Transmittal NO. 19-01: Transmission of Federal EEOICPA Procedure Manual Version 3.0

Following are the content edits that make up Federal (EEOICPA) PM v3.0:

· Chapter 2, The EEOICPA:

o Ch. 2.4b(1) has been modified to remove reference to the Medical Bill Processing Unit. The language included in v2.3 read:

(1) Policy Branch. Personnel in the Policy Branch consist of the Policy, Regulations and Procedures Unit (PRPU), Medical Bill Processing Unit, and the Medical, Health & Science Unit (MHSU).

It has been revised in v3.0 to:

(1) Policy Branch. Personnel in the Policy Branch consist of the Policy, Regulations and Procedures Units (PRPU) and the Medical, Health & Science Unit (MHSU).

(a) The PRPU is responsible for working with the Office of the Director and the SOL in the research, determination and writing of all program policies, regulations and procedures, as well as providing consultative services regarding those policies, regulations and procedures to various DEEOIC staff.

(b) The MHSU conducts and oversees scientific and nursing-related consultative services for DEEOIC staff. This can include industrial hygiene, health physicist, toxicological and nursing-related advice and consulting services. Additionally, these staff provide specific medical and scientific research, reporting and advice in the development of policies, regulations and procedures that involve scientific and/or medical issues.

o Ch.2.4b(1)(b) has been deleted and its content moved to Ch. 2.4c(1).

o Ch. 2.4b(1)(c) has also been deleted. Accordingly, what was Ch. 2.4b(1)(d) has been renumbered to Ch. 2.4b(1)(b).

o Ch. 2.4b(5) has been added to include language regarding the responsibilities of the Branch of Medical Benefits Adjudication and Bill Processing (BMBABP), and states:

(5) Branch of Medical Benefits Adjudication and Bill Processing (BMBABP). Personnel in this branch are responsible for medical bill processing, adjudication of certain medical benefits that require pre-approval (like home health care related activities) for claimants who have accepted conditions, and program integrity.

(a) The Medical Bill Processing Unit (MBPU) oversees the medical bill processing systems, transactions and coding necessary to assure prompt and accurate payment for approved medical benefits, and works with OWCP and the Central Bill Processing contractor to develop and implement appropriate bill payment codes, procedures and resolutions to issues which arise.

(b) The Program Integrity Team provides analysis, investigations, audit and reporting regarding whether payments made to claimants or providers were accurate and appropriate, and align with necessary treatments for approved conditions. When potential billing inaccuracies or discrepancies are identified, they will work to provide training and/or implement bill adjustments, as appropriate and necessary.

(c) The Medical Benefits Adjudication Unit (MBAU) provides medical benefits adjudication and decisions regarding requests for medical care or equipment that requires preauthorization.

o Ch.2.4c(1) has been added and includes the following language which was previously Ch. 2.4b(1)(b):

(1) A separation must exist between the DOs and FAB to maintain impartiality in case adjudication functions. The designated CE assigned to a case handles all necessary development on outstanding claim elements not related to the RD currently in front of the FAB for review, and may issue a RD whenever the case record contains enough evidence on file to support a RD on any of the outstanding claim elements. While the CE may concurrently work on a case assigned to FAB, the CE may not engage in any case adjudication activity relating to a claim under evaluation by FAB. Moreover, FAB may not seek CE assistance with regard to its evaluation or development of a claim under consideration for finalization.*