for the approved hours. You may submit a new claim with medical support for the additional hours.
c) If the total amount of FECA benefits estimated by the agency is more than 10% above the correct amount, OWCP will not process the payment. Instead, the Office will offer you a new election with the correct amount of FECA benefits payable.
INSTRUCTIONS TO THE AGENCY:
Items A through D (top of form) are self-explanatory.
Section I (Agency Estimate of FECA Entitlement):
Item A: Enter all three pay rate types and effective dates if applicable. Choose the greatest amount of the three and enter the amount and effective date in Line 1. A recurrent pay rate should only be used if: (1) the employee stops work more than 6 months following their first return to regular, full time duty and (2) the loss of time is due to disability rather than medical examinations or treatment.
For unusual situations, please refer to Payrate Desk Aid.
Item B: If the employee works a regular schedule, enter the differentials earned weekly. If an irregular schedule, give the total amount earned for the year prior to the date in Line 1 divided by the number of weeks worked in that year.
Please refer to Payrate Desk Aid for guidance on inclusions and exclusions. If in doubt, consult a Claims Examiner.
Item C: Add lines 1 through 5 and enter the total in Line 6.
Item D: Circle the appropriate rate: 2/3 for employees without dependents; 3/4 with dependents. Dependents include: spouse; children under 18 living with or supported by the employee; children under 23 in school full time; children over 18 incapable of self support; and parents wholly supported by the employee.
Item E: Enter the total hours claimed, from Form CA-7a.
Item F: Enter the total hours in the employee's normal work week.
Item G. Formula For FECA Entitlement: Use this formula to calculate estimate of FECA entitlement and enter the result in Line 10.
Example of computation: The weekly pay from line 6 is $574.00. The employee is married, works 40 hours a week, and is claiming 82 hours of leave. FECA entitlement is calculated as follows:
$574.00 x 3/4 x 82 hrs -- 40 hrs = $882.52
II. Agency Certification
Item H & I are self explanatory. For Line J, subtract Line I from Line H.
Sign and date and advise the employee of the amount they owe to the agency.
III. Employee Claim: If the employee elects not to repurchase the leave, retain the form in the agency files. If the employee elects to repurchase the leave, submit all claim documents (CA-7, CA-7a & CA-7b) plus any medical documentation too OWCP for processing.
Back to Top of FECA Bulletin No. 96-11
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FECA BULLETIN NO. 96-12
Issue Date: June 30, 1996
Expiration Date: June 29, 1997
Subject: OWCP Guidelines for General Purpose Functional Capacity Evaluations
Background: District offices report significant variability in the content, cost and quality of the Functional Capacity Evaluations (FCE's) provided to injured Federal workers. In addition, because there are no well-structured codes for these various services, processing of FCE bills often involves edit failures, manual resolutions, inappropriate fee schedule reductions, as well as telephone calls and letters from providers. To ensure the quality of these services, control their cost, and simplify the processing of bills, OWCP has developed guidelines for the authorization, evaluation, and payment of FCE's.
Under these guidelines, FCE's can be classified in two primary types according to their purpose, duration and content: (1) a general purpose GP-FCE, and (2) an FCE for placement into an Occupational Rehabilitation Program (ORP-FCE) such as Return to Work or Work Readiness (commonly called work-hardening, work conditioning, etc.). This bulletin discusses the General Purpose FCE (GP-FCE) while the FCE's associated with rehabilitation services are described in Bulletin No. 96-9.
Purpose: To transmit procedures and guidelines for the authorization and reimbursement of General Purpose Functional Capacity Evaluations (GP-FCE's).
Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives, Technical Assistants, Rehabilitation Specialists, Staff Nurses, and Bill Resolution staff.
Action:
1. A CE or Staff Nurse (SN) may authorize a GP-FCE in the following instances:
a. QCM cases undergoing nurse intervention where the treating physician recommends a FCE;
b. cases where management of disability call for clarification of job tolerances, job modifications, etc. and the treating physician, or the second opinion or referee specialist recommend or require this service.
2. Before authorizing the FCE, the CE or SN reviews the case and verifies that: the injury is greater than 3 months old, the functional impairment is of moderate to high complexity, and the services recommended by the physician exceed routine physical performance tests and measurements (e.g. CPT 97750).
3. The CE or SN authorizes the FCE and communicates the approval to the recommending physician, who in turn, makes the referral after requesting the name of a FCE facility. Based on the severity of the case, and the presence or absence of complicating factors, the CE or SN can approve up to eight hours for the GP-FCE.
4. The CE or SN completes the authorization form (Table A) and enters the authorization in the "Notes" section of the Case Management File (CMF). To ensure the accurate processing of facility bills, the following information must be included: the approved service code, the number of hours approved, the name of the provider, and, as necessary, the use of modifiers. He or she notifies the Field Nurse (FN) assigned to the case of the authorization of the FCE and provides the FN with a copy of the authorization.
5. After the FCE referral has been made, the FN conducts a brief telephone interview with the claimant to explain the purpose and expected content of the FCE, and to discuss any concerns the claimant has voiced regarding the FCE, expectations pending the outcome of the FCE, and related issues such as return to work. The claimant is to be made aware of his or her responsibilities regarding attendance, effort and cooperation.
6. The FN schedules the FCE in the selected facility and:
(a) transmits medical and work site information as necessary to the facility,
(b) advises the facility of the purpose of the FCE, the program's requirements regarding the content and timeliness of the facility's report,
(c) provides instructions for billing, and sends copy of the FCE authorization form.
(d) continues to be available to the claimant and the facility to resolve issues that may arise during the performance of the FCE.
7. It is expected that the GP-FCE report will be submitted to the CE or SN within three working days after completion of the evaluation and that it will meet OWCP guidelines (see Table B). Recommendations detailed in the GP-FCE report are evaluated by the CE in light of the nature of the case and the status of other case management procedures. If recommendations are made for a Return to Work or a Work Readiness Occupational Rehabilitation Program, the case is referred to the RS as described in Bulletin No. 96-9.
8. Processing of GP-FCE bills.
(a) Bills from a facility that is providing authorized services are "prompt pay" bills.
(b) The facility should submit a single global bill for the GP-FCE on a Form HCFA-1500 or UB-92. It should contain all the data elements required to process bills through the automated bill processing system, including: the claimant's name, address, and claim file number; and the provider's name address and EIN. In addition, the provider must include the pertinent OWCP service code with the corresponding units (hours) and amount billed.
(c) Because these bills will contain unique alphanumeric codes, they can be identified and batched together prior to data entry. Once data entered, the procedure code will fail Error Code 302, and manual resolution will be required to process the bill to completion. To resolve these suspensions, the designated district office staff should access the CMF "Notes" and verify whether the service has been previously authorized. If so, the date(s) of service on the bill is matched against the authorized date(s) in the "Notes". If a line meets these conditions, the edit failure is overriden.
(d) If a line does not meet the above condition, the bill resolver forwards the bill to the district office staff responsible for the resolution of problematic prompt pay bills. This other staff will consult with the CE, SN and/or facility as necessary and take appropriate action.
Disposition: This bulletin is to be retained in the OWCP (FECA) Procedure Manual until further notice or the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
TABLE B
DEFINITIONS AND GUIDELINES FOR GENERAL PURPOSE FUNCTIONAL
CAPACITY EVALUATIONS (GP-FCEs)
A GP-FCE consists of a series of physical and behavioral tests, measurements, and evaluations.
A GP-FCE includes the following evaluations and measurements:
|
* |
Functional work capacity |
|
* |
Musculoskeletal status/strength measurements |
|
* |
Cardiovascular status |
|
* |
Cognitive status |
|
* |
Behavioral/attitudinal status, and psychologic-readiness/ barriers to return to work, routinely conducted under FCE's |
|
* |
Work tolerance assessments for a specific job and/or vocational options |
|
* |
Other assessments as specified by the requesting claim manager |
The GP-FCE Report includes the following information:
|
* |
Description of evaluation performed |
|
* |
Test, and measurement results, both raw and tabulated data |
|
* |
Normative values where available |
|
* |
Work capacity assessment findings |
|
* |
Activity restrictions when applicable |
|
* |
Attitudinal status, psychologic/behavior work-readiness evaluation results |
|
* |
Vocational status of claimant related to targeted jobs, including accommodation or safety issues, and other factors as relevant |
|
* |
Recommendations regarding therapy needs when indicated and/or requested, such as enrollment in an occupational rehabilitation program, physical conditioning exercises, pain management techniques, or other restorative services with comments on expectations for outcomes. |
When a claimant is being evaluated for an Occupational Rehabilitation Program (ORP), the FCE is specifically tailored to help identify the health care and rehabilitation needs of the claimant who is transitioning back to work. A description of FCE's for ORP's is found in FECA Bulletin No. 96-9.
Back to Top of FECA Bulletin No. 96-12
|
Type |
Code |
RVU |
RVU |
RVU |
|---|---|---|---|---|
|
Type of Service: |
GP-FCE |
|||
|
Procedure Code: |
RE100 |
46.73 |
41.68 |
5.04 |
|
Conversion Factor: |
1.00 |
|||
|
Units: |
Hour |
|||
|
Modifier Code: |
10 |
Allows for a 20% differential of the total |
||
Services authorized: The purpose and the established goals for the GP-FCE, and the claimant's physical limitations and deconditioning influence the duration and the complexity of the evaluation required to complete a FCE of high quality. Four to eight hours may be authorized for the GP-FCE. The authorization is recorded as indicated on Table A.
Modifiers:
On rare occasion, a claimant's condition requires professional assistance beyond the usual scope, or other circumstances are present that require special care and attention. When such claimants require a functional capacity evaluation, fee schedule adjustments for the additional professional time required may be made through the use of the OWCP modifier code "10". This modifier code must be added to the primary code by the FCE provider when services are billed. Also, "10" must be added to the authorization codes entered into the "Notes" area by the claims manager. In most cases, however, the use of modifiers will not be necessary, and the required FCE can be provided within the scope of the OWCP guidelines.
Reimbursement Rates:
Fee schedule rates are established to set maximum amounts for services prior-authorized by OWCP. They are not to be considered expected amounts. Providers are required to bill OWCP at their usual and customary rates; rates greater than those allowed under the OWCP fee schedule are reduced according to the schedule. Maxima are adjusted for geographic variance by multiplying the base rate relative value units times the fee schedule Geographic Adjustment Factor (GAF) values for the appropriate Metropolitan Statistical Area (MSA). Providers should have a clear understanding at the time an FCE is authorized that both time and dollar limitations will apply; related reimbursement issues should be resolved at the time authorization occurs. The provider should always be given a copy of Table A - OWCP FCE Guidelines and Authorized Procedure Code with the approved number of hours indicated.
Coding Conventions: FCE's are included under the general group of services called Occupational Rehabilitation. The first letter (R) of the procedure code indicates Rehabilitation, the second letter (E) indicates evaluation.
Note: Routine psychometric testing performed as a portion of the GP-FCE are included in the FCE reimbursement rate. Comprehensive evaluation services by a psychologist or psychiatrist are not usually anticipated. In those instances where it is believed necessary to treat the work-related injury, justification is to be provided and the services are to be prior authorized by the claims examiner. They are billed under CPT.
Back to Top of FECA Bulletin No. 96-12
TABLE D
PROVIDER DIRECTORY
OCCUPATIONAL REHABILITATION PROVIDERS
A GP-FCE is conducted by trained and licensed medical professionals who are knowledgeable about work-related disorders and occupational rehabilitation services. To ensure the quality of the facilities providing this service, OWCP has developed a Provider Directory based on those facilities that have been certified by the Commission on Accreditation of Rehabilitation Facilities (CARF). The directory contains type of service identifiers and includes those that provide FCE's and ORP services. District offices can add to the directory as more facilities are found that meet OWCP's requirements and provide FCE's of high quality. The directory provides space for comments and the listing of claimants referred; guidelines for additions to the directory at the level of the district office are detailed in FECA Bulletin 96-9. The National Office will also provide periodic updates to the Directory.
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FECA BULLETIN NO. 96-13
Issue Date: June 24, 1996
Expiration Date: June 23, 1997
Subject: BPS - Revision in the Reimbursement Rates Payable for the Use of Privately Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: Effective June 7, 1996, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobiles was increased to 31 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.
Applicability: Appropriate National Office and District Office personnel.
Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual; Instruction CA-77, Instructions for Submitting Travel Vouchers; and 5 USC 8103.
Action: Instruction CA-77, Instructions for Submitting Travel Vouchers, has been revised to reflect the indicated rate change. A copy of the revised instructions is attached to this bulletin and may be reproduced at local levels. It will not be necessary to search and locate vouchers processed subsequent to June 7, 1996; however, if inquiry is received, appropriate adjustment should be made.
Disposition: This Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Attachment
Distribution: List No. 2 -- Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Assistants, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel)
Back to Top of FECA Bulletin No. 96-13
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FECA BULLETIN NO. 96-14
Issue Date: July 15, 1996
Expiration Date: Indefinite
Subject: Employees' Compensation Appeals Board--New Address
Background: Effective July 29, 1996, the Employees' Compensation Appeals Board (ECAB) is moving to the Frances Perkins Building. The new address is:
Employees' Compensation Appeals Board
U. S. Department of Labor
200 Constitution Avenue, N.W., Room N-2609
Washington, D. C. 20210
Purpose: To provide the ECAB's new address to employees of the Division of Federal Employees' Compensation
Applicability: All FECA employees
Action: All form letters in the WP letters system which include appeal rights, and thus contain the ECAB's address, will shortly be modified to show the new address. Managers of each district office must ensure that all macros used locally reflect the new address.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 96-14
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FECA BULLETIN NO. 96-15
Issue Date: July 28, 1996
Expiration Date: July 27, 1997
Subject: Forms--Distribution of FECA Customer Service Brochure
Background: A customer service brochure has been developed to advise disability claimants of basic information about the Federal employees' compensation program. A customized version has been developed for each district office so that information specific to individual district offices can be conveyed along with generic text which applies program-wide. This brochure, which is designated Form CA-14, is to be sent shortly after case creation to all disability claimants whose cases are in UD status (i.e., not closed C1 or C4).
Purpose: To describe how Form CA-14 is to be distributed
Applicability: All FECA personnel
Action:
1. Although the printing order included the request that the brochures be sealed during printing, so that they would be ready to mail on delivery, this was not done. Therefore, it will be necessary for each district office to order enough wafer seals for the current printing (or, in the alternative, the brochures may be stapled together). Future printings will be wafer-sealed.
2. Address labels are to be obtained by running CASE624 during case create. The case create clerk should use these labels to send the brochures to the claimants. Brochures are not to be sent in death cases and in cases closed at the time of case create.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 3--Folioviews Groups A, B, C, and D
(All FECA Employees)
Back to Top of FECA Bulletin No. 96-15
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FECA BULLETIN NO. 96-16
Issue Date: August 12, 1996
Expiration Date: August 11, 1997
Subject: Bill Payment/BPS - Physical Therapy Authorizations
Background: FECA Bulletin 90-22, dated August 1, 1990, issued new procedures for authorizing physical therapy services (PT). To summarize briefly, for orthopedic or neurological cases accepted on or after September 1, 1990, an initial 90-day period of PT was to be authorized via the initial acceptance letter. Additional periods of PT authorization were to be specifically requested and authorized. Indefinite PT was to be authorized for brain and spinal cord injuries, extensive second and third degree burns, and other conditions which rendered the claimant bedridden. For cases accepted prior to September 1, 1990, PT services were to continue to be paid, without prior authorization.
When the bill processing system (BPS) was enhanced during FY 1993, physical therapy edits were put in place which essentially mimicked the existing procedures (now found in the Federal [FECA] Procedure Manual, Chapter 2-0810.16). Because of the inconsistencies which could arise from using the date of adjudication as a starting point for authorizing services, the date of injury was used instead, and the period of initial authorization which did not require pre-approval was 120 days instead of 90. A physical therapy authorization function was placed on the system, so that the BPS edits could automatically check the authorization for services after 120 days from the date of injury. These edits (710, 720, 721) were potentially applicable to cases in which the date of injury was on or after August 1, 1990 (to mirror the September 1, 1990 adjudication date in the original procedures). If the date of injury was prior to August 1, 1990, and the accepted conditions were orthopedic or neurological in nature, PT services usually were paid automatically by the BPS without a PT authorization on the system. If the accepted conditions in a case were such that PT would never be appropriate, or would be questionable, the bills would either be denied automatically or suspend for review.
DFEC has continued to pay for a substantial amount of PT on cases with a date of injury prior to August 1, 1990. The enhanced BPS has now been in place in excess of three years. A number of offices have expressed concern about continuing to pay for unauthorized PT in the older cases. Therefore, effective October 1, 1996, the BPS edit program will be modified to apply the physical therapy edits uniformly to all cases, whether the date of injury is before or after August 1, 1990. The effect of this change is that PT bills which have previously been paid on older cases regardless of (or without) PT authorization will now require specific PT authorization on the system.
The National Office is in the process of mailing letters to claimants who have received PT during the past six months, and whose date of injury predates August 1, 1990. Letters are also being sent to the providers of the PT. The letter informs them that effective October 1, 1996, PT performed more than 120 days after the date of injury must be authorized in advance by OWCP. The requirements for the medical evidence required to authorize PT are also outlined. As a result of these letters being sent out, offices may expect to receive an increase in the number of requests for PT authorization.
In addition, each district office has been provided with a report showing cases with date of injury prior to August 1, 1990, in which PT has been paid during the past six months.
References: FECA Bulletin 90-22, dated August 1, 1990; FECA Bulletin 93-9, dated May 12, 1993; Federal (FECA) Procedure Manual, Chapter 2-0810.16.
Purpose: To outline revised PT authorization requirements.
Applicability: All supervisors, claims examiners, bill resolution personnel, and mail room personnel.
Action:
1. Prompt action should be taken on requests for authorization of physical therapy.
2. Cases which appear on the list provided by National Office should be reviewed prior to October 1, 1996 to determine whether there is sufficient information in the case file to authorize PT. If PT is authorized, the provider and claimant should be notified in writing, and the dates of the authorization should be placed on the system under "PT authorization", case management menu item 34.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 2--Folioviews Groups A, B, and D
(Claims Examiners, All Supervisors, District Medical Advisers, Fiscal Personnel, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Back to Top of FECA Bulletin No. 96-16
Back to FECA Bulletins (1996-2000) Table of Contents
FECA BULLETIN NO. 96-17
Issue Date: September 20, 1996
Expiration Date: September 19, 1997
Subject: Impairment/Schedule Awards: Further Issues in Computing Awards Using the Fourth Edition of the AMA Guides
Background: FECA Bulletin No. 95-17 described various differences between the fourth edition of the AMA Guides to the Evaluation of Permanent Impairment and previous editions of this volume. Since that bulletin was released, several medical and administrative questions have arisen from various district offices and the Branch of Hearings and Review concerning the calculation of schedule awards.
Several comments addressed reports from examining physicians, which sometimes lack complete (or any) citations to tables and figures used and which do not always show clearly how the physician performed his or her calculations. Not surprisingly, examining physicians are usually more aware of the requirements of their respective state systems than those of the Federal Employees' Compensation Act. However, the differences in interpretation result in the need for OWCP staff to make time-consuming clarifications of medical reports.
Several other comments concerned the reviews performed by District Medical Advisors (DMAs) and District Medical Directors (DMDs). Here, too, incomplete or absent citations to tables and figures used in calculating awards and lack of clarity in calculations were noted, as well as illegibility of reports.
It was also indicated that disputes often arise over small differences in calculations as performed by the examining physician and by the DMA or DMD. Such disputes often result in lengthy and time-consuming appeals, and it was suggested that a range be established within which differences between evaluations would be administratively disregarded.
Reference: FECA PM Chapters 2-808 and 3-700; FECA Bulletin No. 95-17
Purpose: To address various issues pertaining to calculation of schedule awards
Applicability: Claims Examiners, Senior Claims Examiners, Hearing Representatives and Examiners, All Supervisors, District Medical Directors and Advisers, Technical Assistants, and Rehabilitation Specialists
Action:
1. Claims Examiners are reminded that where a claim has been accepted for temporary aggravation of a condition, consideration for a schedule award is not appropriate.
2. The attachment to FECA Bulletin No. 95-17 contained lists of tables which should not be used together, because doing so will result in inflated percentages of impairment. This list may be sent to examining physicians, along with a statement that it represents OWCP policy in determining impairment. (As the attachment contains information which is not customized to the individual case, it is not being added to Form CA-1303.)
3. Schedule award evaluations prepared by DMAs and DMDs should include the following information: the part of the body involved, the particular motion(s) affected, and the range of each pertinent motion in degrees; the percentage of impairment; the number of the figure or table used to reach the percentage stated; and the page number of each figure or table used. The DMA or DMD should also indicate how he or she arrived at the total percentage of impairment, i.e, whether by simple addition or use of the combined values table.
The attached form, which is adapted from a form developed in the New York District Office, may be used for this purpose. It is analogous to Form CA-51, which is used to calculate awards for hearing loss. The DMA or DMD's evaluation should be legible (i.e., printed or typed).
4. To address the problems noted in the second paragraph of the Background section above, we will no longer ask the examining physician to calculate a percentage of impairment. Rather, the DMA or DMD will be responsible for taking the calculations provided by the examining physician and arriving at an overall percentage rating. Form CA-1303 will be revised to remove the last question on each attachment, which asks the physician for a percentage of impairment. Also, the form appended to this bulletin may be sent to examining physicians.
5. In some instances, examining physicians may still provide summary ratings. The DMA or DMD will still need to compute the percentage of the award, and his or her assessment will be used as the basis of the award issued.
6. Where more than one method of calculation may be used, the DMA or DMD should use the same one as the examining physician did. Where more than one physician in the case has performed a schedule award evaluation, each using a different method, the DMA or DMD should calculate the award using both methods, and the percentage awarded should be the higher of the two. If the examining physician's calculations are in error, the DMA or DMD's calculations may be used without further medical evaluation.
7. After a schedule award is issued, additional medical evidence showing a different percentage of impairment may be submitted. If there is less than a five percent difference between the DMA or DMD's review and the examining physician's review, no change to the rating will be considered unless the supporting measurements have changed.
8. With respect to particular tables and issues of medical evaluation, the following points are offered (references are all to Chapter 3 of the AMA Guides):
a. Table 16, which addresses upper extremity impairment due to entrapment neuropathy, is used to evaluate impairment due to carpal tunnel syndrome. In ambiguous cases, the choice between mild and moderate impairment may depend on EMG results and/or an assessment of the effect of the impairment on activities of daily living, which in turn depends on the availability of clinical information. The most significant difference between Table 16 and its predecessors is in the calculation of severe impairment.
b. Table 62, which addresses impairment due to arthritis, may be used only if no other abnormality is present, with the exception of joint fractures. The last two paragraphs on p. 82 describes the x-rays needed to support a rating derived from this table. Specifically, a "sunrise view" x-ray is required. Neither an MRI nor any other test may be used instead of the sunrise view x-ray.
c. Pain which is neurological in origin may be included in evaluations for schedule awards, but pain which has other sources (e.g., that which accompanies sprains and strains), must be excluded from evaluation. It is therefore essential to distinguish between these types of pain in evaluating claims for schedule award.
Disposition: Retain until the indicated expiration date.
THOMAS M. MARKEY
Director for
Federal Employees' Compensation
Distribution: List No. 1--Folioviews Groups A and D
(Claims Examiners, All Supervisors, District Medical Advisers, Systems Managers, Technical Assistants, Rehabilitation Specialists, and Staff Nurses)
Attachment to FECA Bulletin 96-17
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OWCP SCHEDULE AWARD (SA) WORKSHEET |
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Resource: AMA Guides to the Evaluation of Permanent Impairment, Fourth Edition |
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CALCULATION |
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