Sample Authorization Letter (DME, Oxygen Therapy Equipment and/or Medical Supplies)

Date:

Claimant Name (or Auth Rep)

Street Address

City, State, Zip

Re: Case ID [Enter Case ID Number]

Dear [Enter Claimant or Auth Rep Name]:

This letter is in reference to your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received a request for authorization for the [Enter purchase or rental] of a [Enter the Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies] for the following covered medical condition(s):

List the condition(s)

After a thorough review of your case file, including communication with your treating physician (if applicable), the following authorization is granted:

Rental of [Enter type of Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies and billing code(s) for the period] of [Enter to and from date] from [Enter vendor name].

If the rental is converted to a purchase, the purchase reimbursement price must be less than the paid rental price.

Purchase of [Enter type Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies and billing code(s)] from [Enter vendor name].

Note that the DEEOIC requires that the approved vendor noted above be enrolled as a provider in our medical bill payment system to be reimbursed. Vendors may call toll free 1-866-272-2682 for program enrollment information or for answers to payment questions.

Reimbursement claims must be submitted with the appropriate modifier to receive payment for Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies.

All fees for the rental/purchase of Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies are subject to the OWCP Fee Schedule.

Add-ons and/or upgrades to the Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies are considered for approval if evidence substantiates a medical need for the enhancement. However, add-ons and/or upgrades to Durable Medical and/or Oxygen Therapy Equipment and/or Medical Supplies are not covered when they are intended primarily for the claimant’s convenience and do not significantly enhance the equipment/supplies functionality.

If you have any questions or concerns regarding this authorization, please call your claims examiner at (XXX) XXX-XXXX.

Sincerely,

[Enter CE name]

DEEOIC Claims Examiner

cc: [Enter supplier name]