Date

CASE ID NUMBER:

EMPLOYEE:

Medical Provider

Street Adress

City, State, Zip Code

Dear Medical Provider;

Our office has determined that the above employee is eligible for an impairment evaluation under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) in relation to the following accepted illness Insert name AND ICD-9/10 of covered illness.

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

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

  • is certified by the American Board of Independent Medical Examiners (ABIME)
  • is certified by the American Academy of Disability Evaluating Physicians (AADEP)
  • possesses knowledge and experience in using the AMA’s Guides
  • possesses the requisite professional background and work experience to conduct such ratings

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

Physicians may bill impairment evaluation using CPT Code 99455 or 99456 with ICD-9 code V70.9.

Diagnostic services related to impairment evaluations must be billed with the appropriate CPT codes. Supporting documentation (e.g. medical reports, evaluation reports, assessment reports and diagnostic testing results) must be submitted with the completed Office of Workers’ Compensation Program (OWCP) Health Insurance 1500 Form (OWCP 1500). If you need a copy of the medical record in our case file to perform the impairment evaluation, please contact me. Reimbursement for these services will be in accordance with the OWCP fee schedule.

Electronic versions of OWCP-1500 and the Provider Enrollment Package are available on-line at:

OWCP-1500 – http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf

Provider Enrollment Package - http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1168.pdf

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

Thank you for your assistance.

Sincerely,

Examiner name

Claims Examiner

Enclosures:

Required Medical Evidence for Determining Impairment Rating By Specific ICD-9/10 Codes

Examiner note: print appropriate section from Impairment Documentation for ICD9 template