Sample medical development leter (physician)


Dear Dr. _________:

This letter is in reference to your patient, ____________, who has been awarded medical benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), for the following accepted, work-related conditions: [Insert Medical Conditions.]

Non-covered conditions which are noted in your patient’s records, and for which benefits are not provided, [Insert non-covered conditions.]

You recently wrote to the Division of Energy Employees Occupational Illness Compensation (DEEOIC) on [Insert Date of Physician Letter], prescribing the following home health care services:

• [Insert description of services prescribed by the doctor]

WHAT DEEOIC IS REQUESTING FROM YOU:

DEEOIC can only authorize home health care services deemed medically necessary for the accepted medical conditions listed above. After a review of your narrative letter and your patient’s medical records, we are seeking clarification from you regarding the medical necessity for the home health care services you have prescribed, as they relate to your patient’s accepted condition(s). If home health care is medically necessary for the treatment of these conditions, we require a narrative letter, describing in detail the specific medical, and/or ancillary services required by your patient, and an explanation as to how these services are causally related to the DEEOIC accepted conditions. Medical evidence should include findings upon physical exam (a face-to-face exam conducted within the past 60 days is required), laboratory and other test results, and any other supporting documentation related to your examination and findings.

Your narrative letter must clearly differentiate between skilled nursing services and non-skilled home health services, and provide specifics as to the frequency and duration of the care your patient requires, i.e.; number of hours a day, days a week, and the time period for which these services are needed. Skilled and non-skilled services should be separately delineated as follows:

(a) Skilled Nursing Care: A description of the specific medical services to be performed by a licensed professional such as a RN/LPN including the frequency that each of these services is to be performed in a 24-hour period (or in a calendar week, if the frequency is less than once a day), and the period of time for which you are prescribing these services.

(b) Non-Skilled Home Health Services: Services of a general nature - - assistance with activities of daily living - - such as bathing, personal hygiene, feeding, and assistance with ambulation, are generally performed by home health aides (HHA), personal care attendants (PCA), or certified nursing assistants (CNA). The need for non-skilled services must be separately described, along with the number of hours each day, or week, for which you are prescribing care.

Thank you for your assistance in providing this requested information. Please respond within 30 days to the address on the letterhead.

The DEEOIC does not endorse or sponsor any home health care provider. Any nursing assessment or other documentation presented from a home health provider is the product of that provider and should be evaluated carefully in conjunction with your knowledge of the patient’s physical findings and medical history.

Physicians may bill DEEOIC for report preparation using CPT Code 99080, in addition to billing for customary medical services (e.g., office visits, diagnostic testing, laboratory services, etc.) provided during the physical examination as long as they relate to an accepted condition. Supporting documentation (e.g., medical reports, evaluation reports, assessment reports, progress report/notes, clinical notes and diagnostic testing results) must be submitted with the completed OWCP-1500 to DEEOIC’s bill processing agent. Reimbursement for services will be in accordance with the OWCP fee schedule.

To receive payment for services, you must be enrolled as a DEEOIC provider. For more information on how to become an enrolled provider, please contact the DEEOIC bill processing agent at 1-866-272-2682 or at http://owcpstaff.dol.acs-inc.com. DEEOIC requires that providers meet basic qualifications, which includes maintaining appropriate licensure, to be enrolled. If you have any questions regarding this request, please contact me at 1-888-XXX-XXXX.

Sincerely,

[Insert Name]

Claims Examiner

cc: [Insert Patient Name]

Attachments: [Individually describe any medical records or other documents attached]