TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Chapter 3-1000 Home and Residential Health Care
TABLE OF CONTENTS. . . . . . . . 12/16 17-02
1 Purpose and Scope. . . . . . . . 12/16 17-02
2 In-Home Health Care Services. . 12/16 17-02
3 Attendant Services Provided
By Family Members . . . . . . . 12/16 17-02
4 Conflict of Interest Policy. . . 12/16 17-02
5 Hospice Care . . . . . . . . . . 12/16 17-02
6 Residential Care Facilities. . . 12/16 17-02
7 Billing Procedures and
Authorization Periods. . . . . . 12/16 17-02
Exhibits
1 Sample Medical Development
Letter (Physician) . . . . . . . 12/16 17-02
2 Sample Medical Development
Letter (Claimant) . . . . . . . 12/16 17-02
3 Sample Authorization Letter. . . 12/16 17-02
4 Billing Codes. . . . . . . . . . 12/16 17-02
1. Purpose and Scope. This chapter describes the procedures for evaluating and approving requests from claimants who are seeking approval for differing types of Home and Residential Health Care (HRHC) services including in-home health care, hospice services, and long-term residential care in an assisted living facility or nursing home. This section also provides procedural guidance with regard to the process for development and authorization of these services.
During the processing of all HRHC claims the Medical Benefits Examiner (MBE), or other designated staff, are responsible for ensuring all documents created during the review process are properly scanned into OIS for recordkeeping purposes and that all appropriate case management updates to the Energy Compensation System (ECS) occur.
2. In-Home Health Care Services (HHC). This section provides clarification with regard to the evidence needed to authorize in-home health care (HHC), which includes skilled nursing services, and attendant services such as home health aides, personal care attendants, etc.
a. Bill Processing Agent. All requests for HHC must be submitted to the Division of Energy Employees Occupational Illness Compensation (DEEOIC) bill processing agent (BPA) via fax, mail, or electronically, to begin the authorization process. The BPA creates an electronic record of all relevant documents and requests, and initiates an electronic message (thread) to the national office (NO), advising of a new, pending HHC request.
b. HHC requests are routed, via the BPA, to the Workers’ Compensation Assistant (WCA). The WCA reviews the request and forwards the information to the appropriate MBE for review and adjudication.
c. Prior Authorization Required. All HHC requests require prior authorization from a MBE, including authorization for initial in-home assessments.
d. Requests for an in-home assessment of a patient’s needs, and/or requests for HHC, can be initiated by a claimant, the claimant’s authorized representative, any licensed doctor who is treating the claimant for an accepted condition, or a HHC provider.
e. Telephone Requests. The MBE must document telephone requests for HHC care in ECS. Moreover, the MBE advises the callers that they must submit their requests, in writing, before the authorization process can begin.
f. Approving Initial In-Home Assessment Requests. The MBE must approve any request for an initial in-home HHC assessment, upon receipt of a signed prescription by the treating physician. When an initial HHC assessment request is properly documented with a physician’s prescription, the MBE approves the initial request and sends an email to the WCA, who sends a thread to the BPA authorizing the assessment. If the MBE receives a request for an initial HHC assessment without a physician’s prescription, the MBE sends a letter to the claimant requesting a signed prescription for the initial assessment. In the letter, the MBE advises that the claimant has 30 days within which to submit a signed physician’s request for an initial HHC evaluation. If medical documentation or signed physician’s prescription is not received within 30 days, the MBE denies the request.
g. Letter of Medical Necessity (LMN). The LMN is a narrative statement of the physician’s opinion regarding the patient’s HHC needs and the medical justification for such services. The treating physician must prepare the LMN based upon a clear understanding of the patient’s medical history (including the accepted work-related illnesses), reported findings from an in-home assessment, face-to-face examination of the claimant, and consideration of other sources of information (such as family members, or prior nursing notes in the case of a reauthorization of services).
Upon receipt of a LMN, or a hospital discharge summary specifically prescribing HHC services, the MBE must conduct a complete review of the case file medical evidence to determine if there is sufficient and well-rationalized documentation from the physician, describing the medical reasons for HHC, as they relate to the covered medical condition(s). The necessary information that the treating physician must provide in the form of a signed LMN includes:
(1) Medical Rationale. A description of the HHC needs of the patient, as they relate to the patient’s covered medical condition(s), based upon a face-to-face medical examination conducted within the past 60 days. HHC exams must be conducted by the patient’s treating physician, a physician’s assistant, or other medical professional licensed and authorized by state law to conduct such examinations within the physician’s practice, or employed by the physician. This should include a detailed description of, and distinction between the patient’s medical need for skilled nursing care, personal attendant care, and/or any other type of care, while in the home; and, an explanation as to how the requested care is linked to the covered medical condition(s). The physician must describe the findings upon physical examination, and provide a complete list of all medical conditions, including conditions not accepted by DEEOIC. If a claimant has one or more non-covered conditions, medical evidence must demonstrate how the requirement for in-home health care relates specifically to the accepted conditions. The physician should also describe laboratory or other findings that substantiate a causal relationship between the accepted condition(s) and the need for assistance or skilled nursing care in the home.
(2) Level of care required. The doctor’s LMN must specify the appropriate type of health care professional who will attend to the patient, i.e., Registered Nurse (RN), Licensed Practical Nurse (LPN), Personal Care Attendant (PCA), Certified Nursing Assistant (CNA), or Home Health Aide (HHA). Generally, approved in-home skilled nursing services (RN/LPN) include services such as: administration of prescription medication, wound dressing changes, administration of intravenous medications, assessment of patient’s medical condition, and communication with treating physician(s) regarding changes in accepted condition(s). Services provided by non-skilled persons such as home health aides or personal care attendants are typically intended for assistance with activities of daily living which often include: mobility within the household, dressing and undressing, toileting, bathing, and meal preparation.
(3) Extent of care required (hours, days, weeks, etc.). A written medical narrative must describe the extent of care to be provided in allotments of time, to include the duration of each function or operation, and the number of times per hour/day/week a particular function or operation is to be performed or repeated. The LMN must also state the duration of time for which care is being prescribed in days, weeks, or months.
h. Incomplete medical evidence. If, upon review, the MBE finds that the medical evidence is incomplete and/or the file does not contain an appropriate medical rationale to support the type(s) of HHC being prescribed for the patient, the MBE prepares development letters to the prescribing physician (Exhibit 1), and the claimant (Exhibit 2).
(1) Physician Letter. The letter to the treating physician is to include the MBE’s request for a narrative medical report addressing the specific requirements needed to substantiate a clear medical basis for HHC. The letter is also to include a request that the physician estimate the length of time for which the patient will ultimately require HHC services. Lastly, the letter is to reference the fact that DEEOIC cannot process the claimant’s HHC request without this additional information. A response from the physician is requested within 30 days. The MBE also faxes a copy of the request letter to the treating physician’s office.
(2) Claimant Letter. The MBE’s letter to the claimant acknowledges receipt of a request for authorization of HHC services and advises that further medical evidence is required to process the claimant’s request. Additionally, the claimant letter contains a copy of the development letter to the prescribing physician, which separately describes the medical evidence requested by DEEOIC. The claimant letter is to include an explanation that without the necessary supporting medical evidence, the request for HHC services cannot be authorized. Finally, the MBE is to request that the claimant contact the prescribing physician’s office to make certain that a response to DEEOIC is provided within 30 days.
(3) No response after 30 days. If, after 30 days, there is no satisfactory response from the treating physician, or no response from the claimant, the MBE prepares a second letter to the claimant (accompanied by a copy of the initial letter), advising that no additional information has been received from the treating physician. The MBE advises that an additional period of 30 days will be granted for the submission of necessary medical evidence. The MBE further advises in the letter that if the requested information is not received, DEEOIC must deny the claimant’s request for HHC services.
(4) No response to second request. If the claimant or the physician does not provide a response to the second request for information within the 30-day period allowed, the MBE issues a letter decision to the claimant denying the claim for HHC. The MBE sends an email to the FO, who sends a thread to the BPA advising that the service has been denied.
i. Claimant Has Final Authority. The claimant, or properly designated Authorized Representative (AR), has final decision-making authority regarding the amount or type of HHC they want. If a claimant calls and states that he/she does not require in-home health care, wishes to discontinue care that is currently authorized, or requests a reduction in the amount of care, the MBE takes one of the following actions:
(1) Discontinue Care. Should the claimant wish to discontinue care, the MBE requests that the claimant send DEEOIC a signed letter declining HHC services. Upon receipt of any written statement from the claimant stating that HHC services are not being requested, or no longer wanted, the MBE writes a letter to the claimant, with a copy to the treating physician and any designated HHC provider, confirming that the claimant is declining HHC services and thus the matter is closed. Additionally, the MBE sends an email to the WCA, who sends a thread to the BPA advising that HHC services are denied or terminated, with an effective end-date in the event of termination.
(2) Modification of Care Currently Authorized. If the claimant contacts DEEOIC and requests a reduction in the amount of care being provided, (e.g.; the claimant only wants a home health aide in the home 8 hours a day, and not 24-hours a day), the MBE instructs the claimant to call his/her prescribing physician and request that the physician prepare a new LMN for DEEOIC. The MBE advises the claimant that DEEOIC cannot modify the amount/type of care being authorized without a letter (LMN) from the physician. Upon receipt of any such letter from the physician, the MBE takes appropriate action with regard to evaluating new medical evidence.
j. Evaluating Medical Evidence. Upon receipt of medical evidence pertaining to either a new HHC request, or an existing HHC authorization, the MBE must determine if the evidence is of sufficient probative value to authorize HHC. To determine the probative value of any medical request for HHC, it is critical that the MBE undertake appropriate analysis of the case file documentation pertaining to HHC services before authorizing such care.
(1) The underlying function of the MBE is to ensure that the covered employee receives the necessary medical care for the accepted medical condition(s) and that any such request for care reasonably corresponds with the medical evidence in the case file. If the physician does not provide sufficient detail concerning the claimant’s physical condition, relationship of the prescribed care to the accepted condition(s), or specific medical rationale for HHC, the MBE must prepare and send a letter to the treating physician specifically describing the deficiency in the medical evidence and stating clearly what information is needed.
(2) When evaluating the medical evidence, the MBE must base any determination solely on the weight of medical evidence in the case file. While the MBE can request clarification or seek additional information regarding the medical justification for home health care, it is not appropriate to reduce or modify the type or level of care without the support of medical evidence obtained from a physician.
(3) Nurse Consultants and Medical Director. DEEOIC employs nurse consultants and a medical director, who are available to both the MBE and CE staff, to assist in the evaluation and analysis of medical evidence. DEEOIC medical staff serve as a technical resource to the district offices in regards to claims-related medical issues and can assist in the determination of appropriate services and procedures that require authorization by DEEOIC.
(4) Second Opinion (SECOP) Medical Examinations. Independent physicians, randomly selected by a third-party contractor, perform SECOP examinations. If the MBE deems the medical recommendations of the treating physician are not supported by appropriate medical rationale and if attempts by the MBE are unsuccessful in clarifying the HHC needs of the claimant via the treating physician, the MBE must immediately arrange for a second medical opinion, or a referee medical opinion, depending on the circumstances. (Refer to Federal (EEOICPA) Procedure Manual Chapter 2-0800, Developing And Weighing Medical Evidence, for guidance pertaining to the SECOP/Referee examination process.) The context of any SECOP or referee examination is the medical necessity of HHC for one or more distinct six-month periods.
For SECOP medical examinations required to evaluate HHC renewals, the MBE is to extend the existing HHC authorization until a SECOP medical examination is completed. Under these circumstances, the MBE takes the necessary actions to update the ECS, and notify the WCA (i.e., an update to reflect a 30 or 60-day extension of an existing HHC authorization), while awaiting the findings of a SECOP doctor).
Upon receipt of the SECOP exam results, the MBE considers the reports from both the SECOP doctor and the claimant’s treating doctor and determines if one report should be assigned a greater probative value than the other. If the MBE determines that the SECOP medical report is of lesser or equal weight, the SECOP report cannot be used to overturn the opinion of the claimant’s treating doctor. If the MBE determines that the two reports are of equal value, the MBE has the option of accepting the treating physician’s report, or seeking resolution by obtaining a referee medical opinion.
A determination regarding the weight of medical evidence and a conclusion regarding the HHC needs of the claimant must clearly identify one or more six-month periods of HHC. Once the period(s) of HHC covered by second opinion decision expires, the MBE treats any subsequent request for HHC as a new request.
k. Emergency Authorizations. In certain emergency circumstances, the MBE may authorize HHC for a preliminary 30-day period while additional development is undertaken. In order to obtain approval for an emergency authorization, the physician or hospital staff contacts DEEOIC’s BPA and advises the BPA that a claimant requires care of an emergency nature (e.g., the claimant is being released from the hospital and requires immediate in-home care).
The BPA obtains any pertinent medical documentation and assesses the emergency nature of the request. A mere discharge following hospitalization is not a sufficient basis to authorize emergency HHC. The hospitalization discharge documentation must clearly describe the emergent medical need for HHC related to an accepted condition. It must also specify the level, extent, and duration of HHC required at the emergency level of care. Upon receipt of an emergency HHC authorization request, the BPA immediately contacts the WCA, advises the nature of the emergency, and provides electronic copies of all documentation obtained. The WCA forwards the information to the MBE for review. The BPA does not make a decision regarding the request, but simply obtains the pertinent documentation and advises of the emergency request.
(1) Upon receipt of supporting medical documentation, the BPA sends the information to the WCA, who sends the information to the MBE for review. The MBE must carefully evaluate these situations to ensure the medical documentation clearly indicates that the patient’s care and well-being are dependent upon HHC services for a DEEOIC accepted medical condition. If the BPA has not already obtained medical documentation to support this need, the MBE requests the attending physician discharge summary and discharge plan stating the level of care needed in the home. If necessary, the MBE may call the hospital or attending physician for clarification of the need for emergency care and discuss needed medical evidence.
(2) If discharge information from a treating physician supports the need for immediate authorization; the MBE provides an emergency 30-day approval pending additional development. When granting an emergency HHC authorization, and for each 30-day temporary extension (while awaiting medical evidence), the MBE notifies the claimant and provider, in writing, of the initial and subsequent periods of authorization. The MBE sends an email to the WCA advising of any authorizations, and the WCA forwards the information to the BPA in the form of a thread.
(3) Upon initial approval of 30-day emergency care, the MBE sends a letter to the treating physician, with a copy to the claimant, requesting the necessary medical evidence to substantiate that the approved level of care is medically necessary to give relief for the accepted medical condition(s). This should occur within the initial 30-day authorization period. The MBE may grant extensions in increments of 30 days, while awaiting the necessary evidence to document that the level of care is medically warranted and necessary. These extensions should generally not exceed a total of 90 days.
(4) Some emergency authorization requests may not warrant approval. In some situations, the evidence supplied may not justify the emergency request. After careful review of the evidence supplied, the MBE sends a letter to the claimant, with a faxed copy to the requestor, if other than the claimant. In the letter, the MBE explains the deficiency that exists in the medical evidence necessary to support the request for emergency care. The MBE further advises that a LMN is required, clearly describing the patient’s discharge circumstances that support the need for a specific level of in-home health care. In addition, the MBE sends an email to the WCA, who updates the thread request indicating the emergency authorization request is under development.
l. Authorization Letters to Claimants. If the MBE determines that the medical evidence, or the emergency request, warrants approval of the HHC being prescribed, authorization may be granted for up to 6 months (up to 90 days for emergency requests). The MBE prepares a letter decision notifying the claimant and the home health care provider of the authorization being approved, and delineating the following information. (See Exhibit 3 for a sample authorization letter):
(1) Covered medical condition(s) for which care is authorized.
(2) Level and duration of the type(s) of in-home care to be provided, i.e., RN 1 hour per day and Home Health Aide 8 hours per day, 7 days a week for a period of 6 months.
(3) Authorized billing codes relevant to the level and duration of the care authorized (see Exhibit 4 for a description of the pertinent codes).
(4) Period of authorization with specific start and end dates.
m. Approval Actions by the MBE. Upon sending the authorization letter to the claimant and provider, the MBE completes the authorization process with the following steps:
(1) Create Authorization: The MBE sends an email to the WCA, who initiates an electronic thread to the BPA to authorize the specific level(s) of care, billing codes (with units), and time period of the authorization.
(2) ECS Reminder. The MBE creates a reminder note to review the HHC authorization 60 days prior to the expiration of the authorized period (or within 30 days of the letter for emergency authorization requests).
n. Insufficient Evidence. After appropriate development as outlined above, if the MBE reviews the medical evidence in the file and determines that there is insufficient evidence to warrant authorization of HHC, the MBE sends a detailed letter-decision to the claimant (with a copy to the HHC provider) advising of DEEOIC’s determination. A letter decision is also required any time medical evidence is received that warrants a reduction in the level of HHC services currently being authorized. Letter decisions to either reduce or deny HHC must include a copy of any SECOP or Referee report if that report serves as the basis for the decision to reduce or deny the requested level of care. The narrative content of the letter decisions must clearly explain how the MBE evaluated the medical evidence, and must provide a rationale for his/her determination. Further, all letter decisions must clearly identify the six-month period(s) being addressed by the decision. The letter-decision must include a sentence at the end with language as follows:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
o. Issuing a Recommended Decision. In the event that the claimant does request a Recommended Decision (RD), the MBE prepares and issues the decision.
p. Receipt of new medical evidence. Upon receipt of new medical evidence during development of a new HHC request, during a currently authorized period of HHC, after an authorized period of HHC has expired, or following a denial of a HHC request, the MBE must review that new evidence to determine if any action is required. New medical evidence could potentially result in one of the following scenarios:
(1) Approval of the HHC request currently under consideration, (including six-month reauthorization), or approval of an HHC request previously withdrawn or denied.
(2) An increase in the current level of authorized services. In this instance the MBE must terminate the current authorization and begin a new six-month HHC authorization period.
(3) A reduction in the current level of authorized services, but only if ordered by the treating physician who initially prescribed the care, or, based on a SECOP medical exam and report. When a decrease in care is warranted, the MBE must terminate the existing authorization and begin a new six-month authorization period.
(4) A denial of the current level of authorized services. (Examples of this would be in cases where HHC was authorized on an interim basis while awaiting results of a SECOP exam, or where a temporary emergency authorization was granted while awaiting additional medical evidence.)
If the claimant’s treating physician provides new medical evidence supporting a reduction in, or a termination of care, that reduction or termination is communicated to the claimant by letter. There is no need to include language regarding the claimant’s right to request a recommended decision.
q. Letters advising of a reduction or termination of services must be copied to the HHC provider and must specifically advise the claimant that the reduction or termination will occur 15 days from the date of the letter. The letter must provide an explanation of any new level of authorized services.
r. No overlapping HHC authorizations. It is important for the MBE to understand that only one six-month HHC authorization period can exist at any given time. Regardless of differing types of service(s) authorized, there can be no overlapping dates. If the medical evidence dictates a change in the care currently authorized, the authorization must be closed, with an end-date, and a new authorization begun.
For example: If the claimant was authorized 8 hours a day of skilled nursing and 8 hours a day of home health aid (HHA) care, for a six-month period, and if the treating doctor prescribed an increase in the HHA care, to 16 hours a day, the entire authorization would be terminated and a new authorization period would be approved for both the skilled nursing and the increased level of HHA care.
s. Reauthorization of HHC Services. The following actions are taken by the MBE during the course of an existing authorization:
(1) 60 Days prior to the expiration of a HHC authorization the MBE reviews the case record to determine if new medical evidence exists in support of a reauthorization of services.
(2) If new evidence exists (face-to-face medical exam, updated medical report, etc.) supporting a reauthorization of services, the MBE follows the guidance under “p” and re-evaluates the case for consideration of a new 6-month period of care.
(3) In the absence of new medical evidence supporting a reauthorization, the MBE sends a letter to the treating physician, with a copy to the claimant. The letter advises of the upcoming expiration date and emphasizes the need for updated medical evidence, if continuing HHC services are necessary.
(4) Following a request for updated medical information, prior to a six-month reauthorization, if no response is forthcoming, the HHC authorization expires and the MBE takes appropriate action to close the HHC claim. However, if the provider or the claimant submits a request for a continuation of services, the MBE evaluates the request, and any accompanying medical evidence.
3. Attendant Services Provided by Family Members. A claimant’s spouse, or relative, may provide authorized attendant care services if properly credentialed. Requirements for licensing, certification, or training, vary from state-to-state. There are two ways an individual can qualify for reimbursement by DEEOIC as a provider of HHC services:
a. A qualified individual can enroll with DEEOIC (OWCP.dol.acs-inc.com), as a HHC provider and can be authorized for reimbursement for a maximum of 12 hours per day.
b. The employee’s spouse or relative can be employed by a DEEOIC enrolled medical provider of HHC services. In this instance, licensing, certification and training become the responsibility of the enrolled provider.
4. Conflict of Interest Policy. DEEOIC has developed a Conflict of Interest Policy regarding the role of authorized representatives. (Refer to Federal (EEOICPA) Procedure Manual Chapter 2-0400.) Conflicts of interest can arise when a duly authorized representative (AR) has direct financial interests as a result of his or her role, aside from the permitted fee enumerated under the EEOICPA. Because the “role” of an AR is so important, DEEOIC will consider the AR to have a prohibited “conflict of interest” if that individual could directly benefit financially from their client’s EEOICPA claim due to something other than the statutorily limited fee for representing a client in connection with his or her EEOICPA claim.
With regard to HHC services, a DEEOIC enrolled provider of medical services will be considered to have a prohibited conflict of interest if, in addition to being the client’s authorized representative, they are also being paid by DEEOIC, directly or indirectly, as a provider of authorized medical services to that individual. Because there is an obvious conflict of interest in these circumstances, DEEOIC will not recognize the enrolled provider as an AR. Under these circumstances, DEEOIC will inform the claimant of the need to designate another person as authorized representative, who does not have such a conflict.
5. Hospice Care. This section provides clarification with regard to the evidence needed to authorize in-home hospice care services.
a. Hospice care is generally requested and authorized when a physician has determined that an individual has a terminal illness and has no more than six months to one year of life remaining. When a treating physician determines that in-home hospice care is required for an accepted condition and prescribes these services for a claimant, it remains the role of the claimant’s treating physician to determine and prescribe all medical services and care, required by the patient for the accepted condition(s).
b. All requests for in-home hospice care require prior authorization from the MBE and must be submitted to DEEOIC’s BPA via fax, mail, or electronically, to begin the authorization process. Upon receipt, the BPA creates an electronic record of the request and generates a thread advising that a new hospice request is pending CE approval.
6. Extended Care Facilities. This section provides clarification with regard to the evidence needed to authorize placement in an extended care facility. When a treating physician determines that extended care is required for an accepted condition and provides a LMN to that effect, the CE may authorize the services.
a. Care in a nursing home, skilled nursing facility, or an assisted living facility may be authorized when the claimant does not need acute care but does require medical services and assistance with activities of daily living.
b. All requests for extended care require prior authorization from the MBE and must be submitted to DEEOIC’s BPA via fax, mail, or electronically, to begin the authorization process. The BPA creates an electronic record of all such documents and requests, and initiates a thread to the district office FO, advising of a new and pending request for extended care. The FO forwards the request to the MBE for review and adjudication.
7. Billing Procedures and Authorization Periods. This section provides guidance with regard to billing protocol and authorization periods relevant to all types of ancillary medical services (e.g. home health care, hospice care and extended care facilities).
a. Authorization Period. All types of care (with the exception of Assisted Living Facilities) may be authorized for a period not to exceed six months. Assisted living may be authorized for a period not to exceed 12 months. Recertification is required for each successive six-month, or 12-month period, or part thereof, and should be completed before the current authorization expires, to allow uninterrupted care. The MBE should make every effort to complete recertification before a current authorization expires.
b. Billing Procedures. The provider submits Form OWCP-1500, which must be accompanied by supporting documentation (e.g. nursing notes, attendant care notes, and itemization of charges with dates and hours of care). Exhibit 4 lists and describes the various billing codes used by DEEOIC, when approving HHC services.
Exhibit 1: Sample Medical Development Letter (Physician)
Exhibit 2: Sample Medical Development Letter (Claimant)
Exhibit 3: Sample Authorization Letter