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Paragraph 18, Third Party Liability Debts , was previously paragraph Paragraph 19, Court Ordered Restitution in Fraud Cases , was previously paragraph 18 and is largely unchanged.
Chapter , Jurisdiction , has been updated to reflect the change in how jurisdiction is assigned upon case create for claimants who reside in Maryland. As in the past, cases are created and assigned based on the claimant's home address, and in the extremely rare case where a home address is not available, then from the claimant's duty station state. If neither are available, jurisdiction is based on the state where the injury occurred.
Previously, updates were made to include a change in the jurisdiction of claims filed by claimants who reside in all zip codes in Maryland, aside from those within a designated area primarily consisting of Prince George's County. District Office 03, Philadelphia, continued to be assigned claims arising in Delaware, Pennsylvania, West Virginia, and Maryland when the claimant's residence had a zip code beginning with "21" and, effective October 1, , their jurisdictional authority was expanded to include new claims for claimants who reside in all zip codes in Maryland, aside from those within an area primarily consisting of Prince George's County which remained under the jurisdiction District Office 25, Washington, DC.
Effective August 22, , jurisdiction for newly created cases for all claimants who reside in Maryland was transferred from Washington, DC's jurisdiction to Philadelphia's jurisdiction. In addition, effective October 1, , jurisdiction for all previously existing cases within all zip codes in the state of Maryland will be transferred from Washington, DC's jurisdiction to Philadelphia's jurisdiction. Paragraph 2, General Jurisdiction , defines home address state, duty station state, and state where the injury occurred, and explains the previous change in procedure based on duty station state to home address state, providing examples for emphasis.
Each District Office's general jurisdiction by state is outlined with changes to District Office 03 Philadelphia and District Office 25 Washington, DC to coincide with Philadelphia's expanded jurisdictional authority for all zip codes in Maryland.
Distribution: List No. The Division of Federal Employees' Compensation DFEC with this issuance clarifies and amends several areas of procedure with respect to the processing of schedule awards. First, it clarifies the actions to be taken when a District Medical Adviser DMA provides a detailed and rationalized review that does not concur with an impairment rating provided by a second opinion examiner.
Section a of the Federal Employees Compensation Act provides that when there is a disagreement between a physician making the examination for the United States and a physician of the employee, a third physician shall be appointed to make an examination to resolve the conflict.
The Act does not provide for a conflict in opinion between two physicians making an examination for the United States, i. Second, it amends established procedure, removing the requirement of DMA review of a referee medical examiner's impairment evaluation. Because of the authoritative weight given to the report of an impartial referee examiner, DFEC has determined that additional review of the referee report is unnecessarily duplicative. Lastly, this update further emphasizes that rated impairment should reflect the total loss as evaluated for the scheduled member at the time of the rating examination.
There are no provisions for apportionment under the FECA and the Employees Compensation Appeals Board ECAB has long held that an impairment assessment should include both work-related impairment as well as non-industrial impairment of the same scheduled member. See Raymond E. Gwynn , 35 ECAB , Paragraph 5, Evaluation of Schedule Awards , paragraph d has been updated with additional clarity, emphasizing that schedule awards include permanent impairment resulting from conditions accepted by the OWCP as job-related as well as and any non-industrial permanent impairment present in the same scheduled member as a work-related condition at the time of the rating examination.
Paragraph 6, Obtaining Medical Evidence , f District Medical Advisor DMA Review 2 e concerning DMA review that does not concur with the impairment rating, the language has been modified to remove "second opinion" to clarify the actions to be taken by the claims examiner when the DMA does not concur with the second opinion examiner's impairment rating. In Paragraph 6, Obtaining Medical Evidence , g If a case has been referred for a referee evaluation , the language has been modified to remove the requirement that a referee report be referred to the DMA.
It is noted that the DMA can still be utilized for interpretation of the referee medical report but only if the CE determines such review is necessary. When conditions are accepted as work related in a case, a corresponding diagnosis code is entered into the case management system for maintenance and bill payment purposes. The U. Paragraph 10 is now titled ICD Codes. The paragraph explains the number of digits in the new codes and the new structure that takes into account the etiology, anatomic site and severity of the injury, with extensions designating the episode of care.
While this one-year period had previously been construed to begin on the date of the original decision, the Employees Compensation Appeals Board ECAB has held that the one-year period should begin to run on the date after the decision was issued. ECAB has also held that when determining the one-year period for requesting reconsideration, the last day of the period should be included unless it is a Saturday, a Sunday or a legal holiday.
Paragraph 3, Preliminary Processing , has been modified slightly, with language advising that with review of a request, sufficient detail should be provided to discern the decision being contested and in effort to ascertain that another form of appeal is not being requested.
Paragraph 4, Time Limitations , clarifies that the one-year period to request reconsideration begins to run on the first day after the original decision rather than on the date of the original decision, and to clarify what is the last day of the one-year period. Paragraph 5, Untimely Application , inclusion of an additional citation.
Chapter , Jurisdiction , has been updated and streamlined to reflect the change in how jurisdiction is assigned upon creation of a case. Previously, cases were created and assigned based upon the claimant's duty station state, and if that was not available then from the claimant's home address, and if that was not available then from the state where the injury occurred. Now, cases are created and assigned based upon the claimant's home address state, and in the extremely rare case where the home address is not available then from the claimant's duty station state.
If neither are available, jurisdiction is based upon the state where the injury occurred. The Division of Federal Employees' Compensation has determined that it would improve overall service to DFEC claimants and Federal employing agencies by making a shift in jurisdiction for certain claims. Updates have been made to include a change in the jurisdiction of claims filed by claimants who reside in all zip codes in Maryland, aside from those roughly encompassing Prince George's County.
Previously, District 3, Philadelphia, handled claims arising in Delaware, Pennsylvania, West Virginia, and Maryland when the claimant's residence had a zip code beginning with "21" and all other Maryland claims fell under the jurisdiction of District 25, Washington, DC.
Effective September 1, , Philadelphia's jurisdictional authority was expanded to include new claims for claimants who reside in all zip codes in Maryland, aside from those within an area roughly encompassing Prince George's County which will remain under the jurisdiction of Washington, DC. Effective October 1, , jurisdiction for existing claims with all zip codes in Maryland, aside from those within an area primarily within Prince George's County, were transferred from Washington, DC's jurisdiction to Philadelphia's jurisdiction.
Paragraph 2, General Jurisdiction , defines home address state, duty station state, and state where the injury occurred, and explains the change in procedure based upon duty station state to home address state, providing examples for emphasis.
Each district office's general jurisdiction by state is outlined with changes to District 3, Philadelphia, and District 25, Washington, DC, to coincide with Philadelphia's expanded jurisdictional authority for all zip codes in Maryland, aside from those roughly encompassing Prince George's County.
Paragraph 3, Special Jurisdiction , has been modified to emphasize the use of the home address state assignation, where applicable, in special jurisdiction cases. Additionally, special jurisdiction cases with the exception of national security cases are identified and assignment outlined as being managed by District 9, Cleveland.
Paragraph 4, Jurisdiction Before Adjudication , has been removed and its contents fully incorporated into Paragraph 2, General Jurisdiction. Paragraph 5, Jurisdiction After Adjudication , has become Paragraph 4, and defines jurisdiction after adjudication in fatal and non-fatal cases and for those claimants who have seasonal residences. A clarification statement that cases should be transferred when the claimant's home address state changes, unless under special jurisdiction or seasonal residency, has been added.
Chapter has been amended. Chapter is entirely new. Chapter , paragraph 9, Second Opinion Examinations, and Chapter , paragraph 3, Second Opinion Examinations, have been revised to reflect the specific medical documentation required to be sent to a second opinion physician upon referral.
Subparagraph a of For unadjudicated case referrals and all referrals for medical management, disability management or surgery: all operative reports regardless of age, all diagnostic tests regardless of age and all medical records from any qualified physician as defined in 5 U.
For schedule award case referrals: all operative reports regardless of age, all diagnostic tests regardless of age, all medical records from any qualified physician as defined in 5 U.
New procedure also provide that should the Claims Examiner determine, in the exercise of his or her judgment, that the unique circumstances of a case file suggest that additional information would be of assistance to the examiner, documentation of such circumstances and the specific changes should be outlined in a Memorandum to the File and made part of the case record. The Division of Federal Employees' Compensation DFEC and the Peace Corps have historically worked together to improve the workers' compensation experience for returning volunteers who have sustained an injury or occupational illness as a result of service with the Peace Corps.
In an effort to provide better outreach to Peace Corps volunteers, DFEC has a link on its home page with information specific to Peace Corps volunteers. To further improve the quality of the information provided in relation to Peace Corps cases and to update its own internal guidance for even more consistent claims handling, DFEC with issuance of this transmittal is releasing an entirely new Procedure Manual PM chapter pertaining solely to claims devoted to Peace Corps volunteers, PM PM had not been updated since early and PM had not been updated since May, Chapter is amended to reflect that all Peace Corps cases including National office claims will initially be handled in the Cleveland District Office, as the Cleveland office has ongoing close contacts with that office.
New PM chapter incorporates the information pertaining to Peace Corps cases that had been in and and includes additional and newly updated information as outlined below; it also removes outdated citations and references that were contained the Peace Corps section of PM chapter was amended to correspond with the jurisdictional rules provided in Paragraph 5, below.
Paragraph 1, Introduction , provides the genesis for the establishment of the Peace Corps and outlines that the chapter will focus on the unique aspects of coverage under that pertain specifically to volunteers in the Peace Corps. It also notes that claims for Peace Corps employees who work for the Peace Corps, other than as volunteers or volunteer leaders, are handled in the same manner as other claims and that there are no special rules for handling claims from such employees.
Paragraph 5, Jurisdiction , outlines that Peace Corps claims are initially adjudicated in the Cleveland District Office, after which they are transferred to other district offices if approved. Paragraph 7, Conditions of Coverage During Training , explains that Peace Corps applicants have the protection of the FECA while performing their training assignments or while engaged in any activity which is a reasonable incident of the training assignment.
This paragraph explains that injuries of trainees and volunteers while abroad are deemed to have occurred while in the performance of duty, and any disease contracted abroad is deemed to have been proximately caused by the employment. A discussion of various types of medical conditions, such as dental disease, mental illness and pregnancy, is included in this paragraph as well.
Also, as first noted in FECA Transmittal , this paragraph specifically notes that injury due to assault or sexual assault including treatment for sexually transmitted disease and mental health treatment are covered under the FECA. Paragraph 9, Conditions of Coverage Returning from Service Abroad , outlines that a volunteer who returns to the United States immediately after completing service abroad has the protection of the FECA while traveling to the United States unless a material deviation occurs.
If the volunteer is terminated at a foreign post of duty, the volunteer has the protection of the FECA only during that part of the trip when on the direct or most usually traveled route between the foreign post of duty and the United States. Paragraph 11, Initial Authorization for Medical Care , outlines that requests for initial authorization of medical care in emergency situations prior to creation of a case should be directed to the Cleveland District Office and requests for treatment, after a case has been created, should be referred to OWCP's authorized billing agent like all other cases.
Paragraph 12, Reporting Injuries and Deaths , outlines that Peace Corps volunteers are required to report injuries in the manner required by 20 C.
Paragraph 13, Claims for Disability Compensation , provides specific information relative to the filing and payment of compensation claims for Peace Corps volunteers. It is noted that the date of the volunteer's separation will be the date pay stops and that entitlement to compensation for temporary or permanent disability begins on the date following the date of separation. Specific information on other elements related to payment of compensation, such as pay rates, effective payrate dates, and waiting days, is also provided.
Continuation of Pay is not paid to Peace Corps volunteers. See 20 C. This includes the full complement of nurse intervention and vocational rehabilitation services provided as part of the Disability Management process. Exhibit 1, Annual Pay Rates for Computing Compensation for Peace Corps Volunteers , provides the payrate amounts, effective the date of injury separation through the present year.
The chapter was then updated in November, , and additional updates are being made at this time as outlined below. Paragraph 1, Purpose and Scope , was updated to include references to other relevant parts of the Procedure Manual, Part 7 Nurse Intervention and Part 8 Rehabilitation. Paragraph 6, DM Codes , was updated to indicate that there are six, not five, types of mandatory codes since Dual Tracking codes are really specific unto themselves.
The portion of this paragraph pertaining to mandatory CE Intervention Codes also now includes a reference to codes for the following circumstances: a second opinion examination has been determined to be unnecessary; valid work tolerance limitations are in file, but the claimant has not returned to work; and valid work tolerance limitations are not in file. The codes are then described in more detail in other paragraphs.
Additional information was also added relative to the RMV code to clarify that it should be entered after concurrence by a Supervisor that the DM record should be deleted and that valid DM cases should not be removed from DM via the RMV code.
Paragraph 7, CE Intervention Codes , which outlines mandatory CE codes, was updated in a few places, and some reorganization took place so that the codes are listed in alpha order within the chapter. The effective date of the status is the date of the most recent medical work release outlining the necessary work restrictions.
The effective date of the status is the date the CE determines that valid work restrictions are not file for all conditions. Additional DM codes were added to assist with the management and monitoring of disability cases:. PRX Pre-reduction cannot be finalized. PRX can be entered after a proposed notice of reduction has been sent to the claimant and subsequent evidence or argument is received which hinders the CE from proceeding with a final notice of reduction.
PTX Pre-termination cannot be finalized. PTX can be entered after a proposed notice of termination has been sent to the claimant and subsequent evidence or argument is received which hinders the CE from proceeding with a final notice of termination.
TRL Transfer of case. TRL can be entered to denote a transfer of a case file from one District Office to another. The TRL code can be entered by the receiving District Office effective the date it received the transferred case. The explanation of the SUR code was updated to indicate that the effective date for the code can be a future date, which was a change made in the noted iFECS release. SUR Surgery Authorized. SUR can be entered when the claimant has approved surgery.
This code is useful for alerting the CE to re-evaluate the disability management options for this case. The effective date of code SUR should be the date the surgery is performed. If the surgery is scheduled for a date in the future, entry of this future date is allowed.
Paragraph 13, Closure Codes and Resolutions , was updated in a few places primarily to account for coding associated with return-to-work in temporary positions and failure to accept appropriate temporary light duty assignments commensurate with 20 C. The OWCP PM chapter will remain, and that chapter may be referenced for a historical perspective, but since it has not been recently updated, this new chapter FECA PM should be consulted for any rehabilitation referral issues, since it contains the most current policies and procedures for DFEC.
Paragraph 1, Authority , provides a reference for relevant statutory and regulatory provisions and provides Employees' Compensation Appeals Board ECAB precedent pertaining to the provision of rehabilitation services. Paragraph 2, Purpose and Scope , defines referral screening and identifies the two related steps. Paragraph 3, Referral Sources and Mechanics , explains the importance of early case referral and identifies the various sources of referrals for rehabilitation.
Paragraph 4, Referral Requirements , outlines the information which each referral for rehabilitation should include and provides the process by which such referral should be transmitted to the RS. Paragraph 5, Active Field Nurse Cases and Dual Tracking , identifies those instances in which a case may be referred for rehabilitation concurrently with active Field Nurse FN services. Paragraph 6, Screening , defines the goal of screening and provides the time frame within which such screening should be completed.
This paragraph also explains the three components required for review medical, non-medical, and injured worker information and provides guidance on how to clarify any vague or missing information. Paragraph 7, Referral Outcome , explains how to open an active rehabilitation case and assign a Rehabilitation Counselor RC when necessary or close a case from referral when the case is not in posture for rehabilitation services.
Paragraph 8, Limited Referrals , defines those instances in which a referral to an RC on a limited basis may be appropriate even though one or more of the referral requirements has not technically been met. The exhibit outlining the special case designations is being updated.
Two new case designations are being added, as outlined below. Chapter paragraph 12 has been updated to reflect that a claimant who is legally married to a same sex spouse is entitled to the augmented compensation rate per the June 26, Supreme Court decision of United States vs. Windsor , which struck down the provision of the Defense of Marriage Act DOMA that prohibited the federal government from recognizing legally married same sex couples.
Chapter paragraph 3 Health Benefits Insurance has been updated to reflect that OWCP will administer health benefits to same sex spouses and children of same sex marriage in accordance with OPM's guidance following the ruling in United States vs. These chapters are being updated. Chapter , paragraph 17, has been revised in its entirety. Paragraph 17, subparagraph c provides new procedures for authorization of "miscellaneous DME" requested under code E Before authorizing E or any unlisted procedure code, the CE should request that the provider identify and submit a procedure code from the AMA booklets that describes the equipment.
If the provider is unable to do so, it should submit justification for the use of the E or unlisted code. Subparagraph d provides the basic evidentiary requirements for authorization of DME. Subparagraph e provides further guidance with respect to purchasing DME.
It should be noted that some agencies have contracted with DME providers to provide items at a discount. These agency programs are voluntary on the part of the claimant, however, OWCP remains the decision maker on what DME is authorized and how.
It also notes that the basic, unadorned DME with the lowest cost that meets the physician's specifications should be authorized. It should be further noted that while the FECA regulations require all DME providers to be registered in Medicare's Durable Medical Equipment, Prosthetics, Orthotics and Supplies Accreditation process, due to changes in the authorizing legislation and other regulations, this Medicare process is not due to be completed nationwide until Accordingly, OWCP will not implement this accreditation process until it is available nationwide.
Subparagraph f is new procedure and describes when and how to perform a rental versus purchase analysis. A medical provider or claimant may sometimes request authorization for rental of DME rather than purchase. In such cases, rental of DME may be authorized for up to 60 days if supported by the medical evidence. Rental of DME beyond 60 days requires the CE to perform a rental versus purchase analysis as described in this subparagraph. Subparagraph i provides procedures on authorizing new and replacement hearing aids.
Price quotes from multiple suppliers are not necessary for hearing aids. However, the CE should still ensure that the hearing aids requested represent the basic, unadorned aids that meet the prescribing physician's specifications.
Subparagraph k emphasizes the importance of advising the claimant in writing of any DME authorization denials. It notes that a formal decision with appeal rights should be provided upon the claimant's request. This chapter describes the steps involved in processing an initial case denial if any one of the five basic requirements has not been established.
Along with FECA PM through , it covers the factors that should be addressed when denying an initial claim and preparing the formal Notice of Decision. Currently, formal decisions are discussed in Chapter Formal Decisions. The issuance of an initial denial is a distinct process, though, and as such, it has been decided that moving information pertaining to the initial denial of a claim to an entirely new chapter is warranted.
In doing so, the process for denying all initial claims including claims for emotional conditions will be updated and expanded to provide clear guidelines for the denial of an initial claim when one of the five basic elements has not been met. Paragraph 1, Purpose and Scope , outlines that the chapter will focus solely on the process of issuing a denial on an initial claim when one of the five basic elements has not been met.
Paragraph 3, Burden of Proof , discusses the claimant's burden of proof for establishing a claim, and the necessary steps the Claims Examiner CE must take before an initial claim can be formally denied. Paragraph 4, Element for Denial , outlines the procedure for reviewing the claim to determine whether the five basic elements have been met after the claimant has been provided the opportunity to submit necessary evidence.
It outlines that the five basic elements should be considered in a hierarchical manner. Paragraph 5, Writing the Initial Denial , discusses how to prepare the initial denial once it has been determined which of the five basic elements has not been established.
It notes that the initial denial is a legal document which serves as a basis for further action in the claim, including appeals, and that it should provide a clear explanation of the disallowance of the claim. Paragraph 6, Emotional Condition Denials , discusses the denial of an initial claim for an emotional condition, and the importance of identifying and discussing all evidence that pertains to the specific issue, including any unsuccessful attempts to obtain significant evidence.
It also discusses the need to distinguish between those workplace activities and circumstances which are factors of employment and those which are outside the realm of employment for purposes of compensation, as well as determining whether the event or situations alleged actually existed or occurred.
This is a new chapter. Chapter was updated in its entirety in October, Additional updates are being made at this time to provide more clarity with regard to DM Track Dates for Traumatic Injury cases which did not meet the eligibility requirements to become Triage COP Cases.
Instructions are provided for those cases where the DM record is created prior to the expiration of the COP period, as well as those cases where the disability extends beyond the COP period. Paragraph 12, Optional Codes , now includes additional new DM codes to assist with the management and monitoring of disability cases:.
This paragraph has also been revised to provide further clarification regarding the use of code MNR Narrative Report Received. Specifically, the use of the MNR code was further defined as being used only when a narrative medical report is submitted in response to a specific request from the CE after the entry of the QAP code.
On August 6, , the President signed the "Honoring America's Veterans and Caring for Camp Lejeune Families Act of " Camp Lejeune Act , which provides for medical care for certain conditions for veterans and their families who were exposed to contaminated water while stationed in Camp Lejeune, North Carolina.
The passage of the Camp Lejeune Act highlighted the need for special tracking of these claims. A federal employee would be entitled to FECA benefits for a timely claimed medical condition including a latent condition caused by water contamination at Camp Lejeune if he or she was exposed to such water contamination in the performance of duty including through employer-provided housing and could provide medical evidence that such exposure caused, contributed to or aggravated that medical condition.
HSA Hurricane Sandy — This case designation will be used to identify cases containing reports of injuries related to Hurricane Sandy which made landfall in late October, and its aftermath. When a physician is selected, the scheduler inputs the appointment date and time into the Medical Management application. The application then saves the appointment information and prompts the scheduler to generate the ME, Appointment Notification Report, for imaging into the case file.
Since the ME report can only be generated through the Medical Management application, it serves as documentary evidence that the referee appointment was scheduled through the use of the rotational system in the Medical Management application. However, over the past year the Employees' Compensation Appeals Board ECAB has questioned the DFEC's documentation of this process and indicated that there was other documentation available that was not being presented as evidence of the rotational selection, and that the ME report alone was insufficient to substantiate proper selection of the impartial specialist.
The ME report can only be generated through the Medical Management application, and the information contained therein cannot be altered; therefore, the ME report serves as documentary "best" evidence that the referee appointment was in fact scheduled through the use of the rotational system in the Medical Management application. To satisfy the concerns and questions raised by the ECAB, and to further document the referee selection process, the DFEC has enhanced the current ME report effective December 17, to provide more information relative to the scheduling of an IME appointment.
The enhancements include a listing of all physicians contacted and bypassed prior to the selection of the IME physician, as well as a certification statement. This information was previously included in certain case files via screen shots, but in many cases that information was not readable due to the quality of the screen shots.
This updated version of the ME report can only be generated for new appointments created on and after the date of this update in iFECS. It cannot be accurately generated for appointments made prior to December 17, , and the prior version of the ME report without bypass information can no longer be duplicated.
As system updates were required to modify this report, updates were also made to the Medical Management application so that the physicians were automatically grouped into zip clusters based upon specified mileage ranges outside of the initial zip cluster 50 miles, 75 miles, and continuing in 25 mile increments up to miles , as seen on the report.
However, to further explain the rotational process and to document the new MEO23 report, paragraph 5, Medical Management Application , has been outlined as described below. The initial paragraph was updated to note that on rare occasions the Medical Management Application MMA will be used to locate a qualified second opinion examiner if a second opinion examiner within the second opinion contract for the District Office cannot be utilized. In these instances, the rotational requirement does not apply.
In sub-paragraph 5a, a typographical error was corrected. Sub-paragraph 5b was updated to clarify that the specified mile radius is calculated from the claimant's home zip code. Sub-paragraph 5d was shortened significantly, since a complete explanation of the rotational process was moved to a new paragraph, 5e.
Sub-paragraph 5e Presentation of Physicians is completely new. This section provides detail regarding how physicians are presented to the scheduler in both the initial zip cluster and then outside of the initial zip cluster.
This paragraph also describes the order the physicians are presented within each of these ranges — first those who have not had a previous appointment scheduled within the Medical Management application presented alphabetically , and then those that have had a previous appointment scheduled within the Medical Management application by the date that the last appointment was scheduled, with the most recent being at the bottom of the presentation order.
Sub-paragraph 5g, formerly sub-paragraph 5f, was updated slightly to reference the rotation previously described in sub-paragraph 5e. Former sub-paragraph 5g was separated into two distinct paragraphs — 5h and 5i. And former sub-paragraph 5h, which described the order in which physicians were presented for selection, has been deleted since the information has been absorbed into sub-paragraph 5e.
New sub-paragraph 5h outlines that when the scheduler inputs the appointment date and time into the Medical Management application, the ME, Appointment Notification Report, is generated for imaging into the case file.
New sub-paragraph 5i describes in detail the data contained in the ME report based upon the system updates made as of December 17, Chapter has been revised in its entirety.
The chapter has been streamlined and updated to include new language, and the structure of the chapter has been changed.
Many of the paragraphs have been reordered, renamed, consolidated, and updated. The number of paragraphs in the chapter has been reduced from 8 to 7. No substantive changes were made to paragraph 1, but the title was updated to Purpose and Scope.
Paragraph 2, Types of Causal Relationship , added some language to clarify the types of causal relationship, and outdated language was deleted. Paragraph 3, Evidence Needed , has been amended to include a reference that a report of a physician assistant or a certified nurse practitioner will be considered medical evidence if countersigned by a qualified physician. Some outdated language has been removed, more detail was added, and the information within the paragraph was reorganized.
Paragraph 4, Evaluating Medical Opinions , has been reconstructed, with new sections addressing when an attending physician negates causal relationship and actions to take when insufficient evidence has been submitted. Paragraph 5, Obtaining Additional Medical Opinion , has been completely rearranged. It addresses when additional medical development may be warranted and how to proceed with such development.
Paragraph 6, High-Risk Employment formerly paragraph 8 , contains essentially the same information as the prior paragraph 8.
Former paragraph 6, Consequential and Intervening Injuries, is now paragraph 7. Paragraph 7, Consequential and Intervening Injuries , provides greater detail as to what factual and medical evidence is needed to properly develop these claims.
The chapter is being updated in its entirety. Chapter has been updated in its entirety, and pertinent information pertaining to death claims, schedule awards, and loss of wage-earning capacity LWEC payments has moved into other Procedure Manual chapters for ease of referencing related guidance within one subject chapter.
The chapter has also been renamed Compensation Claims rather than Calculating Compensation , since the chapter discusses receipt and development of claims, as well as the actual payment process.
Paragraph 1, Purpose and Scope , provides a summary of the information provided in the chapter, as well as pertinent references to other chapters that reference payments. Paragraph 2, Responsibilities , outlines the Claims Examiner's CE's responsibility for adjudicating each claim for compensation, determining the pay elements necessary for calculation of the payment, and for entering all necessary data into the case management system.
Paragraph 3, Certification , discusses the various certification levels and outlines that by certifying a payment, a certifier is verifying that the adjudication and calculation of the payment including all pay elements are correct, that all payment data is entered correctly in the case management system, and that all pay elements entered correspond with the documentation in the file. Paragraph 4, Receipt of Claims , discusses the actions to take upon receipt of a claim initially following the Continuation of Pay COP period and references PM for further guidance.
Paragraph 5, Development of Compensation Claims , provides a discussion of the development actions that may be needed when adjudicating and paying compensation claims. This paragraph also reminds CEs to initiate Disability Management actions in wage claims where the claimant has not returned to full duty at the time payment is being made.
Paragraph 6, Factors in Calculating Compensation , provides a brief outline of the items to consider when paying a compensation claim, and cites the sections within the chapter that discuss those factors.
This paragraph also reminds CEs that payment should be made on the daily roll for intermittent hours lost when a claim is made for intermittent hours only, i. Payment for straight total disability should not be made based on hours lost. The paragraph also stresses the importance of using the correct schedule days and hours when paying "work days. Paragraph 9, Basic Calculations , outlines basic calculations and has examples of such calculations.
Paragraph 10, Special Determinations , provides detailed information for Census workers and Firefighters. Paragraph 11, Waiting Days , provides information pertaining to waiting days and the application differences for Postal and non-Postal cases.
Paragraph 12, Compensation Rate , explains the basis for payment of augmented compensation and provides a discussion of dependents. This includes not only references to a spouse, but also details relating to children over the age of 18 and those incapable of self-support. Paragraph 13, Minimum Compensation , provides information pertaining to the minimum MIN compensation rate and how it is applied.
Paragraph 14, Maximum Compensation , provides information pertaining to the maximum MAX compensation rate and how it is applied. Paragraph 15, Insurance Deductions , discusses insurance deductions and the effective date for necessary deductions. The importance of timely deductions and transferring the health benefits insurance enrollment is stressed. This paragraph also provides an overview of the various types of life insurance coverage, as well as dental and vision insurance coverage.
Paragraph 17, Other Payees , discusses the various payees that may exist in a case other than the claimant. Further information was added in particular to the discussion of Representative Payees. Paragraph 18, Leave Buy Back , provides detailed information on the leave buy back process. Paragraph 19, Wages Lost for Medical Examination or Treatment , discusses payment for time lost due to medical appointments for treatment of the work-related condition, as well as payment of compensation for time lost due to an OWCP-directed examination.
Exhibit 4, Activity Codes , provides a list of all Activity Codes, which are used for payments in certain types of cases. PM already contains a discussion of several elements of pay pertaining strictly to death cases, including an extensive discussion of the various types of possible beneficiaries through Payment in death cases is also discussed in , and burial and termination payments are discussed in and , respectively. A new paragraph has been added to for elements of pay previously mentioned in PM but not already specifically covered in this chapter.
The information has been added to this chapter so that the CE can find all relevant information pertaining to payments in death cases in one chapter, to the extent possible.
Paragraph 22, Additional Payment Considerations , was added to the end of the chapter. Effective December 31, , the employing agency is required to notify the federal employee's spouse, if one exists, if that employee designates a person other than the spouse to receive all or a portion of the FECA death gratuity. These changes took effect on enactment. While incorporating the information pertaining to schedule awards from the previous , this chapter was updated and revised throughout.
Paragraph 1, Purpose and Scope , states that the primary focus of the chapter is to focus on the development, adjudication and payment of schedule awards. Paragraph 2, Impairment and Disability , remains essentially unchanged, except that statutory and regulatory references and ECAB citations were added. Paragraph 3, Permanent Total Disability , also remains essentially unchanged from the prior paragraph of the same name, except the paragraph was re-numbered from paragraph 4 to paragraph 3.
A note was added to clarify that there is no specific case status to differentiate or classify a claimant as permanently, totally disabled as defined by 5 U. Paragraph 4, Entitlement to Schedule Awards , includes much of the information in the prior paragraph 5 of the same name. A reference to possible entitlement to a lump sum was added with a citation for PM Chapter This paragraph was also updated to include a new section referencing that effective August 29, the Secretary added by regulation the skin as a new schedule member, for up to weeks of compensation, for injuries sustained on or after September 11, An update was also made to explain that if a claimant loses wages to obtain medical treatment during the period of a schedule award e.
Paragraph 5, Evaluation of Schedule Awards , includes much of the information in the prior paragraph 6 of the same name. A new section on skin impairment was added. A point of clarification was added noting that impairment ratings for schedule awards include those conditions accepted by the OWCP as job-related, and any pre-existing permanent impairment of the same member or function. Also, a section was added addressing how to calculate impairment for adjoining members.
The prior portions pertaining to obtaining medical evidence and review by the District Medical Advisor DMA were moved into new paragraph 6.
Paragraph 6, Obtaining Medical Evidence , discuses the development to be taken when a schedule award is requested, as well as the necessary review by the DMA. Paragraph 7, Schedule Award Payments , is new and discusses all elements of pay for schedule awards.
PM previously had a discussion of several elements of pay pertaining strictly to schedule awards prior paragraph 7, titled Payment of Schedule Awards. The information contained within that paragraph was combined with the information pertaining to schedule awards in the prior , and a new paragraph 7 was created. This compilation was done so that the CE can find all relevant information pertaining to schedule award payments in one chapter, to the extent possible.
This paragraph includes general considerations such as previous impairment to the same schedule member and the interruption of awards.
Paragraph 8, Schedule Award Decisions , is new and discusses the necessary elements of a formal schedule award decision, including a reference that the medical report used for the final determination should be included with the decision.
Paragraph 9, Claims for Increased Schedule Awards , includes information from the prior paragraph 7, but is now its own section for ease of reference. New information in this paragraph addresses claims for increased awards calculated under the same edition of the AMA Guides and the resulting overpayments that may occur, along with a few other updates for clarification. Paragraph 10, Disfigurement , is not new and remains essentially unchanged from the previous paragraph of the same name.
Exhibit 1, Percentage Table for Schedule Awards , was added. The percentage table for schedule awards was moved from into the schedule award chapter for ease of reference.
The information previously contained in was essentially moved without any changes, except that references to other chapters or paragraphs were updated as needed based on the movement of this information.
The following chapters have been updated in their entirety. This chapter describes various types of disallowances and details the steps involved in preparing and issuing the formal decision. Initial denials of claims are discussed in detail in PM Paragraph 1, Purpose and Scope , outlines that the chapter will focus on the process of issuing post-adjudicatory disallowances, although the general requirements outlined pertain to all types of formal decisions issued by the OWCP.
Paragraph 2, Regulatory Provisions , provides references to 20 C. Paragraph 3, Responsibilities , discusses the OWCP's burden of proof in issuing a post-adjudicatory disallowance. It outlines the necessary steps the Claims Examiner CE must take before a formal decision can be issued and during the adjudication process. It also details the CE's responsibilities with timeframes, signature authority, appeal rights, decision copies, and iFECS coding.
Paragraph 4, Whether Pre-Termination Notices are Required , discusses the instances in which terminations do not require notice prior to cessation of benefits, and the instances in which terminations do require notice prior to cessation of benefits.
It outlines the use of the Letter Decision when denying less complex issues, and the Notice of Decision when denying more complex issues or when a more detailed discussion of the evidence is required.
Paragraph 6, Writing the Decision , discusses that the disallowance is a legal document which should be clearly written and easily understood by all audiences. It outlines that when writing the decision, the CE should use basic language, cite specific references, draw clear findings of fact from the evidence, and consider all of the evidence which bears on the issue at hand.
Paragraph 7, Pre-Termination Notices , discusses the process for issuing decisions when the weight of medical evidence establishes that the claimant is no longer entitled to benefits previously authorized. It also outlines follow-up actions and potential outcomes to the pre-termination notice. Paragraph 8, Termination Decisions , discusses the key points of the pre-termination that need to be included in the final decision, and outlines that the case management system must be properly coded to reflect the termination.
Paragraph 9, Claims for Compensation , discusses the formal disallowance process for claims filed for leave without pay, leave buy back, or other wage loss. Paragraph 10, Medical Authorization Requests , discusses the process of formally denying medical authorization requests, when needed, after any necessary development.
Paragraph 12, Recurrences , discusses the formal disallowance process for both a recurrence of a medical condition and a recurrence of disability. Paragraph 14, Sanctions for Failure to Accept Suitable Work , discusses the process for issuing sanction decisions due to the claimant's refusal or abandonment of suitable work per Section of the FECA.
Paragraph 15, Forfeiture , discusses issuing formal decisions when a claimant fails to make an affidavit or report when required, or knowingly omits or understates any part of his earnings per Section of the FECA.
Paragraph 16, Suspensions , discusses issuing suspension decisions when a claimant fails to cooperate with the OWCP's direction. Paragraph 18, Imprisonment for Felonies Other Than Fraud , discusses issuing suspension decisions and terminating entitlement to all medical and compensation benefits when the claimant has been convicted and imprisoned due to a felony per Section of the FECA. Paragraph 19, Rescissions , discusses the process of issuing formal disallowances per Section of the FECA when it has been determined that the original decision was issued in error.
Exhibits have been deleted from the chapter. Signature authority for attorney fee limits is now outlined in Chapter , Representative's Services, and certification authority for payments is discussed in Chapter , Compensation Claims. This chapter has been updated in its entirety. To satisfy the concerns and questions raised by the Employees Compensation Appeals Board ECAB , and to further document the referee selection process, the DFEC enhanced the ME report effective December 17, to provide more information relative to the scheduling of the appointment.
This has not changed. Paragraph 5 of PM Chapter discusses this application in detail. Effective May 13, , the Medical Management application in iFECS has again been updated; therefore, paragraph e 3 is being updated accordingly to discuss the new functionality. The Medical Management application sets miles as the maximum limit for a zip code range; this has not changed. Previously, though, if that mile range was exhausted without making an appointment, the scheduler had to document the case file by imaging a copy of the bypass report to show that a search within the Medical Management application had been exhausted.
A copy of the bypass report was necessary because an ME report could not be generated since an appointment was unable to be scheduled. With this May 13, update to the Medical Management application, the scheduler no longer has to independently run the complete bypass report in order to document the file.
The scheduler can then proceed with scheduling via an alternative method, including entry of a different zip code in the Medical Management application. This may be necessary, for instance, if the claimant lives in a very remote area and will need to travel to a larger city in order to attend a scheduled examination.
In this instance, the scheduler will enter the zip code of the city to which the claimant will be traveling. The Division of Federal Employees' Compensation DFEC with this issuance outlines a comprehensive strategy for return to work in all situations where a certain defined level of return to work is possible.
This Procedure Manual release complements the DFEC's overall proactive approach to more efficient claims management, which includes claims intake via electronic filing and ECOMP to improve benefit delivery; earlier field nurse intervention to facilitate more effective medical management; active disability management; and a more dynamic and interactive approach to claims management of return to work wherever medically and vocationally feasible.
The DFEC has taken the unusual step of releasing five entirely new chapters that discuss each topic relating to return to work in greater depth for ease of use for claims staff. Our program focus on return to work, coupled with the changing dynamics in the federal workforces including telework and more flexible scheduling, has caused us to revisit program policies that in some instances posed artificial barriers to return to work for workers and their agencies. Since the passage of the Federal Employees Compensation Act FECA in , administrators of the program have been charged with administering the program in a cost effective manner comporting with the intent of Congress as set forth in the legislative history of the Act that "an employee is bound to do what work he can.
To that end, FECA Procedure Manual Chapter has been updated in its entirety, and pertinent information pertaining to loss of wage-earning capacity LWEC determinations has been moved into new Procedure Manual chapters for ease of referencing related guidance within one subject chapter.
The new chapter address wage-earning capacity decisions based on actual earnings, including new use of part-time positions, and the new chapter addresses wage-earning capacity decisions based on a constructed position. Chapter , Recurrences, has also been updated and revised.
This chapter describes policies and procedures for developing claims for recurrent medical conditions and recurrent disability. Now I just login thru a browser. Also they shut down for maintenance A LOT. C H - Sorry to hear you're having problems - can you help me understand what's happening more exactly?
If you'd like to communicate via email, you can reach us at AppFeedbackBenefitWallet conduent. Completely disfunctional. At least the website still works Now I just keep getting a pop up that says the app has been updated and to check the Play store, but no update is available.
So it's just a non-functional waste of space in my phone. Pretty disappointing. Hope they get it fixed soon. Steve - Sorry you're experiencing issues here. What message are you getting when you attempt to do so? Please feel free to reach out directly to AppFeedbackBenefitWallet conduent. In this release we have new exciting enhancements for HSA debit card users that can be accessed from Settings screens of the App.
HSA debit card users can close one or multiple of their existing debit cards. Order a new HSA debit card. Lock or Unlock one or multiple of their exist card. Go Program Way2Go Card. NJ E-ZPass. Community First CU. Alliance Catholic Credit Union.
What is the new process? How will the change affect me as a provider? How do I complete the template? Each request is matched to an original TCN to ensure accuracy. What is considered an adjustment request? An adjustment request is a correction, change or update to a bill.
What is considered an adjustment request continued? How do I request an adjustment? How do I submit an adjustment request? Box London, KY When can I expect a response after submitting a request?
EST for any additional information or assistance. When can I expect a response after submitting a request continued? If you do not have an account, please register as a user by clicking here. Systematic recoupment of overpayments. Systematic recoupment of overpayments Automated Adjustment Process allows for systematic recoupment of overpayments.
The automatic recoupment of an overpayment occurs when a provider has been over paid for a service. The new CPT requires authorization and denies. Go to the Portal. Then click on "Web Registration" and follow the instructions. If you try this and have questions, need technical support or require additional assistance, call the Health Care Solutions Operations Center Helpdesk at or To use the on-line authorization, bill status, and payment status functions, a provider must enroll and must register to use the web portal.
Both enrollment and web registration can be accomplished on the Portal. Level 1 procedures for example, office visits, MRIs without contrast, and some other routine diagnostic tests do not require authorization. If you need a hard copy confirmation of this, complete an online authorization request on the Portal and print the message displayed after the request is submitted.
Level 2, 3 and 4 procedures require authorization. These authorization requests can be made on the Portal or by faxing a completed authorization request and supporting documentation to The Medical Authorization forms are available on the Portal.
These forms request the specific information needed to process each type of authorization request. Or, you may fax the appropriate Medical Authorization form and supporting documentation to When there is a CA, NO authorization is needed for office visits and consultations, labs, hospital services including inpatient , X-rays including MRI and CT scan , physical therapy, and Emergency services including surgery related to the work injury.
You must enroll as a Provider to be paid for services provided under a CA Authorization for these services cannot be requested until a claim number has been established. However, you must be enrolled as a Provider to be paid for the consultation visit. The Claims Examiner will determine if the claim can be expanded for a new condition based on information in file and information submitted with the request or if additional development is needed. If you believe a medication is necessary for the treatment of the injured worker's accepted conditions please submit medical documentation for review by the claims examiner.
Please mail all documentation to U. To speak with a Customer Service Representative regarding an authorization, you may call , toll free. To speak with a Customer Service Representative regarding a bill or reimbursement, you may call , toll free.
No, you may not seek additional payment. If an authorized service has been rendered for the injured worker's accepted work-related condition, he or she is not responsible for charges over the maximum allowed in the OWCP fee schedule or other tests for reasonableness. Therefore, if your bill is reduced by OWCP in accordance with its fee schedule, you may not charge the injured worker for the remainder of the bill.
The Federal Fee Schedule is applied to medical bills and to some durable medical equipment bills. Information for Medical Providers. How do I enroll as a Provider? I have enrolled as a Provider. How do I register to use the web portal?