Sample Medical Benefits Letter

DATE

NAME AND ADDRESS

Dear CLAIMANT NAME:

As a beneficiary under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), you are entitled to medical benefits for treatment of your MEDICAL CONDITION (ICD-9 codes: ICD-9 CODES), effective February 29, 2012. Covered medical services are payable in accordance with the fee schedules and medical benefits policies established under the Energy Employees Occupational Illness Compensation Program (EEOICP). Your medical benefits coverage includes payment to medical providers for services such as medical appointments, hospitalizations, home health care services (see attached Notice Regarding Home Health Services), medical appliances, supplies, and drugs that are prescribed by a qualified physician and approved by the EEOICP.

Within the next few weeks, you will be receiving additional information regarding your medical benefits coverage. This will include a medical benefits identification card, which you will need to show to your physician or other enrolled medical provider you chose to treat your covered condition. This card will be accompanied by instructions and a phone number to call to activate the card. The card will instruct your physician, hospital, durable medical equipment supplier or other health care providers to bill the EEOICP directly, so that you will not have to pay for medical treatment covered under the program. There are no deductibles for services or equipment as long as the services are billed by an EEOICP enrolled medical provider.

To bill us directly, providers must be enrolled in the Program. For information about enrollment and billing, please have your provider contact us at the address and telephone number listed at the end of this letter, or give us your provider’s phone number when you call to activate your medical benefits identification card. We will call and explain the Program to your provider(s) and give them the necessary forms required for submitting bills for reimbursement.

To request reimbursement for out of pocket medical expenses associated with treatment of your accepted condition, you must submit the following forms: (OWCP-915 Form, Claim for Medical Reimbursement Under the Energy Employees Occupational Illness Compensation Program Act), and (OWCP-957 Form, Medical Travel Refund Request). Both forms are enclosed for your convenience and include instructions for completing these forms and submitting any additional required documentation.

Please mail completed forms to:

U.S. Department of Labor

Energy Employees Occupational Illness Compensation Program

P.O. Box 8304

London, KY 40742-8304

If you or your provider(s) have questions regarding submission or payment of bills, or require any other medical bill program assistance, contact a representative toll free at 1-866-272-2682.

Sincerely,

Hearing Representative

Enclosures:

OWCP-915

OWCP-957

Notice Regarding Home Health Care Services

Note: if the EEOICP pays less than the billed amount (in accordance with the fee schedule), you are not responsible for payment of the difference to a provider. Providers and claimants may submit requests for reconsideration of fee determinations in writing, with accompanying documentation to the address supplied in this letter.





Notice Regarding Home Health Services

As a beneficiary under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), you are eligible for those services, appliances, and supplies prescribed or recommended by a qualified physician, which are likely to cure, give relief to, or reduce the degree or the period of the accepted illness.

Home health care is one of the many medical benefits you may receive for an accepted illness under the EEOICPA. Home health care includes both in-home skilled nursing care, and the services of a home health aide to assist you with activities of daily living, related to your accepted condition(s). Examples of these daily activities include assistance with mobility around the house, dressing, feeding and food preparation, and accompanying you to medical appointments.

It is important for you to be well informed about your EEOICPA benefits as they relate to home health care services. This begins with an explanation of the benefits you are entitled to, and the information you and your doctor will be asked to provide before home health care can be approved.

  • A request for home health care must be submitted to the District Office servicing your claim. Your claim number should be clearly noted on any request. There are no restrictions on when you can apply for home health care once a work-related illness is accepted in your claim; however, services are authorized based upon the presentation of medical evidence from your treating physician confirming the need for care due to an accepted illness.

  • Written authorization for home health care must be obtained prior to any service provider entering your residence to conduct services in connection with the accepted work-related illness, except in certain emergency situations.

  • When you initially request home health care, the physician treating you for a work-related illness accepted in your claim will be asked to supply a written explanation of the care you require, called a Plan of Care. This plan of care must explain the need for in-home health care as it relates to the accepted illness (es) in your claim. Your physician is to clearly specify the level of care required (skilled nursing care, home health aide, etc.); the frequency of care required (i.e., number of hours per day or week for each type of care); and the time period for which you will require in-home care. Medical evidence presented by a physician who has not personally treated your accepted work-related illness, or who is otherwise unfamiliar with your treatment needs, is of reduced probative value in assessing home health care requests.

  • Once approval is granted for home health care, you are free to choose from any licensed medical provider of the services you require, as long as the provider is enrolled with the Division of Energy Employees Occupational Illness Compensation (DEEOIC). Moreover, you are free to change providers at any time. The DEEOIC neither endorses nor sponsors any home health care provider, or any other entity providing medical services.

  • Approval for home health care is granted for up to six-month periods and must be renewed with the submission of updated medical information from your treating physician. Changes to an approved level of home health care must be requested in writing and must be accompanied by medical documentation from your treating physician explaining the basis for any alteration in your current plan of care.

  • The DEEOIC may conduct reviews of home health care authorizations using medical consultants, field nurses, or other forms of inquiry with your treating physician at any given time.

As with all forms of health care, you play an important role in determining the appropriate level of care and the types of services being provided to you. If you have questions regarding home health care, direct your concerns to the District Office servicing your claim.