FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0100 

Part 2 - Claims Introduction 

________________________________________________________________ 

TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-0100 Introduction 

 Table of Contents. . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . 1 01/10 10-07 

 2 Structure of Part 2. . . . . . 1 01/10 10-07 

 3 Responsibilities of 

 Claims Examiners . . . . . . 2 01/10 10-07 

 4 Reference Materials for 

 Claims Examiners . . . . . . 2 01/10 10-07 

 

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Part 2 - Claims Introduction 

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1. Purpose and Scope. Part 2 outlines the policies, 

guidelines and procedures for developing, adjudicating and 

managing claims under the EEOICPA. 

This chapter describes the structure of EEOICPA PM Part 2 and 

the responsibilities of the Claims Examiner (CE) in 

administering the EEOICPA. The reference materials listed at 

the end of this chapter are available to staff in each District 

Office (DO), Final Adjudication Branch (FAB) and National 

Office. 

2. Structure of Part 2. 

a. General Topics. The chapters in this section address 

intake of information at Resource Centers (2-0200) and 

initial development by CEs (2-0300). PM 2-0400 addresses 

services provided by representatives. 

b. Employment and Exposure. The chapters in this section 

address the aspects of employment that must be established 

for coverage under the EEOICPA. They include covered 

employment (2-0500), Special Exposure Cohort status (2-

0600), and toxic substance exposure (2-0700). 

c. Eligibility. The first three chapters in this section 

address the medical aspects of entitlement. They include a 

chapter on developing and weighing medical evidence (2-

0800), a chapter describing the criteria for cancer and 

radiation claims (2-0900), and a chapter describing the 

criteria for non-cancerous conditions (2-1000). 

The last two chapters in this group address entitlement 

under the Radiation Exposure Compensation Act (RECA) (2-

1100) and requirements for establishing survivorship (2-

1200). 

d. Entitlement. These chapters address ratings for 

permanent impairment (2-1300), computing compensation 

payments for wage-loss (2-1400), and consequential injuries 

(2-1500). 

e. Decisions and Hearings. This section provides 

guidance on writing recommended decisions (2-1600), and is 

followed by two chapters about the work of the FAB. The 

first (2-1700) addresses the procedures used by FAB, while 

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2. Structure of Part 2. (Continued) 

the second (2-1800) focuses on the decisions FAB issues. 

The final chapter in this group (2-1900) discusses 

reopening claims. 

f. Codes. The last two chapters in Part 2 address coding 

under the Energy Case Management System (ECMS). PM 2-2000 

describes the codes used in overall case processing, while 

PM 2-2100 describes the codes used to track decisions made 

within the Program. 

3. Responsibilities of Claims Examiners. The CE develops and 

adjudicates claims, provides courteous and timely responses to 

requests for information, initiates compensation payments and 

monitors assigned caseloads. 

a. Processing Claims. The CE is expected to exercise 

keen judgment, derived from experience, background, and 

acquired knowledge, tempered with compassion and common 

sense. This involves the ability to assess evidence, 

identify pertinent issues, and make well-rationalized 

judgments. Each case stands on its own merits and must be 

impartially judged based on the facts established in the 

case file. The decision cannot be based on conjecture, 

speculation, or unwarranted presumption. 

4. Reference Materials for Claims Examiners. Each DO has 

resources containing the following items including, but not 

limited to: 

a. Energy Employees Occupational Illness Compensation 

Program Act (EEOICPA) of 2000, as amended, 42 U.S.C. § 7384 

et seq. 

b. 20 CFR Parts 1 and 30 (Regulations) – Claims for 

Compensation Under the Energy Employees Occupational 

Illness Compensation Program Act, issued December 29, 2006. 

c. Executive Order 13179, signed December 29, 2006. 

d. EEOICPA Procedure Manual. 

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4. Reference Materials for Claims Examiners. (Continued) 

e. EEOICPA Bulletins, Circulars, Transmittals, and 

Program Memoranda. The Policy Branch issues these 

documents. 

f. Dorland's Illustrated Medical Dictionary, W.B. 

Saunders Co. 

g. Guides to the Evaluation of Permanent Impairment, 5th

Edition, American Medical Association. 

h. Current edition of The Merck Manual, Merck & Co. 

i. Current directory of the American Medical Association 

for each state within the DO's jurisdiction. 

j. Current ICD-9 coding manual. 

k. NIOSH regulations on dose reconstruction and 

probability of causation (42 CFR Parts 81 and 82, 

Guidelines for Determining the Probability of Causation and 

Methods for Radiation Dose Reconstruction Under the 

Employees Occupational Illness Compensation Program Act of 

2000; Final Rules). 

l. The most recent DO accountability review report. 

m. Road map or atlas covering the DO’s geographical 

jurisdiction. 

n. The Federal Register publications listing covered 

facilities. 

 o. Resource Center procedure manual. 

p. User’s Guide for the Interactive RadioEpidemiological 

Program (NIOSH-IREP). 

q. Directory of Department of Energy records, contacts, 

and description of Department of Energy facilities. 

 r. Shared Drive maintained by the National Office. 

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TABLE OF CONTENTS

Paragraph and Subject Page Date Trans. No.

Chapter 2-0200 Resource Centers

Table of Contents. . . . . . . . i 01/10 10-07

 1 Purpose and Scope. . . . . . . . 1 01/10 10-07

 2 Resource Center Functions. . . . 1 01/10 10-07

 3 ECMS Usage in the Resource

 Centers. . . . . . . . . . . . 4 01/10 10-07

 4 Security, Privacy, Conflicts

 of Interest. . . . . . . . . . 8 01/10 10-07

 5 Employment Verification. . . . . 10 01/10 10-07

 6 Occupational History

 Development. . . . . . . . . . 17 01/10 10-07

 7 Transfer of Cases. . . . . . . . 24 01/10 10-07

 8 Part D/E Claim Files . . . . . . 26 01/10 10-07

 9 Resource Center File

 Retention. . . . . . . . . . . 27 01/10 10-07

10 Wage-Loss and Impairment

 Outreach . . . . . . . . . . . 28 01/10 10-07

Exhibits

 1 RC Checklist Cover Sheet . . . . 01/10 10-07

 2 Occupational History

Interview. . . . . . . . . . . 01/10 10-07

 3 Interview Confirmation

Letter. . . . . . . . . . . . . 01/10 10-07

 4 Impairment Telephone Script. . . 01/10 10-07

 5 Wage Loss and Impairment

FAQs. . . . . . . . . . . . . . 01/10 10-07

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1. Purpose and Scope. This chapter describes the policies 

and procedures governing the Division of Energy Employees 

Occupational Illness Compensation (DEEOIC) Resource Centers 

(RCs).

2. Resource Center Functions. The RCs are situated in key 

geographic locations throughout the United States to 

provide assistance and information to the EEOICPA claimant 

community and other interested parties. The RCs gather

substantial information and documentation, but they do not

perform adjudicatory functions. The RCs provide claim 

development support and program outreach as well as initial 

claim intake.

The District Office (DO) retains all adjudicatory and most

additional development functions. The RCs perform only 

certain initial development and limited follow-up tasks as 

specifically outlined in these procedures. The RCs are 

staffed and managed by contractor staff. Each RC has a 

manager, and each manager reports to the RC Contractor 

Project Manager, who in turn, reports to the DEEOIC RC 

Coordinator located at the National Office (NO). The RC 

Coordinator is responsible for supervising the activities 

of all RC staff, nationwide.

The RC role as it pertains to initial employment 

verification and occupational history development includes 

the following:

a. Claim Intake. Most new Forms EE-1/2 are filed 

directly with the RC located in the geographical area 

where the claimant(s) reside. Forms EE-1/2 received 

directly in the DO undergo employment verification at 

the DO and such claims are referred to the RC only if 

the DO determines that an Occupational History 

Questionnaire (OHQ) is required.

Regardless of place of receipt, the date of filing for 

a claim is the earliest discernible date stamp or 

postmark of a claim form or words of claim. Words of 

claim are any written statements received without a 

claim form that indicate a claimant’s intention to 

seek benefits under the EEOICPA.

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2. Resource Center Functions. (Continued)

Whether filing by telephone or in person, RC staff 

relays information about the program to the claimant. 

The RC explains the eligibility requirements, asks 

about 

conditions that the claimant has developed, and begins 

the process of gathering information for use in 

adjudication.

(1) Filing by Telephone. When a claimant files 

a claim telephonically with RCs but then either 

refuses or fails to sign an actual claim form, 

the RCs must proceed as follows:

(a) Two weeks after the call, the RC 

telephones the claimant, informing him or 

her that the claim form must be signed to 

complete the filing process, and then 

recording the contact in the Telephone 

Management System (TMS) Energy Case 

Management System.

(b) Two weeks after that initial follow-up 

call, the RC sends the claimant a letter 

telling him or her that the unsigned claim 

form will be forwarded to the DO assigned to 

adjudicate the claim, and places a copy of 

the letter in the case file, but that the DO 

Claims Examiner (CE) will administratively 

close the claim because of the lack of a 

signed claim form.

(c) The RC then prepares a memo to the file 

documenting the times, dates, and manner of 

the efforts made to get the form signed, and 

of the warning that the claim will be closed 

administratively.

b. Claim Status. Claim status requests regarding 

initial employment verification or occupational 

history development fall within the purview of the RC 

staff, who also field other claim status requests to 

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2. Resource Center Functions. (Continued)

assist claimants with general questions not requiring 

DO or Final Adjudication Branch (FAB) involvement.

The RC staff member reviews ECMS status codes and 

answers claimant inquiries, memorializing such

activities into the TMS or Notes screen. If the claim 

status request is beyond the scope of the RC staff to 

address, the RC staff member determines the case file 

location in ECMS and directs the caller to the proper 

CE or FAB Hearing Representative (HR).

Inquiries received from a claimant or authorized 

representative seeking claim statuses are referred to 

the adjudicatory DO CE or the FAB HR as necessary. 

When referring a claimant or authorized representative 

to a DO or FAB, the RC provides the 

claimant/authorized representative with the toll-free 

number to the DO or FAB. All RC Managers have full 

read only access to ECMS in order to better assist 

claimants with inquiries. Any inquiries that cannot 

be addressed by the RC staff/Manager go to the CE or 

FAB HR, as appropriate.

c. Program Information. If a potential claimant 

calls for information and/or guidance and no claim is 

on file, the RC staff member informs the potential 

claimant of filing requirements and available 

benefits. No referral to a DO or FAB is necessary. As 

no claim exists in the system, a note memorializing 

the telephone conversation is not entered into ECMS.

Where a current claimant contacts the RC for guidance 

about the claims process (e.g., confirmation that a 

claim exists, questions about submitting new evidence 

or a new claim for benefits), the RC can provide 

guidance to the claimant as needed without referral to 

the DO or FAB. A TMS memorializing the telephone 

conversation is entered into ECMS

Also, RC staff may assist claimants in understanding 

the information being sought in DO development 

letters, explain the means by which such information 

may be obtained, and assist claimants in obtaining 

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2. Resource Center Functions. (Continued)

evidence. The RCs also assist claimants with medical 

bills/documentation and enroll/educate medical 

providers to join and navigate the automated medical 

bill pay system. A TMS memorializing the telephone 

conversation is entered into ECMS.

d. Initial Employment Verification. The RCs take 

initial employment verification steps for all new 

claims (Part B, E, and B/E) filed with the RC that are 

not covered under the Radiation Exposure Compensation 

Act (RECA). The DO conducts initial employment 

verification on claims filed directly with the DO (see 

section 5 below).

(1) Form EE-3 is the principal source for 

claimed employment information. However, if a 

claim is filed without a Form EE-3, the RC does 

not solicit it from the claimant. Rather, all 

claim materials are forwarded to the DO, where 

initial employment verification occurs.

(2) The RC uses DEEOIC tools, including 

procedures, bulletins, and employment 

verification updates and is given access to the 

DEEOIC Shared Drive to view these materials. The 

RC conducts initial employment verification on 

claims submitted by DOE contractor/subcontractor, 

Atomic Weapons Employer (AWE), and Beryllium 

Vendor (BV) employees for use in the adjudication 

of claims filed under EEOICPA.

e. Occupational History Questionnaire. RCs conduct 

occupational history development on all new Part E 

claims and some previously filed Part D/E claims, as 

discussed in section 6 below.

3. ECMS Usage in the Resource Centers. ECMS access is 

granted to the RCs to record claimant interaction and 

obtain claim status updates. Such interaction is recorded

in ECMS Notes or ECMS TMS. RCs cannot input ECMS case 

status codes. Specific technical guidance regarding ECMS is 

provided in the ECMS User’s Reference Guide.

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3. ECMS Usage in the Resource Centers. (Continued)

Some RC activity occurs prior to case creation in the DO, 

and ECMS data input is unavailable. RCs make ECMS entries 

only on created cases. Where the case is not yet created, 

the RC maintains a written account of all claim-related 

activity, including the date on which such activity took 

place. All pre-case create actions at the RC are recorded 

in the RC memorandum to the DO discussed in section 5

below.

a. ECMS Notes. The ECMS Notes field is used for all 

face-to-face contact with a claimant on a created 

case. For example, ECMS notes are used when a 

claimant appears at the RC to submit evidence or claim 

forms, to make an inquiry or raise a concern, or to 

complete the OHQ interview if the interview is done in 

person.

The RC staff member records the claimant’s visit in 

the notes field in ECMS, providing a synopsis of the 

conversation and a description of any evidence or new 

claim filed during the visit. The Notes entry 

outlines the interaction with the claimant, including 

instructions or guidance the RC provides to the 

claimant. The RC discusses only information on a 

specific claim with the claimant in question. Once a 

note is placed in the system, a hard copy is printed 

and forwarded to the appropriate DO or FAB for 

association with the case file.

When creating an ECMS notes entry, the RC selects ‘R -

RESOURCE CENTER USE ONLY’ entry in the “Note Type” 

section in the upper left hand box of the screen.

b. TMS. The TMS feature in ECMS allows RC staff 

members to memorialize telephone conversations and to 

access telephone messages for calls received in the 

RC. TMS provides a mechanism to track and maintain 

telephone contacts on given case files.

RC staff members receive incoming telephone calls, 

return calls and place calls to claimants and others 

regarding questions and concerns arising out of the 

claims process.

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3. ECMS Usage in the Resource Centers. (Continued)

(1) RCs receive various kinds of direct calls. 

Generally, incoming calls are from claimants (or 

their authorized representatives) seeking claim 

status or guidance, or from potential claimants 

seeking program information and guidance 

regarding the claims process.

(2) A RC staff member returns a telephone call 

received in the RC within two business days of 

receipt regardless of the issue at hand. All 

calls related to claims in ECMS are logged into 

the TMS and must be returned accordingly.

(3) Outgoing calls are those generated from the 

RC for a purpose other than returning a telephone 

call. The DO may request RC assistance in 

obtaining evidence from a claimant or conducting 

some additional follow-up on a case file. Many 

RC outgoing calls are generated in the course of 

conducting employment 

verification and occupational history 

development, and are memorialized in ECMS only on 

created cases.

c. Calls from Claimants. Each telephone call to or 

from a claimant must be accurately entered into ECMS 

in accordance with the specific instructions contained 

in the ECMS User’s Reference Guide and ECMS PM 

Chapter. If RC staff members conduct OHQ interviews 

(see below) by telephone, the OHQ interview must be 

memorialized in TMS in the same manner as the inperson interview.

The RC staff member handling the telephone call 

outlines the content of the discussion, the claimant 

request, if any, the guidance or solution offered, and 

the outcome of the call or resolution of the issue at 

hand. Entry of quality data is of the utmost 

importance, and the RC staff member strives to ensure 

accuracy and specificity of data input when telephone 

contact is noted in TMS.

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3. ECMS Usage in the Resource Centers. (Continued)

As with ECMS notes, the RC prints a TMS record once 

completed. The printed TMS record is forwarded to the 

appropriate DO for association with the case file.

d. ECMS Entries. The RC ECMS user may change ECMS 

entries placed into the system by RC staff as needed 

to correct errors, or at the request of the RC manager 

upon his or her final review of claim file material 

before it is forwarded to the DO. However, the RC 

cannot delete ECMS entries, so RC staff and managers 

must ensure that the data entered into ECMS is of high 

quality and free of errors prior to saving the entries 

into the system.

Once an ECMS record is input at the RC level, only NO

DEEOIC staff may remove it. No capability to add or 

alter ECMS claim status codes has been granted to the 

RCs, and all coding operations related to RC activity 

on a case (aside from activities related to input in 

TMS or ECMS Notes) are entered at the DO to correspond

with the date of the activity, as noted on the RC 

memorandum that accompanies case file materials to the 

DO.

e. ECMS Security. Security measures govern access 

to the system due to the sensitive nature of the 

records available 

in ECMS and other claim file documents (e.g.,

employment history, payment information, disease 

history, Social Security Numbers, and addresses).

When a RC staff member is hired, and ECMS access is 

required for that individual, access must be granted. 

Conversely, when an RC staff member’s employment is 

terminated, that person’s ECMS access must be 

disabled.

(1) To give a new RC staff member ECMS access,

the RC manager prepares a memorandum to the RC 

Contract Project Manager requesting such access 

and providing all pertinent employee information. 

The RC Contract Project Manager sends a

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3. ECMS Usage in the Resource Centers. (Continued)

memorandum to the DEEOIC RC Coordinator at NO, 

who reviews the request and advises Energy 

Technical Support of the need to grant access to 

an incoming RC employee.

(2) Upon termination or resignation of an 

employee, the RC Manager prepares a memorandum to 

the RC Contract Project Manager. The memorandum 

provides the former employee’s name, title, 

employee number, and all other necessary 

information, including the date of the employee’s 

termination or resignation. The memorandum 

requests that the former employee’s access to 

ECMS be terminated on a specified date (i.e., 

date of termination or resignation).

(3) The RC Contract Project Manager then 

prepares a memorandum notifying the DEEOIC RC 

Coordinator advising of the RC former employee’s 

scheduled departure. The DEEOIC RC Coordinator

advises Energy Technical Support of the need to 

delete ECMS access to the outgoing RC former 

employee upon receipt of such notification.

4. Security, Privacy, Conflicts of Interest.

a. RC Staff Member with Interest in a Claim. A RC 

staff member may be a party to a claim under the 

EEOICPA or may have a personal or familial interest in 

the outcome of a claim.

(1) Resource Centers must avoid conflicts of 

interest in processing claims and should avoid 

even the appearance of impropriety in their work. 

Their staffs must work without any bias or 

influence that would affect their ability to 

render impartial service to the government in 

carrying out their duties.

Therefore, Resource Center staff cannot process 

claims or conduct either employment verifications 

or occupational histories for immediate family 

members (defined as spouses, children, siblings, 

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4. Security, Privacy, Conflicts of Interest. (Continued)

grandparents, parents, or first or second 

cousins) or for any other individuals with whom 

they would have so close a relationship as to 

affect their judgment.

In such cases, the RC notifies the DEEOIC RC 

Coordinator at NO in writing via e-mail 

memorandum and refers those cases to the nearest 

alternate RC. After the conflict review process 

is completed, the RC manager prepares a 

memorandum to the alternate RC manager asking 

that the occupational history development or 

other task(s) be conducted and forwarded to the 

next nearest DO that does not have jurisdiction 

over the RC in question.

The RC assigned this development action has 14 

calendar days upon the receipt of the assignment 

to complete all these activities and to report to 

the DO.

(2) When a RC staff member has a claim of his or 

her own, or when the situation meets the 

definition of a conflict of interest due to a 

relationship as defined above, the DO case file 

in question is transferred to the nearest DO for 

handling.

For instance, a claim involving an RC staff 

member working at an RC within the jurisdiction 

of the Denver DO is transferred to the Seattle DO 

for handling, and vice versa. Claims involving a 

staff member working at an RC within the 

jurisdiction of the Cleveland DO are transferred 

to the Jacksonville DO, and vice versa.

b. Security and Individual Privacy Concerns. When 

interacting with claimants and other interested 

parties (e.g., authorized representatives) RC staff 

must remain aware of individual privacy concerns and 

maintain compliance with Privacy Act mandates. Except 

as discussed below, RC staff members may not provide 

information about an individual claim for benefits, or 

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4. Security, Privacy, Conflicts of Interest. (Continued)

any other personal information, to anyone other than 

the identified claimant or his or her authorized 

representative.

(1) For RC staff to release any information

regarding a specific claim or claimant to an 

alleged authorized representative of that 

claimant, an authorization form signed by the 

claimant must be in the case file appointing such 

individual as the claimant’s authorized 

representative regarding his or her claim for 

benefits under the EEOICPA.

A claimant may authorize other third parties to 

receive claims information, but may not authorize 

multiple authorized representatives. 

(2) Where information is sought that exceeds the 

RC’s ability to assist the claimant or authorized 

representative (e.g., specific development 

questions regarding the relationship between 

toxic substances and illness), the RC staff 

refers the matter to the proper DO CE or FAB HR, 

denoted in ECMS as the primary CE.

c. Multiple Worksites. In all instances involving 

multiple worksites, the RC closest to the residence of 

the claimant(s) performs the required development 

tasks. For instance, if employment is claimed at all 

three Gaseous Diffusion Plants, and the 

employee/claimant(s) reside in the Paducah, Kentucky 

area, the Paducah RC handles all required tasks with 

assistance from the other RCs as needed.

d. Multiple Claimant Locations. If claimants reside 

in different states and the claim as a whole can be 

better served by utilizing more than one RC, a RC will 

be assigned based upon the geographical locations of 

the claimants. In such cases the RC forwards 

documentation to the adjudicatory DO.

5. Employment Verification. Detailed guidance on 

Employment Verification is found in the PM Chapter covering 

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5. Employment Verification. (Continued)

this subject. Below is an overview of those employment 

verification tasks with associated resource center tasks.

a. Review of ECMS. When the RC is taking a claim 

and reviewing it for initial action (employment 

verification or OHQ), the RC reviews ECMS to determine 

whether a claim already exists in ECMS. If so, the RC 

contacts the adjudicatory DO CE for guidance as to 

whether employment or occupational history development 

is required. If documentation is present in the 

existing claim file to either confirm employment or 

document workplace exposure, the DO advises the RC 

accordingly and no action is needed by the RC. This 

is a case-by-case decision made by the DO.

b. Review of Case File. Upon receipt of a new 

claim, the RC staff member reviews the Forms EE-1/2, 

EE-3, and EE-4 and the DOE covered facility website to 

determine the type of facility claimed (e.g., DOE, BV, 

or AWE). The DOE website lists all major covered 

facilities, applicable time frames, a description of 

the site operations, and in certain instances, the 

names of the major contractors working at those 

facilities. This review also helps to determine the 

need for an OHQ, as AWE, BV and DOE (including DOE 

predecessor agency) federal employment is not covered 

under Part E and no interview is required.

c. Determining Appropriate Subpart. The claim may 

be filed under Part B, Part E, or both, depending upon 

the illness claimed and type of employment. The RC 

uses the DEEOIC case create worksheet (see EEOICPA PM 

1-0300, Exhibit 1), and reviews the claim materials 

for a determination as to benefits being sought and 

conditions claimed to determine under which Part a 

claim is being filed. At any time the RC may consult 

the DO for guidance as to whether an OHQ is necessary.

(1) Claims submitted by AWE employees are 

excluded from Part E coverage unless their 

employment occurred during a time when the AWE 

was undergoing DOE remediation. DOE remediation 

periods can be ascertained by reviewing the DOE 

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5. Employment Verification. (Continued)

covered facility website, but the RC should seek 

DO guidance before conducting interviews about

such claims.

(2) Claims filed by contractors or 

subcontractors of DOE or Section 5 RECA workers 

are always treated as Part E claims for the 

purposes of conducting an occupational history 

interview.

d. ORISE. If employment is claimed at a covered 

facility listed on the DOE website, the RC staff 

member determines whether employment can be verified 

through the Oak Ridge Institute for Science and 

Education (ORISE) database. This database, which is 

accessed via ECMS, contains employment information for 

over 400,000 employees who worked at certain 

facilities from the 1940s to the early 1990s.

Complete usage instructions regarding the ORISE 

database are discussed in the ECMS release notes dated 

April 6, 2005, version 1.8.2.0. Since ORISE is part 

of ECMS, the RC staff member obtains ORISE information 

by entering an employee’s Social Security Number or 

name.

Resource Center staff determines whether appropriate 

data may be found in ORISE by checking the Employment 

Pathways Overview Document (EPOD). If the facility 

description includes the statement, “ORISE – yes,” 

then RC staff first develops employment by accessing 

ORISE. If ORISE information is unavailable or 

inconclusive, additional development is pursued as 

outlined below.

In either case, the RC staff member prints the results 

found in ORISE as part of the evidence of file. If 

employment is listed at a facility not on the ORISE 

list, ORISE is not consulted for verification.

(1) If the ORISE matches claimed employment 

within six months, no additional development is 

required. The RC prints out the ORISE database 

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5. Employment Verification. (Continued)

query result, prepares a memorandum stating the 

date the ORISE action was taken, and forwards all 

available materials to the DO with an RC 

checklist (Exhibit 1).

If an OHQ is required on a Part E claim, the RC 

attempts to complete the OHQ to be forwarded with 

the RC checklist. The findings and associated 

memoranda are subject to CE review and can 

potentially serve as a basis for verifying and 

accepting claimed employment under the EEOICPA.

(2) If the claimed employment cannot be 

confirmed through ORISE, or is only partially 

confirmed, the RC prints the ORISE record and 

determines if other sources of employment 

verification are available as outlined through 

the Employment Pathways Overview Document as 

described in Chapter 2-0500.

e. The EE-5 Process/DOE POC. Employment under the 

EEOICPA is also verified using the EE-5 process. The 

EE-5 process is applicable to employment claimed at 

DOE facilities, including contractor and subcontractor 

employment, as well as Beryllium Vendor and Atomic 

Weapons Employer employees. The RC refers the EE-5 

package according to instructions in the PM.

For those instances in which employment is claimed for 

which there is no applicable DOE operations office, 

the following steps are to be taken:

(1) Employment for which EPOD indicates that a 

corporate verifier is able to confirm employment.

For those instances in which a corporate verifier 

has employment information, resource center staff 

prepares the appropriate correspondence to a 

corporate verifier. EPOD identifies the 

information needed by each specific corporate 

verifier in order for them to confirm employment. 

EPOD also contains the name and address for 

corporate verifier contact persons from whom 

verification should be requested.

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5. Employment Verification. (Continued)

(2) If EPOD does not provide any pathway for 

employment verification at a claimed facility,

the RC center staff informs the claimant that DOE 

does not possess employment records for the 

facility claimed and no other knowledgeable 

source exists to verify employment. In writing 

or by telephone, the RC advises the claimant to 

submit further evidence in support of his or her 

claimed employment directly to the DO. If the 

claimant is the employee or a clearly eligible 

survivor, the RC also asks the claimant to sign 

Form SSA-581 so that the DO may request SSA 

records. The RC does not forward Form SSA-581 to 

SSA, but sends it to the DO with the employment 

verification packet. The RC does not mail this 

form to a claimant.

(4) The RC prepares a memorandum documenting the 

dates on which employment verification actions 

were taken for each claimant. The memorandum is 

forwarded to the DO within seven days of receipt 

of Form EE-1/2. The memorandum is accompanied by 

the Resource Center Claim Checklist (Exhibit 1) 

listing all materials enclosed and further 

actions required.

(5) Each adjudicatory DO District Director (DD) 

designates primary and alternate RC employment 

verification Points of Contact (POCs) and 

provides the RC with their names and contact 

information. The DD must immediately inform the 

RC if a POC is replaced.

(a) Duties. The DO employment verification 

POC serves as the primary contact for all 

responses regarding initial employment 

verification requests made by the RCs. The 

POC reviews all employment verification 

responses, consults ECMS to determine the CE 

handling the claim in question, and forwards 

all employment responses to the handling CE 

within one business day of receipt of the 

response in the DO.

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5. Employment Verification. (Continued)

(b) E-Mail Contact. Each POC has access to 

e-mail for use in verifying employment. The 

POC’s e-mail address is copied on all e-mail 

requests for verification (where such 

request is the desired method of inquiry) 

and the e-mail from the RC provides the 

POC’s name and contact information and 

requests that the employment verification 

response be forwarded to the attention of 

the POC.

(6) The RC prepares the claim package with the 

accompanying memorandum and checklist outlining 

the actions taken and forwards all documents to 

the adjudicatory DO. The RC includes a copy of 

the DOE Verification of Employment Memorandum, 

which serves to acknowledge that DOE has no 

employment information to provide.

(a) Later submissions to the DO do not 

require a formal memorandum, but should be 

accompanied by the Resource Center Claim 

Checklist. Any activity the RC took that 

needs to be captured by the DO in ECMS can 

be outlined either on the Checklist or on a 

separate sheet of paper.

(b) The RC manager verifies the contents of 

the referral package and signs the 

checklist. The RC manager is responsible 

for validating that the information in the 

referral package(s) reflects the RC actions 

taken and accurately reports the dates of 

all activities conducted.

(c) The DO sometimes grants extensions of 

time in the face of extenuating 

circumstances. When RC staff conduct large 

outreach events and take new claims, they 

cannot begin employment verification actions 

until they return to the RC. In this 

instance the RC may ask the DO for an 

extension of time. The RC manager e-mails 

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5. Employment Verification. (Continued)

the DO Employment Verification POC with all 

claim file information requesting an 

extension of time and outlining the reason 

behind the request.

f. SSA-581 and Other Evidence. The following 

evidence, while not exhaustive, may assist in 

evaluating the validity of a period of claimed 

employment. RC staff should use judgment to determine 

which of the listed items staff should request from 

claimants.

(1) Time and attendance forms; W-2 forms and 

other tax statements; wage and earnings 

statements; check stubs; correspondence from the 

employer addressed to the employee; notices of 

promotion, reassignment, layoff, etc; ID cards; 

minutes from employment related meetings; punch 

cards; sign in and out logs; security clearance 

applications; union records; letters and 

certificates of achievement or participation in a 

certain event.

(2) Also, Forms EE-4 (Employment Affidavit) from 

coworkers and others with firsthand knowledge may 

be acceptable to establish employment in 

conjunction with other evidence. The RC may 

assist the claimant in preparing Form EE-4, but 

only contacts employment verifiers as identified 

therein. The RC does not contact coworkers or 

other individuals or gather employment or other 

evidence on behalf of the claimant.

(3) If the claimant is a walk-in employee or a 

clearly eligible survivor, the RC asks the 

claimant to sign Form SSA-581 so that the DO may 

request SSA records for use as a tool in 

additional employment development. The RC does 

not forward Form SSA-581 to SSA, but sends it to 

the DO with the employment verification packet. 

The RC does not mail this form to a claimant.

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5. Employment Verification. (Continued)

g. SEC/Newly Designated SEC. The Secretary of the 

Department of Health and Human Services (HHS) has 

approved additional designations to the SEC class, and 

other designations are anticipated in the future. 

Many new SEC designations are/will be employmentspecific and date-specific. HHS defines SEC inclusion 

specifically in many instances, and it will be 

necessary to identify a person’s job title, years of 

employment, place of employment, and other facts based 

upon the specific language defining the SEC.

Therefore, it is necessary to gather employmentspecific information when verifying employment at 

these sites. The Policy Branch issues Bulletins 

outlining specific guidance for handling newlydesignated SECs. The Policy Branch Chief ensures that 

the RCs receive all Bulletins related to SEC class 

inclusion.

Since Form EE-5 does not contain a section to list 

employment-specific information, the RCs use the cover 

letter to DOE for this purpose. In the DOE cover 

letter the RC requests specific duty station 

information to assist the DO when rendering 

determinations as to SEC class inclusion. The request 

is tailored to meet the exact definition of SEC 

employment as set out by HHS and defined in Bulletins 

issued by the Policy Branch.

6. Occupational History Development. In addition to 

initial employment verification, the RCs conduct initial 

occupational history development on Part E cases only 

regarding claims involving covered Part E employees and 

their eligible survivors. This is done in part by 

completion of the OHQ (Exhibit 2). There are two OHQs, one 

for RECA and one for non-RECA claims.

Whenever possible, this step occurs during claim intake at 

the RC, with the results forwarded to the DO within the 

seven day period in which the initial employment 

verification task is conducted. The RC may conduct the OHQ 

prior to receipt of the claim filing, but the OHQ is not to 

be sent to the DO until a signed claim form is received.

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6. Occupational History Development. (Continued)

If no signed claim form is received, the RC returns the OHQ 

to the claimant with instructions to return to the RC with 

a signed claim form.

a. Time Frames. If the OHQ cannot be completed 

within the initial seven day period, the RC sends the 

claims package to the DO immediately upon completion 

of employment verification (within seven days of 

receipt of claim forms), and then conducts the 

occupational history development.

(1) The RC has a total of 14 calendar days from 

the date of receipt of the claim or receipt of 

the assignment from the DO to conclude the 

occupational history development steps.

(2) If all actions cannot be completed within 

that time frame, the RC advises the DO CE via email of the reason for the delay and outlines a 

reasonable timeframe in which to finalize all 

necessary actions.

(3) If an additional seven calendar days elapse

after the 14 calendar day due date, the RC 

telephones or e-mails the DO CE requesting a time 

extension and providing an action plan.

(4) As soon as the occupational history task is 

complete, and assuming that a signed claim form 

has been received, all documentation is 

immediately forwarded to the DO with a memo or 

Claim Checklist noting the date on which the 

interview(s) was conducted. The RC maintains a 

copy of all case file materials until the 

occupational history development process is 

complete.

(5) If the RC cannot conduct the OHQ within 30 

days of receipt of assignment and/or filing of 

the claim, the RC suspends all activities and 

reports to the DO. No further action is taken. 

The DO CE sends a letter to the claimant 

requesting a response once all materials are 

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6. Occupational History Development. (Continued)

received in the DO. Depending upon the 

claimant‘s response, the CE can assign the OHQ 

task to the RC.

b. Occupational History Development Not Conducted. 

Under the following circumstances, no OHQ development 

occurs:

(1) If beryllium illness or chronic silicosis is 

the only condition claimed, unless otherwise 

directed by the DO. In addition, no occupational 

history development is conducted where only 

ineligible survivors are claiming benefits. For 

a complete discussion of eligible survivors under 

Part E, see EEOICPA PM 2-1200.

In such instances, the claim file material is

immediately forwarded to the DO upon completion 

of the employment verification portion, the DO 

reviews for necessity of further occupational 

history development, and assigns development 

tasks to the RC as needed.

(2) If benefits are approved under Part B, or a 

positive DOE physician panel finding exists that 

DOE accepted under the Part D program and the 

employee is a DOE contractor or subcontractor 

(not a federal employee) then the employee is 

also covered under Part E for those approved 

diagnosis. In all cases, the RC consults ECMS 

for the status of the Part B claim for acceptance

and queries the DO for guidance if a question

arises as to whether or not an occupational 

history development action is required.

(3) If the Department of Justice (DOJ) has 

accepted a RECA Section 5 claim, no occupational 

history development is necessary, unless the 

claim was filed by a survivor. All other RECA 

claims generally require independent adjudication 

and require an OHQ. Cancer claims submitted by 

Section 4 RECA claimants who do not wish to file 

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6. Occupational History Development. (Continued)

with DOJ require an OHQ. See Chapter 2-1100 for 

details.

d. Occupational History Questionnaire and Interview. 

The main function of the RC staff member in his or her 

occupational history development role is to conduct 

the OHQ interview. In cases with multiple survivors, 

all claimants are interviewed, unless one or more 

claimants have been designated to represent all of the 

claimants with regard to the interview process.

(1) Sometimes one claimant will know more about 

possible worksite exposure, or be more 

comfortable with a formal interview process, than 

the others. In such instances, a simple signed 

statement by the other claimants designating a 

certain claimant to be interviewed in his or her

stead will suffice.

(2) Such a signed statement is not a designation 

of an authorized representative, and is only used 

in the interview process. Where an authorized 

representative has been appointed on a claim file 

with multiple claimants, there is no need to 

designate a claimant to participate in the 

questionnaire process. Authorized 

representatives may determine how the 

questionnaire process will be conducted.

(3) Much of the information gathered through

occupational history development is sensitive in 

nature and is subject to Privacy Act mandates. 

Accordingly, the information developed may not be 

disclosed to any individual unless he or she is 

an authorized representative of the claimant or 

an authorized DEEOIC representative (see EEOICPA

PM 2-0400).

e. Timeliness Goals. An interview must be scheduled 

and completed within the timeframes stated in this 

document, and all reworks and follow-up interviews 

must be conducted within seven days of receipt in the 

RC as noted above.

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6. Occupational History Development. (Continued)

To properly conduct the interview, the RC staff must 

understand the work performed by DOE employees. 

Knowledge of the types of hazardous materials 

potentially present at DOE sites, the covered illness 

resulting from claimed exposures, the standard length 

of exposure for the illness to occur, and the medical 

diagnosis required to verify the illness is also 

necessary.

The RC staff must also possess sufficient knowledge of 

the EEOICPA, the DOE and RECA sites, and hazardous 

materials to record sufficient, valid data in 

occupational history questionnaires as well as ECMS 

and TMS notes.

f. Proper Use of OHQ. DEEOIC developed the DOE and 

RECA occupational history questionnaires for use by 

the RC staff, who must properly use them to obtain the 

information DEEOIC requires to evaluate a claim for 

causation. This chapter deals solely with the DOE 

OHQ; for further guidance regarding the RECA OHQ, see 

EEOICPA PM 2-1100.

The interview may be conducted in person or by

telephone. On created cases, all telephonic activity 

regarding occupational history development is captured 

in the ECMS TMS screen, while all in-person activity 

is placed in the ECMS Notes screen. All required ECMS 

coding is input at the DO once the occupational 

history development task is complete and all 

documentation is returned to the DO.

g. Use of Script. When conducting interviews, the RC 

adheres to the script prepared by the DEEOIC. It is of 

the utmost importance that all interviews follow the 

prepared script, but flexibility is allowed for 

follow-up questions that logically flow out of the 

results of the interview.

If the interviewee has little or incomplete knowledge 

about a particular subject, the RC notes such 

deficiencies so that the DO is aware that informationgathering efforts were made.

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6. Occupational History Development. (Continued)

Each interview takes approximately two to three hours 

to complete. It is possible that multiple claimants 

will require an interview for one case file.

(1) Overall, the RC interviewer is responsible 

for the proper conduct of the interview and for 

producing a complete, comprehensive 

questionnaire, including correct grammar and 

spelling.

(2) The RC makes certain to comply with specific 

requests for information from the CE. For 

instance, if the CE wants specific exposure 

information regarding solvents (e.g., benzene 

exposure) the RC follows up with a line of 

questioning to satisfy the CE’s request.

(3) Once the interview is completed, the RC 

staff member gives the claimant the interview 

confirmation letter (Exhibit 3) verifying that 

the interview took place, and its date. A copy 

is sent with the OHQ for inclusion in the case 

file.

(4) All information is saved to the OHQ exactly 

as presented by the interviewee without 

alteration, duplication, or summarization by the 

RC interviewer, and the original paper version of 

the OHQ and a saved copy on a CD is forwarded to 

the appropriate DO within two days of completion.

(5) The RC interviewer in no way interprets the 

information presented by the interviewee. The 

OHQ is a stand-alone document and only the CE may 

interpret its meaning when using it as a 

development tool.

h. No RC Action Required. Neither initial 

employment verification nor occupational history 

development is undertaken where there is no eligible 

survivor under the statute. Where it is obvious that 

no eligible survivor exists (especially in the case of 

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6. Occupational History Development. (Continued)

adult children under Part E) no additional RC action

takes place.

(1) Since occupational history development is 

conducted exclusively on Part E claims, no action 

is necessary where Part E employment is not 

claimed or confirmed. If employment is claimed 

or confirmed at an AWE, a BV, or the employee is 

a DOE (or predecessor agency) federal employee, 

no occupational history interview is conducted.

(2) AWE contractors/subcontractors are not 

afforded coverage under the EEOICPA, and such 

claimed employment does not require occupational 

history development by the RC.

(3) The RC does not conduct initial employment 

verification on claims submitted by RECA 

claimants. However, occupational history 

development is necessary on most RECA claims and 

should be attempted upon receipt of Form EE-1/2 

in the RC.

Since the DO must begin employment verification 

with the DOJ, all RECA claim forms are sent to 

the DO on the date of receipt in the RC for case 

create at the DO. Since the RECA claim forms are 

not held for seven calendar days, as in most 

other cases, whenever possible the RC attempts to 

conclude the occupational history development on 

the date of receipt of the RECA claim forms prior 

to shipment to the DO.

Where occupational history development cannot be 

completed at the RC on RECA claims upon the date 

of filing, the RC copies the RECA claim form 

documents 

and maintains a file at the RC while conducting 

occupational history development actions. In 

such instances the RC has 14 calendar days from 

the date the claim is received in the RC to 

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6. Occupational History Development. (Continued)

conclude the occupational history development 

actions.

The RC prepares a list of all materials being 

submitted on a transmittal sheet outlining the 

material being sent, separated by the claim 

number. All such documentation is associated 

with the proper case file upon receipt in the DO.

i. Materials Destroyed. Once all employment 

verification and occupational history development 

actions are finalized and the CE confirms by telephone 

or e-mail that the DO does not require further 

assistance, the RC destroys its file copy.

j. Follow-Up or Reworks of Complete OHQs. Upon 

review of a completed OHQ, the DO may determine that 

additional information is required or identify an 

error that requires remedy.

(1) Follow-up interviews are conducted when the 

DO identifies additional issues through further 

development of the claim for causation that 

require RC assistance. The CE makes follow-up 

assignments directly to the RC manager with an 

accompanying memo outlining instructions as to 

the required additional development needed.

(2) Reworks arise when an error is found in the 

final product from the RC. Interview reworks are 

conducted only where the CE identifies a 

deficiency (i.e., incomplete or inaccurate data). 

Reworks must be approved by a CE and are 

forwarded to the RC manager by the DO DD with a 

memorandum outlining specific instructions as to 

the deficiency found and the required remedy.

(3) The RC must complete all follow-up and 

rework assignments from the DO within seven

calendar days of receipt in the RC.

7. Transfer of Cases. Once all possible initial 

employment verification/occupational history development 

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7. Transfer of Cases. (Continued)

actions are complete, the RC sends all claim forms, 

associated documents, and the RC checklist to the DO with a 

memorandum outlining RC activities to that point.

Upon receipt of the initial submission, the case is created 

as set out in EEOICPA PM 1-0300. Once the case is created 

and the claim assigned to a CE, the CE reviews all claim 

file materials and employment verification/occupational 

history development materials for ECMS coding.

a. Codes. The CE inputs coding in ECMS to 

correspond with the date on which the action occurred 

at the RC.

b. CE Review. The CE reviews the initial submission

to determine whether additional tasks are necessary at 

the RC level. As noted above, the DO may return any 

part of the package if a deficiency is identified or 

an additional interview is deemed necessary.

The CE uses the information obtained during the 

occupational development as a tool for establishing 

causation (based upon employment and the claimed 

covered illness) in the adjudication process. Also, 

the CE proceeds to develop the claim.

c. Receipt of Materials in the RC After Initial 

Seven Day Memo. Any such materials are sent to the DO 

with the occupational history development package if 

they cannot be included with the seven day memo 

submission. All other materials received at the RC 

after all development is concluded (including 

printouts of TMS and ECMS Notes records) are submitted 

without a memo or checklist.

d. Receipt of Material in the DO Prior to Case 

Create. In some cases the DO receives documentation 

from the RC prior to receipt/filing of a claim form. 

The DO maintains all such information in a dummy 

folder and retains it until the claim form is 

received. When the case is created, RC actions are 

coded to correspond with the day upon which they 

actually occurred, regardless of claim filing date. 

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7. Transfer of Cases. (Continued)

ECMS coding must reflect the true date a RC action was 

taken.

8. Part D/E Claim Files. In the past, Part D/E claims 

potentially required occupational history development at 

the RCs. The CE evaluates the older Part D/E claims on a 

case-by-case basis to determine whether a referral to the 

RC is needed.

a. Exposure Evidence. The CE examines the case file

for the existence of DAR records, other DOE exposure 

records, and other employment records that might 

provide exposure evidence and eliminate the need for 

an OHQ.

Also, the CE consults the Site Exposure Matrices (SEM) 

in conjunction with the case file material to 

determine the need for further development by the RC. 

The CE must make the OHQ assignment to the RC unless 

he or she can establish the plausibility of exposure 

to a toxic substance by other means [e.g., the SEM, 

Document Acquisition Request (DAR) records, other 

employment evidence indicative of exposure].

(1) If the CE determines that an OHQ is required

due to a lack of other exposure and employment 

evidence, an assignment to the RC is made. The 

RC has 14 calendar days from the date of receipt 

of the assignment from the DO to complete the 

occupational history development tasks outlined 

by the CE.

(2) The CE prepares a memorandum to the RC 

requesting that the OHQ be completed. The CE 

lists any specific information (e.g., toxic 

exposure, employment) that needs development. 

Any relevant case file material (e.g., claim 

forms, employment and exposure records) is 

attached for RC review. The CE includes precise 

instructions as to the information being sought. 

The Senior CE or Supervisor reviews the 

memorandum and approves the assignment before it 

is sent to the RC.

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8. Part D/E Claim Files. (Continued)

Upon receipt in the RC, the assignment is logged 

into ECMS Notes. Date of receipt in the RC is 

the first day of the 14 calendar day period.

(3) Once the CE identifies the need for an OHQ 

and tasks the RC with an assignment to conduct 

the interview, the DO sends a letter to the 

claimant. The letter advises the claimant that 

the interview is conducted on behalf of DOL, that 

it is different from any other prior interview 

the claimant may have given, and that it is 

intended to provide the claimant with a thorough 

and timely adjudication of his or her claim.

(4) The CE also “closes out” the OHQ assignment 

(or follow-up or rework) in this manner if the RC 

attempted to complete the OHQ, but was 

unsuccessful because the claimant could not be 

reached or refused to complete it. The status 

effective date in this situation is the date of 

the RC memo to the DO explaining why the OHQ 

could not be completed.

9. Resource Center File Retention. Depending upon the 

circumstances and the need for additional follow-up 

regarding a task described in this chapter, RCs retain or 

destroy file materials as necessary.

a. Office of Worker Advocacy (OWA) Files. There is 

no need to retain materials related to old OWA claim 

files. The RCs may destroy any OWA materials on hand.

b. Part D Files without Employment Verification (EV)

or OHQ Information. This material is disseminated 

from the DOs as necessary based upon DO review and 

identified assignments to the RC. Any such material 

on hand at the RC can be destroyed unless it is being 

used in the process of a DO assignment. Once 

completion of the assignment is confirmed via the 

method outlined below, all materials are to be 

destroyed.

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9. Resource Center File Retention. (Continued)

c. New Incoming Cases. Where only EV is conducted, 

the RC destroys case file material upon completion of 

the EV task and DO confirmation of receipt of all 

documents. Case file materials regarding Part E 

claims that require an OHQ are retained either until 

the OHQ process is complete and the DO confirms 

receipt of the transmitted materials, or in cases 

where the OHQ cannot be conducted, as described above.

d. DO Transmittal. Upon receipt of the EV/OHQ 

and/or all other pertinent documentation required of 

the RC, the DO checks off each item listed on the 

transmittal and then faxes the transmittal to the 

appropriate RC instructing it to destroy its case file 

materials. Upon receipt of the DO transmittal, all 

such materials are destroyed. The transmittal may be 

sent by the DD or any individual designated by the DD 

for such purpose.

e. Receipt of Documents in the NO or FAB. If NO or 

FAB receives a Resource Center transmittal containing 

information for association to a case file at NO or 

FAB, the Policy Analyst/Hearing Representative/CE (or 

designee at the discretion of management) confirms 

receipt via fax to the appropriate RC, instructs the 

RC to destroy their copy of the transmitted material, 

and associates the materials to the case file. The 

faxed instruction sheet is also placed in the case 

file for record keeping purposes.

If NO or FAB receives a transmittal from a Resource 

Center, but the case file is no longer at NO or FAB, 

the Policy Analyst/Hearing Representative/CE (or 

designee at the discretion of management) immediately 

forwards the materials and transmittal sheet to the 

appropriate DO. When the DO receives the transmittal, 

the DO follows the instructions above.

10. Wage-Loss and Impairment Outreach. Due to the complex 

nature of the Part E benefit structure and the requirements 

necessary to qualify for lump-sum compensation, selected 

Resource Centers (RCs) have been tasked to engage in an 

outreach effort to educate claimants on the requirements of 

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10. Wage-Loss and Impairment Outreach. (Continued)

filing for and obtaining impairment and/or wage-loss 

benefits.

a. Outreach. To facilitate communication with 

eligible claimants who are also the covered employee 

or worker (hereafter referred to as employees) certain 

DEEOIC RCs are assigned responsibility for contacting 

identified employees by telephone to explain the 

benefit provisions available under Part E. Assignments 

are as follows:

Jacksonville DO and FAB Savannah River RC

Cleveland DO and FAB Portsmouth RC

Denver DO and FAB Espanola RC

Seattle DO and FAB Hanford RC

b. RC Referral. There are two types of Part E cases 

that are to be identified and referred to the 

designated Resource Center (RC) to initiate employee 

communication:

1. Cases at the Final Adjudication Branch where 

a positive Final Decision has been issued to a 

living employee and there has not been a prior 

claim for impairment and/or wage-loss.

2. Cases at the District Office where a 

positive Final Decision has been issued to a 

living employee and initial development is 

underway for impairment and/or wage-loss.

c. Referral from FAB. For Part E cases at the Final 

Adjudication Branch, when a final decision is issued 

to a living employee with a positive causation 

determination, a copy is to be prepared and forwarded 

to the designated RC. This should be done only in 

situations where there is no indication that a claim 

has been made for impairment and/or wage-loss.

Decisions that pertain strictly to survivors of a 

deceased employee are not to be referred to the RC, 

but processed in the normal fashion. The Washington, 

DC FAB sends final decisions that meet these

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10. Wage-Loss and Impairment Outreach. (Continued)

guidelines to the appropriate RC, based on which DO 

issued the recommended decision on Part E.

d. Development. For any case at the DO that 

contains a final decision with a positive finding on 

causation issued to a living employee and where there 

has been no claim for impairment and/or wage-loss, an 

initial development letter for impairment and/or wageloss benefits is completed and sent to the employee 

with a copy of the letter sent to the assigned RC. An 

example of an initial development letter for 

impairment benefits is included in EEOICPA PM 2-1300. 

Examples of the initial development letters for wage 

loss benefits are included in EEOICPA PM 2-1400.

e. Records. Upon receipt of a final decision or a 

development letter in the RC, the RC should take 

appropriate action to record its receipt. The RC is 

responsible for ensuring that an appropriate system 

for recordkeeping is developed to track referrals, and 

subsequent actions in accordance with the guidance 

provided here. The RC uses a spreadsheet to record

the date the final decision or development letter(s) 

was received in the RC, the employee’s name, claim 

number, the date outreach was completed and whether or 

not the employee intends to pursue impairment and/or 

wage-loss. In addition, the RC will also report on the 

disposition of all referrals on a weekly basis to the 

DEEOIC RC Coordinator. This data should be 

incorporated into the routine weekly RC activity 

report already generated by the RC manager.

f. Contacting the Claimant. The RC staff should 

carefully review Procedure Manual Chapters 2-1300 and 

2-1400, which explain the eligibility requirements for 

compensation benefits and the procedures DEEOIC 

follows for developing impairment and wage-loss

benefit claims. For each referral, the RC initiates a 

telephone call to the employee identified. It is

necessary for the RC to access ECMS to obtain contact 

information for the employee. The purpose of this call 

is to provide information about the potential 

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10. Wage-Loss and Impairment Outreach. (Continued)

impairment and/or wage-loss benefits available, 

respond to questions, and solicit claims.

A script (Exhibit 4) has been developed for use by the 

RC staff in explaining impairment and/or wage-loss 

benefits to the employee at a general level. It is 

important the RC staff adhere to the script. Given the 

complexity of the benefit structure under Part E, it 

is likely that the employee will have questions. The 

RC staff may respond to general follow-up questions; 

for example, eligibility requirements or program 

procedures to develop a claim for impairment and/or 

wage-loss benefits. To help the RCs anticipate and 

answer some of the most common questions regarding 

impairment and wage-loss benefits, DEEOIC has 

developed a Q & A Sheet (Exhibit 5) for use by the 

RCs.

Claim-specific questions or questions that exceed the 

RC’s ability to assist the employee must be referred 

to the assigned CE or FAB hearing 

representative/claims examiner, per ECMS. No attempt 

should be made by the RC representative to offer 

opinion or conjecture as to the likelihood of 

entitlement. All adjudicatory functions are solely the 

responsibility of the assigned CE.

g. Statement from the Claimant. During the 

telephone call, if the employee expresses the 

intention to pursue impairment and/or wage-loss 

benefits or in cases where the RC staff member 

believes the employee may qualify for these benefits, 

the RC advises the employee to submit a signed 

statement or letter to the appropriate DO stating his 

or her intention to pursue benefits.

h. Claimant Information. In cases where the 

employee expresses the intention to pursue impairment 

and/or wage- loss benefits, the RC must also mail the 

brochures titled “How Do I Qualify for an Impairment 

Award” (available on the DEEOIC website at 

http://www.dol.gov/esa/owcp/energy/

regs/compliance/brochure/ESA_how_do_I_qualify.pdf) 

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10. Wage-Loss and Impairment Outreach. (Continued)

and/or “Wage-Loss Benefits” (available at the DEEOIC 

website at

http://www.dol.gov/esa/owcp/energy/regs/compliance/bro

chure/ESA_wage_loss.pdf) with an appropriate cover 

letter to the employee. These brochures were developed 

to explain these two types of benefits and the 

requirements that must be met to qualify for benefits.

i. TMS. All discussions with the employee about 

wage-loss and/or impairment is memorialized into the 

ECMS via the TMS screen. In general, each TMS entry 

contains a synopsis outline of the discussion; the 

employee’s question or request, if any; the guidance 

or solution offered; and a notation as to whether the 

employee intends to pursue impairment and/or wageloss. The TMS screen is printed and the paper record 

of the activity is forwarded to the appropriate DO/FAB 

daily for association with the case file.

j. Special Instructions for Terminal Claimants. 

Designated RCs are responsible for immediately 

notifying via email the DO POC and the assigned CE or 

FAB HR (as denoted in ECMS), on any case needing 

prioritization, such as a terminally ill employee who 

wants to claim impairment and/or wage-loss. The 

designated DO POC is the same individual who handles 

the RC employment verification process. The RC staff 

member still submits the printed copy of the telephone 

contact in TMS to the appropriate DO/FAB for 

association with the case file. For easier 

identification, these TMS records must be marked 

“Priority” on top of the page.

k. Follow Up with the Claimant. The designated RC 

has seven calendar days from the RC’s receipt of the 

employee’s final decision or initial development 

letter(s) to initiate telephone contact. In cases 

where the RC is unable to contact the employee within 

seven calendar days, the RC continues to follow up 

with the employee and documents the contact attempts 

in TMS until contact is successful or the RC makes a 

reasonable determination that further attempts will 

not be productive. The RC representative may use his 

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10. Wage-Loss and Impairment Outreach. (Continued)

or her discretion to determine when to cease further 

contact attempts with the employee, but as a general 

rule, after three recorded attempts in as many days 

has failed to garner employee contact, the RC may 

cease outreach effort.

l. Disposing of the Decision. The RC is to shred 

the final decision and/or development letter after the 

employee has been successfully contacted or after the 

RC has ceased outreach effort with the employee.

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RC Checklist Cover Sheet

Date: _______________

To:

DOL Jacksonville District Office  Attention: __________________

DOL Denver District Office

DOL Cleveland District Office

DOL Seattle District Office

The attached claim forms are submitted with supporting documentation.

Employee: ________________________ SSN: ________________________

Survivor: _________________________ SSN: ________________________

Enclosed documents include:

EE-1/EE-2 Birth Certificate

EE-3 Marriage License/Certificate

EE-4 Death Certificate

Authorization for Representation Divorce Decree

EE-5 (s) Power of Attorney Document

ORISE Printout Adoption Records

Copy - Appendix H or 02-34 letter SSA-581

Copy - Letter to DOE OPS 

Center

Social Security Records (brought in by 

claimant)

Copy – Letter to Corporate 

Verifier Medical Records/Pathology Report

Claimant Employment Records Other

Occupational History 

Questionnaire Other

Occupational History Thank You 

Letter Other

Resource Center Manager ________________________________

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File Number:

Claimant Name: 

Date of telephone call:

IMPAIRMENT TELEPHONE SCRIPT

Good Morning/Afternoon, my name is ______ and I am calling 

from the ________________ Resource Center. May I please 

speak with Mr./Ms. _____________________?

Hello Mr./Ms. _____________, I am calling regarding your 

claim under the Energy Employees Occupational Illness 

Compensation Program Act. Our records indicate that your 

Part E claim was already accepted by the Department of 

Labor (DOL) in a decision issued on __________.

If you have a few moments I would like to tell you about 

additional monetary benefits that you may also be entitled 

to. Is this a good time to talk? (If they say no, ask them 

when would be a good time to call them back. Make note of a 

more convenient time to call back)

Before we start, I would like you to confirm some 

information we have on file. We have your mailing address 

as: (state address we have on record). Is that correct? 

Did you receive a ______________ (final decision or letter) 

from the Department of Labor, regarding possibly filing a 

claim for impairment and/or wage loss benefits? That 

__________ (final decision or letter) was sent to find out 

if you want to file a claim for additional compensation, 

specifically monetary benefits based on impairment and/or 

wage loss.

Each percentage of whole body impairment equals $2,500 in 

compensation. The overall rating shows how much of your 

entire body’s function is impaired due to your covered 

illness. An impairment rating may be performed once your 

covered condition has reached maximum medical improvement 

(MMI). MMI means that your covered condition is unlikely 

to improve with additional medical treatment. A qualified 

physician can determine whether or not you are at MMI.

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The first step is to apply for benefits by providing a 

written, signed statement to DOL that you wish to claim 

impairment benefits.

Once the district office receives your written request, a 

claims examiner will send you a letter describing what 

information is necessary for the impairment rating.

When you receive this letter, please call me at 

 and I will be more 

than happy to assist you further.

*****if claimant received “option letter” from the district 

office, continue with script*****. If not, go to ### wage 

loss section

Impairment ratings are based on the evaluation of specific 

medical tests (i.e. pulmonary function tests, liver 

function tests, etc.) that can be done by any qualified 

physician. In other words, medical evaluations that are 

necessary to evaluate the degree of loss of function of 

body parts that are affected by your covered condition.

The evaluation can be performed by a physician of your 

choice. The physician must hold a valid medical license 

and Board certification/eligibility in the appropriate 

field of expertise (i.e. toxicology, pulmonary, 

occupational medicine, etc.) to perform such an 

evaluation. The physician must also possess the necessary 

professional and medical background in interpreting the 

AMA’s Guidelines to provide such ratings.

You will need to provide the name, address, and telephone 

number of the physician you have selected to perform your 

impairment evaluating. The District Office 

will send the physician a letter outlining the specific 

requirements for performing your evaluation.

Also, DOL can arrange for a qualified physician to review 

the medical information provided by your physician to 

determine the degree of impairment. You will not be sent 

to a physician for this review. If necessary, the 

physician may request medical tests to establish the degree 

of impairment.

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DOL will pay the cost for obtaining the required medical 

tests and the cost for one impairment evaluation.

###Before I let you go, I’d like to ask you a few 

additional questions. Did your covered illness cause you 

to stop working for any period? Did it cause you to accept 

a lower paying job or work less hours?

 

If yes, continue:

If prior to your age for full Social Security retirement 

you lost wages as a result of your covered illness, you may 

be also eligible to receive additional compensation. Wage 

loss benefits are separate from what we were just talking 

about (impairment). It is entirely your choice whether or 

not you want to claim compensation for impairment and/or 

wage loss.

How old were you when you stopped work or lost wages? [If 

they respond that they were 65 or over (if born in xxxx or 

earlier, the age varies with the year of birth) they are 

probably not eligible for wage loss benefits. If under 

that age, they may be). 

If you wish to apply for wage loss benefits, again, please 

send a written and signed request to the 

______________________ district office and state that you 

are applying for wage loss benefits. You should also show 

the date (month and year) when your covered illness started 

causing you to lose wages. Once the district office 

receives your written request, a claims examiner will 

contact you to help you complete the claim with all 

appropriate documentation. Compensation for wage loss ends 

when you reach normal retirement age (per Social Security), 

but each year of qualifying wage loss can pay you $15,000 

if your covered illness caused you to earn no more than 50% 

of your previous average annual wages, or $10,000 if it 

caused you to earn no more than 75% of your previous 

average. The DOL looks at wages in each calendar year, and 

even factors-in inflation.

If you want to file a claim for impairment and/or wage 

loss, and it’s easier for you, please feel free to bring 

your request to this Resource Center and we will help you 

submit it to the district office.

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Do you think that you are interested in filing a claim for 

impairment 

[record response]

Do you think that you are interested in filing a claim for 

wage loss? [record response] ONLY ASK IF APPLICABLE!

Mr./Ms. _________________ do you have any questions at this 

time?

Please do not hesitate to give me a call at 

________________________ should you require assistance with 

filing a claim for these benefits or to get answers to any 

of your questions.

It has been a pleasure speaking with you.

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Resource Center Outreach Effort

Impairment and Wage Loss

Frequently Asked Questions 

Impairment 

1. What is an impairment award?

An impairment award is monetary compensation for the permanent loss of function of a 

body part or organ, due to an illness covered under the EEOICPA.

2. Who is eligible for impairment benefits?

Employees who have received positive causation determinations under Part E of the 

EEOICPA.

3. What proof do I need for DOL to establish impairment?

In general, impairment is a decreased function in a body part(s) or organ(s) established by 

medical evidence. Impairment ratings are based on the evaluation of specific medical tests 

(i.e. pulmonary function tests, liver function tests, etc.) that can be done by any qualified 

physician. In other words, medical evaluations necessary to evaluate the degree of loss of 

function of body parts that are affected by the covered condition.

4. What is considered when determining percentage of impairment?

DOL considers the following:

• Loss of function (whole person) as a result of a covered illness

• Standards applied from the American Medical Association’s (AMA’s) Guides to 

Evaluation of Permanent Impairment, Fifth Edition

• Whether the condition has reached maximum medical improvement (MMI), i.e. 

well stabilized and unlikely to improve with treatment. DOL will award 

impairment ratings for chronic conditions without the need for those claimants 

to wait for a recovery that is unlikely to occur. 

5. How is impairment compensation calculated?

Each one percent of impairment=$2500 

Example: 3% impairment rating = $7500 award

6. How do I apply for impairment benefits?

You apply for benefits by providing a written, signed statement to DOL that you wish to 

claim impairment benefits. No particular form is needed.

7. How does DOL determine impairment?

DOL determines impairment ratings based upon a physician’s evaluation.

The evaluation can be performed by a physician of the claimant’s choice.

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DOL can arrange for a qualified physician to review the claimant’s medical records and make 

an impairment evaluation. The claimant will not be sent to a physician for this review. The 

physician will use the information provided by the claimant’s physician to determine the 

degree of impairment. DOL can also seek an additional evaluation when necessary.

8. What requirements are necessary for a physician to be qualified?

The physician must hold a valid medical license and Board certification/eligibility in the 

appropriate field of expertise (i.e. toxicology, pulmonary, occupational medicine, etc.) to 

perform an evaluation.

The physician must also show that he/she meets at least one of the following criteria: 

• certified by the American Board of Independent Medical Examiners (ABIME) 

and/or American Academy of Disability Evaluating Physicians (AADEP) 

• possesses knowledge and experience in using the AMA’s Guides to conduct 

impairment ratings.

Wage Loss

9. What are wage loss benefits?

Covered employees may receive compensation for wage loss if the loss was caused by a 

covered illness. Wage loss compensation is payable for years of wage loss prior to regular 

Social Security Administration (SSA) retirement age (usually 65 years). The wage loss can be 

total or partial.

10. Who is eligible for wage loss benefits?

Claimants who have received positive causation determinations under Part E of the 

EEOICPA, and experienced wage loss prior to Social Security Administration regular 

retirement age as a result of the covered illness.

11. What type of proof will I be required to submit to prove my wage loss?

In addition to medical evidence, various types of documentation may be submitted to 

establish earnings, such as:

• Social Security earnings statements

• Social Security disability records

• Pay Stubs

• Union records

• Tax Returns

• Pension Records

12. What type of medical evidence is needed to support loss of wages?

• Medical reports showing an inability to work

• Physician’s office notes

• Return-to-work slips

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• Physician’s signed statement explaining a relationship between covered illness 

and period(s) of wage loss

• District medical consultant’s evaluation report

13. How is wage loss compensation computed?

Covered employees may be eligible to receive compensation for wage loss for each 

qualifying year (prior to normal SSA retirement age) in which their earnings fell a 

specific percentage below their average annual earnings (AAW) for the 36-month period 

before they suffered a wage loss (not including periods of unemployment) as a result of 

the covered illness:

• $10,000 for any year in which wages were greater than 50% but less than 75% of 

the calculated average annual wage earnings as a result of a covered illness.

• $15,000 for any year in which wages were less than 50% of their calculated

average annual wage earnings as a result of a covered illness.

14. What is considered when determining wage loss?

DOL considers the following:

• When initial wage loss began

• Dates of wage loss claimed

• Number of years of wage loss prior to SSA retirement age

• AAW amount prior to the first wage loss

15. How do I apply for wage loss benefits?

If you have never claimed wage loss benefits, a written and signed statement that you 

wish to claim wage loss benefits is enough to establish a claim. The statement should be 

sent to the District Office that handles your claim. If you have already made an initial 

wage loss claim, Form EE-10 is used to claim additional calendar years of wage loss..

16. How often can I apply for additional wage loss?

Additional wage loss claims can be filed on a yearly basis. 

17. I am currently receiving SSA disability benefits due to a problem unrelated to my 

DOE work. How will you determine if I have a wage loss due to my accepted illness?

Medical evidence that wage loss is related to a covered illness must be submitted in order 

for wage-loss benefits to be afforded. Wage loss due to an unrelated condition that is not 

approved under Part E is not compensable.

18. Will employees whose onset of illness occurs after retirement be eligible for 

compensation based on wage loss?

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They can be if they were unable to work due to the illness and the inability to work 

began prior to regular SS retirement age.

19. Are wage loss benefits available to survivors of covered employees?

Yes, in addition to the basic $125,000 survivor benefit, a survivor may receive additional 

compensation in increments of $25,000 based on the employee’s years of qualifying lost 

wages. For example, if there are no qualifying lost wages, the survivor receives $125,000.

If the employee had qualifying wage loss for a period of time of at least 10 years but less 

than 20 years, the survivor will receive an additional $25,000, for a total of $150,000. If 

the employee had at least 20 years of qualifying wage loss, the survivor will receive an 

additional $50,000 for a total of $175,000. 

20. If an employee dies before retirement age, do those years qualify in determining 

additional survivor benefits?

DOL will presume that the deceased employee (in a Part E claim only) experienced 

qualifying wage loss for each calendar year after the calendar year of his or her death up 

to and including the calendar year when he or she would have reached his or her normal 

retirement age under the Social Security Act (SSA).

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TABLE OF CONTENTS

Paragraph and Subject Page Date Trans. No.

Chapter 2-0300 Initial Development

Table of Contents. . . . . . . . i 01/10 10-07

1 Purpose and Scope. . . . . . . . 1 01/10 10-07

2 Resource Center Actions. . . . . 1 01/10 10-07

3 Review by the District Office 

 for Potential Development. . . 1 01/10 10-07

 4 Reviewing a New Claim. . . . . . 1 01/10 10-07

 5 Sources of Evidence. . . . . . . 4 01/10 10-07

 6 Advising the Claimant of 

 Deficient Evidence . . . . . . 6 01/10 10-07

 7 Requesting Evidence by

Telephone . . . . . . . . . . . 7 01/10 10-07

 8 Initial Exposure 

Development. . . . . . . . . . . 7 01/10 10-07

 9 Former Part D Claims . . . . . . 8 01/10 10-07

10 Positive DOE Panels. . . . . . . 11 01/10 10-07

11 Reviewing Part B/E Claims. . . . 12 01/10 10-07

12 DOE Former Worker Program. . . . 14 01/10 10-07

13 Terminally Ill Claimants . . . . 17 01/10 10-07

Exhibit

 1 DOL Letter to DOE Former 

 Worker Program . . . . . . . . 01/10 10-07

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1. Purpose and Scope. This chapter explains the 

procedures to be used by the Claims Examiner (CE) for the 

review and initial development of a Part B claim, a Part E 

claim, a Part B/E claim, and for a Part D claim that has 

been developed by the Department of Energy (DOE), after 

receipt by the designated District Office (DO) and entry in 

the Energy Case Management System (ECMS).

2. Resource Center Actions. Resource Center (RC) staff 

conduct initial employment verification on most nonRadiation Exposure Compensation Act (RECA) claims filed 

with the RC and occupational history interviews on all new 

Part E claims with covered employment and eligible 

survivors. The DO conducts initial employment verification 

only on claims filed directly with the DO. However, the CE 

closely reviews all initial development actions taken at 

the RC and determines what additional and follow-up 

measures are necessary.

3. Review by the District Office for Potential 

Development. Regardless of the type of claim (i.e., B 

only, E only, B and E, or a Part D claim developed by the 

DOE), the CE first reviews the claim to determine what 

development is required to issue a recommended decision. 

Key items the CE needs to review to determine whether 

sufficient evidence exists are listed below. These three 

factors are applied differently for each claim type.

a. Medical Condition(s).

b. Employment History. Information provided by the 

RC will assist the CE in determining what additional 

development is required.

c. Survivorship Eligibility, When Appropriate. This 

excludes employee claims and RECA claims for Part B 

only.

4. Reviewing a New Claim. The initial review takes place 

upon the DO’s receipt of the new claim from Mail and Files 

(see EEOICPA PM 1-0200). The CE reviews the claim as a 

whole, weighing employment, medical, and survivorship

eligibility to properly categorize the claim and determine 

what development is required. The information contained in 

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4. Reviewing a New Claim. (Continued)

the RC packet assists the CE in planning additional 

development.

When a deficiency in the evidence is identified, the CE 

must notify the claimant and request evidence needed to 

resolve the deficiency. The CE may also assist the 

claimant with his or her claim by requesting evidence from 

other sources.

a. Medical Development. The CE reviews the claimed 

medical condition(s) on Forms(s) EE-1/2 and the 

completed Case Create Worksheet to determine whether

the claim is applicable under Part B, Part E, or both. 

Refer to Chapter 2-0900 covered occupational illnesses 

under Part B and to Chapter 2-1000 for covered 

illnesses under Part E.

For example, the claimed condition of prostate cancer 

is applicable under both Part B and Part E but the 

claimed condition of asbestosis is applicable only 

under Part E.

(1) The CE must ensure that the condition 

claimed is covered under Part B, Part E, or both, 

based upon the claimed employment and the 

different criteria used to determine covered 

employment under each Part.

(2) The CE develops the medical condition(s), as 

needed, in accordance with EEOICPA PM 2-0800,

Developing and Weighing Medical Evidence.

b. Employment Development. At the same time, the CE 

reviews Form EE-3 and any employment verification 

request forms or evidence received from the RC to 

determine whether the claimed employment is applicable 

under Part B, Part E, or both.

(1) Under Part B, the applicable facility types

include DOE, atomic weapons employers (AWE), 

beryllium vendors (BV), and RECA mines or mills. 

AWE subcontractors are not covered under Part B 

or Part E.

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4. Reviewing a New Claim. (Continued)

(2) Under Part E, the only applicable facility 

type is DOE or a covered RECA Section 5 facility. 

Only DOE contractors/ subcontractors are covered;

federal DOE employees at such sites are not 

covered Part E employees.

AWE and BV employees are not covered under Part 

E. However, if employment is claimed at an AWE 

or BV during a time in which such facility was 

designated a DOE facility for remediation, the 

case file is forwarded to the National Office 

(NO) for review. EEOCIPA PM 2-0500 discusses DOE 

remediation in detail.

(3) The CE looks at the claimed facility 

types(s) (i.e., DOE, AWE, BV, and covered RECA 

mines or mills), time period(s), job title(s), 

and ORISE printouts, if available. The CE then 

determines whether the claimed employment is 

applicable under Part B, Part E, or both, and 

then develops any employment evidence needed.

c. Eligible Survivor Development. When Form(s)EE-2 

is received, the CE reviews the claim and determines 

whether all eligible survivors have been accounted for 

and given the opportunity to apply for survivor 

benefits. Also, the CE reviews the claim for 

sufficient evidence to support the relationship 

between the survivor and the employee.

(1) Under Part B, the eligible survivors are the 

surviving spouse, children, parents, 

grandchildren, or grandparents at the time of 

payment.

(2) Under Part E, the eligible survivors are the 

surviving spouse and certain eligible children at 

the time of the employee’s death (see EEOICPA PM 

2-1200).

The RCs do not develop for employment or occupational 

history if it is clear that no eligible survivor 

exists (which occurs primarily in cases involving 

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4. Reviewing a New Claim. (Continued)

adult children under Part E). The CE must review the 

evidence of record to confirm the absence of an 

eligible survivor before issuing a recommended 

decision based upon RC determination, because the RCs 

do not perform any adjudication functions.

d. Verifying ECMS Accuracy. After reviewing the 

claim, the CE reviews the New Claims Review Checklist 

and ECMS to ensure that the claim was entered 

correctly in ECMS (see EEOICPA PM 2-2000).

5. Sources of Evidence. Decisions are based on the 

written evidence of record. Evidence may include (but is 

not limited to) forms, reports, letters, notes, personal 

statements, and affidavits. Most of the evidence required 

under the EEOICPA may be obtained from the following 

sources:

a. Claimant. Any claimant filing for benefits under 

the Act is responsible for submitting the necessary 

evidence required for the Office of Workers’ 

Compensation Programs (OWCP) to adjudicate the claim.

b. Department of Energy (DOE). The DOE, a federal 

agency, had contractual arrangements with employees, 

contractors, subcontractors, AWEs and BVs with respect 

to the United States Atomic Weapons Program. The Act 

requires DOE to provide the Department of Labor (DOL)

with information relevant to EEOICPA claims. The DOE 

conducts medical screening of former DOE facility 

employees through its Former Worker Program (FWP). 

The procedures for obtaining employee-specific FWP 

records are set forth in Paragraph 12 of this Chapter.

c. Corporate Verifiers. While it produced atomic 

weapons, the DOE maintained relationships with a wide 

variety of external entities such as contractors and 

subcontractors, BVs and AWEs. The CE may need to 

contact these entities to obtain information about a 

claim for compensation.

d. Oak Ridge Institute for Science and Education 

(ORISE). Oak Ridge maintains the ORISE database, 

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5. Sources of Evidence. (Continued)

which may be accessed via the Internet. The ORISE 

database, which contains information for over 400,000 

employees from the 1940s until the early 1990s, is an 

effective source for verifying employment for

individual claims. ORISE is accessible via ECMS, and 

the initial ORISE search is generally conducted at the 

RC when a claim is filed.

e. The National Institute for Occupational Safety 

and Health (NIOSH). NIOSH is an agency within the 

Department of Health and Human Services (HHS) that is 

responsible for estimating the radiation exposure to 

DOE employees, contractors, subcontractors and AWE 

employees during the production of atomic weapons.

NIOSH researches site information for covered 

facilities and sends dose reconstruction reports to 

EEOICPA DOs. The DOs use the dose reconstruction 

reports to determine the probability of causation 

between a claimed cancer and exposure at a covered 

facility, based on the criteria established by NIOSH.

f. Medical Sources. These sources include reports 

from doctors and hospitals providing examination 

and/or treatment to covered employees. By signing

Form EE-1 or EE-2, the claimant authorizes OWCP to 

collect medical documentation pertinent to his or her 

case.

g. Center for Construction Research and Training. 

The Center for Construction Research and Training is a 

research, development, and training arm of the 

Building and Construction Trades Department (BCTD) of 

the AFL-CIO.

CPWR has direct access to 15 building and construction 

trade international unions, signatory contractors, and 

union health, welfare and pension funds. CPWR also 

has access to employment records, union rosters, and 

dispatch records. 

CPWR researches and provides employment information 

for construction and trade worker claims where DOL has 

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been unable to obtain reliable information from other

resources (e.g., DOE, corporate verifiers).

h. Site Exposure Matrices (SEM). The SEM database 

may be accessed via the Internet. SEM is a source for 

obtaining evidence of potential exposures to toxic 

substances at many DOE facilities.

i. Other Sources. The OWCP may receive evidence 

from other sources, such as individuals completing 

employment affidavits, claimant representatives, and 

other state and federal agencies.

6. Advising the Claimant of Deficient Evidence. When the 

CE determines that additional development is required, the 

claimant must be advised of the deficiency and afforded an 

opportunity to respond.

a. Initial 30-day Period. If the CE identifies a 

deficiency in the evidence that requires development, 

a letter is prepared which describes the deficiency 

and additional information necessary to overcome it. 

The CE thoroughly reviews the evidence in the file 

before writing the letter and tailors the letter to 

the individual case. Often 30 days will be sufficient 

time to allow for submission of additional evidence.

For example: If a claimant submits a claim for a noncovered condition and the evidence does not support a 

covered condition under the EEOICPA, the CE advises

the claimant that a covered condition has not been 

claimed and that he or she is allowed 30 days to claim 

such a condition and to provide supporting medical 

evidence. [If the claimant does not claim a covered 

condition and does not provide supporting evidence, 

the CE proceeds with a Recommended Decision for 

denial.]

b. Final Notice. If the claimant fails to submit 

the requested evidence within a 30-day period, in most 

instances the CE sends a follow-up letter advising the 

claimant that OWCP has not received the requested 

evidence and that he or she will be provided with 

additional time to submit the evidence.

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6. Advising the Claimant of Deficient Evidence. (Continued)

 

For example: If a covered condition is claimed, but 

the file is lacking medical documentation, the CE 

allows a reasonable period of time for submission of

the appropriate evidence. In cases such as this, the 

CE makes at least two requests for medical 

documentation.

c. Setting Deadlines. As the EEOICPA is nonadversarial, the CE uses care when setting deadlines. 

The information requested is not always easily 

obtained because most employees were exposed many 

years ago. Thus the CE must be as flexible as 

possible and advise the claimant that additional time 

will be granted if the claimant requests a reasonable 

extension of time. 

7. Requesting Evidence by Telephone. The CE may also use 

the telephone to gather evidence. Person-to-person contact 

often succeeds in obtaining information, addressing 

specific concerns, and defusing contentious situations. 

Any use of the telephone is to be conducted in a 

professional and courteous manner.

a. Documenting Phone Calls. CEs document each call 

in the Telephone Management System (TMS) in ECMS and 

place a copy of the automated telephone record in the 

case file. It is vital to enter a call summary into 

the TMS right after the call, while the information is 

still fresh in the CE’s mind. For more information on 

TMS, see EEOICPA PM 0-0400.

8. Initial Exposure Development. RC staff conduct 

occupational history interviews on most new Part E claims 

filed after August 1, 2005, and on certain Part D/E claims 

filed before that date. In conjunction with this step, the 

CE queries the Site Exposure Matrix (SEM), and prepares the 

Document Acquisition Request (DAR) and forwards it to the 

proper DOE Operations Center or corporate verifier 

requesting exposure information to complement the RC 

findings. A DAR is not always necessary; the CE completes 

a DAR request based upon what medical evidence and exposure 

documentation is already contained in the case file. 

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8. Initial Exposure Development. (Continued)

a. Occupational History Interview. Exposure 

information is partially obtained through the 

occupational history interview conducted at the RC. 

Two separate interview scripts (one for DOE 

employment, one for RECA) are available, and the 

findings outlined in these documents assist the CE in 

clarifying what further exposure development is needed 

as it relates to causation. 

b. Review of Evidence. The CE reviews the claimed 

employment, exposure documentation, the SEM (see 

EEOICPA PM 2-0700), and the claimed condition to 

determine the proper course of development for 

causation. 

c. Assignment to RC. The CE reviews all former Part 

D cases, new Part E cases filed before August 1, 2005, 

and claims filed directly with the DO to determine 

whether an occupational history interview is required.

Such evaluations are made on a case-by-case basis by 

reviewing the evidence in the file as a whole and the 

exposure evidence in particular. 

(1) If the evidence in the file is insufficient

to develop for exposure, the CE assigns an 

occupational history development task to the RC

via memo to the RC manager. 

(2) Upon receipt of such assignment, the RC has 

14 calendar days to complete the occupational 

history interview and return the findings to the 

DO with a cover memorandum outlining all tasks 

and stating when they were conducted. 

 

9. Former Part D Claims. Former Part D claims have been 

incorporated into the existing Part B EEOICPA files. DOE 

may have gathered documents that are relevant to DEEOIC’s 

current development needs. The CE must review these claims 

for medical, employment, and survivorship information (if 

applicable).

The case file may contain copies of records from a Part B 

claim (e.g., medical records, development letters, Forms 

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9. Former Part D Claims. (Continued)

EE-5, a NIOSH dose reconstruction report, a recommended 

decision, a final decision) and/or records that were 

gathered by the DOE Office of Worker Advocacy (OWA). 

As noted above, should an occupational history interview be 

required, the CE assigns the task to the RC. Any 

employment development is conducted at the DO; no RC 

assignment is necessary. The evidence in these claims may 

include:

a. Claim Forms.

(1) Form EE-1, EE-2, or EE-3.

(2) Form 350.2, Employee Request for Review by 

Physician Panel. This is the primary application 

form for current or former DOE contract employees 

under Part D.

(3) Form 350.3, Survivor Request for Review by 

Physician Panel. This is the primary application 

form for a survivor of a former DOE contract 

employee under Part D.

(4) Form KK-1, KK-2 - OWA1-7/6/01 Request for 

Review by Medical Panels. DOE used these forms 

initially for filing claims by the employee and 

by the survivor, respectively, and for the claims 

review by the Medical Panels. These were 

internal forms used by OWA only. 

Once the Office of Management and Budget (OMB)

approved these forms, they became known as Form 

350.2, Employee Request for Review by Physician 

Panel, and Form 350.3, Survivor Request for 

Review by Physician Panel, respectively.

If no DOE/OWA forms are located, the CE reviews the 

file for any correspondence from the claimant that may 

contain words of claim. As with Part B, any 

correspondence referring to a request for benefits or 

a request for review by a physician panel will be 

considered a claim filed under Part E.

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9. Former Part D Claims. (Continued)

b. Highlight Sheet. This form provides a 

chronological description of adjudicative actions, 

follow-up information, and documented phone calls by 

the OWA. This information was entered in OWA’s Case 

Management System (CMS).

c. Medical Records. These records include medical 

narratives, pathology reports, clinical reports, and 

diagnostic reports.

d. Survivorship Evidence. This includes marriage 

certificates, divorce decrees, birth certificates, 

adoption papers, death certificates, obituaries, and 

school records.

e. Employment Evidence. This includes a Document 

Acquisition Request (DAR), which in turn includes 

employment records such as job position descriptions, 

personnel information, security clearance information, 

employment dates, medical records, accident/incident 

reports, radiation records, and dosimetry records.

f. Occupational Medical Questionnaire. This form is 

in the case file if completed by an RC staff member 

and/or by an OWA staff nurse based on conversations 

with claimants.

g. Physician Panel Report. Some case files may 

contain this report, which consists of the OWA 

physician’s discussion, rationale, and conclusion as 

to whether a toxic substance aggravated, contributed

to, or caused the claimed condition(s). Additional 

guidance as to the proper evaluation of these reports 

as they relate to causation is outlined in Paragraph 

10 of this Chapter. 

h. Former Worker Program (FWP) Documents. As 

discussed in greater detail in Paragraph 12 of this 

Chapter, DOE medically screens former DOE facility 

workers. The resulting studies document claimed 

illnesses and exposure. The CE may encounter DOE FWP 

documentation in the case file. The CE reviews DOE 

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9. Former Part D Claims. (Continued)

FWP findings together with all other evidence in file 

when evaluating for causation.

i. Authorized Representative Release Form. The 

claimant may have designated a representative to act 

on his or her behalf in the adjudication process with 

DOE. The CE contacts the claimant to determine 

whether this designation is still valid (see EEOICPA 

PM 2-0400). 

j. Duplicate Records. The CE may find duplicate 

copies of records in the Part D case file. The CE 

maintains the integrity of the Part D case file by 

keeping it in the order that it was received in the 

district office. The CE does not remove any duplicate 

copies of individual records unless it is obvious that 

there is an exact duplicate photocopy of the entire 

case record in the file. In this instance the CE 

shreds the duplicate photocopy.

10. Positive DOE Panels.

a. Official Positive DOE Panels. If a positive DOE 

physician panel finding is present in a Part D case 

file and the DOE approval letter is signed by a DOE 

official, the physician panel finding is considered an 

official positive determination from DOE. Generally, 

such claims are in posture for acceptance of causation 

under Part E, but further development of survivorship 

and potential coordination and offset issues may be 

required of the CE before issuing a recommended 

decision:

(1) Eligible Survivor. In survivor claims the 

CE needs to determine whether the claimant is an 

eligible survivor under Part E and whether the 

accepted covered illness aggravated, caused, or 

contributed to the covered Part E employee’s 

death (see EEOICPA PM 2-1200).

(2) State Workers’ Compensation Benefits/Tort 

Offset. Also, the CE needs to determine whether 

the claimant received any compensation from a 

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10. Positive DOE Panels. (Continued)

state workers’ compensation plan (see EEOICPA PM

3-0400 and 3-0500).

b. Unofficial Positive DOE Panels. If a positive 

DOE panel finding is present in the case file, but no 

accompanying approval letter signed by a DOE official

is present, the case is not in posture for possible 

acceptance. In such a case, the physician panel 

report has not been sent to the claimant and the CE 

does not consider it an official positive 

determination from DOE. Therefore, the CE reviews the 

claim to determine if further development is needed 

concerning survivorship, medical, employment or 

exposure issues, as with any other claim. 

11. Reviewing Part B/E Claims. A claim accepted under 

Part B is also accepted for causation under Part E for the 

accepted Part B covered occupational illness, if all other 

appropriate criteria under Part E are met.

Unlike a Part E claim with an accepted Part B claim, a 

claim that has been accepted under Part E is not

automatically accepted under Part B.

In developing these cases, the CE needs to be alert to the 

differences in medical, employment, and survivorship 

requirements between Part B and E claims (including RECA 

claims), since these differences can result in the need for 

additional development and/or non-approval of the claim 

under Part E, even though it has been approved under Part 

B.

a. Medical Differences Between Part B and E Claims.

Covered illnesses under Part E include all the covered 

occupational illnesses under Part B (i.e., beryllium 

sensitivity, chronic beryllium disease, chronic 

silicosis, and cancer) plus additional covered 

illnesses (e.g., asbestosis).

However, the covered occupational illnesses under Part 

B do not include all the covered illnesses under Part 

E (for example, asbestosis, peripheral neuropathy, and 

anemia).

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11. Reviewing Part B/E Claims. (Continued)

b. Employment Differences in Facility Sites Between 

Part B and E Claims. Covered employment under Part B 

includes all covered employment under Part E (i.e.,

DOE contractor/ subcontractor, RECA).

However, covered employment under Part E does not

include all covered employment under Part B. Part E 

covers employment at a DOE or RECA Section 5 facility. 

It also covers employment at AWE and beryllium vendor 

facilities only during a period when they were 

designated as DOE facilities or during DOE remediation 

periods. Part E does not cover employment for 

beryllium vendors or AWE facilities outside of the 

time they were considered DOE facilities.

c. Survivorship Differences Between Part B and E 

Claims. These issues are addressed in the Survivorship 

Chapter of the PM.

d. RECA Differences Between Part B and E Claims.

(1) An eligible survivor who is the child of the

covered employee under RECA and under Part B is 

not an eligible survivor under Part E unless he 

or she meets the definition of “covered child.”

(2) An employee who does not meet the employment

and other requirements under RECA section 5 (and 

therefore under Part B) may be eligible under 

Part E.

(3) An employee who does not meet the medical 

criteria for covered conditions under RECA 

section 5 (and therefore under Part B) may still 

be eligible under Part E (i.e., all cancers, 

asbestosis, etc.)

e. Requirements for New Part E Claim Filing. If a 

former Part D claim exists, a claimant does not need 

to file a new claim under Part E. If there is a Part 

B acceptance on record, a claimant does not need to 

file a new claim for benefits under Part E. However, 

if a Part B denial is on record, or a Part B claim is 

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11. Reviewing Part B/E Claims. (Continued)

pending a decision, the claimant must file a new claim 

form seeking benefits under Part E. 

12. DOE Former Worker Program (FWP). The FWP began in 

1996 and is designed to evaluate the effects of DOE's past 

operations on the health of workers employed at DOE 

facilities. The program documents medical conditions and 

workplace exposures that may help the CE develop and 

adjudicate claims. Additional information about the FWP is 

available at http://www.eh.doe.gov/health/.

In some instances, FWP records will appear in the Part D 

case file. If no records exist there, or a new Part E, B/E 

claim is filed, the CE requests FWP documents during

initial development.

The CE reviews FWP records in light of the evidence in the 

file as a whole when evaluating a claim. EEOICPA PM 2-0700

explains how the CE uses FWP records in assessing 

causation.

a. Medical Component. FWP records contain valuable 

information about medical conditions and can help the 

CE develop for a covered illness.

(1) The FWP is a screening program and does not 

provide a final diagnosis for the medical 

conditions detected. If the screening tests 

identify a potential disease, the employee is 

referred to his or her treating physician for 

further medical workup and diagnosis.

(2) Results of medical tests conducted by the 

FWP (e.g., pulmonary function tests, beryllium 

lymphocyte proliferation tests, blood tests, Xrays with B reader interpretations, etc.) are 

valid when interpreted by certified medical 

professionals. Therefore, the CE may use such 

test results in evaluating records for a covered 

illness, provided a physician’s interpretation of

the test result is present.

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12. DOE Former Worker Program (FWP). (Continued)

b. Exposure Component. FWP medical screening is 

conducted to evaluate former DOE workers for adverse 

health outcomes related to occupational exposures to 

substances such as beryllium, asbestos, silica, 

welding fumes, lead, cadmium, chromium, and solvents. 

Therefore, these records contain valuable exposure 

information. The CE reviews FWP screening records 

along with the evidence in the file as a whole when 

evaluating claimed exposure.

Also, the FWP asks the former DOE employee to undergo 

a Work History Interview, which examines workplace 

exposure at DOE facilities. The CE uses the results 

of the interview when assessing work history and 

exposure.

c. Existence of FWP Records. The CE must review the 

case file/claim forms to determine whether FWP records 

exist.

(1) Part D Cases. As indicated, some former

Part D cases will contain FWP records. The CE 

searches the case file for cover memos or medical 

records provided by the FWP. The CE should also 

refer to DOE Form 350.2, Employee Request for 

Review by Physician Panel, question 11, or Form 

350.3, Survivor Request, question 11, to 

determine if the employee participated in the 

FWP. If records are not present, but there is 

some indication that they may exist, the CE 

obtains them as outlined below.

(2) New B/E Claims. With regard to new claims, 

the CE must review Form EE-3 and/or section 5(B) 

of the DOL Occupational History Interview (see

EEOCIPA PM 2-0200) to determine if the employee 

participated in a FWP screening program at the 

claimed work site. If so, the CE prepares a 

request package to be sent to the appropriate 

FWP.

d. Obtaining FWP Records. Where no records exist in 

a former Part D case, or a new Part E claim is filed, 

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12. DOE Former Worker Program (FWP). (Continued)

the CE requests the records from the appropriate FWP 

Point of Contact (POC). The complete POC list is 

available for viewing on the shared drive by accessing 

the Part E folder, Former Worker Program subfolder. 

If the records are unavailable at a POC, the POC 

cannot be determined, or a new Form EE-3 is required 

(see below), the CE requests assistance from the 

claimant.

(1) POC Request. After determining that FWP 

records must be requested, the CE reviews the POC 

list to identify the appropriate POC. The CE 

prepares a package and a cover letter to the POC 

(Exhibit 1). The package includes a letter to the 

FWP, a cover memo, Form EE-1 or EE-2, and the new

Form EE-3.

The CE should state in the memo that an EEOICPA 

claim has been received for the named DOE 

employee, the employee participated in the 

specified FWP, and DOL is requesting a copy of 

all FWP records. The memo and package are faxed 

or mailed to the designated POC.

(2) New Form EE-3. FWPs will accept only a new 

Form EE-3 as a release. If the case file 

contains an old Form EE-3, the CE writes to the 

claimant asking the claimant to complete and sign 

a new Form EE-3. Once the new form is received, 

the CE prepares the request package as outlined 

above.

(3) No FWP Records. When the CE cannot locate 

FWP records, the CE contacts the claimant in 

writing to determine if the employee participated

in a FWP at the claimed work site. The CE 

includes a new Form EE-3 with the letter and 

instructs the claimant to complete, sign and 

return the new Form EE-3 to the DO only if the 

employee participated in the FWP.

e. Building Trades National Medical Screening 

Program Database. This database contains work history 

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12. DOE Former Worker Program (FWP). (Continued)

and medical test results for certain employees who 

worked at Amchitka Island, Savannah River, Oak Ridge, 

and Hanford and who filed Part D claims with DOE from 

2000-2004.

(1) The CE views medical data and work histories

contained in the database by accessing the Shared 

Drive, Part E folder, Former Worker Program 

subfolder. The “read me” file in the FWP 

subfolder contains detailed instructions for

navigating the database and retrieving

information.

(2) The CE searches the database for medical 

information and prints the results. The medical 

results generated from the database do not 

contain a physician’s signature.

(a) A letter from the Building Trades FWP 

Medical Director, Dr. Laura Welch, 

describing the information obtained in the 

database search and attesting to its 

validity is located on the Shared Drive, 

Part E folder, FWP subfolder.

(b) The CE prints Dr. Welch’s letter and 

attaches it to the search results. The CE 

places these documents into the case file

and weighs the information with the evidence 

on file as a whole.

13. Terminally Ill Claimants. OWCP strives to process 

claims fairly and expeditiously for all claimants. 

However, claimants who are end-stage terminally ill must 

have priority processing. These claims should be handled 

swiftly and compassionately.

a. Claims Actions. DO and FAB CEs and hearing 

representatives (HRs) are instructed to watch for 

indicators of an end-stage terminally ill claimant any 

time they are reviewing a case file or preparing a 

decision. Indicators of end-stage terminally ill 

claimants include requests for hospice care, medical 

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13. Terminally Ill Claimants. (Continued)

evidence stating that the claimant is at the end-stage 

of an illness, or telephone calls or letters from RCs, 

congressional offices, authorized representatives, 

family members, or medical providers regarding the 

claimant’s illness. Upon receipt of information 

concerning the end-stage of the claimant’s illness, 

the District Director (DD) or Assistant District 

Director (ADD) or FAB Manager (depending on where the 

file is located) must be notified immediately.

The DD/ADD or FAB Manager must use sound judgment in 

determining if priority handling is warranted. If 

medical documents or other information indicate that 

the claimant is in the end-stage of his/her illness, 

or that death is imminent, priority handling of the 

case is required. If the claimant’s medical status is 

unclear, a medical report that establishes that the 

claimant is in the end-stage of a disease or illness 

must be obtained. Once this information is obtained, 

the DD/ADD of FAB Manager will determine whether 

priority handling is warranted.

Once it is determined that a claimant is in the endstage of his/her illness, the DD/ADD or FAB Manager 

must enter the appropriate status code in ECMS and 

prepare the case file in accordance with EEOICPA PM 2-

2000.

Priority handling for terminally ill claimants 

requires that the entire adjudication process be 

expedited. Whenever the file changes hands, the 

person receiving the file should be notified, verbally 

or in writing, of the claimant’s terminal status. The 

supervisor or DD/ADD should facilitate the expedited 

adjudication of the claim by requesting priority 

processing from any other agencies involved, such as 

the DOE, Department of Justice (DOJ), and NIOSH.

If a case requires referral to the NO for reopening or 

policy clarification, the DO or FAB must identify the 

claimant as terminally ill in the memo to the 

Director. Procedures for expediting payment processes 

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13. Terminally Ill Claimants. (Continued)

for terminally ill claimants can be found in the 

EEOICPA PM 3-0600.

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DOL Letter to DOE Former Worker Program

Dear FWP POC Name:

(Survivor/Employee name) has submitted a claim for benefits 

under the Energy Employees Occupational Illness 

Compensation Program. (Mr/Ms/ name) has claimed that 

he/she (his spouse/Father/Mother Full Name) participated in 

the {Site Name} Former Worker Screening Program.

The Department of Labor is requesting copies of all records 

you have for (employee name) to assist us in the 

adjudication of the claim.

Attached is the signed EE-3 which authorizes the FWP to 

release records to the Department of Labor.

If you have any questions regarding this request, please 

contact me directly at (phone number).

Thank you for your assistance in this matter

Sincerely,

Claims Examiner

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TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-500 Establishing Covered Employment 

 

 Table of Contents. . . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . . 1 01/10 10-07 

 2 Facility Coverage. . . . . . . . 1 01/10 10-07 

 3 Comparing Initial Claimed 

 Employment to the Covered 

 Facilities Database. . . . . . 4 01/10 10-07 

 4 Matching Claimed Employment. . . 5 01/10 10-07 

 5 Resource Center Actions. . . . . 6 01/10 10-07 

 6 Verification of Employment . . . 6 01/10 10-07 

 7 Employment Pathways Overview 

 Document (EPOD). . . . . . . . 7 01/10 10-07 

 8 Using the ORISE Database . . . . 9 01/10 10-07 

 9 Contacting DOE . . . . . . . . . 11 01/10 10-07 

 10 Contacting Corporate Verifiers . 14 01/10 10-07 

 11 Verifying Employment through 

 the Social Security 

 Administration . . . . . . . . 15 01/10 10-07 

 12 CPWR . . . . . . . . . . . . . . 19 01/10 10-07 

 13 Other Employment Evidence. . . . 28 01/10 10-07 

 14 Subcontractor Employment . . . . 30 01/10 10-07 

 15 Researcher Employment at DOE 

 Facilities . . . . . . . . . . 33 01/10 10-07 

 16 Employees of Federal or State 

 Governments. . . . . . . . . . 34 01/10 10-07 

 17 Evaluating Evidence to Verify 

 Employment . . . . . . . . . . 35 01/10 10-07 

 18 Developing Non-Covered 

 Employment . . . . . . . . . . 35 01/10 10-07 

 19 Additions or Modifications to 

 Facility Status. . . . . . . . 36 01/10 10-07 

 20 Special Circumstances. . . . . . 40 01/10 10-07 

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Exhibits 

 1 DOE letter regarding facilities 

 for which DOE has no 

 employment records . . . . . . 01/10 10-07 

 2 DOE memorandum serving as DOE’s 

 Form EE-5 for employment 

 verification by ORISE/ . . . . 01/10 10-07 

 3 SSA-581(Authorization to Obtain 

 Earnings Data from the 

 Social Security Administration) 01/10 10-07 

 4 Telephone Contact Information 

 for inquiries to SSA . . . . . 01/10 10-07 

 5 CP-1 Referral Sheet to CPWR. . . 01/10 10-07 

 6 CP-2 Employment Response 

 Report from CPWR . . . . . . . 01/10 10-07 

 7 Letter to claimant 

 regarding CPWR referral. . . . 01/10 10-07 

 8 DEEOIC Subcontractor Worksheet . 01/10 10-07

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1. Purpose and Scope. The EEOICPA lays out a set of 

employment criteria which must be satisfied before a claim 

can be considered for compensability. These criteria, taken 

together, form the basis of covered employment. This section 

of the EEOICPA Procedure Manual lays out the guidance to be 

followed by the Claims Examiner (CE) for gathering and 

evaluating evidence to determine whether a claimant meets the 

necessary employment criteria specified in EEOICPA. 

2. Facility Coverage. The EEOICPA provides facility 

definitions that serve as the basis for determining covered 

employment. The following summaries provide a general 

definition of each type of facility covered: 

a. Atomic Weapons Employer (AWE) Facilities. An AWE 

facility means a facility, owned by an atomic weapons 

employer that is or was used to process or produce, for 

use by the United States, material that emitted 

radiation and was used in the production of an atomic 

weapon, excluding uranium mining or milling. Coverage at 

the facility may be further extended after the period of 

processing or production of radioactive material for use 

in a weapon, if there is a finding in a NIOSH report on 

residual radioactive contamination that the potential 

exists for residual radioactive contamination at that 

facility. AWE facilities are designated by the 

Department of Energy (DOE).

(1) Coverage extends only to the employees who 

worked directly for the AWE at the facility. 

Contractor or subcontractor services provided onsite or off-site for an AWE are not covered. 

(2) Atomic weapons employees are covered under 

Part B of the EEOICPA for cancer only. No coverage 

is afforded these employees under Part E. 

(3) Designating additional AWE facilities is the 

responsibility of DOE; however, applicable time 

frames for AWE production activities at a 

particular facility are determined by DOL. 

(4) Determinations on whether an AWE facility has 

a period of residual radioactive contamination and 

the length of that period are the responsibility of 

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2. Facility Coverage. (Continued) 

the NIOSH. Periodic reports are issued listing 

affected sites. Facilities with residual 

radioactive contamination are covered as AWE 

facilities even if there is a change in the owner 

or operator of the facility. 

b. Beryllium Vendor (BE Vendor) Facilities. Be Vendor 

facilities are companies which are either named in the 

Act or DOE has determined that they processed or 

produced beryllium for sale to, or use by DOE. The Act 

names several beryllium vendors by corporate name and 

these are known as statutory beryllium vendors. Any 

employee of a statutory beryllium vendor who worked for 

the vendor during periods when the company was engaged 

in activities related to the production or processing of 

beryllium for sale to or use by DOE, has covered 

employment, regardless of work location. Other 

beryllium vendors, which are location-specific, were 

designated by DOE through publication in the Federal 

Register. The final list of designated beryllium 

vendors was issued on December 27, 2002. 

(1) Beryllium vendor coverage extends to direct 

employees of the vendor, its contractors or 

subcontractors, or any Federal employee who may 

have been exposed to beryllium at a facility owned, 

operated or occupied by the vendor. 

(2) Coverage for beryllium vendor employment is 

limited to those benefits available under Part B of 

the EEOICPA for beryllium sensitivity and chronic 

beryllium disease. 

c. Department of Energy (DOE) Facilities. A DOE 

facility means any building, structure, or premise, 

including the grounds upon which such building, 

structure, or premise is located in which operations 

are, or have been, conducted by, or on behalf of, the 

DOE (except for buildings, structures, premises, 

grounds, or operations covered by Executive Order 12344, 

dated February 1, 1982, pertaining to the Naval Nuclear 

Propulsion Program); and with regard to which the DOE 

2. Facility Coverage. (Continued) 

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has or had either (A) a proprietary interest; or (B) 

entered into a contract with an entity to provide 

management and operation, management and integration, 

environmental remediation services, construction, or 

maintenance services. 

(1) The extent of benefits available to those who 

worked at DOE facilities is dependent on the type 

of employment, specifically whether the employee 

was a DOE federal employee or an employee of a DOE 

contractor or subcontractor. Under Part B, coverage 

extends to both DOE federal employees and 

contractor or subcontractors employees working at 

the site, while under Part E coverage is only 

extended to contractor or subcontractor employees. 

(2) The definition of DOE includes its predecessor 

agencies including: 

(a) Manhattan Engineer District (MED)(August 

13, 1942-December 31, 1946) 

(b) Atomic Energy Commission (AEC)(January 1, 

1947 – January 18, 1975) 

(c) Energy Research and Development 

Administration (ERDA)(January 19, 1975– 

September 31, 1977) 

(d) Department of Energy (October 1, 1977 – 

present) 

(3) Designations of DOE facilities or changes in 

DOE facility time frames are the responsibility of 

DOL. Further information regarding how DOL assesses 

claims for DOE facility status is discussed later 

in this chapter. 

d. Remediation Employment. At many AWE facilities, 

there is a DOE period of remediation designated sometime 

after the years of active processing ended. In those 

2. Facility Coverage. (Continued) 

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instances when a facility is designated as a DOE 

facility for remediation only, in order to have covered 

employment at that location, the employee must have been 

employed by the contractor performing the remediation 

work. Such remediation workers are eligible for the 

full range of benefits under both Parts B and E of 

EEOICPA. 

e. Facilities with multiple designations. Many 

facilities covered under the EEOICPA have multiple 

designations. There can exist any combination of AWE, 

Beryllium Vendor and DOE facility designation at the 

same facility. For those instances in which an employee 

works at such a facility during periods separately 

designated for different facility types, the employee 

will have eligibility for every category for which 

he/she has verified employment. 

f. RECA Section 5. This is a special category of 

employment that involves miners, millers and ore 

transporters at uranium mining facilities. For the 

purposes of this chapter, RECA Section 5 employees are 

not addressed. For information regarding handling these 

types of claims, please refer to Chapter 2-1100 of the 

EEOICPA Procedure Manual. 

3. Comparing initial claimed employment to the covered 

facilities database. The first step the CE takes in 

assessing covered employment is determining which claimed 

employment on the EE-3 Employment History form corresponds 

with a known covered AWE, Be Vendor or DOE facility. The CE 

does this by comparing what is written on the EE-3 with the 

facilities identified on a web utility located at: 

http://www.hss.energy.gov/HealthSafety/FWSP/Advocacy/faclist/findfacility.

cfm

When performing the comparison between the claimed employment 

and the facility database, the CE must be diligent in 

assessing the evidence. While in many instances, employment 

at a particular location or facility will be obvious, in 

other situations it may not. Evidence presented by a 

claimant must be scrutinized against the database to assist 

in determining the location where employment occurred. In 

3. Comparing initial claimed employment to the covered 

facilities database. (Continued) 

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some situations, the claimant may use various words, phrases 

or other descriptors to identify a work location. Moreover, 

the CE must be mindful that often the name of a facility is 

different from the employer name provided by the claimant. 

Given these realities, the CE must cross reference the data 

provided by the claimant with the information in the facility 

database. This can involve searching by facility name, state 

or location, or key word. The “Find this Keyword” search 

feature is particularly helpful as it is the broadest 

possible way to look for potential covered employment based 

on claimant statements. 

a. Certain employers should be screened out of the 

review process if it is clearly discernable that there 

is no affiliation to the atomic weapons industry. For 

example, employment as a clerk at a shoe store or 

cashier at a department store would not require action 

on the part of the CE to further consider as part of the 

review for potentially covered employment. 

4. Matching claimed employment. The outcome of the initial 

employment facility screening will result in either part or 

all of the claimed employment having possibly occurred at a 

covered facility, or none of the claimed employment being 

linked to a facility. In any instance where all claimed 

periods of employment are linked to a location identified on 

the facility database, the CE is to proceed to employment 

verification as discussed later in this chapter. 

Alternatively, if the CE is only able to match a portion of 

the claimed employment to a facility listed in the facility 

database, or there is no match found, action must be taken to 

communicate the findings to the claimant. The CE is to 

contact the claimant to notify him or her as to which 

employment can form the basis of a claim and which does not 

appear linked to a covered facility. The claimant is to be 

afforded the opportunity to provide clarifying evidence. The 

process for this action is further discussed in paragraphs 17 

and 18 of this chapter. It should be noted that this 

development may occur concurrently with other actions being 

taken in conjunction with the claim such as requests for 

additional medical or factual evidence. 

4. Matching claimed employment. (Continued) 

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When there is sufficient evidence to conclude that employment 

may have occurred at a covered facility, the CE may then 

proceed with the verification of employment as described 

later in this chapter. If the claimant does not respond to 

the inquiry or does not provide any type of clarifying 

evidence, the CE may proceed with adjudication of the claim 

based on the evidence of record. If there is no match 

between any claimed employment and a covered facility, the CE 

may proceed to deny the claim. In any instance where claimed 

employment is not verified, it must be described in any 

recommended decision. 

5. Resource Center Actions. As outlined in Chapter 2-0200, 

resource center staff take initial employment verification 

steps for those cases originating at a resource center. This 

includes matching claimed employment to covered employment 

and initiating action outlined in paragraphs 6 through 12, 

below, as appropriate. 

6. Verification of Employment. Once matches are 

established between claimed employment and a covered 

facility, the next step is employment verification. 

Employment verification is the process by which the CE 

establishes the factual accuracy of the claimed employment 

history. Evidence must be collected that establishes that: 

a. The employer qualifies for consideration under the 

law as an AWE, Be Vendor, DOE, or DOE contractor or 

subcontractor. 

b. The employee worked for claimed employer. 

c. The employee performed duties at that covered AWE, 

Be Vendor or DOE facility. 

The process of employment verification is recognized as a 

difficult and challenging hurdle in many cases. Because the 

atomic weapons program dates back to the early 1940s, the 

large number of public and private organizations involved, 

the high level of security involved, and the shear scope of 

the industrial process, locating pertinent individual 

employment records can be difficult. Moreover, it is also a 

6. Verification of Employment. (Continued) 

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reality that records are missing, degraded, lost or 

destroyed. This imperfect situation presents particular 

difficulties to the CE when attempting to establish the 

factual accuracy of claimed employment. 

As the statute allows latitude in the assessment of evidence, 

it is not necessary for the CE to collect evidence that 

establishes that the claimed employment is proven beyond a 

reasonable doubt, but merely that a reasoned basis exists to 

conclude that the employment occurred as alleged. This 

ensures that the claimant receives favorable treatment during 

the employment verification process. Once the CE has 

conducted an examination of the available factual evidence in 

support of the claimed employment, he or she must decide 

whether a sufficient basis exists to verify that each of the 

three elements of covered employment are satisfied. 

a. SEC employment. In matching claimed employment to 

covered employment, the CE is to be mindful that there 

are numerous classes in the Special Exposure Cohort 

(SEC), described in Chapter 2-0600. It is important 

that the CE always consult the most current list of SEC 

classes so that claims fitting into the class can be 

promptly adjudicated, without overdevelopment of covered 

employment. 

7. Employment Pathways Overview Document(EPOD). The EPOD 

is a document that has been created to assist the resource 

center staff and CEs in identifying the appropriate 

pathway(s) to be taken as part of the employment verification 

process. This document lists every facility published in the 

Federal Register that is covered under the Act (except RECA 

facilities) and provides an outline of the identified methods 

for verifying claimed employment at each location. EPOD is 

initially available on the shared drive in the Employment 

Verification Folder within the Policies and Procedures 

Folder. 

The pathways listed in the EPOD are not intended to provide 

an exhaustive list of means to verifying employment at a 

facility, but rather represent what constitutes best 

practices for verifying employment most efficiently given the 

7. Employment Pathways Overview Document(EPOD). 

(Continued) 

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programmatic experience gained since passage of the Act in 

2000. The CE should locate the facility(ies) identified on 

the EE-3 in EPOD and ascertain the programmatic implications 

based upon the claimed employment. 

Specifically, EPOD identifies which methods, or combinations 

thereof, described below are appropriate to pursue to verify 

covered employment in the most expeditious manner possible. 

The recommended sequence for utilizing resources follows the 

numbered items 8 through 13 in this chapter. 

EPOD replaces lists 1, 2, 3 and 4 from previous guidance. It 

also replaces the “CE Employment Verification Referral 

Sheet.” If EPOD is silent on verification at a facility, the 

CE is to utilize Social Security Records (Paragraph 11, 

below) and “other employment evidence” (Paragraph 13, below). 

The facilities in EPOD are listed alphabetically by state. 

On the first page of EPOD there is a list of states and, for 

those states with a large number of facilities, there are 

additionally letters after the state name. These letters 

provide a rough index of the facilities in that state. The 

state names and letters allow the user to navigate through 

the document. For example, to navigate to South Carolina the 

user places the cursor on South Carolina and presses “Cntrl + 

right click” at the same time and the utility will jump to 

South Carolina. Alternatively, if a user wants to view the 

S-50 plant in Tennessee, the most expeditious method would be 

to move the curser over the letter S after Tennessee and then 

press “Cntrl + right click” at the same time and the utility 

will jump to S-50. 

For many claims, DOE can provide employment information for 

employees covered under the Act. Since this is not always 

the case, it is necessary to include in the case file in 

every instance in which there is no appropriate referral to 

DOE, a letter from DOE so stating. (Exhibit 1) Therefore, for 

every facility in EPOD in which there is no referring DOE 

contact information, the CE is to place a copy of the DOE 

letter in the file. 

8. Using the ORISE database. For every EEOICPA-covered 

facility for which there is some employment data in ORISE, 

EPOD will indicate “ORISE – yes.” When this occurs, resource 

center staff and/or the CE conduct an ORISE search in ECMS as 

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outlined below. If there is no mention of ORISE in EPOD for 

the facility, the resource center staff or CE proceeds to the 

next recommended method for verifying employment noted in the 

facility description in EPOD or in this chapter. 

a. Resource center staff and/or the CE logs into ECMS 

as described in Chapter 2-2000, and chooses the 

“Inquiry” tab and selects “Search ORISE data.” A screen 

appears which provides fields for the first name, last 

name, and social security number of the employee. To 

conduct a search, the CE must enter, at a minimum, a 

partial last name, or social security number for the 

employee. 

b. Once resource center staff and/or the CE enters the 

employee’s name and/or social security number, the 

system searches the database and provides the results at 

the bottom of the page under ORISE Search Results. If 

the database finds a match, the name and social security 

number appears. The resource center staff and/or CE 

select the result to review the employment data. 

c. ORISE categorizes information in two rows of data. 

The first row categorizes the information by Facility 

and lists all the facilities or employers(for which data 

exists in ORISE) where the employee worked. The second 

row categorizes information in columns by Facility, 

Hire/Terminate Date, Dept. Code, Job Title, and Badge 

Number. ORISE was not created for the purpose of 

adjudicating claims, so information therein may be 

incomplete. In some cases it provides the name of the 

employer with a notation in the “HT” column, which 

provides “H” for hire and “T” for termination, with the 

numbers in the adjacent columns representing the 

corresponding dates for hire and termination. 

8. Using the ORISE database. (Continued) 

The translations for the codes in the “pay” column are 

as follows: 

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H = Hourly 

W = Weekly 

M = Monthly 

O = Operations (hourly) 

S = Salaried 

C = Construction 

d. Because ORISE was not created for the purpose of 

adjudicating claims, resource center staff and/or the CE 

must consider the context of the information. For 

example, there may be data in ORISE confirming that an 

employee worked at a facility in 1949, but the resource 

center staff and/or CE must ensure that the covered time 

period for this facility includes 1949. Additionally, 

for many employees, the information in ORISE is 

incomplete. For example, for some employees the 

database may show the employee’s name and facility, but 

does not include specific hire and termination dates. 

If this is the case, the CE develops hire and 

termination dates using alternate methods described in 

paragraphs 9 through 13 in this chapter. 

e. If the information from the ORISE database is used 

to verify any portion of employment, a copy of the ORISE 

employment results is printed and placed in the case 

file along with the memorandum from DOE stating that the 

data contained in the ORISE database is reliable(Exhibit 

2). These documents may be used as affirmation of 

employment and are placed in the case file. 

f. The absence of data from ORISE may not be used as 

the basis for stating that an employee did NOT work at a 

given facility either for the entire time period claimed 

or for portions of claimed employment. 

g. There are some employers and/or facilities in ORISE 

that are not covered under the EEOICPA. Resource center 

staff and/or the CE need to carefully review the ORISE 

results for any non-covered employers. For example, the 

Puget Sound Shipyard for which ORISE ascribed the 

8. Using the ORISE database. (Continued) 

acronym PSSY is contained in ORISE, but is not covered 

under the EEOICPA. In the event that ORISE “confirms” 

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such non-covered employment, it does not render such 

employment as covered. If an employer is not covered, 

no degree of verification that a person worked there 

will serve to extend EEOICPA coverage to that facility. 

All decisions on adding facilities are made by the 

National Office through the process described in 

paragraphs 17 and 18 of this chapter. 

9. Contacting DOE. When claimed employment can not be 

verified in ORISE, the resource center staff/CE use the Form 

EE-5, found in Exhibit 2 (Forms) of Chapter 0-0500 of this 

Procedure Manual to obtain employment information. To 

determine whether the claimed employment is such that an EE-5 

referral to DOE is appropriate, resource center staff and/or

the CE look up the name of the facility(ies) and/or employers 

in EPOD. If there is a notation in EPOD signaling “EE-5 

Referral to (contact information)” next to the facility, 

resource center staff and/or the CE proceed with the EE-5 

procedures specified in this paragraph. If the employee was 

employed at multiple work sites for which different DOE 

operations offices are responsible, resource center staff 

and/or the CE send separate employment verification packets to 

each unique DOE operations office that is appropriate given 

what is claimed on the EE-3. 

a. EE-5. The resource center staff and/or the CE 

complete the top portion of the EE-5 by providing the 

employee name, SSN, claimed employer, and named claimed 

facility. Resource center staff and/or the CE also write 

a cover letter to the appropriate DOE operations office 

or offices, make a copy of the EE-1 or EE-2, as 

appropriate, and a copy of the EE-3 to be included in 

the package with the EE-5. The completed package is 

then submitted to every appropriate DOE contact listed 

in EPOD for each facility requiring such a referral. It 

may be necessary to submit separate employment 

verification packets to each responsible DOE operations 

office. 

b. Subcontractor employment indicated. Resource 

center staff and/or the CE review the EE-3 and make a 

9. Contacting DOE. (Continued) 

preliminary determination of whether the employee is 

claiming DOE subcontractor employment. If so, resource 

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center staff and/or the CE note this in the cover letter 

to DOE and request any information the DOE might have to 

help substantiate that the company was hired by the DOE 

or a DOE contractor to provide a service on-site during 

the time period when the employment is claimed. 

Questions regarding subcontractor employment are 

referred to the same operations’ offices as the EE-5 

package, and not to DOE Germantown. 

c. Upon receipt of an EE-5 from DOE, the CE reviews it 

for completeness. DOE is responsible for selecting one 

of three options provided on the form and attaching any 

relevant information. In addition, the DOE 

representative completing the form must certify its 

accuracy. The CE returns any form that does not meet 

these requirements to DOE for correction. The three 

options available to DOE and the appropriate procedural 

responses are as follows: 

(1) For any of the claimed employment in which DOE 

selects “Option 1 – Verified Employment,” the CE 

accepts this time period as verified and no further 

action needs to be taken to establish this fact. 

(2) If DOE selects “Option 2 – No verification is 

possible, but other pertinent evidence exists,” 

this indicates that DOE has some information on the 

employee, generally suggesting that the individual 

was on site or somehow associated with the 

facility, but the information is insufficient for 

the DOE to provide verification. If Option 2 is 

selected, the CE develops the case further for 

employment as outlined in this chapter.

(3) If DOE selects “Option 3 – No evidence exists 

in regard to the claimed employment,” it indicates 

that DOE has no evidence at all regarding the 

claimed employment. If Option 3 is selected, the CE 

develops the case further for employment as 

outlined in this chapter. 

9. Contacting DOE. (Continued) 

d. Timeframes. If the CE does not receive a completed 

form from DOE within 30 days of the initial submission, 

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the CE prepares a second request for the completed EE-5. 

If DOE is ultimately unable to verify employment, the CE 

is to utilize other procedures as outlined in this 

chapter. 

e. No Response from DOE. If the CE does not receive a 

response from DOE within 60 days from the initial 

request, additional development is necessary. 

(1) Contact DOE by telephone. If no response is 

received, the CE contacts the appropriate 

Operations Office by telephone. The CE asks the 

contact person identified in EPOD whether a 

response to employment verification is forthcoming. 

If DOE responds via telephone that they have no 

records to verify employment, the CE documents this 

to the case file with a memo outlining DOE’s 

response. This serves as the “EE-5” for purposes 

of a DOE response. 

(2) Contact the claimant. After 60 days with 

either no response or a response that no records 

are available from DOE, the CE contacts the 

claimant for additional employment information. 

f. Document Acquisition Request (DAR) Processes. For 

cases involving DOE contractor employees, the CE or 

resource center makes a request to DOE for records 

useful for developing information regarding toxic 

exposures. Although DAR records are predominately used 

in the adjudication of the toxic exposure component of 

Part E cases, DAR records can also contribute to the 

evidence of covered employment, especially in cases 

involving DOE subcontractor employment, which is further 

described in paragraph 14 of this chapter. DAR records 

can include site medical records, job descriptions, 

radiological records, incident or accident reports and 

others. Generally, a request for DAR records is only 

made of DOE once employment is confirmed. However, some 

DOE operations offices have stated that they prefer to 

receive the DAR request at the same time as they receive 

9. Contacting DOE. (Continued) 

the EE-5. If resource center or district office staff 

are aware of such a situation, they include the request 

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for DAR records in the EE-5 package. The point of 

contact at DOE for DAR records is also included in EPOD. 

For more details on the DAR process, refer to Chapter 2-

0700 of this manual. 

g. Dosimetry Records. It is general program policy 

for NIOSH to obtain dosimetry records from DOE as part 

of the dose reconstruction process. The dosimetry 

records become associated with the file when the 

district office receives NIOSH’s dose reconstruction 

report. Nevertheless, in instances in which dose 

records may be useful for confirming that an individual 

was on site or was monitored for radiation exposure the 

CE may request such records from DOE as part of 

employment development. 

10. Contacting Corporate Verifiers. Many of the facilities 

designated under EEOICPA are operated by private companies 

and neither DOE nor any of its predecessors have possession 

of the employment or personnel records. However, many of 

these companies are still in business, or have been bought by 

other companies which have maintained records of past 

employees. Many of these companies have agreed to provide 

employment verification for purposes of adjudicating claims 

under EEOICPA. These companies are referred to as corporate 

verifiers. For each facility that has been identified as 

having a corporate verifier, EPOD provides the name and 

contact information for the corporate verifier. The CE is to 

follow the instructions listed in EPOD to obtain such 

employment information. General procedures for handling 

corporate verifiers include: 

a. It is not necessary for the CE to submit a copy of 

documentation from the case file to the corporate 

verifier. Instead, a cover letter providing the details 

of the request is to be submitted. In most cases, the 

cover letter includes the employee’s name, SSN, date of 

birth, employer name and the dates of claimed 

employment. 

10. Contacting Corporate Verifiers. (Continued) 

b. Once the CE has received a response from the 

corporate verifier, the CE reviews it to determine if it 

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is sufficient to verify the claimed period of 

employment. If the corporate verifier affirms the 

entire period of employment being claimed, the CE 

accepts the period as factual. The CE must obtain the 

verification from corporate verifiers in writing. While 

an employment verification can be initiated through a 

phone call, there must be documentation from the 

verifier in the case file to substantiate a finding of 

covered employment. If the corporate verifier is unable 

to substantiate the claimed period of employment or can 

substantiate a portion of it, the CE requests additional 

information. The CE can proceed with a request to the 

Social Security Administration(SSA) for information as 

described in paragraph 11 of this chapter, and should 

also ask the claimant for additional information, as 

outlined in paragraph 13 of this chapter, as 

appropriate. 

c. If verification is for a beryllium sensitivity or 

chronic beryllium disease (CBD) case, the CE need not 

verify all employment, only enough employment sufficient 

to substantiate the exposure at any time during a 

covered time period. For additional information 

regarding development of a beryllium claim, refer to 

Chapter 2-1000. 

d. Corporate verifiers sometimes change. If a CE 

learns of a change in contact information or locates new 

contact information, this information should be sent to 

the National Office Employment Contact in the Policy 

Branch. 

11. Verifying Employment through the Social Security 

Administration (SSA). Absent confirmation of employment 

through ORISE, DOE or a corporate verifier, the CE requests 

additional information from SSA. Also, for those facilities 

for which EPOD does not provide any suggested employment 

verification pathway, the resource center and/or CE requests 

records from SSA by following the procedures outlined below. 

11. Verifying Employment through the Social Security 

Administration (SSA). (Continued) 

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a. Obtain a release from the claimant. Once the 

resource center and/or CE determine that SSA information 

is required to verify employment, the CE prepares a 

letter to the claimant for his or her release of SSA 

information. The claimant is advised that additional 

employment verification is necessary. A Form SSA-581, 

“Authorization to Obtain Earnings Data from SSA,” should 

be enclosed (Exhibit 3). The following information is 

required on the SSA-581: 

(1) For Employee Claims: The employee, the 

resource center staff or CE complete the following 

sections of the SSA-581: name; social security 

number; date of birth of employee; and other 

name(s) used. The employee or his or her 

authorized representative must also fill in his or 

her address/daytime telephone number and sign and 

date the form. 

(2) For Survivor Claims: The survivor, resource 

center staff or CE complete the following sections 

of the SSA-581 form: name of social security number 

holder (employee); employee’s social security 

number; date of employee’s birth; date of 

employee’s death; and other name(s) used. The 

survivor writes in his or her address/daytime 

telephone number; indicates the appropriate box and 

shows relationship; signs and dates the form and 

prints his or her name in the requested space. 

The resource center staff or CE explains to the 

survivor that he or she must provide proof of the 

employee’s death and his or her relationship to the 

employee. Proof of death includes: a copy of the 

death certificate, mortuary or interment record, or 

court-issued document. Proof of relationship 

includes: marriage certificate, birth certificate, 

adoption papers, or other court-issued document(s). 

SSA requires that these documents be submitted in 

order to process requests from survivors. 

11. Verifying Employment through the Social Security 

Administration (SSA). (Continued) 

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b. Timeframes on the SSA-581. The resource center 

staff or CE complete the form with the years deemed 

necessary to verify employment and/or establish wageloss on the “Periods Requested” line. The CE or 

resource center staff identify this time period by 

reviewing the EE-3 and all the related documentation in 

the file, as well as a review of ECMS. 

In the box titled, “Requesting Organization’s 

Information,” the CE or resource center staff sign the 

section, “Signature of Organization Official,” and 

provides the district office toll free telephone and fax 

numbers. 

The resource center staff or CE must ensure that the 

upper right hand corner of the form allocated for 

“Requesting Organization” indicates the correct district 

office where SSA’s response should be sent. 

c. The original (signed) SSA-581, and supporting 

documents (if the request is submitted by a survivor) 

must be submitted via Federal Express to the SSA, Wilkes 

Barre Data Operations Center (WBDOC), at the following 

address: 

Social Security Administration 

Wilkes Barre Data Operations Center 

PO Box 1040 

Wilkes Barre, PA 18767-1040 

d. Once the claimant’s release has been obtained, the 

CE or resource center staff prepare a package for SSA 

referral. The package to SSA includes a cover letter 

requesting SSA to perform an earnings search on the 

named employee. Attached to the cover letter is Form 

SSA-581 that indicates the name of the employee, 

employee SSN, and the years of employment to be 

researched. Upon release of the package to the SSA, the 

CE or resource center staff will input code “SS” into 

ECMS. 

11. Verifying Employment through the Social Security 

Administration (SSA). (Continued) 

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e. Following submission of a Form SSA-581, the CE (or 

designee) is responsible for determining if SSA has 

received the earnings request (Form SSA-581) and for 

obtaining a status update on the employment verification 

request. 

(1) If there has been no response from SSA within 

thirty (30) calendar days of the date of the 

submission to SSA, the CE calls to obtain a status 

update. The telephone call should be documented in 

the TMS section of ECMS and a printed copy placed 

in the case file. If SSA indicates that no SSA-581 

form has been received, the CE must resubmit the 

form. Otherwise, the CE obtains the status and 

monitors for further follow-up. 

(2) Inquiries to SSA are made by calling one of 

ten phone numbers (Modules) depending on the last 

four digits of the relevant SSN. (Exhibit 4)

(3) In response to the SSA-581, SSA provides a 

statement of earnings, known as an SSA-L460. If 

the CE does not receive a completed SSA-L460 within 

thirty (30) days of the first inquiry call to SSA 

(the 60th day), the CE follows-up with a call to 

determine the status of the request and proceeds as 

necessary. After 60 days, it is necessary to 

obtain a newly signed SSA-581 from the claimant and 

resubmit the form to SSA as outlined above. 

f. Tracking SSA requests and costs. After the 

completed SSA-581 form is sent, and a copy is placed in 

the case file, a SSA Point of Contact (POC) designated 

by the District Director ensures that the form is logged 

into a tracking spreadsheet. Each district office is 

responsible for developing a system of logging and 

tracking each claim, but the spreadsheet should contain, 

at a minimum, the case number and the date sent to SSA. 

g. Response from SSA. Depending on the response from 

the SSA and the circumstances of the employment, the CE 

does one of three things. The CE either accepts the 

11. Verifying Employment through the Social Security 

Administration (SSA). (Continued) 

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period of employment as verified; develops for 

additional information, such as work location or the 

other elements needed for subcontractor employment, as 

appropriate; or denies the claimed period of employment. 

The CE documents receipt of the SSA response by entering 

code “SR” into ECMS. 

12. CPWR. The Center for Construction Research and 

Training, formerly known as the Center to Protect Workers’ 

Rights (CPWR), and which continues to utilize the acronym 

CPWR, is a research, development, and training arm of the 

Building and Construction Trades Department (BCTD) of the 

American Federation of Labor-Congress of Industrial 

Organizations (AFL-CIO). DEEOIC has contracted with CPWR to 

research and provide employment information for 

construction/trade worker claims where DEEOIC has been unable 

to obtain reliable information elsewhere. It is especially 

useful for obtaining information on DOE subcontractors and on 

workers employed in the trades. Instructions for development 

of subcontractor employment are provided in paragraph 13 of 

this chapter. Any time subcontractor employment is suggested 

on the EE-3, the subcontractor worksheet described in 

paragraph 14 must be completed. Once that is completed, 

there are essentially two pathways by which information from 

CPWR can be obtained for the use of EEOICPA claims 

adjudication: 

a. Web-accessible database. If the resources already 

covered in this chapter do not provide sufficient 

documentation for a finding of covered employment, the 

CE can utilize CPWR, if appropriate. With regard to 

locating information to substantiate the existence of a 

contract between DOE and a company, CPWR has created a 

web-accessible database which the CE can use in 

identifying and confirming the existence of contractor 

or subcontractor employers at certain covered 

facilities. Facilities for which CPWR has contractor 

and subcontractor information have been identified in 

EPOD as “CPWR.” If the CE determines that the claimed 

employment involves subcontractor employment at a 

facility in which EPOD indicates “CPWR has 

contractor/subcontractor information,” the CE first 

12. CPWR. (Continued) 

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reviews the EE-5, the DAR request and any material 

received from DOE. If this information is insufficient 

for a finding of covered employment, the CE reviews the 

CPWR database for any information therein linking the 

claimed employer to the claimed DOE facility, by 

following these instructions: 

(1) The CE goes to www.btcomp.org. A log-on 

screen appears. Each district office has been 

assigned one original user name and password. 

(2) Upon access to the web site, a disclaimer 

notes the database is a general information 

resource tool. It is not intended to nor does it 

contain all of the documents that relate to DOE 

contractors and/or subcontractors. However, the 

DEEOIC considers the information available in the 

database to be accurate and correct. Once the CE 

accepts the disclaimer, the database opens into 

basic search mode. The database allows various 

ways to search for information: by subcontractor 

name, by site, or by scrolling down the 

subcontractor master list. 

(3) To search by contractor/subcontractor name, 

the CE enters the name of the company identified in 

the evidence from the case record. The company 

name may be the current recognized employer name, 

an acronym for the employer, or a previous version 

of the name. The CE searches the database using 

various combinations of spellings or aliases for 

the employer name. This increases the likelihood of 

a positive outcome and reduces the number of false 

negative results. For example, if a CE enters the 

name “Bowles Construction Company” the database 

returns a negative result. However, if the CE 

enters “Bowles” or “Bowles Construction” the 

employer appears in the return. 

(4) To search by site, i.e. covered facility, the 

CE clicks on the list box labeled “by site” on the 

left hand side of the screen and selects the 

facility for which he or she is seeking contractor 

12. CPWR. (Continued) 

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or subcontractor information. This returns all 

employers known by CPWR linked to that facility. It 

may be necessary for the CE to scroll down to view 

all named employers. To view detail for a named 

employer, the CE merely needs to access the “view” 

link under the options category. In some 

instances, a contractor or subcontractor name might 

be linked to multiple covered facilities. In these 

instances, the detailed return for the employer is 

separated into sections by covered site. 

(5) It is also possible for the CE to search the 

comprehensive listing (master list) of all 

contractor employers listed in the database which 

appears if no name or site search criteria are 

applied or if the option “show all” is selected. A 

unique document identification (Doc Id) has been 

assigned to each contractual finding. The Doc Id 

is used by CPWR as a means of tracking and is not 

accessible by the CE. 

(6) After the CE has accessed the database and 

conducted appropriate research to locate a 

contractor/subcontractor, the CE documents the case 

file. In the case of a positive result, the CE 

prints a copy of the screen for the case file. The 

printout must show all the results of the database 

search including the employer name, site name, 

contractual relationship indicator, dates verified, 

type of work performed, description of evidence, 

document ID, and date of database update. 

Generally, this information must be printed based 

on a “landscape” print mode setting. The printout 

should also list the date of the database search, 

the date of the latest update of a facility and any 

of the pertinent facts. In the situation where a 

database search does not return any result, the CE 

completes a “Memorandum to the file” noting the 

lack of information in the database for the claimed 

contractor/subcontractor. The memorandum is dated 

and signed by the CE. Caution: The database 

contains records on employers linked to DOE, but 

for which no probative documentation has been 

12. CPWR. (Continued) 

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located. Any employer found in the database that 

does not have the “contractual relationship” 

indicator checked cannot be used to confirm that 

the employer is a valid contractor or subcontractor 

and should not be printed out for the file. 

(7) The purpose of the database is solely to show 

a relationship between a DOE facility and a 

contractor or subcontractor employer. A positive 

result may return varying levels of information 

about an employer linked to a facility. For 

example, a database return may merely list that a 

contractor or subcontractor was linked to a 

particular facility, but not when. In addition to 

the database results, additional development may be 

needed independent of the database to ensure that 

such evidentiary gaps are filled. 

(8) If the contractor or subcontractor is not 

listed in the database, additional development is 

necessary. The CE is not to assume that a search 

of the database that does not return any results 

establishes that the claimed employer was not a 

contractor or subcontractor. The CE must use all 

other resources that may potentially establish a 

contractual relationship. 

b. Referrals to CPWR. If information beyond that 

which is listed in the CPWR database is needed, CPWR can 

be asked to provide certain types of information to 

assist in these cases. The types of information CPWR 

can provide includes proof of a contractual relationship 

between DOE at a covered facility and an identified 

employer (contractor or subcontractor) during a specific 

time period, evidence that an employee worked for a 

specific employer during the claimed time period and, as 

appropriate proof that the employee worked on the 

premises of a DOE facility during a covered time period. 

CPWR is not permitted to offer an opinion as to the 

validity of the evidence presented to substantiate a 

claim. Weighing and evaluating the evidence is solely 

the responsibility of DEEOIC, with guidance provided in 

12. CPWR. (Continued) 

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this chapter. Procedures for handling requests for 

information from CPWR are as follows: 

(1) For any of the claimed contractor or 

subcontractor employment at a DOE facility for 

which CPWR has information, the CE is to determine 

whether the employee worked in an occupation for 

which CPWR has information. CPWR has information 

about the following: 

• Asbestos Workers (can include those who 

worked with insulators and pipe 

coverings) 

 • Boilermakers (includes Riggers) 

• Bricklayers (can also be called brick 

mason, mason, stone mason, tile layer, 

tile setter, terrazzo worker) 

• Carpenters (can include latherers, 

millwrights, pile drivers, drywall 

hangers, framers and finishers) 

• Electrical Workers (can include 

electricians, line men, power installers, 

wireman, telephone workers, instrument 

mechanic, telephone installer) 

 • Elevator Constructors 

• Iron Workers (can include erectors, 

structural steel erectors, ornamental 

erectors, glaziers, welders, connectors 

and rodmen) 

• Laborers (can include flaggers, 

miners/tunnel workers, shaft drillers at 

the Nevada Test Site & Amchitka, and 

machinists and janitors) 

• Machinists 

• Operating Engineers (includes heavy 

equipment operators such as operators of 

bulldozers, graders, cranes and front end 

loaders, also includes well drillers, 

mechanics and stationary engineers who 

operate boiler rooms, electrical 

generators and heating and cooling 

systems) 

• Painters (can include glaziers, drywall 

finishers) 

12. CPWR. (Continued) 

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• Plasters and Cement Masons (can include 

masons, cement finishers, concrete 

pourer) 

• Plumbers and Pipefitters (can include 

fitters, sprinkler fitters, gas welders, 

instrument mechanics and steamfitters) 

• Roofers 

• Security Guards 

• Sheet Metal Workers (includes duct 

worker, shop worker) 

• Teamsters 

(2) If the employee worked at a facility for which 

CPWR has information and in a trade for which CPWR 

has employment information, the CE is to confer 

with the district office Point of Contact (POC) for 

CPWR referrals. The POC is selected by each 

district office to serve as the principal liaison 

between DEEOIC and CPWR. There is one POC per 

district office who is responsible for all 

communication between the district office and CPWR. 

Also, the POC is responsibility for certifying 

outgoing referrals and reviewing incoming 

responses.

(3) If the POC agrees that the claim requires a 

CPWR referral, the POC or CE prepares three forms. 

These forms are a Subcontractor Worksheet (guidance 

for use is in paragraph 14 of this chapter), a CP-1 

Referral Sheet (Exhibit 5) and a CP-2 Employment 

Response Report (Exhibit 6). The subcontractor 

worksheet apprises CPWR of the established 

documentation on record relevant to establishing 

covered employment. The CP-1 provides general 

information concerning the employee’s case file. 

The CP-2 is a form CPWR uses to respond to 

employment data requests. 

(4) The CE or POC complete the CP-1. Section 1 

requires information concerning the case to be 

listed, such as employee name, claim type, file 

number and Social Security Number. In Section 2, 

the referring District Office is to be identified 

12. CPWR. (Continued) 

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along with the number of attached CP-2 Employment 

Response Reports. Any special requests or other 

relevant information for CPWR is to be listed in 

the comment section.

(5) For each claimed employer at a facility where 

CPWR can provide assistance, the CE or POC prepare 

a separate CP-2 Employment Response Report. The CE 

or POC may prepare as many copies of the form as 

necessary. The CP-2 contains two sections. The CE 

or POC completes Section 1 and describes the 

employment to be researched by CPWR. It is 

important that the information specify both the 

periods of employment requiring verification and 

the type of evidence being requested, such as 

evidence of a contractual relationship, proof of 

employment with the claimed employer, or evidence 

of employment on the premises of the claimed 

facility. Section 2 of the CP-2 is reserved for 

CPWR to report any findings pertaining to the 

claimed employment.

(6) Upon completion of the DEEOIC portions of the 

CP-1 and CP-2, the POC reviews all the material. 

He or she ensures that the information contained on 

the referral forms is reported accurately and 

satisfies all of the requirements for submission to 

CPWR. Once the review is complete and the POC is 

satisfied that the forms are completed correctly, 

he or she signs and dates the CP-1. The CP-1 

Referral Sheet is certified on the day the referral 

is mailed out of the district office.

(7) A copy of the completed package is kept for 

the case file. The original package, to include the 

CP-1, CP-2 and the subcontractor worksheet is 

express mailed to CPWR. 

(8) On the same day that the referral package is 

mailed to CPWR, all claimants and/or the authorized 

representative in the case are to be notified of 

CPWR involvement. The CE or POC must prepare a 

letter for each claimant that describes CPWR’s 

12. CPWR. (Continued) 

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involvement in the case (Exhibit 7) and send it to 

each of the claimants and/or authorized 

representative in the case.

(9) CPWR is able to accept a minimum of 2500 

through a maximum of 6000 CP-2’s annually. Once 

the POC or backup person determines the number of 

cases to be sent to CPWR during a given week, he or 

she is to batch all the referrals and express mail 

(initial request should not be e-mailed) them 

weekly to: 

Anna Chen (achen@zenithadmin.com) 

Zenith Administrators 

201 Queen Anne Avenue, North 

Suite 100 

Seattle, WA 98109 

1-800-866-9663 

(10) The POC or the backup person is the ultimate 

arbiter of all issues involving the CPWR referral 

process. He or she is not to certify for 

submission any referral package that does not meet 

the requirements for referral. Any incomplete or 

inaccurate referral package must be returned to the 

CE. The POC notifies the CE of any deficiency and 

the steps necessary to correct the problem. CPWR 

is permitted to contact claimants directly. 

However, any request for claimant contact must be 

submitted to the POC, who then provides the 

necessary contact information.

(11) The POC is responsible for tracking all CPWR 

referrals and responses. For each referral, the 

district office must track the following 

information: 

(a) case number 

(b) facility name(s) 

(c) employer name(s) 

12. CPWR. (Continued) 

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(d) number and date of referral(s) to CPWR, 

(e) number and date of response(s) received 

from CPWR, 

(f) CE initiating request 

(g) Target due date (40 days from the date of 

referral). 

(h) Number of overdue referral (s) (41 or 

more dates from the date of referral). 

By the tenth day of each month, the DO POC sends 

the National Office an email summarizing the total 

number of CPWR referrals and responses for the 

preceding month, the number of outstanding requests 

(>40 days), the number of referrals determined to 

be eligible, the number of referrals determined to 

be ineligible, and the total number of referrals to 

date. The number of referrals determined to be 

eligible is defined as the number of referrals that 

CPWR determined as valid requests. The number of 

referrals determined to be ineligible is defined as 

the number of referrals that CPWR determined as 

invalid requests, e.g. the name was incorrect, the 

social security number was incorrect, the 

subcontractor was not a part of their database, 

etc. Contractually, CPWR can process a limited 

number of claims during the contracted time period. 

The report assists the National Office in tracking 

the number of requests by each district office on a 

monthly basis. 

(12) In instances in which CPWR needs additional 

CP-2’s subsequent to their preliminary research and 

requests such from the POC, the CE and POC must 

confer on the requests and determine if additional 

CP-2s are needed. If they agree with CPWR’s 

assessment, the POC forwards via email or fax the 

appropriate number of additional CP-2s to the 

aforementioned address. If they do not agree with 

12. CPWR. (Continued) 

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CPWR’s assessment, the POC provides an explanation 

to CPWR. 

(13) CPWR has 30 calendar days from receipt of a 

referral to conduct appropriate research into the 

claimed employment, complete each CP-2 based on the 

evidence gathered, and express mail the response to 

the appropriate POC. Responses are bundled 

according to case file number. 

(14) District office mailroom staff date stamp 

incoming responses according to established 

procedures and forward them to the designated POC. 

The POC enters the receipt date in the tracking 

database and immediately forwards the CPWR response 

to the appropriate CE. 

(15) When reviewing the CPWR response, the CE or 

POC is responsible for carefully assessing the 

relevance of any evidence or information submitted 

by CPWR. In instances where additional action is 

needed subsequent to a CPWR response, the CE must 

further develop the case. For example, if the 

evidence provided by CPWR confirmed that the 

employee was employed by a covered employer, yet 

failed to place the employee on the premises during 

a covered period, then additional development is 

necessary to place the employee on the premises. 

Additionally, if CPWR provided the names and 

addresses of individuals that may have known the 

employee, yet this information was not previously 

contained in the factual evidence, the CE requests 

an affidavit (as outlined in Paragraph 13, 

entitled, “Other Evidence,” of this Chapter) from 

individuals identified by CPWR. 

13. Other Employment Evidence. Evidence of employment by 

DOE, a DOE contractor, beryllium vendor, or atomic weapons 

employer may be made by the submission of any trustworthy 

contemporaneous records that on their face, or in conjunction 

with other such records, establish that the employee was so 

employed, and the location and time period of such 

employment. No single document noted in this section is 

13. Other Employment Evidence. (Continued)

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likely to provide all elements needed for a finding of 

covered employment, but rather each piece of evidence can 

contribute valuable elements needed to make a finding of 

covered employment. 

Documentation from the following sources may be considered: 

a. Records or documents created by any federal 

government agency (including verified information 

submitted for security clearance and dosimetry badging), 

any tribal government or any state, county, city or 

local government office, agency, department, board or 

other entity or other public agency or office. 

b. Records or documents created as a byproduct of any 

regularly conducted business activity or by an entity 

that acted as a contractor or subcontractor to DOE. 

c. DEEOIC internal resources. The DEEOIC district 

offices each have gained experience with the facilities 

covered under this program. As part of adjudicating 

claims, each office has accumulated documentation 

substantiating various subcontractor relationships. Once 

such a relationship has been established at a facility 

for a given time period, the CE can use this information 

in the adjudication of other cases in which the same 

subcontractor employment is claimed during the same time 

period. 

d. Affidavits or other types of signed statements 

attesting to the accuracy of a claim. The CE requests 

that the claimant use the EE-4 Employment History 

Affidavit to collect statements from knowledgeable 

parties. Statements provided by way of an affidavit are 

considered in conjunction with other evidence submitted 

in support of a claim. Affidavits are considered 

particularly appropriate as a means of demonstrating 

that an employee worked at a particular location and are 

best used with other information, such as SSA records. 

Affidavits alone are usually insufficient to prove the 

existence of a contractual relationship between DOE and 

a company. 

13. Other Employment Evidence. (Continued)

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Additionally, the CE has the discretion to assign 

different probative weight to different affidavits. For 

example, the CE may find that an affidavit from a former 

CEO of an employer has significantly more probative 

value than that of one from a relative who may benefit 

from any award granted. The CE must use his or her own 

judgment to ascertain what weight to give to any given 

piece of evidence, including affidavits. 

14. Subcontractor Employment. Subcontractor employment at 

beryllium vendors and DOE facilities is covered under the 

Act, provided that certain developmental elements are met. 

a. Definitions. 

(1) Contractor. An entity engaged in a 

contractual business arrangement with DOE to 

provide services, produce material or manage 

operations. 

(2) Subcontractor. An entity engaged in a 

contracted business arrangement with a contractor 

to provide a service on-site.

(3) Service. In order for an individual working 

for a subcontractor to be determined to have 

performed a “service” at a covered facility, the 

individual must have performed work or labor for 

the benefit of another within the boundaries of the 

facility. Examples of workers providing such 

services include janitors, construction and 

maintenance workers. The delivery and loading or 

unloading of goods alone is not a service and is 

not covered for any occupation, including workers 

involved in the delivery and loading or unloading 

of goods for construction and/or maintenance 

activities. 

(4) Contract. An agreement to perform a service 

in exchange for compensation, usually memorialized 

by a memorandum of understanding, a cooperative 

agreement, an actual written contract, or any form 

of written or implied agreement is considered a 

14. Subcontractor Employment. (Continued) 

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contract for the purpose of determining whether an 

entity is a “DOE contractor.”

b. Standard. Mere presence on the premises of a 

facility does not confer covered employment. There are 

three developmental components that must be met before a 

decision of covered subcontractor employment can be 

reached. These elements are: 

(1) the claimed period of employment occurred 

during the covered time frame as alleged, and 

(2) a contract to provide “covered services” 

existed between the claimed subcontractor and a 

contractor at the facility or the identified vendor 

(during the covered time frame),and 

(3) the employment activities (work or labor) took 

place on the premises of the covered facility. 

c. Subcontractor employment at beryllium vendor 

facilities. Under the Act, persons providing a service 

on the premises of beryllium vendors during covered time 

periods are entitled to the same benefits as employees 

of the beryllium vendor during those same covered time 

periods. For some beryllium vendors, the corporate 

verifier for the vendor at which the subcontractor 

performed work has records of subcontractor employees, 

and therefore in verifying beryllium vendor subcontractor employment the CE first contacts the 

corporate verifier for any information they have on the 

individual and his or her subcontractor employer. In 

those situations in which an employee is alleging 

beryllium sub-contractor employment and the beryllium 

vendor is unable to confirm employment, the CE is to use 

SSA records, affidavits and other evidence as described 

in this chapter. 

d. Subcontractor employment at DOE facilities. Because 

DOE generally did not keep records of employees of 

subcontractors, particular evidentiary challenges are 

involved in proving subcontractor employment. To prove 

14. Subcontractor Employment. (Continued) 

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each of the elements needed, it is generally necessary 

to gather and evaluate documentation from multiple 

sources, including DOE, SSA and CPWR. To assist the CE 

in making determinations on subcontractor employment and 

to ensure that all the developmental elements are met 

for any period that is ultimately accepted as covered 

employment, a Subcontractor Worksheet (Exhibit 8) has 

been created that the CE completes in all subcontractor 

situations, as described in this item. Once completed, 

this worksheet is kept in the case file as aid to 

understanding the basis used to make subcontractor 

employment determinations. 

(1) The subcontractor worksheet has two parts, 

claimed and verified employment. The claimed 

section refers to the information provided by 

either the employee or survivor on Forms EE-1, EE-2 

and EE-3, including claimed employment dates, 

facility(ies) and subcontractor (employer). 

(2) The verified section refers to the 

documentation on record that supports the 

information reported on the Forms EE-1, EE-2 and 

EE-3. Verified contract/employment identifies the 

source that confirms the employer’s link to the 

DOE; verified earnings identifies documents which 

support that the employee was employed by a 

specific subcontractor and verified premises 

identifies documents used to support the employee’s 

presence at a covered facility during the covered 

time period. 

(3) In completing the subcontractor worksheet, the 

CE will likely use an assortment of documentary 

evidence from different sources to make a finding 

of covered subcontractor employment. For example, 

SSA records may show that the employee worked for 

Sentell Brothers, thus establishing verified 

earnings. Documentation from CPWR may show that 

Sentell Brothers was a subcontractor during the 

period of verified earnings at K-25, X-20, Y-12 and 

Oak Ridge in general. DOE may also provide 

documentation showing that the employee had a 

14. Subcontractor Employment. (Continued) 

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clearance to work at K-25 doing construction or DOE 

provides dosimetry badging information specific to 

K-25. In this situation, the CE has sufficient 

documentation to make a determination that the 

employee worked as a K-25 subcontractor employee 

during the time period for which the earnings, the 

contractual information and the presence on the 

premises requirements are all met. For all 

instances in which the CE is required to evaluate 

potential subcontractor employment, the CE writes a 

memo to the file outlining the findings for each 

period, providing a narrative evaluation of the 

evidence for each of the developmental elements of 

the subcontractor standard and an explanation of 

why the standard was or was not met. 

15. Researcher Employment at DOE Facilities. A DOE 

contractor employee is also defined as “An individual who is 

or was in residence at a Department of Energy facility as a 

researcher for one or more periods aggregating at least 24 

months.” In order for an employee to meet the “researcher” 

provision under the Act, the following criteria must be met: 

a. Research. There needs to be probative evidence in 

the file that the individual was actually performing 

research on the premises of the DOE facility. Visiting 

the site, obtaining medical tests on site or similar 

non-work related reasons that people may have for going 

on site at a DOE facility do not qualify under this 

provision. Evidence that can be used to document that 

an individual was performing research on site include 

published journal articles, affidavits or some other 

documentation affirming that the individual was engaged 

in research. 

b. Living on-site not required. Although some DOE 

facilities provide dormitory-style accommodations which 

often house researchers, “in residence” can be satisfied 

by working “on the premises,” and the individual need 

not have been living on the premises of the DOE 

facility. 

15. Researcher Employment at DOE Facilities. (Continued) 

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c. Research can be unpaid. There is no requirement 

that the researcher is/was paid for the work. 

16. Employees of Federal or State governments other than DOE 

and its predecessors. Employees of federal and state 

governments, (other than direct employees of DOE, ERDA, the 

AEC or MED) can be DOE contractor employees, as outlined in 

this paragraph. 

a. Standard. A civilian employee of a state or 

federal government agency can be considered a “DOE 

contractor employee” if 

 (1) the government agency employing the individual 

is found to have entered into a contract with DOE 

for the accomplishment of one or more services on 

the premises of that DOE facility that such 

government agency was not statutorily obligated to 

perform, and 

 (2) DOE compensated the agency for that service. 

b. Proof of contract. The district office contacts 

the federal or state agency directly in an effort to 

obtain the desired information. The District Director 

designates an individual in the district office to be 

responsible for coordinating and contacting federal and 

state agencies. This approach facilitates better 

communications with the agencies, especially for 

agencies with numerous requests. The point of contact 

is to provide copies of contracts and contacts to the 

National Office for development of a database. The CE 

should not pressure a state or federal agency to produce 

employment or contractual records. 

c. If the evidence is unclear as to whether employment 

by a state or federal agency can be determined to be DOE 

contractor employment using the guidance in this 

paragraph, the CE obtains clarification from the 

claimant. The CE reviews any documentation submitted by 

the claimant and undertakes any additional development 

necessary to clarify the individual’s employment status. 

16. Employees of Federal or State governments other than DOE 

and its predecessors. (Continued) 

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Upon finding that the employee does not meet the 

definition of a “DOE contractor employee” who worked for 

a state or federal agency, and this is the sole 

employment listed on the form EE-3, the CE denies the 

claim. The CE issues a recommended decision denying the 

claim on the basis that the employment by the state or 

federal agency does not qualify the claimant as a “DOE 

contractor employee” as defined in EEOICPA. 

d. Uniformed members of the Military. A claimant 

cannot obtain EEOICPA benefits based upon service in the 

military. If the claimant provides information or 

identifies himself/herself as military personnel, the CE 

sends a letter to the claimant stating that uniformed 

military personnel are ineligible for benefits under the 

EEOICPA. Only civilian employees who performed services 

on the premises of DOE facilities via contracts are 

considered DOE contractor employees. 

17. Evaluating Evidence to Verify Employment. Once all 

evidence from appropriate sources has been received, the CE 

determines if the evidence is sufficient to verify the three 

components of covered employment listed in paragraph 6 of 

this chapter. The CE evaluates all evidence carefully in 

making this determination and uses discretion regarding 

documentation that reasonably establishes the presence of the 

employee at a particular facility during certain periods of 

time. Additionally, with regard to subcontractor employment, 

the evidence must reasonably satisfy all the components 

necessary to establish covered employment, as discussed in 

paragraph 14 of this chapter. 

In weighing the evidence submitted in support of covered 

employment, the CE considers the totality of the evidence and 

draws reasonable conclusions. 

18. Developing non-covered employment. As mentioned in 

paragraph 4, there will be instances in which the CE is only 

able to match a portion of the claimed employment to a 

facility and/or employer listed in the facility database, or 

there is no match found. In these instances the CE 

18. Developing non-covered employment. (Continued) 

communicates this to the claimant. The CE prepares a letter 

to the claimant explaining which employment is covered under 

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the Act and which is not, including any pertinent dates. A 

description of what constitutes an AWE, BE Vendor or DOE (as 

explained in paragraph 2) should be included in the letter. 

In the event that the claimant believes some of this noncovered employment should be covered, the CE requests that 

the claimant supply any pertinent evidence substantiating 

that the employment should be covered during specific years. 

Namely, the CE asks the claimant to provide evidence 

demonstrating that the place of work met the definition of an 

AWE, BE Vendor or DOE facility during the years the employee 

worked there. For example, the claimant can be asked to 

submit evidence such as contractual documents, business 

reports, internal memos, purchase orders, news articles, 

affidavits, etc. A period of 30 days is granted to the 

claimant to submit evidence in support of extending covered 

employment to additional facilities/employers and/or years. 

After appropriate development, the CE decides whether any 

evidence submitted warrants a referral to the National 

Office. If the claimant has submitted pertinent evidence in 

regard to adding a facility/employer and/or years of 

coverage, the CE prepares a brief memo to the file explaining 

the circumstances of the situation and requests a review of 

the case file by the National Office which asks the National 

Office to make a determination regarding the new evidence of 

an additional covered facility/employer or years. 

19. Additions or modifications to facility status. While 

EEOICPA defines what constitutes an AWE, Be Vendor or DOE 

facility, updates are periodically made to facility 

designations as new information becomes available. In 

instances when a claimant submits information in response to 

the request outlined in paragraph 18, the National Office 

takes a number of steps outlined in this paragraph to make a 

determination regarding whether the facility status should be 

modified. Depending on the facility type, authority rests 

with either the DOL or DOE to make modifications. Facility 

modifications or additions are dependent on the collection of 

probative evidence satisfying the legal definition of the 

facility. 

19. Additions or modifications to facility status. 

(Continued) 

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a. Atomic Weapons Employer. New designations are the 

responsibility of DOE. Accordingly, requests for new 

AWE designations are referred to DOE. 

(1) Time frame changes relating to specific years 

of processing at an AWE are the responsibility of 

DOL. Evidence must be presented clearly 

demonstrating that the AWE processed or produced 

material that emitted radiation and was used in the 

production of an atomic weapon. 

b. Beryllium Vendor. The statutory deadline for 

adding additional beryllium vendors was December 31, 

2002 and therefore no additional beryllium vendors can 

be designated under the Act. 

(1) Time frame changes relating to Be Vendors are 

the responsibility of DOL. Evidence must be 

presented clearly demonstrating that the Be Vendor 

had a contractual agreement involving beryllium 

with DOE, or its predecessors, and that the company 

is performing/or did perform those berylliumrelated contractual tasks in the years to be added 

to coverage. 

c. Department of Energy facility (DOE). Facility or 

time frame changes relating to DOE facility listings are 

the responsibility of DOL. Evidence must be presented 

clearly demonstrating that the facility meets the 

definition of a “Department of Energy facility” under 

the Act. Under the EEOICPA, a DOE facility means any 

building, structure, or premise, including the grounds 

upon which such building, structure, or premise is 

located in which operations are, or have been, conducted 

by, or on behalf of, the DOE (except for buildings, 

structures, premises, grounds, or operations covered by 

Executive Order 12344, dated February 1, 1982, 

pertaining to the Naval Nuclear Propulsion Program); and 

with regard to which the DOE has or had either (A) a 

19. Additions or modifications to facility status. 

(Continued) 

proprietary interest; or (B) entered into a contract 

with an entity to provide management and operation, 

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management and integration, environmental remediation 

services, construction, or maintenance services. 

Interpreting and applying the definition of a DOE 

facility is within the adjudicatory authority of DEEOIC. 

To determine whether a facility is a DOE facility under 

the Act, certain parameters must be met. 

(1) Operations. To show that operations were 

performed on behalf of DOE, the evidence must 

demonstrate that DOE paid for operations at that 

location. These operations are not limited to those 

involving radiation or weapons. Everyday 

operations such as providing library services in a 

technical library are sufficient to meet this 

statutory requirement. 

(2) Proprietary Interest. To show that DOE had a 

proprietary interest, evidence that DOE owned the 

building, structure or premises, such as a deed or 

affirmative statement from DOE acknowledging 

ownership. DOE ownership of intellectual property 

or equipment, regardless of size, does not fulfill 

the proprietary interest definition. 

(3) Contracts. To show that DOE entered into a 

contract with an entity to provide management and 

operation, management and integration, 

environmental remediation services, construction, 

or maintenance services, the best possible evidence 

is to produce the contract. Typically contracts 

with DOE or its predecessors identify the contract 

type on the first page, so in those cases in which 

contracts are located, it is generally not 

difficult to discern contract type. The contracts 

identified in this portion of the law are among the 

19. Additions or modifications to facility status. 

(Continued) 

more common and significant contracts used 

throughout the DOE complex in the following ways: 

(a) Management and Operation (M&O) contracts 

are those contracts DOE often had with major 

companies to manage and operate large DOE 

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facilities, such as Union Carbide and Carbon 

at K-25 and Y-12. 

(b) Management and Integration (M&I) 

contracts were also used by DOE to run major 

DOE sites, but an M&I contractor generally had 

numerous smaller site contractors for which 

the M&I’s job was to “integrate” the work of 

the smaller companies. The Idaho National 

Laboratory is an example of a DOE facility 

which has been run from time to time by M&I 

contract. Companies holding M&O and M&I 

contracts at DOE facilities are generally 

considered the “prime contractor” for that 

facility, though sometimes facilities will 

change from the M&O model to the M&I model. 

(c) Contracts for environmental remediation 

services, construction, or maintenance 

services are also common throughout the DOE, 

but are generally smaller in size than the 

major M&O’s and M&I’s. Remediation contracts 

were also utilized by DOE to clean up 

radiation at numerous AWE facilities. In 

these instances the locations are designated 

as DOE facilities for the period of 

remediation under DOE contract and the 

remediation workers are covered. 

(d) Some common types of contracts issued by 

DOE that do not meet the statutory definition 

include research & development, output, and 

procurement. 

20. Special Circumstances. There are some special 

circumstances regarding eligibility for benefits pertinent to 

the Naval Nuclear Propulsion Program and EEOICPA claims from 

citizens of the Republic of the Marshall Islands, as outlined 

below. 

a. Naval Nuclear Propulsion. As noted in the section 

above, the statutory definition of a DOE facility 

specifically excludes, “buildings, structures, premises, 

grounds, or operations covered by Executive Order No. 

12344, dated February 1, 1982 (42 U.S. C. 7158 note) 

pertaining to the Naval Nuclear Propulsion Program.” As 

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a consequence of this exclusion, DEEOIC is unable to 

provide covered employment to those AEC employees and 

AEC contractors who worked at locations devoted to Naval 

Nuclear Propulsion operations. 

b. Marshall Islands. DEEOIC has received claims for 

compensation under EEOICPA from citizens and nationals 

of the Republic of the Marshall Islands (RMI). The 

Marshallese base their claims on employment related 

exposure arising from the United States’ nuclear weapons 

testing program conducted in the RMI. The DOE facility 

known as the Pacific Proving Ground was a weapons test 

site in the South Pacific from 1946 to 1962. 

In 1986, the United States and the Marshall Islands 

terminated their trust territory relationship through 

enactment of the Compact of Free Association (Compact). 

The Compact is a comprehensive document encompassing a 

variety of agreements, including a number of socioeconomic, agricultural, and monetary compensation 

programs. Under the Compact, the RMI became an 

independent sovereign nation and U.S. laws ceased to 

apply unless otherwise specified. 

For the purposes of the administration of the EEOICPA, 

this Compact has been interpreted as precluding coverage 

for RMI citizens and nationals. If the CE determines 

that a claim for benefits is from a citizen or nationals 

of the Marshall Islands, the CE explains, in the 

conclusions of law portion of the recommended decision, 

that there is no provision under EEOICPA for coverage of 

20. Special Circumstances. (Continued) 

claims based upon employment in the RMI by citizens or 

nationals of the RMI. The CE inserts the following 

wording in the conclusions of law as a summary of the 

DEEOIC policy: 

Since interpreting EEOICPA to apply to claims 

by Republic of the Marshall Islands (RMI) 

citizens or Nationals based upon employment in 

the RMI would constitute an invasion of the 

sovereignty of the RMI, the presumption 

against applying a statute extraterritorially 

is invoked. Furthermore, there appears to be 

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no contrary intent by Congress to rebut the 

presumption and, to the extent that Congress 

has expressed any intent, its approval of the 

Compact of Free Association between the United 

States and the RMI suggests that it did not 

intend for EEOICPA to apply extraterritorially 

in this situation.

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EEOICPA TR. No. 10-07 Exhibit 1 

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EEOICPA TR. No. 10-07 Exhibit 2 

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EEOICPA TR. No. 10-07 Exhibit 3 

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EEOICPA TR. No. 10-07 Exhibit 4 

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EEOICPA TR. No. 10-07 Exhibit 5 

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Date

 COVERED EMPLOYEE:

 CLAIMANT:

 FILE NUMBER:

Dear:

This letter is in reference to the claim you submitted on (Filing 

Date) under the Energy Employees Occupational Illness Compensation 

Program Act (EEOICPA) for (insert covered diagnosis). We are in 

the process of verifying (insert employee name) employment at the 

(insert the claimed employer, employment periods, facility, and 

location). To date, we have been (able or unable) to verify 

his/her (insert summary of the verified employment, if any). 

However, (the Department of Energy or Corporate Verifier) was 

unable to verify (employee name) employment at (insert the claimed 

employer, employment periods, facility, and location).

Because you indicated on the Employment History for Claim under 

EEOICPA – Form EE-3, an occupation or employer which normally 

performed work related to a construction or a building trade, we 

are referring your case to the Center for Construction Research and 

Training, formerly known as the Center to Protect Workers’ Rights 

(CPWR). The Department of Labor has contracted with CPWR to 

research and obtain employment records for those employees who may 

have worked or belonged to a union associated with the construction 

or building trades (i.e. laborer, teamster, plumber). CPWR 

performs research and training for the Building and Construction 

Trades Department under the American Federation of Labor-Congress 

of Industrial Organizations (AFL-CIO), and therefore has direct 

access to union records across the country. It is possible a 

representative from CPWR may contact you to clarify questions they 

may have regarding (employee’s name) employment history. Please 

know that they are not your assigned claims examiner and can not 

provide you with the status of your claim or collect any 

documentation related to your case. If you have any questions 

related to your claim or CPWR’s involvement, please contact the 

(District Office at XXX-XXXX)

Sincerely, 

Claims Examine

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EEOICPA TR. No. 10-07 Exhibit 8 

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TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-0600 Establishing Special Exposure Cohort Status 

 Table of Contents. . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . 1 01/10 10-07 

 2 Identifying SEC Claims . . . . 1 01/10 10-07 

 3 Determining SEC 

 Eligibility. . . . . . . . . 1 01/10 10-07 

 4 Statutory SEC Classes. . . . . 2 01/10 10-07 

 5 Additional SEC Classes . . . . 4 01/10 10-07 

 6 Workday Requirement . . . . . 5 01/10 10-07 

 7 Specified Cancers . . . . . . 7 01/10 10-07 

 8 Procedures for Processing 

 SEC Claims . . . . . . . . . 10 01/10 10-07 

 

Exhibit 

 1 SEC Class Screening 

 Worksheet. . . . . . . . . . 01/10 10-07 

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1. Purpose and Scope. The Energy Employees Occupational 

Illness Compensation Program Act (EEOICPA) established the 

Special Exposure Cohort (SEC) to compensate eligible 

members of the Cohort without the need for a radiation dose 

reconstruction and determination of the probability of 

causation. This means an employee who meets the necessary 

employment criteria to be included in a designated SEC 

class and is diagnosed with a specified cancer receives a 

presumption of causation that the employment caused the 

specified cancer. This chapter describes the procedures for 

establishing eligibility under the SEC. 

2. Identifying SEC Claims. A person filing a claim can 

allege inclusion in a SEC by checking the section on Forms 

EE-1 or EE-2 which asks whether the employee worked at a 

location that has been designated for membership in the 

SEC. 

In addition, a claimant can identify the particular 

location that may qualify for consideration for the SEC. 

The Claims Examiner (CE) must review the initial 

application forms including Form EE-3, Employment History, 

carefully to determine whether the potential exists for 

inclusion in one or more SEC classes. 

3. Determining SEC Eligibility. To be eligible for 

benefits under the SEC provision, an employee must belong 

to a SEC class. In establishing the SEC, Congress 

designated four statutory SEC classes. The EEOICPA also 

allows for addition of new SEC classes based on analysis 

and determination by the U.S. Department of Health and 

Human Services (HHS). 

A SEC class can be based on a whole facility, limited to 

specific buildings in a facility or even specific processes 

within a facility. In some cases, a SEC class may be limited 

to specific job titles or duties in a particular facility. In 

addition, each SEC class will have specific workday 

requirements that must be met; typically an employee must 

have been employed for a number of workdays aggregating at 

least 250 workdays at one or more SEC work sites. The workday 

requirement at Amchitka, Alaska SEC class is met by any 

employee who spent any part of one workday at that facility, 

during which he or she was exposed to ionizing radiation in 

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3. Determining SEC Eligibility. (Continued) 

the performance of duty related to the Long Shot, Milrow or 

Cannikin underground nuclear tests. Finally, to be eligible 

under the SEC, an employee must also have been diagnosed with 

at least one of twenty two (22) specified cancers as listed 

under paragraph 6. 

4. Statutory SEC Classes. The EEOICPA designated the 

following statutory SEC classes according to their 

respective covered facilities: 

a. Gaseous Diffusion Plants (GDP) located in 

Paducah, Kentucky, Portsmouth, Ohio or Oak Ridge, 

Tennessee. A DOE employee, DOE contractor employee or 

an atomic weapons employee qualifies for inclusion in 

this SEC if he or she was: 

(1) Employed for an aggregate of 250 workdays 

prior to February 1, 1992, at one or more of the 

above GDPs; and 

(2) Monitored during such employment through the 

use of dosimetry badges for exposure to radiation, 

or worked in a job that had exposures comparable to 

a job that is or was monitored through the use of 

dosimetry badges. 

(a) If the employee qualifies for possible 

inclusion in the SEC on the basis of work at 

a GDP, but Form EE-3 does not indicate 

whether a dosimeter was worn, the Claims 

Examiner (CE) must determine whether the 

employee had exposure during his or her 

employment that is comparable to a job that 

is or was monitored through the use of 

dosimetry badges. 

In making this determination, the CE assumes 

that the employee had comparable radiation 

exposure if employment occurred during the 

following periods at the particular GDPs: 

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4. Statutory SEC Classes. (Continued) 

Paducah GDP: 7/52 – 2/1/92 

Portsmouth GDP: 9/54 – 2/1/92 

Oak Ridge GDP (K-25): 9/44 – 12/87(not 

2/1/92) 

b. Amchitka Island, Alaska. The EEOICPA grants SEC 

membership to DOE employees, DOE contractors or DOE 

subcontractors, who were employed prior to January 1, 

1974 on Amchitka Island, Alaska, and were exposed to 

ionizing radiation in the performance of duty related 

to the Long Shot, Milrow, or Cannikin underground 

nuclear tests. The CE considers the following factors 

in determining whether the employee was exposed to 

radiation in the performance of duty: 

(1) Exposure to ionizing radiation from the Long 

Shot, Milrow, and Cannikin underground nuclear 

testing/explosions which occurred on Amchitka 

Island. The first detonation, Long Shot, 

occurred on October 29, 1965. The 80 kiloton 

underground nuclear explosion leaked 

radioactivity into the atmosphere. Radioactive 

contamination on Amchitka Island occurred as a 

result of activities related to the three 

underground nuclear tests and releases from Long 

Shot and Cannikin. 

(2) As a result of these airborne radioactive 

releases, employees who worked on Amchitka 

Island could have been exposed to ionizing 

radiation from the Long Shot underground 

nuclear test. It is believed that such 

exposure began approximately one month after 

the detonation occurred. Thus, for purposes 

of determining SEC employment, the period 

from approximately December 1, 1965 to 

January 1, 1974 is to be used, unless the 

claimant can show that the employee was 

exposed during the month immediately 

following the detonation. 

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4. Statutory SEC Classes. (Continued) 

(3) In contrast to other SEC classes with 250 

workdays requirement, this SEC class requires 

that the employee worked at Amchitka Island for 

any length of time during the period from 

approximately December 1, 1965 to January 1, 1974 

and was exposed to ionizing radiation from 

underground nuclear tests. 

5. Additional SEC Classes. HHS has authority to 

designate additional classes of employees to be added to 

the SEC. A class of employees may be included as a member 

of the SEC if HHS determines that it is not feasible to 

estimate with sufficient accuracy the radiation dose that 

the members of the class received and there is a reasonable 

likelihood that such radiation may have endangered the 

health of the members of the class. 

a. Overview of the SEC Designation Process. The 

designation process begins with a petition 

submitted to the National Institute for 

Occupational Safety and Health (NIOSH), Office of 

Compensation Analysis and Support (OCAS). The 

petitioner may include one or more DOE employees 

(including DOE contractor or subcontractor 

employees), or AWE employees, who would be 

included in the proposed class of employees, or 

their survivors. Individuals or entities 

authorized by these employees in writing or labor 

organizations representing or formerly having 

represented these employees may also submit a 

petition. 

NIOSH may also initiate a petition if it determines 

that it cannot complete a dose reconstruction for a 

class of employees. 

(1) NIOSH evaluates the petition for inclusion 

in the SEC to determine if it contains the 

minimal qualification to proceed with the SEC 

designation process in accordance with 42 C.F.R. 

§ 83.13 or § 83.14. 

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5. Additional SEC Classes. (Continued) 

(2) If NIOSH determines that minimum 

qualification for review and evaluation has been 

met, it forwards the petition to the Advisory 

Board on Radiation and Worker Health (Advisory 

Board) along with its evaluation. During one of 

its regular Board meetings, the Advisory Board 

reviews NIOSH’s evaluation, hears from the 

petitioners if they choose and other interested 

parties. The Advisory Board also reviews any 

other information it determines to be appropriate 

for the petition. 

(3) The Advisory Board submits a recommendation 

on a new SEC class to the Secretary of HHS within 

30 calendar days of the Board meeting. 

(4) The Secretary of HHS makes the final 

decision to add or deny a new class to the SEC 

based on the recommendation of the Advisory Board 

and the NIOSH evaluation. If the Secretary of HHS 

decides to add a new class to the SEC, he or she 

issues a designation letter to Congress with the 

definition of the class. 

(5) A new SEC class becomes effective 30 

calendar days after Congress receives the 

Secretary’s designation letter, unless Congress 

objects or provides otherwise. 

6. Workday Requirement: Eligibility under the SEC 

provision typically requires 250 workdays of eligible 

employment at one or more SEC work sites. In most cases, 

the determination of 250 workdays of employment is 

straightforward. However, there are some cases where the 

employee worked for less than a year, where additional 

guidance is required to calculate the 250 workdays. 

a. A workday is considered equivalent to a work 

shift. Additional hours worked as overtime will not 

add up to additional workdays, e.g., two hours 

overtime for four days is not equivalent to another 

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6. Workday Requirement: (Continued) 

(8-hour) workday. However, two work shifts worked 

back-to-back would be two work shifts, i.e., two 

workdays. For an employee whose work shift spans 

midnight, e.g., 11 PM to 7 AM shift, the work shift is 

still just one workday. 

b. When the employment information shows that the 

employee worked for a particular period, the CE should 

not attempt to discern and deduct from the workday any 

infrequent periods of non-presence or non-work, like 

sick leave, strikes, layoffs or vacation time that may 

be specified. However, if the employment evidence 

clearly establishes that the employee was not present 

and/or working at the SEC work site for an extended 

period(s) while on the company payroll, this extended 

period(s) should not be credited towards meeting the 

250 workday requirement. 

c. The period of 250 workdays starts with the 

worker’s first day of employment at the SEC work site. 

There may be breaks in employment, but the workdays 

may only be accumulated at eligible SEC sites. 

 d. Where the number of days is not apparent in the 

employee’s primary employment record, e.g., from the 

employer or union (records for pension, dues, union 

local records, etc.), the following table may used for 

conversion: 

250 days =

50 five-day weeks, or

42 six-day weeks, or

12 months (five-day weeks), or

10 months (six-day weeks), or

2,000 hours

One month =

21 days (if evidence indicates 

six-day weeks, 25 days

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6. Workday Requirement: (Continued) 

 e. Where records of an employee’s earnings are 

available, such as W-2 Forms or Social Security 

earnings records, but the periods of employment are 

not, estimate the 250 workdays as follows. Divide the 

annual wages earned at the SEC work site by the 

employee’s hourly rate to determine the number of 

hours worked. If the number is greater than 2,000 

hours, it meets the 250 workday requirement. The 

problem with converting dollar amounts to workdays is 

that they may be rough estimates of actual employment. 

As such, this method should only be used when all 

primary employment data is lacking. 

f. There will be some situations where the above 

approach will not be applicable. These cases will 

need to be treated on a case-by-case basis, and if 

necessary, a referral to the Unit of Policy, 

Regulations and Procedures (UPRP) may be required. 

7. Specified Cancers: In addition to satisfying the 

employment criteria under a SEC class, the employee must 

also have been diagnosed with a specified cancer to be 

eligible for compensation under the SEC provision. The 

following are specified cancers in accordance with 20 

C.F.R. § 30.5(ff): 

a. Leukemia. [Chronic lymphocytic leukemia (CLL) is 

excluded]. The onset must have occurred at least two 

years after initial exposure during qualifying SEC 

employment. 

b. Primary or Secondary Lung Cancer. [In situ lung 

cancer that is discovered during or after a postmortem exam is excluded.] The pleura and lung are 

separate organs, so cancer of the pleura is not to be 

considered an SEC cancer.

c. Primary or Secondary Bone Cancer. This includes 

myelodysplastic syndrome, myelofibrosis with myeloid 

metaplasia, essential thrombocytosis or essential 

thrombocythemia, primary polycythenia vera [also 

called polycythemia rubra vera, P. vera, primary 

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7. Specified Cancers: (Continued) 

polycythemia, proliferative polycythemia, spent-phase 

polycythemia, or primary erythremia] and 

chondrosarcoma of the cricoid (cartilage of the 

larynx). 

d. Primary or Secondary Renal Cancers. 

e. Other Diseases. For the following diseases, 

onset must have been at least five years after initial 

exposure during qualifying SEC employment: 

(1) Multiple myeloma (a malignant tumor formed 

by the cells of the bone marrow); 

(2) Lymphomas (other than Hodgkin’s disease); 

(3) Primary cancer of the: 

(a) Thyroid; 

(b) Male or female breast; 

(c) Esophagus; 

(d) Stomach; 

(e) Pharynx (including the soft palate, or 

back of the mouth, the base of the tongue, 

and the tonsils); 

(f) Small intestine; 

(g) Pancreas; 

(h) Bile ducts; 

(i) Gall bladder; 

(j) Salivary gland; 

(k) Urinary bladder (including ureter and 

urethra); 

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7. Specified Cancers: (Continued) 

(l) Brain (malignancies only, not including 

intracranial endocrine glands and other 

parts of the central nervous system); 

(m) Colon (including rectal/colon); 

(n) Ovary; 

(o) Liver (except if cirrhosis or hepatitis 

B is indicated); 

f. Carcinoid Tumors. These tumors, except for those 

of the appendix, are considered primary cancers of the 

organs in which they are located. If the organ is one 

on the specified cancer list, the carcinoid tumor may 

be considered as a specified cancer. 

(1) Carcinoid tumors should be recorded by the 

organ of the specified cancer. For example, the 

CE should use the ICD-9 code of 230.7 for a 

carcinoid tumor in the small intestine. 

(2) Carcinoid syndrome and monoclonal 

gammopathies of undetermined significance are not 

currently recognized as malignant conditions. 

Consequently, these conditions should not be 

considered as cancers. 

g. Names or Nomenclature. The specified diseases 

designated in this section mean the physiological 

condition or conditions that are recognized by the 

National Cancer Institute under those names or 

nomenclature, or under any previously accepted or 

commonly used names or nomenclature. Cases where there 

is uncertainty as to whether a diagnosed cancer should 

be considered a specified cancer must be referred to 

UPRP. 

h. Spread of Cancer. Where cancer has spread to 

various sites (organs) it may be difficult to identify 

the site of origin for the cancer. If the pathology 

report (or medical report) lists several alternatives 

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7. Specified Cancers: (Continued) 

and at least one site is considered a SEC cancer, the 

claim should be processed first as a SEC cancer claim. 

8. Procedures for Processing SEC Claims. Processing SEC 

claims entails coordination between the UPRP and District 

Offices/FAB staff. 

a. Role of the UPRP: 

(1) Issues bulletins with guidance on processing 

newly designated SEC classes. This will include 

specific instructions on how to evaluate evidence 

in the case file to determine SEC eligibility. 

(2) Prepares a comprehensive list of all 

reported cases with claimed employment at a newly 

designated SEC work site during the period of the 

SEC class. It will include pending cases, cases 

previously denied and those at NIOSH. This 

comprehensive list will be provided to the 

District Offices and FAB at the time of the 

issuance of the SEC bulletin. 

(3) Unresolved questions on processing SEC 

claims, including questions on the definition of 

a SEC class, uncertainty as to whether a 

diagnosed cancer should be considered a specified 

cancer or questions regarding calculation of 250 

work day requirement may be referred to UPRP for 

guidance. 

b. Role of the Claims Examiner: 

(1) Identifies a potential SEC claim by 

reviewing the information on the claim forms or 

other pertinent evidence in the case file to 

determine if there is sufficient evidence to 

suggest that an employee worked as a member of a 

named SEC class. For newly designated SEC 

classes, the CE is to review the comprehensive 

list provided by UPRP as noted in paragraph 

7a(2).

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8. Procedures for Processing SEC Claims. (Continued) 

(2) Reviews corresponding bulletins for 

designated SEC classes for procedures on 

evaluating evidence to determine if the SEC 

criteria are met. 

(3) Completes an initial screening of cases in 

the comprehensive list provided by UPRP for a 

newly designated SEC class. A screening worksheet 

is included as Exhibit 1. The worksheet must be 

completed for all cases on the comprehensive 

list. Upon completion, the worksheet is to be 

included in the case record. 

Based upon the initial screening, the cases on 

the comprehensive list are grouped into three 

categories: those likely to be included in the 

SEC class; those not likely to be included in the 

SEC class; and those for which development may be 

needed to determine whether the case can be 

accepted into the new SEC class. 

The purpose of this initial screening is to 

prioritize handling of cases that are likely to 

be included in the newly designated SEC class. 

This screening step is only applicable to cases 

on the comprehensive list. It is not applicable 

to new claims submitted after the list is 

generated or when a comprehensive list is not 

generated. Once screening and prioritization is 

complete, a more detailed review of all the cases 

(priority given to cases that are likely to be 

included in the SEC class) and full development 

must take place to determine if a case is 

eligible for benefits under the SEC. 

(a) For cases on the comprehensive list at 

FAB, the designated CE2 Unit is to conduct 

the initial screening and completion of the 

worksheet. 

(4) Evaluates medical evidence in the case file 

of a potential SEC case to determine if the 

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8. Procedures for Processing SEC Claims. (Continued) 

employee has been diagnosed with a specified 

cancer. 

(5) If the employee has a specified cancer, the 

CE must verify that the employee meets all 

employment criteria in the SEC class designation, 

including the workday requirement. In determining 

whether the employment history meets the workday 

requirement, the CE can consider employment at a 

single SEC class, or in combination with work 

days at other SEC classes. 

The CE also reviews any documentation that NIOSH 

may have acquired or generated during the dose 

reconstruction process to determine if the 

employee satisfies the employment criteria of a 

SEC class(es). 

(a) NIOSH will identify and return dose 

reconstruction analysis records for cases 

with specified cancers that may qualify 

under a SEC class to the appropriate 

district office along with a CD for each 

case. The CD contains all of the 

information generated to date, e.g., CATI 

report, correspondence, and dose 

information. Also included on the CD in the 

Correspondence Folder, should be a copy of 

the NIOSH letter sent to each claimant 

informing the claimant of the new SEC class 

and that his or her case is being returned 

to DOL for adjudication. The CE must print 

out a hard copy of the NIOSH letter for 

inclusion in the case file. 

(b) There may be some cases not identified 

by NIOSH that the CE determines may be 

included in the SEC class. If any such case 

qualifies under the SEC class and the case 

is with NIOSH for a dose reconstruction, the 

CE notifies the appropriate point of contact 

at NIOSH via e-mail to pend the dose 

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8. Procedures for Processing SEC Claims. (Continued) 

reconstruction process and return dose 

reconstruction analysis records to the 

appropriate district office. The CE then 

prints a copy of the “sent” e-mail (making 

sure the printed copy documents the date it 

was sent) for inclusion in the case file. In 

addition, the CE must write a letter to the 

claimant to advise that the case file has 

been withdrawn from NIOSH for evaluation 

under the SEC provision. 

 (6) Proceeds in the usual manner for a 

compensable claim and prepares a recommended 

decision if the employee has a diagnosed 

specified cancer and meets the employment 

criteria of the SEC class. The CE notifies the 

appropriate point of contact at NIOSH via e-mail 

so that they may close their file. The CE then 

prints a copy of the “sent” e-mail for inclusion 

in the case file. 

(7) Refers potential SEC cases that were 

evaluated but which do not qualify under the SEC 

provision, e.g. cases with non-specified cancers, 

specified cancers with insufficient latency 

period, or cases with insufficient SEC 

employment, to NIOSH for full or partial dose 

reconstruction. 

(a) For those cases which were previously 

submitted to NIOSH for dose reconstruction 

but were returned to the district office for 

consideration in a SEC class, a new NIOSH 

Referral Summary Document (NRSD) is not 

required. Instead, the CE notifies the 

appropriate point of contact at NIOSH via email to proceed with the dose 

reconstruction. The CE then prints a copy of 

the “sent” e-mail for inclusion in the case 

file. The e-mail should include a brief 

statement of why the case should proceed 

with dose reconstruction, e.g., nonEEOICPA Tr. No. 10-07 13 

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8. Procedures for Processing SEC Claims. (Continued) 

specified cancer, insufficient latency 

period or does not meet the 250 work day 

requirement. 

The CE also notifies the claimant by letter 

that the case is returned to NIOSH for dose 

reconstruction and the reason(s) it does not 

qualify for the SEC class. The CE is to 

send a copy of this letter to NIOSH. 

(b) If the claim meets the SEC employment 

criteria and includes both a specified 

cancer and a non-specified cancer, medical 

benefits are only paid for the specified 

cancer(s), any non-specified cancer(s) that 

has a probability of causation of 50 percent 

or greater, and any secondary cancers that 

are metastases of a compensable cancer. 

For the non-specified cancer, the CE 

prepares a NRSD for a dose reconstruction to 

determine eligibility for medical benefits. 

In these SEC cases, all cancers must be 

listed on the NRSD, including the specified 

cancer(s). 

(1) One exception to this rule is an 

accepted SEC claim where the 

specified cancer is a secondary 

cancer. For instance, prostate 

cancer (non specified cancer) 

metastasizes to secondary bone 

cancer. If secondary bone cancer 

is accepted as a specified cancer 

under the SEC provision, both 

primary and secondary cancers 

(prostate and bone cancer) are 

accepted for medical benefits 

under Part B. 

However, per regulation 20 C.F.R. 

§ 30.400, “payment for medical 

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8. Procedures for Processing SEC Claims. (Continued) 

treatment of the underlying 

primary cancer...does not constitute 

a determination by OWCP that the 

primary cancer is a covered 

illness under Part E of the 

EEOICPA.” As such, it may be 

necessary for the CE to refer the 

prostate cancer to NIOSH for dose 

reconstruction to determine 

eligibility for benefits under 

Part E. In this case, only 

prostate cancer is included in the 

NIOSH NRSD for a dose 

reconstruction since the secondary 

bone cancer metastasized from the 

prostate cancer. 

(8) If the CE determines that a case on the 

comprehensive list, which includes a final 

decision, does not require any action, the CE 

writes a brief memo to the file indicating that 

the file was reviewed and noting the reason why 

no additional action is necessary. A case 

classified as not requiring any action is a case 

that does not meet the SEC criteria and there is 

no need to return it to NIOSH for dose 

reconstruction. 

c. Role of the District Director: 

(1) The District Directors have been delegated 

authority to sign a Director’s Order to reopen a 

denied final decision if the evidence of record 

establishes that the employee is diagnosed with a 

specified cancer and likely to be included in the 

SEC class. If the District Director is unsure 

whether the SEC is applicable to a case, the case 

must be referred to UPRP. 

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8. Procedures for Processing SEC Claims. (Continued) 

(2) Once a Director’s Order is issued, the CE is 

responsible for issuing a new recommended 

decision. 

(d) Role of the Hearing Representative (HR): 

(1) Reviews cases pending a final decision for 

possible inclusion under the SEC provision. If 

the employee qualifies under the SEC provision 

and the district office issued a recommended 

decision to deny, the HR is to reverse the 

district office’s recommended decision and accept 

the case. 

Every effort should be taken to avoid a remand of 

a potential SEC claim to the district office. 

However, if the HR determines that the case 

cannot be approved based on the SEC designation 

and that referral to NIOSH is appropriate, the HR 

must remand the case for district office action. 

(2) All cases on the comprehensive list provided 

by UPRP that are located at a FAB office must be 

reviewed for possible inclusion under the SEC 

provision. If no action is required, FAB must 

write a brief memo to the file as noted under 

paragraph 7b(8). 

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____________________________________________________________ 

SEC Class Screening Worksheet 

1)Employee 

Name:______________________________________________________ 

2)SS#______________________________________________________ 

3) Is there proof of a diagnosis of specified cancer? Y/N 

 If yes,(list cancer type and diagnosis date) 

___________________________________________________________ 

4) Does there appear to be at least 250 days of employment 

at the SEC site? Y/N 

If yes, identify employment period: 

______________________________________________________ 

5) If either question 3 or 4 is answered “no”, is there 

anything in the file to suggest that additional development 

might change the answers to “yes?” Y/N 

If so, what development is needed? 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

Coding Action Taken: 

□ Coded ISL “SEC inclusion likely” (#3 and #4 both Yes) 

□ Coded ISD “SEC development needed” (#5 is a Yes) 

□ Coded ISU “SEC inclusion unlikely” (#5 is a No) 

________________ _____________________________________ 

Date Signature 

EEOICPA Tr. No. 10-07 

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Exhibit 1 

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TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-0700 Establishing Toxic Substance Exposure 

Table of Contents. . . . . . . . i 01/10 10-07 

1 Purpose and Scope. . . . . . . . 1 01/10 10-07 

2 Rules for Establishing 

 Exposure . . . . . . . . . . . 1 01/10 10-07 

3 Sources of Evidence. . . . . . . 9 01/10 10-07 

 4 Document Acquisition 

 Request. . . . . . . . . . . . 9 01/10 10-07 

 5 Requesting the DAR . . . . . . . 10 01/10 10-07 

 6 Completion of DAR. . . . . . . . 12 01/10 10-07 

 7 DOE Remediation Employment . . . 14 01/10 10-07 

 8 Site Exposure Matrices (SEM) . . 15 01/10 10-07 

 9 SEM Policy and Management. . . . 16 01/10 10-07 

 10 SEM Searches . . . . . . . . . . 18 01/10 10-07 

 11 SEM Inquiries. . . . . . . . . . 34 01/10 10-07 

 12 National Office Specialist 

 Review . . . . . . . . . . . . 37 01/10 10-07 

Exhibits 

 1 DAR Cover Letter . . . . . . . . 01/10 10-07

 2 DAR Questionnaire. . . . . . . . 01/10 10-07

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1. Purpose and Scope. This chapter describes the 

procedures that the Division of Energy Employees 

Occupational Illness Compensation (DEEOIC) uses to 

establish toxic substance exposure under Part E of the 

Energy Employees Occupational Illness Compensation Program 

Act (EEOICPA). 

These procedures outline means to develop for exposure to 

toxic substances at a covered Department of Energy (DOE) 

and Radiation Exposure Compensation Act (RECA) Section 5 

facility. In particular, the chapter addresses the Site 

Exposure Matrices (SEM) and guidance for its use and 

explains required actions when SEM data is lacking or 

incomplete. 

2. Rules for Establishing Exposure. To establish that an 

employee was exposed to a toxic substance, the evidence of 

file must show evidence of potential or plausible exposure 

to a toxic substance and evidence of covered DOE 

contractor/subcontractor or uranium employment at a covered 

DOE/RECA facility during a covered time period. 

a. Documentation. Exposure to a toxic substance can 

be established by the submission of probative 

documentation that shows such substance was present at 

the facility where the employee worked, that there was 

a reasonable likelihood for employee exposure, and 

that the employee came into contact with such 

substance. 

b. Presence and Contact. Whenever possible, the 

claims examiner (CE) considers such issues as whether 

the substance was present, not only in the facility, 

but in the specific building(s) and/or areas where the 

employee worked, and whether the substance was used 

during the processes involved as part of the 

employee’s job duties and exposure routes (e.g., a 

welder exposed to fumes). The SEM (discussed below) 

will be especially helpful in evaluating for the 

presence of a toxic substance in a certain 

building/area/work process. 

(1) Presence of toxic substance. The CE may 

look to the SEM, facility exposure records, Data 

Acquisition Request (DAR) records, the 

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2. Rules for Establishing Exposure. (Continued) 

Occupational History Questionnaire (OHQ), 

employee records, verified affidavits, DOE Former 

Worker Program (FWP) screening records, NIOSH 

site profiles, employee submitted evidence, and 

other evidence that establishes a toxic substance 

was present at the facility where the employee 

worked. The CE may also use Industrial Hygienist 

(IH) referrals as discussed below. 

(2) Employee contact with a toxic substance. 

The CE’s review of the evidence described above 

may be sufficient to establish that the employee 

came in contact with the toxic substance. 

Information such as the claimant’s response to 

the OHQ performed by the Resource Center (RC), 

reviewed in conjunction with DAR records and the 

SEM, may help the CE decide what further 

development may be necessary (e.g., to determine 

whether contact was likely given the employee’s 

labor category, labor process, or given safety 

controls or risk factors that may have been 

present at the worksite). 

(3) Plausibility. When evaluating the evidence 

to determine whether a toxic substance was 

potentially present at a given facility (by 

building, area, work process, labor category) and 

whether it is likely that an employee came into 

contact with a toxic substance in the course of 

employment at a covered facility, the CE must 

determine whether such contact is plausible. 

To do so, the CE must review all evidence on file 

and decide whether it makes sense that the 

claimed exposure could have potentially occurred. 

Sometimes this evaluation will require a referral 

to an IH. 

For example, if an employee is claiming lung 

cancer due to exposure to uranium metal 

maintained exclusively in a glove box (an 

enclosure to protect the worker from uranium 

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2. Rules for Establishing Exposure. (Continued) 

exposure), the CE must examine whether or not an 

exposure route is plausible. 

Without evidence that the employee was involved 

in machining uranium or cleaning out the glove 

box, or that he or she was exposed in some other 

way such as a leak in the glove box, no exposure 

route (inhalation which would potentially be 

linked to lung cancer) is plausible. 

(4) Sample Evaluation of Presence and Contact. 

A chemical operator involved in cascade 

operations at K-25 claims peripheral neuropathy. 

His responses to the OHQ show he worked with a 

variety of toxic substances on a routine basis, 

including mercury. Information obtained through 

the DAR records confirms his worksite (K-33), 

which is located within K-25, and job duties. 

The CE searches SEM (see paragraph 10 below) and 

confirms the presence of mercury at the K-33 

cascade building. Further, SEM supports a link 

between mercury and peripheral neuropathy. A 

physician’s report indicates a diagnosis of 

peripheral neuropathy and mentions that the 

employee has had tingling in his arms for 

approximately a year. An accident report notes a 

major mercury spill during the time in which the 

claimant worked at K-33. 

The evidence is sufficient to establish that the 

employee had peripheral neuropathy and potential 

exposure to mercury in the course of his 

employment at a covered DOE facility. The 

mercury spill accident report lends support to 

the finding that it is plausible, given the 

facts, to assume that the claimant encountered an 

occupational exposure to a toxic substance in the 

course of his work. 

Any question as to route of exposure (e.g. 

inhalation, absorption), even if presence is 

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2. Rules for Establishing Exposure. (Continued) 

established, should be referred to an IH, as 

outlined in paragraph 12 below. 

c. Burden of Proof. If no medical evidence is 

submitted that would lend support to a connection 

between the claimed condition and potential exposure 

to a toxic substance (and no such evidence is 

available from the sources referenced in the previous 

section), the CE requests such evidence from the 

claimant before issuing a denial. While the CE must 

exhaust all reasonable development prior to issuing a 

denial, the claimant does bear the overall burden of 

proving his or her claim. 

d. Causation Test for Toxic Exposure. The CE must 

develop the requisite employment and exposure evidence 

to render a causation determination. Specific 

causation requirements for cancer and other conditions 

are outlined in other chapters. In general, the CE 

develops the evidence on file and a determination is 

made based upon the “at least as likely as not” 

causation test. 

While resources are provided to assist the CE, there 

is no simple one-step tool for making this 

determination. Instead, the CE must base the 

determination on the totality of evidence in the case 

file. The CE does not use studies or reports obtained 

from the Internet or other sources to justify case 

decisions, unless the National Office (NO) has 

specifically authorized such usage. In addition, the 

CE may not base a decision on a vague reference to 

“medical literature.” 

(1) Causation Test for Toxic Exposure. Evidence 

must establish a relationship between exposure to 

a toxic substance and an employee’s illness or 

death. The evidence must show that it is “at 

least as likely as not” that such exposure at a 

covered DOE/RECA facility during a covered time 

period was a significant factor in aggravating, 

contributing to, or causing the employee’s 

illness or death, and that it is “at least as 

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2. Rules for Establishing Exposure. (Continued) 

likely as not” that exposure to a toxic 

substance(s) was related to employment at a 

covered DOE/RECA facility. 

(2) “At Least as Likely as Not.” Part E only 

requires proof that established exposure “at 

least as likely as not” was a significant factor

in aggravating, contributing to or causing the 

employee’s illness, disease or death. As with 

Part B, “at least as likely as not” means 50% or 

greater likelihood. 

When a referral to NIOSH for a cancer claim 

related to radiation results in a probability of 

causation of greater than or equal to 50%, the 

regulations provide that this requirement has 

been met. In other cases the CE bases a 

determination on a review of the evidence of file 

as a whole, to determine if the “at least as 

likely as not” standard has been met. The CE 

weighs all of the evidence available and provides 

a clearly written rationale supporting his or her 

findings in the recommended decision. 

(3) Significant factor. The CE evaluates the 

evidence as a whole when attempting to determine 

whether or not exposure to a toxic substance was 

indeed a significant factor in contributing to, 

aggravating, or causing the claimed illness or 

death of the employee. In most instances this 

evaluation will be done on a case-by-case basis. 

In some cases a District Medical Consultant (DMC) 

evaluation will be necessary. The CE looks at 

the claimed exposure, the presence of such 

exposure, the duration of the verified 

employment, and any other important 

exposure/employment factors when ascertaining the 

possible role the toxic substance exposure played 

in the onset of the covered illness. 

e. Using SEM to Evaluate Causation in General. The 

SEM is not used to establish or deny causation by 

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2. Rules for Establishing Exposure. (Continued) 

itself, but is used as a tool to assist in the 

evaluation of causation in light of the evidence as a 

whole. The purpose of this searchable database is 

twofold. First, the database details many possible 

toxic substances that may have been present at a given 

facility. Second, the database describes the 

relationship between a specific toxic substance and a 

covered illness. 

The CE reviews the database to assist in a 

determination of whether the claimed toxic substance 

was present at the facility where employment occurred 

and whether or not a relationship exists between 

exposure to a toxic substance and a particular covered 

illness. However, the database does not serve as a 

comprehensive list of all potential toxic substances 

that could be present at a facility, and the CE must 

confirm additional claimed toxic substances through 

employment records, DAR records, DOE FWP records, and 

other means. If the CE cannot confirm the presence of 

a toxic substance through these sources, the claimant 

should be notified and given an opportunity to present 

additional evidence that establishes the presence of 

such a toxic substance. Finally, once the CE 

completes all reasonable development and carefully 

weighs the evidence on the whole, including the SEM 

findings, the CE must determine whether or not a 

referral is needed to a DMC or Industrial 

Hygienist/Toxicologist to further evaluate causation. 

Procedures for this and other actions are outlined 

below. 

f. DOE Physician Panels. Cases with positive DOE 

physician panel findings approved by DOE (signed by a 

DOE official) under the old Part D are accepted for 

causation on the basis of those findings for all 

conditions claimed under Part E that were approved by 

the panel. The CE uses the DOE physician panel finding 

as the basis for the decision and no further 

development for causation is required. 

If the positive physician panel decision is not 

approved by DOE (not signed by a DOE official) it is 

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2. Rules for Establishing Exposure. (Continued) 

not an approved finding, however, unsigned reports 

still may contain useful information for causation 

development such as medical and exposure evidence that 

might prove useful in reaching a causation decision 

based upon all of the other evidence of file. The CE 

reviews negative panel reports like any other piece of 

medical evidence in light of the weight of the 

evidence of file as a whole. 

g. Evidentiary Requirements for Survivor Claims. 

The CE uses any and all of the medical evidence of 

file in order to develop for causation in a survivor 

claim. Not only must the evidence of file establish 

that it is at least as like as not that toxic exposure 

caused, contributed to, or aggravated a covered 

illness, the evidence must also establish that the 

covered illness caused or contributed to the death of 

the covered employee. 

h. Developing for Toxic Substance Exposure. When 

developing Part E cases the CE uses established 

development techniques in addition to certain other 

steps unique to the Part E adjudication process. The 

Final Adjudication Branch (FAB) develops medical 

conditions and employment where possible to avoid 

issuing a remand order for further development if such 

development can be conducted at the FAB with little 

additional effort. 

(1) Development Using Existing Case File 

Materials. In many instances a Part E claim has 

a corresponding Part B and/or D case file already 

in existence. When an existing Part B and/or D 

case file exists, the CE examines the case file 

materials for medical, employment, and exposure 

evidence to assist in the causation development 

process. 

Under Part D, DOE collected exposure and 

employment data through DARs. The CE must 

examine all existing Part D case file material 

for DAR records and review all documentation 

presented with the new Part E claim filing and 

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2. Rules for Establishing Exposure. (Continued) 

any corresponding Part B or D case file to render 

a causation determination. A filing under Part D 

is automatically considered a filing under Part 

E, without a requirement for the filing of 

another claim form. 

(2) A General Rule about Reasonable 

Development. Given the complex nature of claim 

file development under Part E, it is necessary 

for the CE to judiciously determine whether or 

not the facts warrant issuing a decision or 

whether additional development is necessary. As 

a general rule, the CE utilizes the tools 

outlined in this chapter to the fullest extent 

possible and issues a decision once all 

development avenues have been reasonably 

explored. While the CE issues decisions accepting 

claims for benefits as soon as the evidence 

support an acceptance and all statutory criteria 

are met, denial situations must be heavily 

weighed and decisions issued only when additional 

development is unlikely to produce the evidence 

needed to reach a decision. In essence, the CE 

evaluates all of the evidence of file to 

determine whether or not it is plausible that, 

given the evidence at hand, the claimed illness 

arose out of the claimed occupational exposure to 

a toxic substance at a covered facility.

When attempting to determine whether or not 

sufficient development has been conducted, the CE 

can look to the claimed condition and the 

evidence at hand to make an informed 

determination. If the claimed condition is 

generally a condition that arises out of 

occupational exposure, it is incumbent upon the 

CE to pursue additional development whenever 

possible. However, if the condition is one that 

is unlikely to be caused by occupational 

exposure, the CE can be more certain that 

additional development might not be necessary and 

a decision can be issued. 

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2. Rules for Establishing Exposure. (Continued) 

(3) Example. If the claimed illness is chronic 

silicosis, chronic beryllium disease (CBD), 

asbestosis, or another condition known to arise 

almost exclusively out of occupational exposure, 

but the evidence is not sufficient to accept the 

claim, the CE refrains from issuing a denial if 

additional development might establish the 

employee’s claim for benefits. 

However, if the claimed illness is heart disease, 

diabetes, arteriosclerosis, thrombosis, or 

another disease that often is caused by nonoccupational risk factors, the CE can send a 

development letter and allow the claimant an 

opportunity to present evidence. If no evidence 

is received, the CE may issue a decision after 

weighing the evidence as a whole and determining 

that no causal link exists between the claimed 

illness and the covered Part E employment. 

3. Sources of Evidence. Establishing exposure to a toxic 

substance is a key element in developing claims filed under 

Part E. Developing for such exposure can be complex, and 

many tools are available to assist the Claims Examiner (CE) 

in this endeavor. 

a. DAR records, which are obtained from DOE, contain 

a wealth of employment and exposure evidence. They 

contain a mixture of employment, medical, and exposure 

evidence. The CE prepares a DAR to DOE pursuant to 

the guidance in paragraphs 5 and 6 below. If the site 

information contained in SEM is reasonably complete 

and sufficient to establish the claimed exposure, no 

further exposure information should be sought from DOE 

through a DAR. The DAR can be used to obtain specific 

information if a claimant is alleging an incident that 

might not have been captured in SEM. 

b. The DOE Former Worker Program (FWP) is an ongoing 

effort to evaluate the effects of occupational 

exposures (e.g., to beryllium, asbestos, silica) on 

the health of DOE workers. These records contain 

employment, medical, and exposure data. 

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3. Sources of Evidence. (Continued) 

Exposure information obtained from FWP work history 

interviews taken after the enactment of the EEOICPA, 

in October 2000, should be used only when corroborated 

by other evidence that supports the claimed exposure 

(i.e., DAR information, SEM). 

c. Center to Protect Workers’ Rights (CPWR) can 

provide data for use in verifying 

contractor/subcontractor employment and exposure.

d. Employment and exposure evidence from the 

claimant or other sources, such as verified 

affidavits, facility records, is weighed along with 

the evidence as the whole. 

e. The SEM (see paragraph 8 below) provides sitespecific exposure information, information about toxic 

substances and employment processes at a given site, 

and some limited information concerning potential 

adverse health effects produced by exposure to certain 

toxic substances. 

f. DOE Physician Panel findings are also a source of 

employment, medical, and exposure information. 

g. Occupational History Questionnaire (OHQ) data 

obtained by the RC staff document the workplace 

exposure experienced by an employee. The OHQ is used 

as a piece of evidence to be evaluated along with the 

evidence of the file as a whole. 

4. Document Acquisition Request. The DAR is the process 

by which the DO gathers DOE work records on a specified 

employee. The CE reviews the case file before deciding 

which documentation to request from the DOE on the DAR 

Questionnaire. The CE must carefully consider the specific 

data needs for the individual case. Information received 

in response to the DAR may vary from site to site, but will 

contain some or all of the following information: 

a. Radiological Dose Records. These documents are 

radiation exposure records based on readings from 

dosimetry badges or similar personal recording 

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4. Document Acquisition Request. (Continued) 

devices. They are generally taken at regular 

intervals over the employee’s employment. 

b. Incident or Accident Reports. Any abnormal 

incidents or large plant accidental substance releases 

affecting the employee are documented in these types 

of documents. 

c. Industrial Hygiene or Safety Records. Documents 

in these categories could contain periodic inspection 

reports for health and safety purposes. 

d. Pay and Salary Records. These documents include 

an employee’s pay, salary, any workers’ compensation 

claim or other documents affecting wages. 

Examples of records from the DOE database could 

include, but are not limited, to Official Personnel 

Files of Contractor Employees, Contractor Job 

Classification, Employee Awards Files, Notification of 

Personnel Actions, Classification Appraisals, Wage 

Survey Files, and Unemployment Compensation records. 

The CE generally does not need these types of 

documents unless wage loss is either being claimed by 

the claimant or a wage-loss claim is obvious to the CE 

from the case file. 

e. Job Descriptions. These are descriptions of the 

various employment positions at the plant and the 

duties required to perform the job. 

f. Medical Records. These include personal medical 

histories of the employee if that employee visited the 

plant infirmary (e.g., Health Unit Control Files, 

Employee Medical Folder). 

g. Other. This category includes any other 

documentation needed on a case-specific basis which 

does not fit into any of the other six categories. If 

this category is checked and a specific request is 

listed by the CE, DOE personnel may contact the DOL CE 

for clarification of the request. 

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5. Requesting the DAR. After reviewing the case file, 

including the OHQ from the RC, the CE requests the DAR 

information. This is done concurrently with FWP 

development. The process for collecting the information 

differs slightly depending on whether DOE or a corporate 

verifier (CV) is receiving the DAR. The CE must also 

review SEM to determine what exposure information already 

has been assembled from DOE records and other sources. If 

exposure information necessary to develop the claim already 

exists in SEM, the CE does not request such information in 

the DAR. 

a. DAR Point of Contact (PoC) List. This list can 

be found on the NO shared drive and is divided into 

two sections: DOE DAR PoC and No Known Contact. Each 

District Director (DD) is responsible for updating and 

maintaining these records. 

The DOE DAR PoC is similar to the current DOE 

Operations Center PoCs for employment verification. 

There are some differences, however, so the CE must 

use this list when requesting DAR documentation 

directly from the DOE. A DAR Cover Letter and DAR 

Questionnaire are sent only to a DOE DAR PoC. 

b. Sites With No Known DAR PoC. For these sites, 

the CE undertakes alternate exposure development. 

Since no known contact exists, a DAR Questionnaire is 

not used. 

6. Completion of DAR. When appropriate, the CE completes 

a DAR Cover Letter and Questionnaire asking for toxic 

exposure evidence. If a particular DOE site does not have 

the ability to scan and submit documentation digitally on a 

CD, the DOE submits paper documents. 

a. Package to DOE. The package includes a cover 

letter (Exhibit 1) addressed to the DOE PoC, DAR 

Questionnaire (Exhibit 2) completed by the CE, and 

copies of Forms EE-1/EE-2 and EE-3. 

(1) The CE prints or types the identifying 

information of the employee in Blocks 1 and 2 of 

the DAR. The CE annotates any maiden names in 

Block 1. 

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6. Completion of DAR. (Continued) 

(2) The CE indicates the DOE facility on Form 

EE-3 in Block 3 of the DAR and any employer name 

information in Block 4. If the claimant 

indicates on Form EE-3 that he or she worked for 

multiple subcontractors at the same DOE facility, 

the CE completes a separate DAR Questionnaire for 

each subcontractor. This process helps 

distinguish between contractors or subcontractors 

for which DOE has records and those for which it 

does not. 

Similarly, if the claimant claims multiple DOE 

sites on Form EE-3, the CE completes a separate 

DAR for each DOE site, as the DAR PoC may be 

different. 

(3) After reviewing the case file, the CE 

requests the records that are relevant to the 

case by checking the appropriate box(es) in Block 

5, “Types of Records Being Requested.” 

(4) If the CE has a specific question(s) that 

needs to be addressed which is not covered in the 

broader categories listed on the DAR request, the 

CE completes the “Site Specific Exposure 

Questions” section of the Questionnaire. The CE 

considers the condition(s) claimed as well as any 

specific alleged exposures. 

For example, if the claim is for aplastic anemia, 

the CE may want to ask DOE if and when arsenic or 

benzene was used in a particular building at the 

site during a particular timeframe. 

b. DAR Response. When DOE’s response is received, 

the CE enters an “ER” code into ECMS (see DEEOIC ECMS 

procedures for status effective dates and other 

information). 

(1) DOE will have collected the documents 

requested in Block 5. The DOE checks the 

corresponding box in Block 6 immediately to the 

right of the requested category, either “Included 

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6. Completion of DAR. (Continued) 

on CD” or “Unavailable”, depending on whether the 

DOE has any records related to that particular 

set of records. “Included on CD” also includes 

hard copy documentation in the event the DOE 

facility does not have imaging capability. 

(2) Also, DOE will respond to any site-specific 

exposure questions posed by the CE in Block 8, 

confirming the exposure, denying the possibility 

of exposure, or indicating there is insufficient 

evidence to answer the question accurately. The 

DOE may attach a piece of evidence to the DAR 

which particularly answers a site-specific 

question or otherwise clarifies the DOE response 

to the question. In these instances, the DOE 

also checks the “SUP” or supplemental box 

signaling the special response.

(3) Once the DAR response is received, the CE 

reviews both the questionnaire and the contents 

of the CD to confirm that all requested documents 

have been received and that the specific 

questions about exposure have been adequately 

answered. Any documents identified on the CD as 

material to the claim must be printed and placed 

in the case file. 

c. Follow-up with DOE. If DOE does not respond to 

the RC’s initial employment verification request or 

the DAR questionnaire, the CE contacts the DOE to 

determine the status of the request. 

(1) The DOE is given 30 days to respond to the 

request (Form EE-5 or DAR). If the DOE does not 

respond within that time, the CE drafts an 

inquiry to the DOE, noting the date of the 

initial request and asking the DOE to respond as 

soon as possible. The CE provides his or her 

contact information so that the DOE can quickly 

respond. 

7. DOE Remediation Employment. Since Part E provides 

coverage for DOE contractor/subcontractor employees and 

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7. DOE Remediation Employment. (Continued) 

their eligible survivors, a claimant alleging DOE 

contractor/subcontractor employment due to remediation must 

prove that a contract/subcontract in fact did exist between 

the claimed employer and DOE/DOE contractor to conduct 

remediation activities for DOE at the facility in question 

during the time when DOE was conducting remediation. When 

developing for exposure in a remediation case, the CE 

should follow the same steps as is used to develop for DOE 

contractors and subcontractors. 

8. Site Exposure Matrices (SEM). The SEM is a web-based 

tool designed to assist the CE in developing for exposure 

to a toxic substance. The SEM identifies the toxic 

substances that were commonly used in each DOE and RECA 

Section 5 facility, and contains two general categories of 

information that may be searched: chemical profiles and 

site-specific information tailored to the covered facility 

or site. 

Under no circumstances is SEM used as a stand alone tool to 

deny a claim. Information in SEM can sometimes be used in 

conjunction with other supporting case file evidence to 

approve a claim. 

a. Site-Specific Data. For a given covered facility 

or site, SEM provides information about the nature and 

location of work processes performed (e.g., fuel 

separation, instrument maintenance, or welding); the 

work groups involved (e.g., first line supervisor, 

instrument mechanic, or welder); the toxic substances 

used (e.g., plutonium nitrate, arsenic, or mercury); 

and site-specific aliases and potential exposure 

information about work processes, work groups, toxic 

substances, buildings, and areas. 

b. Potential Nature of Exposure. Data from SEM is 

interpreted to mean that a worker had a potential for 

exposure to a toxic substance. The CE must review the 

information yielded from DAR responses, DOE FWP 

records searches, and the OHQ to hone the SEM search. 

c. Employment Data. The CE must obtain as much 

background as possible to determine the type of work 

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8. Site Exposure Matrices (SEM). (Continued) 

or process the employee performed, the dates of such 

work or process, the building(s) or area(s) involved, 

and the toxic substance(s) alleged to have been 

present to determine through SEM the type of chemicals 

an employee could potentially have been exposed to 

while working in a particular building and/or 

performing a certain job or process. This information 

can be gathered from the OHQ, DAR, EE-5, or other 

sources. 

d. Validity of SEM. All information in SEM is 

considered valid and factual. The toxic substance, 

work process, and facility information in SEM is 

deemed verified by DOE or other sources, and if a 

certain toxic substance is listed as present in a 

given building or facility, the data is accepted as 

fact and no additional confirmation from DOE or any 

other source is necessary. 

e. Additions to SEM. The database is continually 

updated and does not contain 100% of the toxic 

substances potentially present at a given facility. 

As a result, simply because certain information is 

absent from SEM does not warrant a claim denial and 

also does not warrant delaying adjudication until such 

information might be included in SEM. The CE conducts 

reasonable development by reviewing the evidence as a 

whole and issues decisions once such development 

allows the CE to adjudicate a claim. 

9. SEM Policy and Management. The following paragraphs 

provide a basic outline of SEM and its use as a 

developmental tool. See the “Site Exposure Matrices 

Website User Reference Guide” (available on the Shared 

Drive, Part E folder, SEM subfolder, or accessed through 

the SEM menu) for complete and detailed instructions as to 

the use of SEM. 

a. Policy. SEM is used as a tool to assist the CE 

in evaluating the evidence as a whole to determine the 

existence of a causal link between covered employment, 

exposure to a toxic substance during such covered 

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9. SEM Policy and Management. (Continued) 

employment, and a resultant illness arising out of 

such exposure. 

As noted above, in certain cases it will be possible 

to accept a claim based upon the information contained 

in SEM if such information can be coupled with 

approved policy guidance as outlined below. 

Under no circumstances is a claim for benefits denied 

solely due to a lack of information contained in SEM, 

because the data for each facility will never be 100% 

complete. 

b. Management of SEM at NO. A NO SEM Point of 

Contact (PoC) manages all issues arising out of SEM 

usage. Implementation questions, requests for 

access/denial of access to SEM, and any new evidence 

that might warrant inclusion into SEM are forwarded to 

the NO SEM PoC. 

(1) The NO SEM PoC has a counterpart in the DO 

SEM PoC, who, the DD appoints to interact with 

the NO. 

When evidence of an exposure not listed in SEM is 

verified or strongly alleged (supported by 

documentation) at a facility, the DO SEM PoC 

prepares a memorandum to the NO SEM PoC (for 

signature by the DD or designee) requesting IH 

review for possible inclusion of the toxic 

substance in SEM. All associated evidence of the 

presence of the toxic substance is attached to 

the memorandum. 

The NO SEM PoC will review the evidence with the 

NO IH and other NO staff (i.e., Medical Director, 

Toxicologist, and Health Physicists) to determine 

whether the evidence should be included in SEM. 

If so, the NO PoC advises the Web Site 

Administrator or appropriate individual to add 

the information to the database. 

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9. SEM Policy and Management. (Continued) 

In general, the DO SEM PoC interacts with the NO 

SEM PoC on all issues arising out of SEM 

operations. 

(2) The DO SEM PoC obtains SEM access for DO 

staff by e-mailing the NO SEM PoC with a request 

that a staff member be granted access to the 

system and providing the employee’s name, job 

title, and e-mail address. After review, the NO 

SEM PoC advises the Web Site Administrator by email to grant access to the individual in 

question. 

The Web Site Administrator contacts all 

individuals with newly granted access through email, providing access information such as a user 

name and a temporary password. 

(3) Access is disabled when an employee resigns 

or is terminated. The DO SEM PoC provides an email to the NO SEM PoC with the name of the 

employee whose access is being disabled and the 

precise date upon which access must be denied. 

The NO SEM PoC e-mails the Web Site Administrator 

requesting that the access be disabled on the 

requested date, and access is terminated. Due to 

the sensitive nature of the information housed in 

SEM, it is important that the DO SEM PoC notify 

the NO SEM PoC of the need to disable an account 

within 7 days of an employee’s departure. 

 c. Additions to SEM. DEEOIC encourages claimants 

and other interested parties to submit new siterelated scientific research, studies, or information 

concerning the presence of toxic substances at covered 

facilities for evaluation and possible inclusion in 

SEM. The SEM website at www.sem-dol.gov contains a 

link for individuals to provide comments or 

documentation of toxic substance use at a particular 

facility. 

10. SEM Searches. The CE reviews all evidence of file to 

properly craft his or her SEM query. The CE reviews 

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10. SEM Searches. (Continued) 

employment evidence for job description and facility. 

Also, employment and exposure evidence in the case file 

(e.g., facility records, DAR records, OHQ responses, 

NIOSH/PHS/DOJ data about RECA claims) is reviewed to 

determine as best as possible exactly where the employee 

worked and what processes or toxic substances were used in 

the building or area in which the employee worked. In 

order to effectuate a thorough and proper search, it is 

necessary for the CE to develop SEM queries from multiple 

criteria, including: labor category; process; and health 

effect. While labor category is the preferred field to 

begin a search, it is not the only field that should be 

investigated. 

a. Data Fields. Various fields in SEM hold an array 

of valuable data viewable by site: the number of toxic 

substances present (with information about each 

substance); health effects or diseases known to be 

associated with a toxic substance; site history; 

buildings; processes; labor categories; known 

incidents; and exposure factors. 

All fields contain references to the document utilized 

by SEM to provide the given information. The CE 

navigates the search fields based upon the known 

evidence of file, triangulating on the necessary 

information required to assist in the development and 

determination of causation. 

A search based upon facility-wide information (e.g., 

all toxic substances known to have been present at the 

Nevada Test Site) generally will not be specific 

enough without other qualifiers such as work category 

and/or work process, and may not produce usable 

information for a causation determination. 

At a minimum, especially when searching DOE sites, the 

CE establishes the employee’s job category, work 

process, and/or building/area or employment before 

performing a SEM search. The more information a CE has 

about an employee’s occupational history when 

searching SEM, the more likely it is that the SEM 

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10. SEM Searches. (Continued) 

search will prove useful in helping the CE determine 

causation. 

b. Searches of Universal Information. This set of 

fields contains the most recent scientifically based 

evidence about toxic substances and their relation to 

illnesses. The occupational disease links in SEM are 

imported from the widely accepted and well 

rationalized medical science database called Haz-Map, 

a database of the National Library of Medicine (NLM). 

While the NLM database, Haz-Map, is often utilized in 

other circumstances as a resource, the CE must never 

use Haz-Map as a development or adjudicatory tool. 

Only SEM is acceptable for use in case file 

development and adjudication. It is unacceptable to 

base a decision, particularly a remand order, on any 

information contained in Haz-Map beyond the 

established links populated directly into SEM. HazMap serves many purposes for the public and medical 

professional fields and will often cite suggestive 

research that it has not accepted as a basis for 

finding a demonstrable link between a given substance 

and an occupational illness. 

(1) The “Toxic Substance Information” field is 

useful when the evidence indicates the toxic 

substance(s) to which the claimant was 

potentially exposed. When a toxic substance is 

selected, SEM provides a “chemical profile” of 

the substance, including its Chemical Abstracts 

Service (CAS) number, which identifies the 

chemical, aliases for the substance name, 

chemical and physical properties (e.g., liquid or 

gas, odor, and color), and health hazard ratings 

assigned by sources routinely used by industrial 

hygienists to evaluate workplace substances. 

(2) The “Toxic Substance by Alias or Property” 

field is used to find a toxic substance using an 

unofficial name, or by a physical or chemical 

property. Using this link allows the CE to find 

the identity of toxic substances by keying in 

part or all of the name, unofficial name (alias), 

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10. SEM Searches. (Continued) 

or description of a toxic substance using a 

physical or chemical property. 

The result may be no match, one match, or 

multiple matches. For example, searching for 

“yellow” will return a list which includes 

uranium dioxide, and searching for “yellowcake” 

will return a shorter list which still includes 

uranium dioxide. 

(3) The “Toxic Substance by Chemical Category” 

field is used to find a toxic substance by 

category, such as gases or metals. If the 

claimant is not specific about the substance to 

which he or she was exposed, but describes it in 

general terms, this link will allow the CE to 

review a list of substances to which the employee 

may have potentially been exposed. After 

selecting a chemical category from the drop down 

menu (gases, metals, acids, etc.), a listing of 

all toxic substances within that category at the 

site is shown. 

Example: The CE knows that the employee worked 

as a laborer in the pilot plant at the Feed 

Materials Production Center (Fernald) and is 

claiming chronic bronchitis. The OHQ indicates 

that the claimant does not recall exact 

exposures, but does recall a sharp, pungent odor 

and states that he “breathed in this gas all the 

time.” The CE selects “Gasses” from the chemical 

category drop down menu and all gasses known to 

have been present at Fernald are listed. The CE 

searches each gas and finds that sulfur dioxide 

was present in the pilot plant and that laborers 

are a labor category of possible exposure and 

that the gas has a pungent odor and that chronic 

bronchitis is a health effect of exposure. 

(4) SEM provides a list of known health effects 

produced by a given toxic substance. SEM can 

also be searched to determine whether or not a 

given facility contained a toxic substance that 

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10. SEM Searches. (Continued) 

could produce the health effect claimed. When 

searching this way, the CE searches by the 

claimed illness (e.g., asthma, skin cancer) to 

determine what toxic substances at a given site 

could have potentially caused, contributed to, or 

aggravated the claimed condition. 

(a) The “Toxic substance by health effect” 

section displays the toxic substances that 

could cause the health effect or disease. 

For example, the above-described laborer 

from the Fernald Pilot Plant claims chronic 

sinusitis as a result of his or her 

employment at Fernald. A search of the 

condition “chronic sinusitis” shows that no 

toxic substances contained within the 

Fernald database match the search criteria, 

meaning that no known substances involved in 

a work process at Fernald could have induced 

chronic sinusitis. 

While this is not sufficient evidence to 

deny causation, the CE must evaluate other 

evidence to determine whether or not the 

employee’s condition was caused, contributed 

to, or aggravated by his or her employment. 

(b) The CE also can search SEM for toxic 

substances that cause a health effect by 

searching with a disease or health effect 

alias. That is, if the CE does not know the 

official name of the disease (e.g., 

pulmonary disease, chronic obstructive, a 

general term for lung ailments that can 

include emphysema, chronic bronchitis, and 

in some cases asthma) the CE can search by 

the word “lung.” This generates a search of 

all toxic substances present at a given 

facility that could affect lung function. 

The CE can review the list of substances to 

determine if they were present in the 

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10. SEM Searches. (Continued) 

employee’s work process or building and 

whether these substances could potentially 

cause one of the lung diseases commonly 

referred to as COPD. 

(c) The CE uses the “Disease or Health 

Effect by Alias” search if the organ 

affected by the disease is known. Using 

this link opens a page which allows the CE 

to find health effects or diseases by keying 

in all or a portion of the formal name of a 

health effect or disease. The SEM provides 

a list of health effects or diseases, which 

contain the search text in their formal 

names. For example, searching for “liver” 

returns Hemangiosarcoma of the liver. 

c. Searches Specific to Selected Site. This section 

contains the most recent information about covered DOE 

facilities, uranium mines, uranium mills, and uranium 

transport operations. The CE searches these site 

fields for specific information about a facility, the 

work processes performed there (e.g., PUREX fuel 

separation, instrument maintenance, welding), and the 

toxic substances involved in those work processes, 

broken down by labor category (e.g., welder, yellow 

cake operator, electrician). 

This group of searchable fields assists the CE in 

evaluating whether or not the employee’s work history 

meets the presence and contact standard in the 

causation test for toxic substance exposure set out 

above. The CE searches site-specific fields when the 

CE knows the site of employment and also when the CE 

knows the building/area of employment, the work 

process performed and/or the labor category claimed. 

 (1) Site History. This section contains 

unclassified references from official DOE or DOE 

contractor web sites providing a description of 

the DOE facility or uranium mine or uranium mill. 

It provides dates of operation, known 

owners/operators, and historical reference data 

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10. SEM Searches. (Continued) 

about the site. This description is available in 

SEM for both DOE facilities and uranium mines and 

mills. 

 (2) Areas. This section is only displayed if 

the selected site has defined areas. All defined 

areas are viewable by selecting a drop down menu 

identifying each known area by number and/or 

title. This section is used when the CE knows 

the area in which the employee worked. Work 

processes, labor categories, toxic substances and 

incidents will be listed for each specified area 

at the site. 

For example, the employee claims to have worked 

on the bull gang in Area 16 at the Nevada Test 

Site from 1966 to 1970 and is claiming 

occupational asthma. The CE searches the Nevada 

Test Site facility by Area and queries Area 16, 

which shows all known potential toxic substances 

in that area, all labor categories, and work 

processes. 

A search of the toxic substances present at the 

time of the claimed employment shows that of all 

substances present, cobalt can cause occupational 

asthma. A further search indicates that the bull 

gang labor category, involved in the labor 

process of reentry and mineback operations, is 

shown as a risk factor for cobalt exposure during 

the time in which employment is claimed. 

Verification of the claimed employment by DOE is 

sufficient to establish potential exposure. 

 (3) Buildings. This section is searchable when 

the CE knows the official or unofficial name of 

the building in which the employee worked. This 

section lists all historical references to the 

building, hazardous chemicals present, the area 

where the building was located, work processes, 

labor categories, and known incidents involving 

the building. This search category is available 

only for DOE sites. Data for uranium mines and 

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10. SEM Searches. (Continued) 

mills will simply state the site history, 

processes, and searchable labor categories. 

(a) The building information subsection 

lists all the major buildings (by number and 

title) at the site (e.g. the K-33 Process 

Building within the K-25 East Tennessee 

Technology Park). 

(b) The CE enters a building by alias, or 

common name, for a worksite that does not 

appear in the searchable buildings list 

(e.g., the K-33 Process Building above is 

also known as the “Cascade Building”). SEM 

lists the proper names and numbers of 

buildings to which the slang or common name 

could refer. This search capacity assists 

in locating a building when no formal 

building name is identified in the 

employment history. 

(4) Processes. This section lists all known 

processes at the site (e.g., carpentry, ash 

crushing, crane operations) and contains the 

related labor categories, timeframes, and toxic 

substances. This category is searchable for DOE 

facilities and uranium mines and mills. When 

searching for a labor process, the CE may know 

the type of process in which the employee was 

involved (e.g., welding, drillback core sampling, 

solvent recovery), but not the specific labor 

category involved. 

Knowing the work process can assist the CE in 

conducting a search for potential exposure to 

toxic substances, because sometimes several 

different job categories can be involved in one 

work process and a process might be spread out 

among several different buildings within a 

facility (e.g., a process operator at Portsmouth 

GDP involved in cascade operations could have 

worked in X-326, X-330 and X-333, all buildings 

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10. SEM Searches. (Continued) 

in which the work process “cascade operations” 

took place). 

(a) DOE facilities list all processes known 

to have occurred at the site. For instance, 

if the CE knows an employee worked in 

Building 202-A at the Hanford Site, SEM 

indicates that the process in that building 

was PUREX fuel separation, lists all labor 

categories involved in this operation, and 

the toxic substance present when this 

operation took place. 

This assists the CE in determining the toxic 

substances to which an employee could 

potentially have been exposed, based upon 

the process listed and the timeframes in 

which the employee may have been involved in 

such processes. 

(b) For RECA mills, the following 

categories are examples of processes: 

laboratory, maintenance, and all other than 

laboratory and/or maintenance. Some mills 

did not have a laboratory component and 

therefore list fewer than three processes 

(e.g., Slick Rock in Colorado lists only 

maintenance and all processes other than 

maintenance). The CE must identify the 

labor sub category (actual work performed) 

whenever possible. 

For example, if the CE knows that an 

employee worked as a bulldozer operator at 

Grand Junction in Colorado, the CE searches 

the labor subcategory field to identify that 

job title. Once it is identified, the CE 

clicks on the bulldozer labor subcategory 

and finds that a bulldozer operator is 

classified in the labor process “all other 

than laboratory and maintenance.” All 

potential toxic substance exposure for that 

subcategory and labor process group is 

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10. SEM Searches. (Continued) 

listed, and the CE can match the findings 

against the claimed/verified illness and 

exposure. 

(c) Much of the work performed at RECA 

mines was fairly uniform and easily 

categorized with regard to process. While 

SEM does not list work processes for a RECA 

mine, labor categories exist as outlined 

below. Only exposure arising from processes 

and work that actually took place at a 

uranium mine or mill is considered when 

evaluating a claim for causation. 

(d) Individuals employed in the transport of 

uranium ore or vanadium-uranium ore to 

and/or from covered RECA mines or mills are 

covered under the EEOICPA. However, when 

developing exposure for an ore transporter, 

the CE only counts exposure that could 

potentially have taken place on the premises 

of a covered RECA mine or mill. 

Exposure that could have potentially 

occurred when the ore transporter was in 

transit is not covered under the EEOICPA and 

is not considered by the CE when developing 

for causation. See EEOICPA PM 2-1100 for a 

more complete discussion of covered exposure 

under RECA. 

(5) Labor Categories. The CE can search by 

labor category if the employee’s job title or job 

title alias specific to a certain facility is 

known. It is important to narrow down employment 

verification requests and information obtained on 

Form EE-3 to determine the exact labor function 

performed by an employee if possible. 

The RC staff must make certain to obtain the most 

specific employment information that is available 

from the employee/survivor and the employment 

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10. SEM Searches. (Continued) 

verifier entity when conducting initial 

employment verification. 

The CE must conduct additional development where 

necessary to further identify the exact 

definition of the employee’s functions and the 

timeframe(s) of those functions at a given site, 

seeking the greatest specificity possible. 

(a) Labor category information lists all 

the labor classifications or work group 

titles at the site (e.g., electrician, crane 

operator, barrier operator). 

(b) If the employee’s job title does not 

appear on the drop down list of labor 

categories above, the entry on the claims 

form may be a slang or unofficial title. 

The CE may be able to find the official 

labor category, (e.g., maintenance mechanic) 

by keying in the slang or commonly used 

title (e.g., pipe fitter). 

 (c) Construction worker exposures are 

separated into two categories: those due to 

toxic substances inherent to the 

construction craft, and those caused by 

performing the construction work on a DOE 

site. The CE must consider both exposure 

categories when assessing exposure for 

construction workers. 

Construction exposure is searched as its own 

category outside of the facility lists. As 

such, it does not matter where the 

construction took place. If the CE is 

searching SEM for a construction worker’s 

claim, the CE searches by toxic substance 

and by work process (e.g., adhesive work, 

brazing, carpentry) and labor category 

(e.g., electrician, millwright, iron 

worker). Searches for construction trade 

exposures contain the same toxic substances, 

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10. SEM Searches. (Continued) 

work processes, and labor categories for all 

covered facilities. 

(d) For RECA mines, three labor categories 

are listed: prospecting, mining, and 

support/maintenance. The CE determines the 

duty performed (e.g., mining or maintenance) 

when searching SEM for information about a 

site listing more than one process. Some 

sites list only one possible work process 

and the CE need only confirm that employment 

is claimed or verified at the given site. 

Once the work process is identified at the 

mine where employment took place, the CE can 

search a list of toxic substances to 

determine the one(s) to which an employee 

could have potentially been exposed while 

working at the mine. 

For instance, the Arrowhead #1 mine in Eagle 

County, Colorado, lists “prospecting, no 

mining” as the only work process performed 

at that site. This means that the only work 

process performed at the Arrowhead #1 site 

was prospecting for uranium and that no 

actual uranium mining operations took place 

at that site. 

The Bay Mule mine in San Miguel County, 

Colorado, lists “mining” as its only work 

process. A mixture of possible work 

processes will be listed for the RECA 

facilities depending upon what type of work 

activities actually occurred at the site. 

 

 (6) Incidents. The incident information field 

lists known major incidents and accidents 

experienced at the site. The entries provide a 

brief descriptive title of the incident, the year 

the incident occurred, and the location of the 

incident (building or area). An example would 

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be: Uranium cylinder rupture and release, 1976, 

Building X-344. 

(a) This information may assist in 

corroborating a claim if the claimant has 

referred to a particular accident or 

incident as having caused acute or extreme 

exposure to a toxic substance. Facility 

incident and accident information may be 

found in DAR responses, employment records, 

DOE FWP records, and OHQ summaries. 

(b) The CE must evaluate incidents and 

accidents with regard to the evidence of 

file as a whole. Simply corroborating a 

claimed exposure is not sufficient to 

establish causation. The CE must review the 

medical evidence and, if necessary, seek the 

opinion of an IH or DMC about the 

possibility as to whether or not the type of 

incident or high exposure event (as viewed 

in association with the evidence as a whole) 

could prove a significant factor in causing, 

contributing to, or aggravating the claimed 

illness. Further, certain incidences of 

high or extreme exposure should be 

considered when evaluating whether or not a 

required disease latency period can be eased 

or waived entirely. 

(7) Exposure Factors. This section lists the 

safety programs, risk factors and timeframes used 

to gauge an employee’s potential exposure as it 

relates to work process, labor category, 

building, and area. 

(a) Safety programs serve as controls that 

may have reduced the likelihood of employee 

exposure to toxic substances (e.g., through 

use of respirators, protective clothing). 

(b) Risk factors are conditions or 

practices that may have increased the 

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10. SEM Searches. (Continued) 

likelihood of employee exposures to toxic 

substances, such as periods of time when 

employees were not properly protected. 

(c) Timeframes reflect known periods within 

which a known correlation exists. For 

example, certain timeframes outline the 

period in which it is known that a certain 

toxic substance was present in a certain 

building (e.g., from 1956 to 1988 ammonium 

fluoride was present in Area 200 East and 

involved in the work process of PUREX fuel 

separation activities). 

Also, timeframes outline periods in which 

certain safety programs or measures were in 

place at a given building or area. This 

information may assist the CE when 

evaluating the likelihood that a claimant 

was exposed to a toxic substance. 

Safety Control Example: In 1999, DOE 

enforced beryllium controls such that work 

could only be performed in certain 

buildings. The employee claims beryllium 

illness from beryllium exposure in 2000, yet 

the employment evidence shows that he or she 

worked in a building where beryllium was 

never present due to DOE controls. When 

dealing with beryllium, the CE must be aware 

of the potential for residual contamination, 

and in this instance it must be 

unequivocally verified that beryllium was 

never present at the facility in question. 

d. Links Within Searchable Fields. Within SEM the 

various areas, facilities, buildings, processes, 

activities, labor categories, incidents and toxic 

substances which are known to have existed or occurred 

onsite are linked to one another. For example, such 

relationships expressed in the matrices might be: 

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10. SEM Searches. (Continued) 

(1) “Toxic xxx was in building aaa at some 

time;” 

(2) “Activity bbb was performed by Labor 

Category ddd and involved work with Toxic yyy in 

Building lll;” 

(3) “Activity bbb was performed during Labor 

Process ddd and involved work with Toxic zzz in 

Building lll;” and 

(4) “Labor category ppp involved work at all 

parts of the site”). 

e. Sample SEM Search # 1. DOE verifies employment 

at the Portsmouth GDP from 1955 to 1960. Form EE-3 

indicates that the employee worked as an instrument 

mechanic in Building X-333 from 1955 to 1960. The 

verified diagnosed medical condition is aplastic 

anemia. 

A search of the SEM by Health Effect shows that 

aplastic anemia can be caused by arsenic, benzene, and 

plutonium exposure. The CE further consults the HazMap database link which provides a description of 

aplastic anemia and indicates that arsenic, benzene, 

and plutonium are among the hazardous agents that can 

cause the disease. A latency period of weeks to years 

is indicated. 

The Building information for Building X-333 lists all 

known chemicals used at that site, and arsenic, 

benzene, and plutonium are among them. The SEM 

further shows that the Labor Process of Instrument 

Maintenance took place in Building X-333 from 1953 to 

1957 and lists the Labor Category Instrument Mechanic 

as involved in this process during this timeframe. 

The CE reviews the SEM findings as well as other 

relevant evidence (medical opinions provided by 

qualified physicians that opine a link between the 

occupational exposure and the aplastic anemia, DAR 

records showing definite arsenic and benzene exposure, 

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10. SEM Searches. (Continued) 

DOE FWP records, and OHQ results supporting a finding 

of potential occupational exposure to benzene, arsenic 

and plutonium) to determine whether sufficient 

evidence exists to accept the claim. In this 

instance, the evidence as a whole supports acceptance. 

f. Sample SEM Search # 2. An employee claims 

employment as a chemical operator in Building X-705 at 

the Portsmouth GDP from 1966 to 1982. DOE confirms the 

employment. The employee is claiming asthma and 

chronic bronchitis, and medical evidence diagnosing 

COPD has been received. The CE reviews the OHQ and 

finds that the claimant indicated in his interview 

that he does not know specifically what chemicals he 

was exposed to, but does recall working with an acidic 

substance with a sour, vinegar-like odor. 

The CE reviews SEM, searching by labor category and 

building, and finds that acetic acid was used in the 

employee’s work process in Building X-705 and that it 

has a sour, vinegar-like odor. A SEM search for 

health effects for acetic acid shows that it is known 

to be associated with occupational asthma. The DAR 

record response does not show that the claimant worked 

with acetic acid in the course of his employment, but 

that he did come into contact with various solvents. 

The CE should follow up with the treating physician to 

clarify the diagnosis. The CE may consider referral 

to a DMC to review the evidence and determine whether 

or not the potential for acetic acid exposure caused 

the claimant’s lung condition. The CE will also want 

the DMC to try and specify the lung condition. 

g. RECA SEM Searches. When searching for a specific 

RECA location (mine or mill), the CE locates the 

facility by the state in which it operated, by its 

name, or by its alias. For instance, the uranium mill 

“Durango” can be found by searching mills in Colorado, 

by the name “Durango,” or by searching the site alias: 

Vanadium Corp of America, or VCA. 

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10. SEM Searches. (Continued) 

RECA mines are also located in SEM by the county in 

which they operated. RECA mine and mill work process 

categories are more general than the DOE work process 

categories. The CE attempts to determine the exact 

labor category (specific job title or activity) 

whenever possible when conducting a SEM search about a 

RECA facility. 

Uranium mines are categorized as being either 

underground or surface mines, and typical mining 

operations include the following: drilling; blasting; 

shovel/machine digging; and hauling materials. 

11. SEM Inquiries. Whenever a SEM query is conducted, the 

CE must document the case file record to show that a SEM 

search took place and enter the corresponding ECMS coding. 

a. Recommended Decision. Prior to issuing a 

recommended decision (RD) denying benefits, the CE 

must ensure that the most updated version of the SEM 

data is contained in the case file and referenced 

properly in the decision. 

(1) This is done by double checking the search 

initially conducted to make certain that an 

element not found in the initial search (i.e., a 

toxic substance) has not been added to the SEM 

since the date of the initial search. The CE 

prints out the results of the new search 

immediately prior to issuing the RD. 

(2) The CE must make certain that the SEM record 

is properly preserved in the case file for FAB 

review. SEM will show the latest date on which 

an update was made to the system that changes the 

data available about a given facility. 

(3) If the date listed in SEM remains the same 

as it was when the original search was conducted, 

the CE will know that no new information has been 

added to SEM and no new search is required. 

However, if the date has been changed since the 

date of the last search, the CE must search SEM 

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11. SEM Inquiries. (Continued) 

again to determine whether additions or changes 

will change the outcome of the SEM search and 

potentially affect the outcome of the 

adjudication. 

b. Decisions Issued As Needed. Because SEM is a 

living document that is updated as data becomes 

available, the CE does not wait for information in SEM 

to be updated before issuing a decision. If a SEM 

search is conducted and no information is available, 

or the site is not yet complete or searchable in the 

database, the CE issues a decision after developing 

the case as completely as possible, pursuant to normal 

procedures. 

c. FAB Review. FAB ensures that the SEM search was 

conducted, where applicable, during the FAB review of 

the recommended decision. 

(1) FAB may remand the case to the DO if a SEM 

search was needed but not conducted, or if the 

search was conducted improperly in a way that 

materially affects the outcome of the RD, or if 

the SEM data relied upon by the DO was changed or 

updated significantly enough to warrant 

additional development or a potentially different 

adjudicatory outcome. 

(2) Before issuing the FAB decision, the FAB 

must ensure that the SEM record is the most 

complete and updated data available in SEM and 

that no significant changes (additions of toxic 

substances or changes in work process definitions 

or timeframes) have been made since the issuance 

of the recommended decision. 

(3) This checking of the SEM search data to 

determine whether or not a new data element was 

added that will alter the outcome of the decision 

is conducted in the same manner as set out above 

for denied recommended decisions. 

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11. SEM Inquiries. (Continued) 

(4) The FAB CE/Hearing Representative (HR) does 

not print out a copy of a new search, but places 

an entry into ECMS Notes indicating that no new 

evidence exists in SEM to alter the findings in 

the recommended decision. 

(5) If new evidence is uncovered that does alter 

the findings of the RD, a remand order may be 

necessary. However, if the SEM data is updated 

after the issuance of the recommended decision or 

the DO SEM search, and such update does not 

affect the outcome of the decision, a remand is 

not warranted. 

d. Use of SEM Findings. When using SEM as a finding 

in an RD or a decision of the FAB, the CE/HR cites the 

technical document upon which the SEM data search 

result is founded, as well as SEM, in the decision. 

As always, the DO CE or FAB CE/HR clearly outlines the 

rationale for accepting or denying causation based 

upon all of the evidence weighed as a whole. Below is 

an example of the language approved for use when 

referencing SEM. 

Decision Language Example: Source documents used to 

compile the U.S. Department of Labor Site Exposure 

Matrices (SEM) establish that a person in the labor 

category of “Operator” at the Savannah River Site 

could potentially be exposed to the toxic substance 

asbestos. The SEM lists asbestosis as a possible 

specific health effect of exposure to asbestos and 

contains a list of the buildings at the Savannah River 

Site where that particular toxic substance is or was 

present during the years that the claimant worked 

there. The employment record provided by the 

Department of Energy (DOE) contains several numbers 

that appear to reference the employee’s work location 

including a number G160-235. The most comparable 

building listed in the SEM was 235F. Data contained 

in SEM for 235F establishes that asbestos was used in 

this building and that the labor category of 

“Operator” is associated with this building. 

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12. National Office Specialist Review. If the CE 

identifies an exposure issue that requires review by an IH, 

the CE alerts his or her supervisor. Prior to seeking NO 

assistance, the CE must exhaust all reasonable exposure 

development pursuant to the guidance set out in this 

Chapter. 

If the supervisor grants approval for the referral, the CE 

prepares an e-mail to the Health Services Program Analyst 

(HSPA) requesting review. The HSPA forwards the e-mail to 

a Medical Health Science Unit (MHSU) specialist who reviews 

the contents and assigns the question to the appropriate 

specialist based upon their scientific discipline. 

However, if the MHSU specialist determines that the issue 

does not warrant a referral, the e-mail is returned 

instructing the CE to pursue further development. Once the 

issue is assigned to an IH for review, the IH conducts such 

review and responds to the CE in a timely manner. 

a. Questions for IH. The CE outlines succinctly 

what information is known about the issue (e.g., the 

employee was a stainless steel welder at Savannah 

River from 1982 to 1985 who is diagnosed with asthma) 

and what is needed from the expert (could the employee 

have been exposed to nickel)? The CE uses the 

information in SEM and the case file as a whole to 

frame the question as carefully as possible based upon 

the claimed employment, process and illness. A 

Statement of Accepted Facts (SOAF) must accompany the 

referral to the IH. 

(1) The facility in question (narrowed down to 

building and area where possible) and the work 

performed is always a critical factor when 

querying the IH about exposure. The CE uses SEM 

whenever possible to assist in this narrowing 

process, but if no information exists in SEM, the 

CE crafts the question as best as possible based 

upon whatever evidence is available in the case 

file. 

(2) The CE may also forward a general question 

about a facility when information cannot be found 

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12. National Office Specialist Review. (Continued) 

in SEM and the facility in question is either not 

yet uploaded to SEM or the data is incomplete. 

For instance, a CE may need to know whether 

asbestos was present as a general rule in the 

Clarksville facility. The CE may ask a general 

question such as this of the IH, but should 

include as much specificity in the query as 

possible, especially labor category, processes, 

and time periods. 

b. IH Review. The IH reviews the issue framed by 

the CE and determines whether more information from 

the case file is required to answer the question, or 

if the entire case file is needed. The IH role is to 

anticipate, recognize, and evaluate hazardous 

conditions in occupational environments, and to opine 

based upon his or her specialized knowledge. The IH 

strives to answer the question based upon the 

information outlined by the CE. 

However, if additional information is required, the IH 

may request whatever documentation from the case file 

is necessary. If required, the IH requests the entire 

case file if individual pieces of information from the 

file will not suffice to answer the question posed by 

the CE. 

(1) The IH mainly addresses issues about routes 

of exposure (e.g., whether or not a welder at a 

given facility could have been exposed to 

nickel). An IH also may verify whether or not a 

toxic substance was/could have been present 

during a certain work process (e.g., welding, or 

instrument maintenance) at a given site, or if a 

certain labor category (e.g., welder, or 

instrument mechanic) could have come into contact 

with a given toxic substance in the performance 

of his or her duty at the site. 

The IH may also be asked to determine the 

plausibility that a certain toxic substance was 

present or that a claimed exposure could have 

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12. National Office Specialist Review. (Continued) 

occurred based upon the work history and/or 

accident/incident report. 

(2) The IH also reviews SEM searches performed 

by the DO to determine whether or not they were 

performed correctly and accurately. 

c. Request for Case File. If the IH requests the 

entire case file, the CE prepares the WS/WR memorandum 

for the DD’s signature. The WS/WR memorandum is 

addressed to the Policy Branch Chief at NO. Upon 

receipt of the case file, the Policy Branch Chief 

forwards the case file to the IH for review. 

 

d. IH Memorandum. The IH renders an expert opinion 

in the form of a memorandum that addresses the issue 

as specifically as possible. The IH’s reply addresses 

the specific question posed by the CE in the email/SOAF/WS/WR memorandum, and employs his or her 

specialized training to make findings based upon the 

evidence of file and clearly rationalized science. 

e. DMC Referrals to IH. In certain instances, a 

case forwarded to a DMC may not contain enough 

information regarding occupational toxic exposure for 

the DMC to render an expert opinion. In these 

situations, the DMC should refer the case to an IH 

through the DO. 

(1) DMC referrals for causation which do not 

adequately identify a route and extent of 

exposure require the DMC to contact the Medical 

Scheduler (MS) via e-mail within 3 days of 

receipt of the referral package, and request an 

IH referral. If exposure data are inadequate due 

to an incomplete SEM profile, incomplete DOE 

records, or other missing information that makes 

a causation determination impossible without a 

clearer exposure evaluation, then an IH referral 

is warranted. If the Medical Scheduler is 

unavailable the DMC should then contact the 

assigned CE. 

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12. National Office Specialist Review. (Continued) 

(2) The MS forwards the DMC’s IH referral 

request via email to the assigned CE for review. 

A copy of this email is placed in the case file. 

Telephone requests for an IH referral must be 

documented in the Telephone Management System 

(TMS). 

(3) Upon receipt of the email from the MS, the 

CE forwards the case file and Statement of 

Accepted Facts (SOAF) to the Supervisor/Senior CE 

for review. If the Supervisor/Senior CE concurs 

with the need for an IH referral, he or she sends 

an email with the SOAF attached to the Health 

Services Program Analyst (HSPA) located at the 

NO, requesting an IH review and places a copy of 

the SOAF and the sent email in the claimant’s 

file. The CE enters the “WS” code into ECMS 

(Washington, DC: Sent To), with a reason code of 

“IH” (Industrial Hygienist Review) (see DEEOIC 

ECMS procedures for status effective dates and 

other information). The “WS” code ensures that 

the time taken for review by an IH will not be 

counted as time necessary for DMC review. 

(a) Upon receipt of the email from the 

Supervisor/Senior CE, the HSPA assigns the 

referral to an IH. 

(b) The IH reviews the SOAF and any other 

relevant information that may be requested, 

and renders an expert opinion in the form of 

a memorandum based upon the facts of the 

claim, the information available through 

SEM, and professional judgment regarding the 

likelihood and extent of any exposure(s). 

The IH then emails a copy of the memorandum 

to the CE, Senior CE, and Supervisor. 

(c) The IH has 15 days from receipt of the 

referral to complete the memorandum. If 15 

or more days pass without receipt of the 

memo, the CE notifies the Senior 

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12. National Office Specialist Review. (Continued) 

CE/Supervisor, who then follows up with an 

email to the HSPA. 

(d) When the IH memo is received the CE 

reviews the opinion to ensure that the 

question asked has been sufficiently 

answered, gives a copy of the memorandum to 

the MS, and places a copy in the claimant’s 

file. The CE then enters the “WR” code into 

ECMS (Washington, DC: Received Back From). 

(e) The MS will FedEx a copy of the IH 

memorandum to the DMC for review and notify 

the CE, Senior CE, and the Supervisor via email of when this action was taken. 

(4) The CE continues to monitor and track the 

file after the IH memorandum has been furnished 

to the DMC. 

(a) The DMC has 21 days from the date of 

receipt of the IH memorandum to return a 

completed report accompanied by a bill to 

the MS. If the DMC report is not received 

within 21 days from the date of the IH 

memorandum, the CE notifies the MS, who 

follows up with a phone call to the DMC. 

The call is documented in TMS. 

(b) If, upon review of the IH memorandum, 

the DMC has questions, the DMC contacts the 

IH via email. 

(5) If the Supervisor/Senior CE determines that 

the case does not warrant an IH referral after 

receiving the SOAF and file from the CE, the 

Supervisor/Senior CE returns the SOAF and case 

file to the CE with instructions to pursue 

further exposure development. 

(a) The CE notifies the MS via email that 

further exposure development is needed, 

places a copy of the sent email in the case 

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12. National Office Specialist Review. (Continued) 

file, and mails an exposure development 

letter to the claimant. In the letter to 

the claimant, the CE advises that exposure 

development is needed for adjudication. The 

CE enters code DO (TD) - Development of 

Toxic Exposure into ECMS with a status 

effective date the date of the letter. Upon 

mailing the request to the claimant the CE 

enters an ECMS note describing the action 

and inserts a 30-day call-up. 

(b) The MS notifies the DMC via phone that 

further exposure development is needed for 

the case. The call is documented in TMS. 

(c) After 30 days has passed with no 

response from the claimant, the CE prepares 

a second letter to the claimant (accompanied 

by a copy of the initial letter), advising 

that following the initial letter, no 

additional information has been received. 

The CE advises that an additional period of 

30 days will be granted for the submission 

of requested information, and if the 

information is not received a decision will 

be issued. The CE enters code DO (TD) - 

Development of Toxic Exposure into ECMS with 

a status effective date the date of the 

second letter. 

(d) The CE notifies the MS via email that 

the requested information has not been 

received, places a copy of the sent email in 

the case file. 

(e) Upon receipt of the email from the CE 

the MS prepares a letter to the DMC 

notifying that the requested information has 

not been received. In the letter, the MS 

requests the DMC to return or destroy the 

case material. A copy of this letter is 

placed in the case file. 

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12. National Office Specialist Review. (Continued) 

(f) If the claimant submits relevant 

exposure data in response to the CE’s 

request, it must be reviewed to determine if 

it is of sufficient probative value to 

request an IH referral or return to the DMC. 

If the CE determines that there is 

insufficient evidence to warrant an IH 

referral, a decision can be issued. If the 

CE determines that the new information is 

sufficiently comprehensive to obviate the 

need for IH review, referral to the DMC can 

be completed. 

f. Complex Referrals. Some referrals to NO will be 

so complex as to require IH and medical or possibly 

toxicology review. In these instances, the NO Medical 

Director and/or the NO Toxicologist may also review 

the case materials/case file to assist in addressing 

the CE’s inquiry. The proper specialist will be 

determined by an MHSU specialist at NO upon review of 

the query and/or case file materials. The NO Medical 

Director and/or Toxicologist will provide expert 

opinions in such cases where a review is necessary by 

more than one specialist at the same time. 

If an issue referred to the NO contains elements that 

might require expertise in the field of occupational 

exposure, medicine, and/or toxicology, it is forwarded 

to NO as outlined above with an initial e-mail query. 

The appropriate specialist(s) will review the query 

and determine what additional information (including 

the case file) is necessary to resolve the issue at 

hand. 

g. Synergistic or Additive Effect. In certain 

instances a physician might opine that a claimant’s 

radiation and toxic substance exposure together worked 

in tandem to produce a synergistic or additive effect 

that brought about a cancer. DOL has not found 

scientific evidence to date establishing a synergistic 

or additive effect between radiation and exposure to a 

toxic substance, and if the physician presents this 

finding he or she must provide actual scientific or 

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12. National Office Specialist Review. (Continued) 

medical research evidence to support the finding 

before the CE may consider the assertion.

If a physician makes this assertion the CE requests 

that the physician provide medical evidence of a 

synergistic or additive effect and a clearly 

rationalized medical opinion as to whether or not the 

effect is of a significant nature to establish that 

the combination of the radiation and the exposure to a 

toxic substance was “at least as likely as not” a 

significant factor in aggravating, contributing to, or 

causing the cancer.

(1) If the physician provides rationalized 

scientific evidence revealing a synergistic or 

additive effect, the DO sends the case file to NO 

for review by a NO Health Physicist (HP) and/or 

the DEEOIC Medical Director. The HP reviews the 

physician report and all evidence of file and 

drafts a memorandum containing his or her 

professional opinion as to causation which is 

sent to the CE for use in issuing a determination 

in the case. See the ECMS section to this Chapter 

for referral coding.

EEOICPA Tr. No. 10-07 44 

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U.S.DEPARTMENT OF LABOR EMPLOYMENT STANDARDS ADMINISTRATION 

 OFFICE OF WORKERS’ COMPENSATION PROGRAMS

 DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL 

ILLNESS COMPENSATION

 (District Office Address) 

(Date)

EMPLOYEE NAME:

CLAIM FILE NUMBER:

(DAR POC Address)

To Whom It May Concern: 

A claim for benefits under the Energy Employees Occupational Illness Compensation Program 

Act (EEOICPA) has been submitted with respect to the employee named above, claiming 

employment at a Department of Energy facility. He or she is claiming that employment for the 

Department of Energy or one of its contractors or subcontractors has contributed to a covered 

illness. Your facility has been identified as having possession of or access to records which may 

identify employment and toxic substance exposure regarding this individual. 

Included as an attachment to this cover letter is a copy of the claimant’s EE-1 or EE-2 Claim for 

Benefits, the EE-3 Employment History and a Document Acquisition Request (DAR) 

Questionnaire. Marked on the attached DAR Questionnaire is the name of the employee, 

employee SSN, employer name and the facility where employment is alleged to have occurred as 

well as selected categories of documentation we hope you have at your facility. 

Please conduct a reasonable search for the requested documentation and provide a copy of those 

records in digital PDF format on a compact disc (CD) if available. You may make as many 

copies of the DAR Questionnaire as necessary. 

Please return the completed DAR Questionnaire, the CD and any hard copy documents to the 

address provided above. If you have received this request in error or if you have any other 

concerns, please feel free to contact me directly at ***-***-  or fax ** *-***-****. 

Sincerely,

Claims Examiner

Attachments:

EE-1/2 Claim for Benefits 

EE-3 Employment History 

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EEOICPA Tr. No. 10-07 Exhibit 2 

January 2010 

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EEOICPA Tr. No. 10-07 Exhibit 2 

January 2010 

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EEOICPA Tr. No. 10-07 Exhibit 2 

January 2010 

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EEOICPA Tr. No. 10-07 Exhibit 2 

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Part 2 – Claims Medical Evidence 

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TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-0800 Developing and Weighing Medical Evidence 

 Table of Contents. . . . . . . i 01/10 10-07 

1 Purpose and Scope. . . . . . . 1 01/10 10-07 

2 Sources of Medical Evidence. . 1 01/10 10-07 

3 Types of Medical Evidence. . . 2 01/10 10-07 

4 Contents of a Medical Report . 3 01/10 10-07 

5 Developing Medical Evidence. . 6 01/10 10-07 

6 Weighing Medical Evidence. . . 8 01/10 10-07 

7 Using Death Certificate to 

 Establish Diagnosis. . . . . 11 01/10 10-07 

8 Using Affidavits to 

 Establish Date of Diagnosis. 12 01/10 10-07 

9 Reviews by District Medical 

 Consultant (DMC) . . . . . . 12 01/10 10-07 

10 Role of CE in DMC Referrals . 13 01/10 10-07 

11 Role of Medical Scheduler in 

 DMC Referrals. . . . . . . . 21 01/10 10-07 

12 Second Opinion Examinations. . 23 01/10 10-07 

13 Referee Specialist 

 Examinations . . . . . . . . 27 01/10 10-07 

14 Failure to Undergo 

 Medical Examination . . . . 29 01/10 10-07 

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Paragraph and Subject Page Date Trans. No. 

Exhibits 

 1 Medical Consultant 

 Referral Form . . . . . . . . 01/10 10-07 

 2 Statement Of Accepted Facts 

 (SOAF). . . . . . . . . . . . 01/10 10-07 

 3 Sample Questions for DMC . . . 

 4 ICD-9 Codes and Corresponding 

 Procedure Codes . . . . . . . 01/10 10-07 

 5 Sample Letter to District 

 Medical Consultant. . . . . . 01/10 10-07 

 6 Sample Letter to Second 

 Opinion/Referee Physician. . . 01/10 10-07

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1. Purpose and Scope. Proper development and weighing of 

medical evidence is essential to the sound adjudication of 

claims for benefits and to the comprehensive management of 

Energy Employees Occupational Illness Compensation Program Act 

(EEOICPA) claims. This chapter discusses the Claims Examiner’s 

(CE) function in developing and evaluating medical evidence and 

weighing conflicting medical opinions. 

2. Sources of Medical Evidence. Most medical reports come 

from one of these sources: 

a. Claimant's health care provider, including the 

attending physician, consulting experts and medical 

facilities. Treatment records from a clinic operated at an 

employing facility would also be considered records of a 

health care provider. 

b. Department of Energy’s Medical Monitoring Programs, 

administered by certain Department of Energy (DOE) 

facilities that maintain medical examination records and 

exposure data on their employees. For example, the DOE 

Former Worker Programs began in 1996 and are designed to 

evaluate the effects of the DOE's past operations on the 

health of former workers at DOE facilities, and offer 

medical screening to former workers. 

c. ORISE (Oak Ridge Institute for Science and Education), 

which administers the beryllium screening program by 

providing initial beryllium-related testing at various 

locations across the country. Individuals who test 

positive for beryllium sensitivity are offered more 

extensive testing for chronic beryllium disease (CBD) and 

medical monitoring. 

d. District Medical Consultants (DMC), who furnish 

medical opinions, guidance and advice based upon review of 

the case file and familiarity with EEOICPA requirements. 

e. Second Opinion Physicians, who may provide 

examination, diagnostic testing, and rationalized medical 

opinion when a detailed, comprehensive report and opinion 

are needed from a specialist in the appropriate field. 

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2. Sources of Medical Evidence. (Continued) 

f. Referee Specialists, who may examine the employee, 

arrange diagnostic tests and furnish rationalized medical 

opinion to resolve conflicts between the claimant's 

physician and the DMC/Second Opinion Physician where the 

weight of medical evidence is equally balanced. 

3. Types of Medical Evidence. Medical evidence in EEOICPA 

cases consists of the following major categories: 

a. Treatment records are the most prevalent form of 

medical evidence. They consist of any record made during 

the evaluation, diagnosis and treatment of a patient by his 

or her health care providers. They include: 

(1) Attending physician records (e.g., chart notes, 

reports, etc.) They include records of medical 

consultants assisting the attending physician. 

(2) Records of doctors consulted by the patient for 

an independent medical opinion. 

(3) Evidence of diagnostic testing (e.g., x-ray 

films, EKG tracing, etc.) and the reports of medical 

providers interpreting the tests. 

(4) Treatment records from hospitals, hospices, or 

other health care facilities. 

b. Medical evaluations may occur for a variety of reasons 

other than to further the diagnosis and treatment of the 

patient. What distinguishes medical evaluations from 

treatment records is the purpose of the examination. 

Medical evaluations include: 

(1) Evidence from the Department of Energy’s Medical 

Monitoring Programs (e.g., former worker screening 

records, pre-employment physicals, termination 

physicals, etc.) 

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3. Types of Medical Evidence. (Continued) 

(2) Examinations required under state or federal 

compensation programs (e.g., evaluations for state 

workers’ compensation claims, Social Security 

disability examination, etc.) 

(3) Medical reports or opinions obtained for 

litigation under state or federal rules of evidence. 

c. EEOICPA reports produced following a referral to a 

DMC, second opinion physician or referee specialist. 

d. Other types of medical evidence include: 

(1) Death certificates which contain information 

about the cause of death or date of diagnosis. 

(2) Secondary evidence relied upon by a doctor in 

forming an opinion. For example, a doctor may rely 

upon information provided by an Industrial Hygienist 

(IH) in determining the cause of an illness. 

(3) Affidavits containing facts based on the 

knowledge of the affiant regarding the date of 

diagnosis. 

(4) Cancer Registry records may be used in some cases 

to establish a diagnosis of cancer and date of 

diagnosis. 

4. Contents of a Medical Report. The value of findings and 

conclusions contained in medical records varies. 

a. Treatment Records. 

(1) A doctor’s report of examination usually contains 

a description of subjective complaints, objective 

findings, assessment and plan for follow up or 

treatment. The Subjective, Objective, Assessment and 

Plan format is often shown in the medical records by 

the letters S, O, A and P. Even where the SOAP 

abbreviation is not used, the records tend to follow 

this pattern. 

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4. Contents of a Medical Report. (Continued) 

(a) The subjective section records information 

obtained from the patient. It generally contains 

information about why he or she is seeking 

treatment, complaints, medical history and 

current treatment. A subjective section might 

state, for example, “Patient comes in today to 

have us look at a lump on his neck that has 

gotten larger over the last month.” 

 

(b) The objective section records the doctor’s 

findings based on his observation, examination 

and testing. An objective section might state, 

for example, “The patient looks older than his 

stated age, his breathing is labored and his xray shows a spot on his left lung.” The three 

general classes of objective findings are: 

 

 (i) Laboratory findings such as complete 

blood count (CBC), tissue biopsy, bone 

marrow smear or biopsy, beryllium lymphocyte 

proliferation test (LPT), etc. 

(ii) Diagnostic procedures such as x-rays, 

ultrasound, computerized axial tomography 

(CAT), magnetic resonance imaging (MRI), 

electromyelogram (EMG) and similar 

techniques of visualizing or recording 

physiological conditions. Some objective 

tests are subject to greater interpretation 

by the health care provider. 

For example, an x-ray used to diagnose a 

broken leg is more objective, while a 

Minnesota Multiphasic Personality Inventory 

(MMPI) used to diagnose schizophrenia is 

more subjective. 

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4. Contents of a Medical Report. (Continued) 

(iii) Physical findings which are noted by 

the doctor’s visual inspection, palpation 

and manipulation of the body. They include 

description of demeanor, readings of 

temperature or pulse, description of 

respiration, observation of affect, etc. 

(c) The assessment section contains the doctor’s 

opinions, suspicions and diagnoses. In most 

cases, the value of a medical report is found in 

the assessment. The scope of the assessment will 

vary with the type of medical condition and its 

complexity. 

The assessment section may contain statements 

such as, “The pathology report was reviewed and 

showed the presence of small cell carcinoma of 

the lung” or “Based on the patient’s rest tremor, 

balance problems and rigidity of muscles, I 

believe he has Parkinson’s disease.” 

(d) The plan section describes the treatment 

plan and prognosis. The doctor may, for example, 

prescribe medication, refer the patient to an 

expert, or suggest additional testing. 

(2) Reports of tests and procedures should contain 

the employee’s name, date of the test, the objective 

data obtained, and the signature of the person 

responsible for conducting the test or procedure. 

Where appropriate, reports should include a 

physician’s interpretation of laboratory tests or 

diagnostic procedures. 

Tests for which interpretation is necessary include, 

but are not limited to, pathology reports, lymphocyte 

proliferation tests, X-rays, MRIs, CAT scans, 

pulmonary function tests, MMPIs, and the Beck 

Depression Inventory. In cases where no interpretation 

is provided, the CE must seek a medical 

interpretation. The CE is not to interpret test 

results, as that is a medical judgment. 

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4. Contents of a Medical Report. (Continued) 

(3) Hospital, hospice and clinic records will contain 

the same type of doctor’s records and diagnostic 

testing as outlined above. Also, the CE should review 

the admission summary, surgery reports, nursing notes, 

the discharge summary, autopsy reports, etc. 

b. Medical Evaluations. Generally, medical evaluations 

contain the following types of information: 

 

(1) A description of why the examination is being 

conducted. The report may state, for example, “Mr. 

Smith is referred by the Department of Labor and 

Industries for an independent medical evaluation 

regarding his claim for asbestosis.” 

(2) A description of the information the physician 

has reviewed and relied upon in reaching his or her 

conclusions. This often includes a discussion of the 

course of treatment, which describes past treatment 

undergone by the patient and the physician’s 

recommendation for present and future care. 

(3) A description of any examination and tests 

performed during the evaluation. 

(4) Opinions of the evaluating physician with an 

explanation of evidence used and a discussion of how 

the conclusions were reached. 

 c. EEOICP Referrals. DMC, Second Opinion Physician or 

Referee Specialist reports should contain the same general 

information as any other medical assessment. In addition, 

the report should contain a well-reasoned response to any 

questions presented by the CE in the referral, including a 

summary of the evidence and medical references used. 

5. Developing Medical Evidence. Although it is ultimately 

the responsibility of the claimant to submit medical evidence in 

support of his or her claim, the CE must assist the claimant to 

meet the statutory requirement for medical evidence for any 

illness claimed. This may include seeking clarification from a 

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5. Developing Medical Evidence. (Continued) 

DMC, a second opinion physician or a referee specialist. The CE 

develops medical evidence to adjudicate a claim, determine 

percentage of impairment, establish a causal relationship 

between a covered illness and wage-loss, and resolve 

inconsistencies and conflicts in medical opinions. 

a. Deficient Evidence. When a deficiency in the medical 

evidence is identified, the CE contacts the claimant or the 

treating physician to request additional medical evidence. 

For example, an initial claim is submitted to the District 

Office (DO) for skin cancer but does not include a 

pathology report or any other positive diagnostic evidence. 

The CE writes to the claimant, identifies the deficiency 

and requests the specific evidence needed to establish skin 

cancer under Part B and Part E. 

b. Telephone Requests. In many situations, a minor 

deficiency in the medical evidence can be easily overcome 

with a telephone call to the physician’s office to request 

specific documents. If, however, a phone call does not 

produce a favorable result, the CE should send a written 

request. 

(1) Statements made by the physician over the 

telephone do not constitute valid medical evidence. 

(2) If the doctor relays information essential to the 

outcome of a claim, the CE must document the call in 

ECMS and request that the physician submit a written 

statement. 

c. Written Requests. The CE may decide that the best 

method of collecting the evidence is to submit a written 

inquiry directly to the physician (with a copy to the 

claimant). 

(1) If records are requested from a treating 

physician, the Form EE-1/EE-2 submitted by the 

claimant serves as a medical release to obtain the 

requested medical information. 

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5. Developing Medical Evidence. (Continued) 

(2) If a reply is not received within 30-45 days or 

the response does not resolve the deficiency, the CE 

considers other options for obtaining the required 

medical evidence (e.g., a DMC referral, cancer 

registry or death certificate). 

d. Unavailable Medical Records. If a treating 

physician’s records have been destroyed or are otherwise 

unavailable, the CE attempts to obtain a statement from 

that physician. 

(1) The Physician’s Statement should contain the 

following information: 

(a) An affirmation that the physician treated 

the employee for the claimed condition(s). 

(b) A statement that the requested medical 

records are no longer available. 

(c) A discussion that includes the diagnosis and 

date of diagnosis. 

(d) The physician’s signature and the date 

signed. 

(2) A Physician’s Statement is considered a medical 

document and not an affidavit. 

6. Weighing Medical Evidence. When medical evidence is 

submitted from more than one source, the CE must evaluate the 

relative value, or merit, of each piece of medical evidence. 

This is particularly important in cases where there is a 

conflict between the medical evidence received from the DMC and 

the treating physician. A thorough understanding of how to weigh 

medical evidence will assist the CE in determining when and how 

further medical development should be undertaken and assigning 

weight to the medical evidence received. 

a. How to Evaluate Evidence. In evaluating the merits of 

medical reports, the CE assigns greater value to: 

 

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6. Weighing Medical Evidence. (Continued) 

(1) An opinion based on complete factual and medical 

information over an opinion based on incomplete, 

subjective or inaccurate information. 

(2) A well-reasoned or well-rationalized opinion over 

one that is speculative. 

(3) The opinion of an expert in the relevant medical 

field over the opinion of a general practitioner or an 

expert in an unrelated field. 

(a) Medical evidence used to establish a 

compensable medical condition must be from a 

physician. The definition of physician includes 

surgeons, podiatrists, dentists, clinical 

psychologists, psychiatrists, occupational 

medicine practitioners, optometrists, and 

osteopathic practitioners within the scope of 

their practice as defined by state law. 

(b) Chiropractors may only be considered 

physicians in EEOICPA cases for treatment of 

manual manipulation of the spine to correct a 

subluxation as demonstrated by x-ray to exist 

(usually relevant only in consequential 

injuries). 

(c) However, chiropractic care may be authorized 

as treatment for an accepted condition. Any such 

treatment must be prescribed by a physician, and 

the physician must provide rationale as to how 

the type of treatment in question relates to the 

covered condition. 

b. In weighing medical evidence, the CE evaluates the 

probative value of each piece of the evidence of file and 

considers the following questions with respect to each 

report. 

(1) Is there a definitive test? Some conditions can 

be established by objective testing. A positive 

pathology report from a physician is sufficient 

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6. Weighing Medical Evidence. (Continued) 

evidence of the diagnosis of cancer. A physician’s 

report of a positive beryllium lymphocyte 

proliferation test of lung lavage cells showing 

abnormal findings is sufficient evidence of the 

diagnosis of beryllium sensitivity. 

(2) Is the physician’s opinion rationalized? The 

term “rationalized” means that the statements of the 

physician are supported by an explanation of how his 

or her conclusions are reached. This explanation and 

discussion are what constitutes medical rationale. 

This is of particular importance when there is a 

complex medical issue or when there are conflicting 

medical opinions in the case file. 

(3) Is the physician’s opinion based upon a complete 

and accurate medical and factual history? For 

example, a physician opined that his patient’s lung 

cancer is related to exposure to diesel engine 

exhaust. This doctor’s opinion has less probative 

value if the doctor erroneously cites an incorrect 

date of diagnosis or exposure date. 

(4) Is the physician a specialist in the appropriate 

field? The physician's qualifications will have a 

bearing on the probative value of his or her opinion. 

For example, if a general practitioner has a patient 

with rest tremors, balance problems and muscle 

rigidity, a diagnosis of alcohol abuse with 

dehydration may seem reasonable. However, if a 

conflicting report is received from a board-certified 

neurologist diagnosing Parkinson’s disease based on 

the same symptoms, it would carry greater weight 

because a neurologist is an expert on neurological 

disorders. This is particularly true for an illness 

like Parkinson’s disease that cannot be confirmed by 

an objective laboratory test. 

(5) Is the physician’s opinion consistent with the 

findings? A physician’s preoperative opinion that a 

patient has cancer is of little probative value if the 

pathology report of a tumor biopsy shows no malignancy. 

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7. Using Death Certificate to Establish Diagnosis. A death 

certificate signed by a physician may be used to establish a 

diagnosis of cancer if the following actions have failed to 

produce viable medical evidence: 

a. Claimant Advised. The CE must advise the claimant in 

writing of the medical evidence necessary to establish a 

diagnosis of cancer and grant him or her the opportunity to 

submit all available medical records. This letter must 

address the specific documents that are missing and explain 

the specific types of records needed. 

b. Additional Medical Development. If the claimant 

cannot secure medical records, the CE must contact 

potential sources of medical information, such as doctors’ 

offices, hospitals, clinics, nursing facilities, or 

laboratories, to determine whether any records exist which 

could establish a diagnosis. The CE requests, either in 

writing or by telephone, any medical records and reports 

that may include a diagnosis (i.e., pathology report, 

autopsy report, physicians’ reports, lab results, medical 

payments, hospitalization, surgeries, initial examinations, 

referrals, etc). Any contact with a medical facility must 

be documented in the case file or ECMS even if the outcome 

is not positive. 

In most cases, a death certificate must be signed by a physician 

to be accepted as medical evidence. However, if the death 

certificate lists the name of the physician as the certifier, 

but is not signed, this is still acceptable if the death 

certificate is signed by another official attesting to its 

truthfulness. 

Some states have implemented electronic upload of death 

certificates. A death certificate may be used to establish a 

diagnosis of cancer if it listed the physician as the certifier 

along with a license number and an electronic signature. 

Nothing in this section should be interpreted as limiting the 

use of a death certificate for other purposes, such as evidence 

of the cause of death under Part E. 

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8. Using Affidavits to Establish Date of Diagnosis. While an 

affidavit cannot be used to establish a medical diagnosis, it 

can be used to establish a date of diagnosis after the CE has 

made a reasonable effort to establish the date of diagnosis from 

the medical records. CE actions should include the following: 

a. Advice to Claimant. The claimant must be advised in 

writing that medical evidence (i.e., pathology report, 

autopsy report, physician’s reports) should be submitted to 

establish a date of diagnosis. 

b. Additional Medical Development. If the claimant and 

the CE cannot obtain medical evidence to establish the date 

of diagnosis, the CE must request copies of affidavits from 

those in a position to know the former worker’s condition 

during the illness. For example, a home health nurse or 

relative who provided care to the employee may provide an 

affidavit. 

c. Death Certificate. If reliable affidavits are not 

received, then the CE may use the date of diagnosis or date 

of death from the death certificate. 

 

d. Medical Review. If an affidavit reveals evidence of a 

medical condition, but no physician’s diagnosis is 

contained in the file, the case may be forwarded to either 

the DMC or to an outside physician for review and possible 

confirmation of a diagnosis. 

 

9. Reviews by District Medical Consultant (DMC). A DMC plays 

a vital role in resolving medical issues by evaluating medical 

evidence and rendering independent medical opinions. The DMC is 

crucial in cases where the employee is deceased and the medical 

records are minimal or inconclusive. Some other examples of DMC 

services include the following: 

a. Clarification and confirmation of diagnosis if the 

evidence is inconclusive. 

b. Opinion about consequential injuries or surgical 

procedures to determine coverage under the Act. 

c. Opinion on the appropriateness of medical treatment. 

 

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9. Reviews by District Medical Consultant (DMC). (Continued) 

d. Opinion on causation under Part E from a medical 

 standpoint. 

 

e. Opinion regarding the onset and period of illnessrelated disability for a wage-loss claim. 

f. Opinion on impairment if the employee elects to have a 

DMC perform the rating. 

g. DMC may interpret and clarify other physicians’ 

reports, test results or technical language in complex 

cases or cases where the attending physician is deceased. 

10. Role of CE in DMC Referrals. The CE maintains 

responsibility for the case and uses the services of the DMC 

only for direction and clarification. Under Part E, the CE must 

have fully evaluated toxic exposure including the use of Site 

Exposure Matrix (SEM) or referral to Industrial Hygienist (IH) 

prior to DMC referral. 

a. CE determines when a DMC referral is required. 

(1) The following are some examples of when a DMC 

referral may be required: 

(a) The CE is unable to conclude whether pre1993 medical evidence is sufficient to diagnose 

chronic beryllium disease. 

(b) Medical tests are submitted which do not 

provide clear diagnosis or interpretation (e.g., 

an LPT that does not clearly state that the test 

is positive or negative). 

(c) It is unclear if a medical condition not 

shown on the death certificate was a significant 

factor in causing, contributing to or aggravating 

an employee’s death. For example, an employee 

dies of a heart condition, but the covered 

condition claimed by a survivor was asbestosis. 

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10. Role of CE in DMC Referrals. (Continued) 

(d) To determine if the confirmed exposure to a 

toxic substance is linked to the illness claimed 

by the employee. 

 (2) The followings are examples of when a DMC 

referral may not be necessary: 

(a) The CE determines other action, such as 

requesting additional records from the claimant 

or treating physician, may be more appropriate. 

In most cases, a DMC referral is not necessary if 

the treating physician with the proper expertise 

provides plausible medical evidence that is well 

rationalized. 

(b) The CE determines that additional evidence 

relevant to the DMC referral might be available 

through an Occupational History Interview or 

Document Acquisition Request. Once the relevant 

evidence is reviewed, a DMC referral may not be 

necessary, e.g., when there is no evidence of 

exposure to a toxic substance. 

 b. Referral to DMC. When referring a case to a DMC, the 

CE must provide the following to the Medical Scheduler as a 

complete package: 

(1) A Medical Consultant Referral Form (Exhibit 1). 

The CE completes the entire form (except the name and 

address of the DMC, which the Medical Scheduler 

enters), signs it and places it on the front of the 

referral package. It is crucial that the CE selects 

the most appropriate preferred medical specialty to 

perform the review. The CE considers the following in 

determining the preferred medical specialty: 

(a) Causation questions are usually best handled 

by occupational medicine specialists. 

Occupational medical specialists can also 

evaluate the diagnosis and treatment of 

occupational lung conditions, i.e. asbestosis, 

silicosis, CBD, pneumoconiosis, and COPD. 

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10. Role of CE in DMC Referrals. (Continued) 

(b) Diagnosis or treatment questions are usually 

best handled by medical specialists for the 

condition or procedure being considered. 

Selecting generalist/internal medicine/family 

practice is appropriate if the condition involves 

a medical specialty not listed on the referral 

form. For example, heart problem, kidney problem 

or bone and joint problem should be directed to a 

generalist. 

(c) Impairment questions are best performed by 

specialists with specific impairment experience 

for the particular organ system. 

(2) A Statement of Accepted Facts (SOAF) (Exhibit 2), 

which is a narrative summary of the factual findings 

in a case. It must include: 

(a) Identifying information, including the 

claimant’s name, case file number and relevant 

personal information (e.g., date of birth, date 

of death, etc). 

(b) A description of the medical evidence, 

including any accepted conditions or other 

diagnosed medical conditions. Medical 

information in the case file that is not relevant 

to the referral need not be reiterated in the 

SOAF. 

(c) A detailed description of the claimant’s 

employment history and exposure data including 

any relevant information from Site Exposure 

Matrices (SEM) and opinion from the industrial 

hygienist (IH) referral. 

(i) Where the employee worked, dates of 

employment, and his or her job title and 

duties if relevant to the referral. 

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10. Role of CE in DMC Referrals. (Continued) 

(ii) Any exposure of the employee to toxic 

substances that are linked to the claimed 

medical condition. 

(iii) Information about the nature, extent 

and duration of exposure. 

(iv) Job descriptions or industrial hygiene 

records, if available. If not, data from 

the United States Department of Labor, 

Bureau of Labor Statistics, Occupational 

Outlook Handbook, found on the internet at: 

http://www.bls.gov/search/ooh.asp?ct=OOH

For example, using this site the CE might 

state, “The DOL Bureau of Labor Statistics 

has found that the job of Boilermakers and 

boilermaker mechanics is to make, install, 

and repair boilers, vats, and other large 

vessels that hold liquids and gases. 

Boilers supply steam to drive huge turbines 

in electric power plants and to provide heat 

and power in buildings, factories, and 

ships.” 

(d) General Requirements for SOAF:

(i) All evidence on which the SOAF is based 

must be part of the case record. The CE may 

not make findings based on undocumented 

evidence. 

 

(ii) Facts must be complete and correctly 

stated. Omission of a critical fact or 

incorrect statement diminishes the validity 

of a medical opinion. 

(iii) Facts must be specific as to time of 

occurrence. Whenever possible, workplace 

factors should be quantified so the 

physician can correlate the exposure with 

medical or scientific data on causality. 

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10. Role of CE in DMC Referrals. (Continued) 

Quantification might include levels of 

exposure, concentrations of asbestos fibers 

in the air, levels of noxious substances, 

the (approximate) number of times exposed, 

etc. Terms such as light, heavy, undue, 

severe, and abnormal should be avoided, 

since they are subject to great differences 

of interpretation. 

(iv) Facts must be clearly stated. Simple 

words and direct statements reduce the 

potential for ambiguity or 

misinterpretation. Use of legal terms and 

program jargon should be avoided. 

(v) Facts must be presented in an orderly 

manner, and grouped chronologically within 

sections relating to employment, exposures, 

and medical conditions. 

(3) List of Questions for the DMC to address. (See 

Exhibit #3 for example) 

(a) For referrals under Part B, questions should 

be specific to each statutory requirement for any 

of the compensable occupational illnesses. 

(b) The CE must limit the questions to those 

that address the particular issue or problem for 

which clarification is required. Questions must 

be specific. 

For example, in a pre-1993 CBD claim, a general 

question is, “Based upon your review of the 

enclosed medical evidence, do you feel that the 

claimant had CBD?” A specific question is, “Does 

the x-ray show characteristic abnormalities 

consistent with CBD?” 

(c) For referrals under Part E, questions should 

identify the standard of proof required. 

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10. Role of CE in DMC Referrals. (Continued) 

For example, rather than ask “Was asbestosis a 

cause of death?” the CE asks, “Is it at least as 

likely as not that asbestosis was a significant 

factor in causing, contributing to or aggravating 

the employee’s death?” 

(d) The CE is not to rely upon the DMC for any 

non-medical issues, for example requesting legal 

conclusions (e.g., whether the employee has 

cancer as defined by the EEOICPA). 

(4) A Form OWCP-1500 (Health Insurance Claim Form), 

completed as outlined: 

The CE or Medical Scheduler initially completes the 

following portions of Form OWCP-1500: Employee’s 

name, address, date of birth, sex and SSN. (If the 

employee is deceased, the address section does not 

need to be completed). Section 24C (type of service) 

and 24E (diagnosis code) must both be completed with a 

“1.” The CE or Medical Scheduler must also enter an 

ICD-9 code in section 21 and a procedure code in 

section 24D. Exhibit 4 provides a list of ICD-9 codes 

and procedure codes that correspond to the type of 

medical service requested. For example, if the OWCP1500 is for payment of a DMC file review for 

impairment, the CE enters ICD-9 code V49.8 in section 

21 and procedure code FR004 in section 24D. 

 

The DMC completes sections 24 A, F, G; 25; 28; 30; 31 

and 33 and signs the bill. The completed form is 

given to the Medical Scheduler. 

 c. Post Referral to DMC. The Medical Scheduler advises 

the CE via email that the case has been sent to the DMC. 

The CE continues to monitor and track the file after the 

request has been sent to the DMC. 

 

 

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10. Role of CE in DMC Referrals. (Continued) 

 (1) If the DMC identifies exposure issues that 

require further development before he or she can render 

a medical opinion, the DMC must contact the Medical 

Scheduler within 7 days of receipt of the referral 

package. The Medical Scheduler advises the CE and the 

CE supervisor. 

 The CE and the supervisor evaluates the exposure issue 

as noted by the DMC to determine if the CE can pursue 

further exposure development or if an IH referral is 

warranted. 

 

 After development, the Medical Scheduler submits the IH 

report or additional exposure information to the same 

DMC to proceed with the medical evaluation. Once the 

issue has been resolved, the DMC has 21 days to return 

a completed report accompanied by a bill to the Medical 

Scheduler. If the DMC has further questions or is 

unable to proceed with rendering a medical opinion, the 

DMC must contact the Medical Scheduler. 

 (2) If the CE does not receive the medical report 

from the DMC within 30 days from the date of the 

completed referral, the CE notifies the Medical 

Scheduler, who follows up with a phone call to the 

DMC. 

(3) Once the medical report and completed OWCP-1500 

is received from the DMC, the CE reviews it for 

accuracy and completeness. The review should include 

the DMC’s interpretation of test results, evaluation 

of medical reports submitted for review, answers to 

each question posed, and the DMC’s rationale showing 

how his or her opinion is supported by the evidence in 

the file. The CE also reviews the OWCP-1500 to ensure 

that fees charged are appropriate to the services 

performed. The basic fee for file review and narrative 

medical report is $300 per hour. DEEOIC has 

established $2,400 as limits for a file review. If a 

bill for medical file review is over $2,400, the CE 

must advise the District Director. 

 

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10. Role of CE in DMC Referrals. (Continued) 

 (a) If the medical report and OWCP-1500 are 

accurate, appropriate and complete, the CE 

contacts the Medical Scheduler to authorize 

payment of the medical bill no later than the 

next business day. 

 

 (b) If the report and OWCP-1500 are not 

accurate, appropriate or complete, the CE 

determines whether a telephone call to the DMC 

can resolve the deficiency. If not, the CE 

notifies the Medical Scheduler by memo or email, 

indicating the discrepancies or deficiencies. If 

necessary, the Medical Scheduler notifies the DMC 

and requests an addendum report and/or 

clarification of the fees charged. 

d. ECMS. To ensure prompt payment of all physician 

referral bills (i.e. DMC, second opinion, referee or expert 

medical bills), ECMS must also be updated to set up the 

"prior approval" process through the medical bill 

processing agent (BPA). The CE enters the prior approval as 

if entering a new medical condition. The following fields 

in ECMS are required:

 (1) Condition Type – Select ‘PA’, for prior approval

(2) ICD-9 Code – Enter the ICD-9 code that 

corresponds to the type of medical bill to be paid. 

The ICD-9 code entered in ECMS must match the ICD-9 

code in the OWCP-1500 as specified in paragraph 

10b(4). See Exhibit 4 for a list of ICD-9 codes. 

(3) Status Effective Date - Enter the date of the 

physcial examination or the date of referral for file 

review.

(4) Eligibility End Date - Enter the date of the 

physcial examination for second/referee/expert 

opinions, or the date the DMC’s response.

(5) Medical Condition Status – Change the medical 

condition status to ‘A’.

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10. Role of CE in DMC Referrals. (Continued) 

e. Request for Report. If the claimant requests a copy 

of the DMC’s report, the CE provides a copy of the report 

with a cover letter, which includes a disclaimer paragraph. 

For example, “Attached is a copy of the medical report that 

you requested. Please be advised that {Enter the DMC’s 

name} is a medical consultant for the Department of Labor. 

The Department of Labor will make the final decision in 

this claim. Please do not contact {Enter the DMC’s name} 

regarding this report. If you have additional evidence to 

submit in support of your claim or if you have any 

questions or concerns regarding this report, please contact 

me at {Enter the DO’s toll free number}. 

f. Advises the District Director or designee, through a 

CE or supervisor, of any problems with regards to the 

timeliness or quality of the DMC reports or complaints from 

the claimant. 

11. Role of Medical Scheduler in DMC Referrals. Each District 

Director designates a Medical Scheduler, who processes and 

tracks DMC referrals and ensures prompt payment of the bills. 

The following are the Medical Scheduler actions: 

 a. Returns any incomplete DMC package to the CE with a 

memo in the front of the file listing the information 

needed. 

b. If the DMC package is complete, emails designated 

National Office staff person on all referrals to an outside 

DMC. This email includes the employee’s name, file number 

and the preferred DMC medical specialty requested. To 

ensure equitable distribution of work among the DMCs, the 

designated National Office staff person chooses a DMC from 

a master list and emails the Medical Scheduler the name of 

the assigned DMC, mailing address, phone number and email 

address. 

c. Compares the list of treating physicians shown on the 

Consultant Referral Form to the assigned DMC from the 

National Office. If a DMC has been involved in the 

treatment of the claimant or if the DMC is not available 

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11. Role of Medical Scheduler in DMC Referrals. (Continued) 

to perform the review, the Medical Scheduler requests 

another DMC from the National Office. 

d. Prepares a cover letter to the DMC after ensuring 

availability. The cover letter includes a description of 

the billing specifications (Exhibit 5). If the package 

does not contain a Form OWCP-1500, the Medical Scheduler 

completes one as outlined above. 

e. Sends a copy of the cover letter, Medical Consultant 

Referral form, SOAF, List of Questions, medical records and 

OWCP-1500 to the DMC, and retains a copy of the cover 

letter and Medical Consultant Referral form outside the 

case file for tracking purposes. 

If referral is to an internal DMC, the cover letter, 

Medical Consultant Referral form and copies of medical 

records need not be provided to the DMC. Rather, the 

entire file can be routed to the internal DMC, who can 

respond to the list of questions submitted based on review 

of the original SOAF and records contained in the case 

file. 

(1) Includes an express mail envelope and air bill so 

that the external DMC can return the completed report 

and bill to the proper DO. 

f. Notifies the CE via email once the package is mailed 

to the external DMC or the file is forwarded to an internal 

DMC. 

g. Maintains a copy of the Form OWCP-1500 along with a 

copy of the medical report in a separate folder when the 

DMC responds within 30 days. The original medical report 

and OWCP-1500 are forwarded to the CE for review and 

inclusion in the case file. 

 h. Requests an addendum report if the CE cannot resolve 

deficiencies in the DMC report directly with the DMC. The 

second request to the DMC for an addendum report must 

include: 

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11. Role of Medical Scheduler in DMC Referrals. (Continued) 

(1) A cover letter to the DMC indicating the 

discrepancies as written by the CE. 

(2) Copies of all medical evidence (or the case file 

for internal DMC referrals). 

(3) The SOAF. 

i. Submits approved OWCP-1500 and a copy of the DMC 

report to the BPA for processing upon confirmation by the 

CE that the DMC report and OWCP-1500 are complete and 

accurate. To ensure prompt payment of the medical bill, 

the Medical Scheduler or Fiscal Officer writes “Approved” 

in the top right hand corner of the OWCP-1500 with a 

signature and date in black ink. The OWCP-1500 must also be 

stamped PROMPT PAY in black ink, and the Prompt Pay date 

(date received in the DO plus 7 days) must be entered in 

block 11. The Medical Scheduler destroys the DMC report and 

OWCP-1500 once BPA has paid the bill. 

j. Serves as the liaison between the DMC and DEEOIC claim 

staff. For example, if the DMC is unable to proceed with 

the medical review for any reason,(e.g., need for an IH 

referral, SOAF is incomplete, etc.), the DMC discusses the 

issue with the Medical Scheduler. The Medical Scheduler 

notifies the CE or the supervisor. 

k. Notifies the District Director or assigned National 

Office staff person of any problems dealing with the DMC or 

a staff member of the DMC.

12. Second Opinion Examinations. Section 30.410 of the EEOICPA 

regulations states that: 

OWCP sometimes needs a second opinion from a medical 

specialist. The employee must submit to examination by a 

qualified physician who conforms to the standards regarding 

conflicts of interest adopted by OWCP as often and at such 

times and places as OWCP considers reasonably necessary. 

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12. Second Opinion Examinations. (Continued) 

To prevent conflicts of interest, a DMC cannot serve as a second 

opinion physician. The databases for DMCs and second opinion 

physicians are separate and distinct. 

a. Role of the CE. 

 

(1) Determines when a second opinion is necessary and 

indicates the specialty of the second opinion 

physician required and, if necessary, the time period 

within which the examination is to take place. 

(2) Ensures that all necessary medical information is 

sent to the Medical Scheduler. The same procedure for 

a referral to a DMC (see paragraph 10 above) including 

providing paperwork (Medical Consultant Referral Form, 

SOAF, OWCP-1500, etc.) and prompt payment of second 

opinion medical bills will be followed. The exception 

is that the Medical Scheduler must call the second 

opinion physician to schedule a timely appointment. In 

addition, section 21 of the OWCP-1500 must be entered 

with ICD-9 code V68.2 and section 24D must be entered 

with the procedure code SEP01 for second opinion file 

review only or SEP02 for second opinion file review 

requiring physical examination (See Exhibit 4). 

(3) Prepares a letter to the physician that lists the 

questions that he or she must specifically address. 

The CE must limit the questions to only those that 

address the particular issue or problem for which 

clarification is required. 

(4) Calls the physician’s office to ensure that the 

claimant has attended the appointment. 

(5) Makes all required entries in ECMS for activities 

related to second opinion referrals (See paragraph 

10d). 

 

(6) Advises the District Director or designee, 

through a CE or supervisor, of any problems with 

regards to the timeliness or quality of the medical 

reports or complaints from the claimant. 

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12. Second Opinion Examinations. (Continued) 

b. Role of the Medical Scheduler. 

(1) Follows the same procedure for a referral to a 

DMC (see paragraph 11 above) for completing and 

providing paperwork including prompt payment of second 

opinion medical bills. 

(2) Schedules the second opinion medical appointment 

in accordance with the CE’s request. 

(a) The Medical Scheduler must make the 

appointment within a reasonable amount of time 

after initially requested by the CE. 

(b) If the CE indicates a certain period within 

which the examination is required, the Medical 

Scheduler contacts the physician to see if the 

deadline can be accommodated. If not, another 

physician is selected, if possible. 

(3) Selects the physician through the ACS web portal 

http://owcpstaff.dol.acs-inc.com under Provider Search 

link. 

(a) To allow for the rotation of physicians used 

for second opinions, the DO must develop and 

maintain an internal tracking system (e.g., a 

spreadsheet) that the Medical Scheduler can use 

to identify when a particular physician last 

provided a second opinion. It should be possible 

to add contact information as well. 

 

If a physician subsequently states that he or she 

no longer wishes to be involved in the program, 

this information must be added to the system so 

the Medical Scheduler knows not to contact that 

physician. 

(b) For jurisdictions that have small numbers of 

available physicians, it may be necessary to use 

the same second opinion physician on a more 

regular basis. This is acceptable as long as the 

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12. Second Opinion Examinations. (Continued) 

physician has not been involved with any medical 

examinations of the claimant. 

(4) Arranges for the examination within a reasonable 

distance from the residence of the employee, if 

possible. Unless unusual circumstances exist, the 

examination must be scheduled within 100 miles of the 

employee's residence. A distance of 25 miles or less 

is preferable. If extended travel is required, the 

arrangements and reimbursement are handled on a case 

by case basis. 

(5) Ensures that the physician is enrolled in the 

EEOICPA program. A DEEOIC provider number is required 

before the physician can be paid. If the physician 

does not have a DEEOIC provider number, the Medical 

Scheduler must include a copy of the Provider 

Enrollment Form OWCP-1168 and the complete provider 

package with the letter sent to the physician. After 

the completed form is returned, the Medical Scheduler 

forwards it to the BPA, which provides the Medical 

Scheduler with a DEEOIC provider number for the 

physician. 

(6) Contacts the physician to make sure he or she is 

willing to accept the employee for evaluation and 

schedules an appointment. 

(7) Notifies the claimant, in writing, of the second 

opinion examination. The claimant must be notified at 

least 30 days prior to the scheduled appointment. 

 

(8) Forwards the Form OWCP-1500, cover letter 

describing the billing specifications (Exhibit 6), 

list of questions for the second opinion physician to 

address, SOAF and any medical documentation. 

(9) Enters a call-up for the CE in ECMS for the date 

of the appointment so the CE can call the physician to 

determine if the employee attended the appointment. 

c. Role of the District Director/Designee. 

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12. Second Opinion Examinations. (Continued) 

(1) Evaluates complaints about specific physicians. 

(2) Evaluates and reviews medical evaluations $2,400 

or higher. 

(3) Evaluates problems with the quality and 

timeliness of the physician’s reports. 

(4) Determines whether a physician should be removed 

or added to the pool of physicians to be considered 

for future examinations. 

13. Referee Specialist Examinations. The same referral 

procedures are followed as a second opinion examination. 

However, section 21 of the OWCP-1500 must be entered with ICD-9 

code V65.8 and section 24D must be entered with procedure code 

REF01 for referee referrals requiring only a file review or 

REFER for referee referrals requiring also a physical 

examination. 

a. Regulatory Authority. Section 30.411(b) of EEOICPA 

states that: 

If a conflict exists between the medical opinion of 

the employee’s physician and the medical opinion of 

either a second opinion physician or an OWCP medical 

adviser or consultant, or a qualified physician 

submitting an impairment evaluation; the OWCP shall 

appoint a third physician qualified in the appropriate 

specialty who conforms to the standards regarding 

conflicts of interest adopted by OWCP to make an 

examination. This is called a referee examination. 

In most instances, careful weighing of the medical evidence 

should allow for resolution of the issues without having to 

resort to a referee or "impartial" specialist. However, 

where the weight of medical evidence is divided equally 

between the opinion of the treating doctor and that of the 

second opinion physician, a referee opinion must be 

obtained. 

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13. Referee Specialist Examinations. (Continued) 

b. Value of Report. The probative value of the referee 

specialist's report, if sufficiently rationalized, is 

granted special weight. Usually, the opinion of a referee 

specialist constitutes the greater weight of the medical 

evidence of record. 

c. Factors to Consider. The CE/Medical Scheduler should 

consider the following points with respect to referee 

medical examinations: 

(1) A conflict of medical opinion must actually exist 

as determined by weighing the medical evidence. The 

CE must decide the relative value of opposing opinions 

in the medical record by considering all factors, to 

include each physician’s specialty and qualifications, 

completeness and comprehensiveness of evaluations and 

rationale, and consistency of opinions. 

(2) The questions to the referee medical examiner 

must be case-specific. Since this examination is made 

to resolve a particular conflict, the CE must ensure 

that the questions to the physician are sufficiently 

detailed and narrow to resolve the conflict. 

(3) The referee specialist's report, once received, 

must fulfill its intended purpose, i.e., it must 

resolve the conflict in medical opinion. Therefore, 

the CE must ensure that the referee specialist's 

report is comprehensive, clear and definite; that it 

is based on accurate information; and that it is 

supported by sound and substantial medical reasoning. 

If the report is vague, speculative, or incomplete, or 

it does not contain sufficient rationale to justify 

the conclusion reached, it is the responsibility of 

the CE to secure a supplemental report from the 

referee specialist to correct the defect. 

(4) If the referee specialist is unable or unwilling 

to provide a supplemental report, or if the 

supplemental report is still incomplete, vague, 

speculative or unjustified, the Medical Scheduler 

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13. Referee Specialist Examinations. (Continued) 

arranges for a second referee evaluation. This 

measure is undertaken with care, since a premature or 

inappropriate second referee examination would defeat 

the intent of Section 30.411 and could lead to a 

suspicion that OWCP is "shopping" for a physician 

whose opinions it prefers. 

14. Failure to Undergo Medical Examination. Under the 

following circumstances, the adjudication process may be 

suspended for failure to undergo a medical examination. 

a. Follow-up Action. If the employee is to be examined 

as part of a second opinion or referee examination, the CE 

contacts the physician’s office on the date of the 

examination to confirm the employee kept his or her 

appointment. If the employee was examined, the CE should 

expect a report within 30 days. This guideline also 

applies if a case is referred for a file review. 

b. Failure to Appear. If the physician’s office reports 

that the employee did not appear for his or her scheduled 

appointment, the employee and any representative should be 

contacted by a documented phone call or in writing to 

request an explanation. If a reasonable explanation is 

provided, the CE re-schedules the examination, through the 

Medical Scheduler and sends written confirmation of the 

date, time and location of the rescheduled examination to 

the employee and representative, if any. 

If the employee does not respond to the CE’s request for an 

explanation or if an explanation is provided and the CE 

determines good cause is not established, or if the 

employee fails to appear for the re-scheduled examination 

without good cause, the CE issues a letter advising the 

employee and representative that the issue to be resolved 

(i.e., adjudication of a consequential injury, request for 

surgery, medical supply, etc.) cannot be further 

adjudicated until the medical examination is completed. 

EEOICPA Tr. No. 10-07 29 

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14. Failure to Undergo Medical Examination. (Continued) 

The CE suspends any further action to adjudicate the 

outstanding issue until the employee agrees to undergo a 

medical examination. This suspension does not affect the 

employee’s entitlement to ongoing benefits for other 

medical conditions and/or treatments which have been 

accepted in the case. 

EEOICPA Tr. No. 10-07 30 

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____________________________________________________________________________________________

Medical Consultant Referral Form 

Employee: Employee's name File Number: File number

I. Purpose of Referral (check one or more):

 Impairment Rating Diagnostic Clarification

 Part B CBD/Silicosis Review Incapable of Self Support

 Part E CBD Wage Loss

 Causation Other:____________________________

II. Preferred Medical Specialty (check one or more):

 Aerospace Medicine Hematology Pathology

 Anesthesiology Internal Medicine Pulmonary

 Emergency Medicine Neurology Rehabilitation Medicine

 Family Practice Obstetrics-Gynecology Surgery 

 Forensic Medicine Occupational Medicine Toxicology 

 General Preventive Medicine Oncology Other:___________________

 Geriatric Medicine Pain Medicine 

 

III. Requested Impairment Evaluation (check one, if more than one organ system evaluation needed check 

Whole Body)

 Cardiovascular (Heart/Blood Vessel) Hematopoietic (Blood) Pulmonary (Lung) 

 Digestive Tract Mental/Behavioral Skin

 Ear, Nose, Throat (ENT) Musculoskeletal Urinary/Reproductive

 Endocrine Neurology (Nervous) Whole Body 

 Eye Pain Other:___________________

 

IV. The following physicians have been involved with this case:

1. Physician's name 5. Physician's name

2. Physician's name 6. Physician's name

3. Physician's name 7. Physician's name

4. Physician's name

V. Medical Condition/s Claimed: Medical condition claimed, Medical condition claimed, Medical condition 

claimed, Medical condition claimed. 

Attachments:

 Statement of Accepted Facts (SOAF) with questions for resolution

 Copies of medical reports

 X-rays

 Other (specify):_____________________________________________________________________ 

(Printed Name) (Title)

(Signature) (Date)

EEOICPA Tr. No. 10-07 Exhibit 1 

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Statement of Accepted Facts (SOAF) 

Employee: Employee's name File Number: File number

Date of Birth: Employee Date of Birth

Date of Death: Employee's Date of Death

Medical Information: 

Employment Information: 

Other:

Claims Examiner Claims Examiner

(Printed Name)

Date

(Signature) (Date)

EEOICPA Tr. No. 10-07 Exhibit 2 

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____________________________________________________________________________________________

Questions:

CE: Choose from options below or add your own 

1. ImpairmentPlease provide a whole body impairment rating for the accepted conditions listed 

above in accordance with the 5th edition of the American Medical Association Guides to the 

Evaluation of Permanent Impairment (AMA Guides) with specific page and table references 

included in your report. Please provide the rationale and objective findings to support your 

conclusions. 

2. ImpairmentIf it is not possible to complete an impairment rating based on the medical evidence 

we provided, please advise us what medical records and/or testing is required to complete the 

rating. 

3. DiagnosisIn your opinion, do the medical records support a diagnosis of medical condition? If 

so, please provide the first date of diagnosis, diagnosis, and the ICD-9 code. 

4. CausationIf medical condition was diagnosed, in your opinion is it at least as likely as not that 

exposure to toxic substances during the course of employment at covered facility was a 

significant factor in aggravating, contributing to, or causing the employee’s medical condition? 

5. CausationDoes the employee’s work history and exposure potential make it at least as likely as 

not that the exposure to the toxic substances was a significant factor in causing, contributing to or 

aggravating the employee’s medical condition? 

6. CausationIf so, please provide the earliest date of diagnosis(es) and ICD-9 code of the condition 

you believe is related. Please provide the rationale and objective findings to support your 

conclusion that the condition(s) are related to the work exposure.

Claims Examiner Claims Examiner

(Printed Name)

Date

(Signature) (Date)

EEOICPA Tr. No. 10-07 Exhibit 3 

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ICD-9 CODES AND CORRESPONDING PROCEDURE CODES

ICD-9 Code V49.8 DMC File Review

Procedure Codes FR001 Causation file review completed by DMC

FR002 Supplement file review completed by DMC (i.e. Causation, 

Impairment, Diagnosis Clarification, Wage Loss) 

FR003 Diagnosis clarification file review completed by DMC

FR004 Impairment rating file review completed by DMC

ICD-9 Code V70.9 Impairment Rating by Non DMC (Includes 

physical exam) 

Procedure Code PE001 File review including physical exam (Non DMC)

ICD-9 Code V68.89 Wage Loss 

Procedure Code WL001 File review completed by DMC

ICD-9 Code V68.2 Second Opinion 

Procedure Codes SEP01 File review only 

SEP02 File review including physical exam 

 

ICD-9 Code V68.2 Expert Referral 

Procedure Codes CNSLT File review only 

CNSL1 File review including physical exam 

 

ICD-9 Code V65.8 Referee Referral 

Procedure Codes REF01 File review only 

REFER File review including physical exam 

ICD-9 Code V68.81 Medical Records Fees

Procedure Code MR001 Payment for medical records 

EEOICPA Tr. No. 10-07 Exhibit 4 

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Sample Letter to District Medical Consultant

Dear Dr. : 

I want to thank you for agreeing to provide your medical opinion 

on this case in your capacity as a district medical consultant 

(DMC) for the Energy Employees Occupational Illness Compensation 

Program (EEOICP). 

Please refer to the DMC Handbook and related EEOICP policies and 

procedures that govern all aspects of DMC’s standard operation 

procedures. 

Please review the medical reports and test results of record, 

the Statement of Accepted Facts prepared by this office and any 

other pertinent information and answer fully each question posed 

by the submitting Claims Examiner. All medical opinions must 

contain detailed supporting rationale based on actual findings 

and accepted medical literature. Unsupported conjecture and 

speculative judgments cannot be accepted. [If the issue is 

degree of permanent impairment of the whole body, please fully 

show how the percentage of impairment is derived in accordance 

with the AMA Guides to the Evaluation of Permanent Impairment 

(Guides). This should include references to specific pages and 

tables in the Guides and you should indicate whether the 

employee has reached maximum medical improvement.] 

If the referral is inappropriate, please contact me and return 

all the case material. Some examples of inappropriate referral 

would include a referral in which you have a conflict of 

interest, or questions posed that are not within your area of 

qualified clinical expertise, [or you are not a qualified expert 

in the area of impairment ratings in an impairment referral,] or 

you cannot perform the evaluation within the time limitations, 

or you do not understand or agree with the basis or implications 

of “accepted conditions” or the Statement of Accepted Facts. 

 

Billing: After completing your review, submit your report along 

with the attached OWCP-1500 to our office for review. The OWCP1500 must be signed and dated with DOL Provider Number and 

Federal Tax ID Number annotated in block # 25 and # 33. A FEDEX 

envelope and pre-paid air bill are enclosed for your 

convenience. If this form is not used, we may have difficulty 

EEOICPA Tr. No. 10-07 Page 1 of 3 Exhibit 5 

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identifying your bill and reimbursement may be delayed. 

Note: The bills for your services cannot be approved until 

you fully answer the questions and you provide detailed 

supporting rationale for your opinion. 

Fees: The basic fee for review of the file and narrative medical 

report is $300 per hour. Please note that the program has 

established 8 hours and $2,400 as limits for a DMC case review 

with the understanding that most reviews are completed in 1-3 

hours. However, the program also recognizes that the review of 

a particularly complex case may require additional time and 

effort. In such a case, please annotate your report with 

justification as to why additional time and/or research were 

required to answer the questions. Charges exceeding these 

amounts are closely reviewed by the District Director who may 

approve or deny any additional amount based on the degree of 

complexity of the case, the comprehensiveness of the report, or 

the extent of appropriate and necessary research performed. 

Security of Files: Confidentiality concerns are addressed in 

the DMC Handbook and related program policies and procedures. 

DEEOIC files and related materials are to be treated in a 

confidential manner. Files and related material must not be 

reproduced for any reason. When not in actual use, files and 

related material must be kept in secure storage under lock and 

key accessible only to those individuals providing services 

under this agreement. These files and related material remain 

the property of the U.S. Department of Labor. Please destroy 

the case materials once your report is accepted. As per the 

privacy policy, no information containing personally 

identifiable information (PII) may be sent by email from nonFederal government email servers. Information containing PII 

should be faxed using a “Medical Confidential” cover page. For 

more information on privacy and email transactions, please 

review http://esa/owcp/Bulletin/OWCPBULLETIN08-2.pdf. 

 

Please make every effort to submit your report within 15 

calendar days of receipt of this package. If you feel that your 

report will be late, please contact me immediately. Your report 

and the OWCP-1500 are to be sent to the following address: 

EEOICPA Tr. No. 10-03 Page 2 of 3 Exhibit 5 

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___________________________________________________________ 

Division of Energy Employees Occupational Illness Compensation 

Attn: XXX; Medical Scheduler 

(Address of DO) 

Before mailing, please use the DMC checklist, found in the DMC 

Handbook, to make sure that you have complied with the 

requirements of the program. 

Again, we appreciate your cooperation and wish to thank you for 

your assistance in this matter. If you have any questions or 

concerns regarding this referral, please contact me at: XXXXXX-XXXX. 

Sincerely, 

Medical Scheduler 

Enc: Medical File 

Statement of Accepted Facts (SOAF) 

Questions 

OWCP – 1500 

FEDEX Envelope 

EEOICPA Tr. No. 10-07 Page 3 of 3 Exhibit 5 

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Sample Letter to Second Opinion/Referee Physician 

Dear Dr. Name: 

Arrangements have been made with your office for the above named 

claimant to undergo an independent medical assessment on {Date} 

at {Time}.

The purpose of the examination is to assess this employee’s 

medical condition with respect to the stated condition(s) in the 

claim. Enclosed is a copy of the pertinent medical evidence 

from the case file; a Statement of Accepted Facts, which 

presents a broad history of the case; and a list of questions to 

be addressed. You are advised to review this information prior 

to the examination to garner an understanding of the case 

context. 

[NOTE: This sentence can be used if required - The patient has 

been instructed to bring with them {Identify specific medical 

information}. However, you are authorized to refer the employee 

for any non-invasive diagnostic testing which you feel is 

required to address the questions raised by the District Office. 

The provider of such services must submit billing directly to 

the address listed above for payment. The above listed case 

file number must appear on any billing submitted. 

As long as your report contains the necessary information, you 

are ensured payment by the Office of Workers’ Compensation 

Program (OWCP) for services rendered. Enclosed in this package 

is a Form OWCP-1500 with appropriate authorization codes. This 

form must be used to bill for your service. If you have any 

difficulties completing the form, please contact me. Please be 

aware that payment cannot be processed until a report is 

received which addresses the particular questions being raised. 

Please note that you must not release your report to the 

claimant or representative, but should instead refer any request 

for it to the Department of Labor Claims Examiner. 

Also, please note that the rescheduling of an examination cannot 

be done without the authorization of the DOL’s District Office.

EEOICPA Tr. No. 10-07 Page 1 of 2 Exhibit 6 

January 2010 

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___________________________________________________________ 

If there are any questions or concerns, please contact me 

directly at the District Office at XXX-XXX-XXXX. You may fax 

the report with the completed billing form attached to XXX-XXXXXXX. 

Sincerely, 

Medical Scheduler

EEOICPA Tr. No. 10-07 Page 2 of 2 Exhibit 6 

January 2010 

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________________________________________________________________ 

TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-0900 Eligibility Criteria for Cancer and Radiation 

 Table of Contents . . . . . . . i 01/10 10-07 

 1 Purpose and Scope . . . . . . . 1 01/10 10-07 

 2 Identifying a Claim for 

 Cancer. . . . . . . . . . . . 1 01/10 10-07 

 3 Covered Cancers . . . . . . . . 1 01/10 10-07 

 4 Pre-Cancerous and Non-Malignant 

 Conditions. . . . . . . . . . 5 01/10 10-07 

 5 Specified Cancers . . . . . . . 5 01/10 10-07 

 6 Non-SEC Cancers . . . . . . . . 6 01/10 10-07 

 7 Non-SEC Cancer and Dose 

 Reconstruction. . . . . . . . 6 01/10 10-07 

8 Preparing Non-SEC Cancer Claim 

 Files for Referral to NIOSH . 8 01/10 10-07 

9 Preparing Amendments to NRSD 

 for Non-SEC Cancer Claims . . 10 01/10 10-07 

10 Cases Pended While at NIOSH . . 11 01/10 10-07 

11 Cases Pulled While at NIOSH . . 11 01/10 10-07 

12 NIOSH Actions . . . . . . . . . 13 01/10 10-07 

 13 Receipt of Dose Reconstruction 

 Results from NIOSH. . . . . . 16 01/10 10-07 

 14 Review of Claim for Rework 

 of Dose Reconstruction. . . . 19 01/10 10-07 

 15 Procedures for Requesting 

 Rework. . . . . . . . . . . . 25 01/10 10-07 

 16 Reviews of Dose Reconstruction 29 01/10 10-07 

 17 Proving Causation Between 

 Diagnosed Non-SEC Cancer and 

 Covered Employment. . . . . . 31 01/10 10-07 

 18 Calculation of PoC Using 

 NIOSH-IREP Computer Program . 35 01/10 10-07 

 19 Establishing Causation for 

 Cancer under Part E . . . . . 39 01/10 10-07 

EEIOCPA Trans. No. 10-07 

January 2010 

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________________________________________________________________ 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-900 Eligibility Criteria for Cancer and Radiation 

Exhibits 

 1 NIOSH Referral Summary 

 Document (NRSD) . . . . . . . 01/10 10-07 

 2 Instructions for Completing 

 the NRSD. . . . . . . . . . . 01/10 10-07 

 3 Smoking History Request, 

 Form EE/EN-8. . . . . . . . . 01/10 10-07 

 4 Ethnicity Request, 

 Form EE/EN-9. . . . . . . . . 01/10 10-07 

 5 NIOSH Referral Letter to 

 Claimant. . . . . . . . . . . 01/10 10-07 

 6 Examples of Rework Request. . . 

7 Review of Dose Reconstruction 

 Letter to Claimant. . . . . . 01/10 10-07 

 8 Primary Cancer Sites. . . . . . 01/10 10-07 

 9 HHS Chronic Lymphocytic 

 Leukemia Guideline Letter . . 01/10 10-07 

 10 Glossary of ICD-9 Codes and 

 Their Cancer Descriptions . . 01/10 10-07 

 

EEIOCPA Trans. No. 10-07 

January 2010 

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________________________________________________________________ 

1. Purpose and Scope. This chapter discusses the procedures 

for determining whether an employee has been diagnosed with a 

covered cancer and the procedures for establishing causation as 

a result of exposure to radiation. 

2. Identifying a Claim for Cancer. The Claims Examiner (CE) 

must first identify whether the claim is being made for cancer. 

If Form EE-1 or Form EE-2 is marked for a cancer, then a cancer 

claim is established. The claimant is expected to identify the 

specific type of diagnosed cancer on the claim form. 

3. Covered Cancers. Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA) regulations states that to 

establish a diagnosis of cancer, medical evidence must be 

presented which sets forth the diagnosis and the date of the 

diagnosis. The CE must verify that sufficient medical evidence 

is submitted to substantiate a diagnosis of cancer. 

a. Diagnosis of Cancer. The case record must include 

medical report from a qualified physician that lists a 

cancer diagnosis. The cancer diagnosis must be based on the 

following evidence: 

(1) Tissue examination is the most conclusive method 

for making a cancer diagnosis as it provides the 

physician with the following vital information 

regarding the tumor or lesion: 

(a) The tissue of origin (where the tumor or 

lesion originated); and 

(b) The benign, uncertain, or malignant status. 

Only malignant (cancerous) tumors/lesions are 

addressed in this chapter. 

(2) Tissue examinations are described by the 

following methods: 

(a) Pathology report (tissue has been removed 

from site); 

(b) Surgical pathology report (organ, tumor, or 

lesion has been surgically removed); 

(c) Autopsy report; or 

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3. Covered Cancers. (Continued) 

(d) Post-mortem examination report. 

(3) A diagnosis can sometimes be made based on one or 

more of the following methods which are listed in 

order of preference. If the CE is unable to determine 

an affirmative diagnosis based on the medical evidence 

submitted, the case may be referred to a District 

Medical Consultant (DMC). 

(a) Cytology report describes cells obtained by 

scraping (e.g., from bone marrow), or by washing 

(e.g., fluid from lungs). An examination 

conducted by one of these cytology methods is 

generally less conclusive than tissue examination 

because the organization and extent of the tumor 

may not be as apparent. A positive cytology 

report would be a basis for further tests. 

(b) Imaging (e.g., X-ray, CAT Scan, MRI) are the 

least specific type of tests in the diagnosis of 

cancer. Generally, X-rays are used as a basis 

for further tests. Radiology tests are extremely 

beneficial in determining the spread of cancer 

and/or determining the effects of cancer 

treatments. 

(4) If the employee is deceased and none of the tests 

listed above were done, a survivor’s claim will likely 

be based on official documents. In this situation the 

CE must attempt to obtain the documents listed below. 

Referral to a DMC should be made only if the CE is 

unable to determine an affirmative diagnosis. 

(a) Hospital admission/discharge reports or 

physician’s reports describing the tumor; 

(b) Hospice records; 

(c) If all efforts to obtain additional 

documents fail, a death certificate signed by a 

physician may be used to establish a cancer 

diagnosis. However, a death certificate alone 

should be used only as a last resort. 

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3. Covered Cancers. (Continued) 

b. Diagnosis of Multiple Primary Cancers. 

(1) If more than one primary cancer is identified in 

the medical evidence in the same organ with the same 

diagnosis date and the cancers are classified as the 

same type of cancer, all of the identified cancers are 

to be considered as only one primary cancer. 

For example, if three biopsies are taken from the left 

breast on the same date and all are listed as 

infiltrating ductal carcinomas, the biopsies are to be 

considered as indicating only one primary cancer of 

the left breast. 

However, if biopsies taken from the left breast on the 

same date indicate a lobular carcinoma and an 

infiltrating ductal carcinoma, these cancers are 

considered as two primary cancers, since the cancer 

types are different. 

If a physician clearly notes that there are two (or 

more) separate primary cancers, the physician’s 

interpretation prevails whether or not a pathology 

report confirms multiple primary cancers. 

(2) The above guidance applies only to multiple 

primary cancers of the same type in an organ. 

Situations involving bilateral organs are more 

complicated. Bilateral organs include the lungs, 

kidneys, adrenals, ovaries, and testes. 

Biopsies taken from the left and right lungs might 

indicate the same type of cancer, e.g., non-small cell 

adenocarcinoma, in the right and left lungs. While 

one cancer may actually be metastatic from the other 

lung, without any indication in the pathology report 

or other medical evidence, it would be impossible to 

determine whether these two adenocarcinomas are two 

primary cancers or just one cancer. 

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3. Covered Cancers. (Continued) 

Cases involving primary cancers identified in 

bilateral organs and classified as the same type of 

cancer should be referred to an oncologist DMC for 

review. 

If biopsies identify two different cancers, e.g., a 

non-small cell adenocarcinoma in the right lung and an 

oat cell carcinoma in the left lung, these two 

carcinomas should be considered as separate primary 

cancers. 

c. Date of Diagnosis. The date of initial diagnosis is 

required in any claim for cancer. The date of diagnosis is 

also a critical element used in the Interactive RadioEpidemiological Program (IREP) for calculating the 

probability of causation (PoC). The employee’s 

occupational exposure to radiation must be before the 

initial date of diagnosis for cancer in order for it to be 

compensable under Part B. While the date of diagnosis may 

be noted on Form EE-1 or Form EE-2, the CE must 

independently review all of the medical evidence submitted 

in a claim package to determine the earliest date of cancer 

diagnosis. 

(1) When using a pathology report to determine the 

date of diagnosis, the date that the tissue is 

obtained should be used as the date of diagnosis. The 

pathology report must be signed by a physician. 

(2) In certain claim situations, the CE will have to 

use reasonable discretion in the type of evidence that 

will be used to accept the date of diagnosis. For 

example, if the employee is deceased, and the only 

documentation available to support the diagnosis of 

cancer is the employee’s death certificate signed by a 

physician, the CE may accept affidavits from 

survivor(s) and/or other individuals to establish that 

the cancer was diagnosed subsequent to the employee’s 

initial exposure to radiation. 

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3. Covered Cancers. (Continued) 

For example, a home health nurse might indicate in an 

affidavit his or her knowledge that on a specified 

date, a physician made a diagnosis of the employee’s 

condition, as well as the circumstances under which he 

or she acquired such knowledge. However, affidavits 

may not be used to establish the medical diagnosis 

itself, only the date of diagnosis. 

d. Deficiency in Medical Evidence. The CE must advise 

the claimant of any deficiency in medical evidence and 

allow the claimant a period of up to 60 days to submit 

additional medical evidence. 

4. Pre-Cancerous and Non-Malignant Conditions. With the types 

of diagnostic methods described above, some conditions, which 

could develop into cancer if left untreated, are being diagnosed 

and treated in the very early stages of development. If the 

medical evidence provided by the claimant establishes a 

diagnosis which demonstrates the condition is in a pre-cancerous 

stage of development or is non-malignant, the condition is not 

covered under this chapter and would not be covered under Part 

B. However, the CE may still need to develop for benefits under 

Part E for causal relationship between the pre-cancerous 

conditions or non-malignant conditions and toxic exposure. 

5. Specified Cancers. Members of the Special Exposure Cohort 

(SEC) who are diagnosed with any of the 22 specified cancers are 

eligible for benefits without the need for a dose 

reconstruction. Eligible members of a SEC class have a 

presumption that the diagnosed specified cancer was caused by 

eligible SEC employment.

Meeting the criteria of the SEC does not guarantee survivor 

compensation under Part E. Under Part E, the evidence must also 

establish that the covered cancer caused, contributed to, or 

aggravated the death of the employee. 

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6. Non-SEC Cancers. Any primary cancer that cannot be 

considered as a specified cancer for a SEC claim is considered a 

non-SEC cancer. A primary cancer incurred by an employee at a 

non-SEC site is also considered a non-SEC cancer. In some cases, 

a cancer is identified by its secondary site because the primary 

site is unknown. In these cases, the primary site must be 

established by inference (see paragraph 17e). If the primary 

site that was established by inference is not considered a 

specified cancer, it is also considered a non-SEC cancer. 

7. Non-SEC Cancer and Dose Reconstruction. Once the CE has 

determined that the employee has a diagnosed non-SEC cancer 

(other than chronic lymphocytic leukemia (CLL))and covered 

employment, the claim must be referred to the National Institute 

for Occupational Safety and Health (NIOSH) for a dose 

reconstruction to determine the PoC between the diagnosed nonSEC cancer and the dose potentially received during the covered 

employment. If CLL is the only diagnosed cancer, the CE does not 

send the case to NIOSH because NIOSH has identified CLL as a 

non-radiogenic cancer. However, the CE must still develop CLL 

for toxic substance exposure if there is a claim under Part E. 

Refer to paragraph 17i for further handling. 

a. Claimant Not SEC Member. When a claim is filed based 

on SEC membership but the employee is not a SEC member 

(i.e. the employment was outside the designated SEC time 

period or the employee did not work the necessary workdays 

at the SEC site), the CE must forward the claim to NIOSH 

for dose reconstruction, as long as the employee was 

diagnosed with a cancer and has confirmed covered 

employment. 

b. SEC Case with Award. For any SEC cases where an award 

has been made for a specified cancer, any non-SEC cancers 

for the case must be forwarded to NIOSH for dose 

reconstruction to determine eligibility for medical 

benefits. In these SEC cases, all cancers must be listed on 

the NIOSH Referral Summary Document (NRSD), including the 

specified cancer(s). 

 

(1) An exception to this rule includes those SEC 

claims where a primary cancer which is not a specified 

cancer metastasizes to a secondary cancer site that is 

considered a specified cancer. For instance, prostate 

cancer (non-specified cancer) metastasizes to 

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7. Non-SEC Cancer and Dose Reconstruction. (Continued) 

secondary bone cancer (specified cancer). If the bone 

cancer is accepted as a specified cancer under the SEC 

provision, both primary and secondary cancers 

(prostate and bone cancer) are accepted for medical 

benefits under Part B. However, per regulation 20 

C.F.R. § 30.400, “payment for medical treatment of the 

underlying primary cancer...does not constitute a 

determination by OWCP that the primary cancer is a 

covered illness under Part E of the EEOICPA.” As such, 

it may be necessary for the CE to refer the prostate 

cancer to NIOSH for dose reconstruction to 

determine eligibility for benefits under Part E for 

prostate cancer. In this situation, since the bone 

cancer is a secondary cancer with known primary site 

(prostate), it is not included in the NIOSH NRSD for 

dose reconstruction. 

c. Multiple Skin Cancers. When a claimant provides 

evidence that the covered employee had a relatively large 

number of skin cancers, the CE will proceed as follows. 

(1) Each malignant skin neoplasm (e.g., basal or 

squamous cell cancer) will be considered as a separate 

primary cancer, unless it is noted in the medical 

record that the neoplasm is a metastatic lesion. 

(2) For NIOSH dose calculations, the date of 

diagnosis and the location (e.g. arm, neck, back) of 

the skin cancer are important and should be indicated 

in the medical section of the NRSD. 

d. Multiple Primary Cancers for Other Organs/Locations. 

If more than one primary cancer location is identified for 

an organ in the medical records (e.g., multiple sites of 

primary cancer in the lung), the CE should note that fact 

in the medical section of the NRSD, including the cancer 

locations within the organ and the diagnosis date. NIOSH 

will perform dose calculations for each primary cancer site 

in a specific organ. When NIOSH reports the dose 

reconstruction results, the CE will calculate PoC values 

for each of the primary cancers in that organ. 

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8. Preparing Non-SEC Cancer Claim Files for Referral to NIOSH. 

This preparation includes completion of a NIOSH Referral Summary 

Document (NRSD). The NRSD (Exhibit 1) is a tabular form 

containing the medical and employment information accepted by 

the CE as factual. This form provides NIOSH with the necessary 

information to proceed with the dose reconstruction process. 

a. Instructions. Step-by-step instructions for 

completing the NRSD are included in Exhibit 2. Only the 

NRSD is approved for use in submitting a case to NIOSH. 

b. Smoking History. The employee’s smoking history is 

required for cases that include primary lung cancer 

(including primary trachea, bronchus, and lung) or for 

secondary cancer with an unknown primary cancer that 

includes lung cancer as a possible primary cancer. 

(1) The method used to gather smoking history is Form 

EE/EN-8 (Exhibit 3). 

(2) Upon receipt of the information from the 

claimant, indicate the smoking level (at the time of 

cancer diagnosis) using the designations shown in the 

NRSD. If the case evidence contradicts information 

obtained on the questionnaire, the CE should clarify 

the discrepancy with the claimant prior to referral to 

NIOSH. 

(3) If the claimant does not return the initial 

questionnaire within 30 days, the CE must send a 

follow-up letter advising that the questionnaire must 

be returned within the next 30 days or the case will 

be administratively closed. After a total of 60 days 

has elapsed, the CE informs the claimant by letter 

that the case will be administratively closed under 

Part B. The case may still be developed for causation 

based on toxic substance exposure under Part E. 

(a) If the CE can obtain the relevant 

information from the employee’s medical records 

or Document Acquisition Request (DAR), the NRSD 

may be completed using that information and 

forwarded to NIOSH with an explanation of where 

the information was acquired. 

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8. Preparing Non-SEC Cancer Claim Files for Referral to NIOSH. 

(Continue) 

c. Ethnicity. Employee’s ethnicity is required for skin 

cancer cases. 

(1) The method used to gather this information is 

Form EE/EN-9 (Exhibit 4). 

(2) Upon receipt of the information from the 

claimant, indicate the ethnicity using the 

designations shown in the NRSD. 

(3) If the initial questionnaire is not returned by 

the claimant within 30 days, the CE must send a 

follow-up letter advising that the questionnaire must 

be returned within the next 30 days or the case will 

be administratively closed. After a total of 60 days 

has elapsed, the CE informs the claimant by letter 

that the case will be administratively closed. 

If the CE can obtain the relevant information from the 

employee’s medical records or DAR, the NRSD may be 

completed using that information, and forwarded to 

NIOSH with an explanation of where the information was 

acquired. 

d. Case Referred to NIOSH. 

(1) The evidence in file must support any finding 

made by the CE and documented in the NRSD. The CE must 

make a copy of the NRSD and place it in the case file. 

 

(2) A copy of the entire case file is forwarded with 

the NRSD to NIOSH. 

(3) The CE advises the claimant in writing that the 

case has been sent to NIOSH for dose reconstruction 

(Exhibit 5). 

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9. Preparing Amendments to NRSD for Non-SEC Cancer Claims. 

Sometimes CEs obtain additional information on a case after it 

has been referred to NIOSH but before the completion of the dose 

reconstruction. This includes new information related to the 

employee’s employment, new medical condition(s), or other 

survivor-related information. 

When new information become available, this information must be 

forwarded to NIOSH so it is available for dose reconstruction. 

The CE must include the portion of the NRSD that has changed 

based on new evidence reviewed by the District Office (DO). 

Mark “Amendment” on the top of the NRSD and include the 

employee's name, DOL case number, NIOSH tracking number, and DOL 

Information (including the Senior CE or journey level CE’s 

signature). The CE clearly identifies and separates any 

“Amendment” NRSDs from NRSDs that are submitted with the DO’s 

weekly package to NIOSH. 

a. NIOSH Reports. NIOSH provides weekly reports to the 

DOs listing the cases for which the NIOSH contractor 

started performing dose calculations in the past week. The 

CE responsible for the case(s) listed on the report must 

review the information in the case file against the 

information sent to NIOSH in the NRSD. Any revisions to 

information contained in the original NRSD must be 

forwarded to NIOSH using an amended NRSD. This will allow 

NIOSH to use the correct information in its dose 

reconstruction. 

b. “Supplement” NRSD. If the CE needs to submit 

additional evidence to NIOSH, such as additional medical 

information for the same reported cancer, this must be 

submitted using a NRSD with “Supplement” marked, and only 

the DOL case number, NIOSH tracking number, and employee’s 

name need be included. A supplemental NRSD should be used 

only for a submission that does not change the original 

information in the NRSD. Clearly mark any supplemental 

packages and separate them from NRSDs that are submitted 

with the DO’s weekly package to NIOSH. 

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10. Cases Pended While at NIOSH. During the dose 

reconstruction process, NIOSH may place a case in a “pend 

status” for technical reasons. Examples may include: the 

addition of time to a facility’s covered period; a technical 

dose reconstruction issue for a facility; or a change to a site 

profile, based on the identification of additional dose data. 

Placement in pend status does not stop the dose reconstruction 

process, but may delay completion of the dose reconstruction. 

Placing a case in a pend status alerts the NIOSH staff that 

clarification is needed on a specific issue that may affect the 

dose reconstruction. DOL is not necessarily notified of a case 

placed in pend status for technical reasons or when these issues 

are resolved. 

 

11. Cases Pulled While at NIOSH. During the dose 

reconstruction process, it may be necessary for NIOSH to contact 

the CE to resolve a discrepancy, or request clarification. 

Normally this contact is via e-mail or telephone. All contact 

from NIOSH is to be handled as quickly as possible, and a 

response provided within three working days. If the question 

cannot be answered without further development, the CE advises 

NIOSH of the steps being taken and an approximate time frame for 

completion. 

In cases where further development is needed as determined by 

NIOSH or DOL, NIOSH pulls the case from the dose reconstruction 

process and advises the CE by email. NIOSH may also pull a case 

to allow DOL to determine if a case can be accepted under a SEC 

class. Since a pulled case stops the dose reconstruction 

process, the CE must proactively develop the case so the dose 

reconstruction process can proceed or a decision can be rendered 

on a SEC case. 

a. Cases Pulled by DOL. When DOL determines that further 

development is needed before a dose reconstruction can 

proceed, the supervisor, Senior CE (or journey level CE), 

or DO NIOSH liaison sends an e-mail (with copies to the 

other two DO staff) to the NIOSH Public Health Advisor 

(PHA) with a request that NIOSH pull the case status while 

DOL develops the case for additional information. The CE 

must advise the claimant in writing when a case is pulled 

by DOL from the dose reconstruction process. 

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11. Cases Pulled While at NIOSH. (Continued) 

(1) The e-mail briefly explains the specific 

information the DO is attempting to clarify or obtain, 

e.g., employment, medical, smoking or race/ethnicity 

questionnaire, etc. 

(2) On receipt of the development information, DOL 

staff notifies the appropriate NIOSH PHA (with copies 

to the other two DO staff) by e-mail of the resolution 

of the issue and requests that the case be removed 

from pulled status. The DO must also prepare and 

forward, as necessary, an amended NRSD containing the 

new information. The CE must also advise the claimant 

in writing that the case is removed from pulled status 

and dose reconstruction may proceed. 

b. Cases Pulled Due to SEC. NIOSH may identify cases 

submitted for dose reconstruction that should be considered 

for inclusion in a SEC class, typically when a new SEC 

class is designated. NIOSH pulls these cases from the dose 

reconstruction process and returns these cases with the 

dose reconstruction analysis records in the form of a CD to 

the appropriate district office for further development. 

NIOSH also sends a letter advising the claimant that his or 

her claim is being returned to DOL for adjudication. 

If DOL identifies a case that qualifies under the SEC 

provision but was not pulled by NIOSH from the dose 

reconstruction process, the CE, through the Senior CE 

(SrCE) or journey level CE, notifies the appropriate NIOSH 

PHA via e-mail to return the dose reconstruction analysis 

records for further development. In these cases, the CE 

will send a letter to the claimant advising that the case 

is pulled from the dose reconstruction process for 

evaluation under the SEC provision. 

If it is determined that the case does not qualify for the 

SEC class, the CE, through the SrCE or journey level CE, 

notifies the appropriate NIOSH PHA via e-mail to proceed 

with the dose reconstruction. The CE prints a copy of the 

“sent” e-mail for inclusion in the case file. The e-mail 

includes a brief statement explaining why the case should 

proceed with dose reconstruction, e.g., non-specified 

cancer, insufficient latency period or does not meet the 

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11. Cases Pulled While at NIOSH. (Continued) 

250-work-day requirement. In addition, the CE notifies the 

claimant by letter that the case is returned to NIOSH for 

dose reconstruction and the reason(s) it does not qualify 

for the SEC class. The CE also sends a copy of this letter 

to NIOSH.

12. NIOSH Actions. Upon receipt of a claims package from DOL, 

NIOSH takes several actions to determine the employee’s 

radiation dose. 

a. Request DOE Records. These records will include 

radiation dose monitoring and radiation exposures 

associated with the employment history. 

b. Interview the Claimant(s). The purpose of the 

interview(s), also known as the Computer Assisted Telephone 

Interview (CATI), is to identify any additional relevant 

information on employment history and develop detailed 

information on work tasks and radiological exposures. 

c. Apply Dose Reconstruction Methods. This allows NIOSH 

to estimate radiation doses for workers seeking 

compensation for cancer who were not monitored or 

inadequately monitored, or whose records are missing or 

incomplete for exposure to radiation at a Department of 

Energy (DOE) or Atomic Weapons Employer (AWE) facility. 

d. Conduct Closing Interview. After providing the 

claimant with a copy of a draft dose reconstruction report, 

NIOSH conducts a closing interview with the claimant to 

review the dose reconstruction results and the basis upon 

which the results were calculated. This is the claimant’s 

final opportunity during the dose reconstruction process to 

correct or provide additional information that may affect 

the dose reconstruction. 

e. Obtain Signature on Form OCAS-1. Subject to any 

additional information provided by the claimant, the 

claimant is required to sign and return Form OCAS-1 to 

NIOSH within 60 days, certifying that he or she has no 

additional information and that the record for dose 

reconstruction should be closed. 

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12. NIOSH Actions. (Continued) 

Upon receipt of the signed Form OCAS-1 and completion of 

any changes in the dose reconstruction resulting from new 

information provided, NIOSH forwards a final dose 

reconstruction report, “NIOSH Report of Dose Reconstruction 

under EEOICPA”, to DOL and to the claimant. 

(1) NIOSH does not forward the dose reconstruction 

report to DOL for adjudication without receipt of Form 

OCAS-1 signed by the claimant or an authorized 

representative of the claimant. 

 (a) The claimant’s signature on Form OCAS-1 

does not mean that the claimant agrees with the 

dose reconstruction. Rather, the claimant is 

agreeing to the process and that he or she 

provided NIOSH with all relevant evidence. 

(b) If the claimant or the authorized 

representative fails to sign and return Form 

OCAS-1 within 60 days, NIOSH will 

administratively close the dose reconstruction 

and notify DOL of this action after notifying the 

claimant or the authorized representative. 

(c) Upon receiving this notification by NIOSH, 

the CE must also administratively close DOL’s 

claim by entering a "NO" in the case status 

screen, since DOL cannot determine the PoC, a 

necessary step in adjudication of the claim, 

without a dose reconstruction estimate produced 

by NIOSH. The CE enters the date of receipt of 

the NIOSH letter (date stamp) as the status 

effective date. 

(d) If the employee meets the employment 

requirements, prior to entering the 

administratively closed code (“NO”) in Part E 

ECMS, the CE must determine if a causal link 

exists between the claimed illness and exposure 

to toxic substances (other than radiation) at a 

DOE facility or certain RECA facility. If no 

causal link is established, the CE places a “Memo 

to the File” explaining the sequence of events 

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12. NIOSH Actions. (Continued) 

and then administratively closes the case in ECMS 

Part E. 

(e) The CE must advise the claimant by letter 

that the case is closed. If the claimant later 

decides to sign the Form OCAS-1, he or she will 

be required to notify DOL, after which the claim 

will be referred back to NIOSH for reopening. 

The claimant should be advised that DOL cannot 

complete adjudication without NIOSH’s findings. 

 

(f) If additional information is submitted, 

NIOSH will review the evidence, prepare a new 

dose reconstruction report, and send a new Form 

OCAS-1 to the claimant and allow for an 

additional 60-day comment period. 

(2) If the case has multiple claimants, NIOSH will 

wait 60 days for receipt of all signed Forms OCAS-1. 

If, after 60 days, NIOSH does not receive Form OCAS-1 

from any of the claimants, NIOSH will administratively 

close the dose reconstruction and notify DOL of this 

action after notifying the claimants or the authorized 

representatives. The CE must also administratively 

close DOL’s claim in accordance with paragraph 12e(1). 

If, after 60 days, NIOSH receives only one signed Form 

OCAS-1, NIOSH will forward the dose reconstruction 

package to DOL. 

(a) The CE writes to the claimant(s) who did not 

sign Form OCAS-1 and ask why he or she did not 

sign Form OCAS-1. The claimant(s) should be 

asked to provide this information within 30 days. 

The CE should consider any arguments given by the 

claimant(s), and if substantive, refer the case 

back to NIOSH. Substantive arguments may include 

discovery of additional relevant information 

related to dose reconstruction, e.g., information 

or documents concerning radiological exposures, 

other co-workers, or operations and radiological 

controls at the specific facility. 

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12. NIOSH Actions. (Continued) 

(b) If arguments for refusals to sign are not 

provided or not substantive, or if no response is 

received within 30 days, the CE should issue a 

Recommended Decision (RD) awarding (or denying) 

benefits to all eligible claimants (even those 

claimants who did not sign the form). One signed 

Form OCAS-1 is sufficient to proceed with issuing 

a decision. 

13. Receipt of Dose Reconstruction Results from NIOSH. 

a. Content of NIOSH Report. The "NIOSH Report of Dose 

Reconstruction under EEOICPA" provides the information that 

the CE needs to perform a PoC calculation, which is 

necessary to render a decision on the claim. The NIOSH 

report includes the following information:

(1) Annual dose estimates related to covered 

employment for each year from the date of initial 

radiation exposure at a covered facility to the date 

of cancer diagnosis; 

(2) Separate dose estimates for acute and chronic 

exposures, different types of ionizing radiation, and 

internal and external doses, providing dose 

information for the organ or tissue relevant to the 

primary cancer site(s) established in the claim; 

(3) Uncertainty distributions associated with each 

dose estimated, as necessary; 

(4) Explanation of each type of dose estimate 

included in terms of its relevance for estimating PoC; 

(5) Identification of any information provided by the 

claimant relevant to dose estimation that NIOSH 

decided to omit from the basis for dose 

reconstruction, justification for the decision, and if 

possible, a quantitative estimate of the effect of the 

omission on the dose reconstruction results; and 

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13. Receipt of Dose Reconstruction Results from NIOSH. 

(Continued) 

(6) A summary and explanation of information and 

methods applied to produce the dose reconstruction 

estimates, including any factual findings and the 

evidence upon which those findings are based. 

 

b. NIOSH CD. When the case is returned to DOL, NIOSH 

will forward all case file documents via compact disc (CD), 

since all documents referred to NIOSH and used in the dose 

reconstruction are optically scanned into the NIOSH 

computers. NIOSH will uniquely identify (on the label on 

the CD case) the employee’s Social Security number. The CD 

will include the dose reconstruction input file (Excel 

spreadsheet) to be used for calculating the IREP 

probability of causation. The NIOSH CD should be kept with 

the case file. 

 (1) Information contained on the NIOSH CD will 

include: 

 (a) Dose reconstruction files, CATI; dosimetry 

data; the NIOSH Report of Dose Reconstruction 

under EEOICPA; NIOSH’s PoC calculation; Form 

OCAS-1; the NIOSH-IREP input file; and pertinent 

Atomic Energy Commission (AEC)/DOE reports, 

journal articles or other documents. 

(b) Correspondence, including NIOSH letters to 

claimants, phone conversation notes, and e-mails. 

(c) DOE files (data files listed in order of 

importance on the CD), including DOE dose and 

work history information and other DOE documents 

that NIOSH requested, such as incident reports 

and special studies. 

(d) DOL files, including a copy of the case file 

optically imaged by NIOSH and the OCAS tracking 

sheets (signatures and dates). 

 

(2) NIOSH will incorporate all important information 

from the above sources into the dose reconstruction 

report. Publicly available documents will be 

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13. Receipt of Dose Reconstruction Results from NIOSH. 

(Continued) 

referenced by citation. Documents not publicly 

available will be placed in the record and, as noted 

above, will be included on the CD. 

(3) The CE need not review all of the documents on 

the CD. Those documents that normally will not 

require review include the DOE documents, the claimant 

interview, the NIOSH-run PoC calculation, and the 

NIOSH-conducted closing interview. 

NIOSH runs the PoC calculation to reduce the time 

needed to complete the dose reconstruction, and the 

PoC results are incorporated into the dose 

reconstruction findings. NIOSH’s IREP run is used for 

its internal purposes only, and the CE should not use 

NIOSH’s IREP calculations as a basis for a 

determination in the claim. The CE must always run 

the IREP separately. 

(4) NIOSH will have the pertinent documents (dose 

reconstruction report, other records of import to the 

CE) in a directory titled “A_DR Files” so that the CE 

can include those documents in the hard copy for 

review. The CE prints the dose reconstruction report 

and the signed Form OCAS-1 and includes them in the 

case file. 

After running the PoC calculation, the CE prints and 

retains a hard copy of the DOL IREP run in the case 

file. 

c. NIOSH Unable to Perform Dose Reconstruction. In some 

cases, it may not be possible for NIOSH to complete a dose 

reconstruction because of insufficient information to 

reasonably estimate the dose potentially received by the 

employee. In these situations, NIOSH notifies any claimant 

for whom a dose reconstruction cannot be completed and 

describes the basis for this finding. NIOSH forwards its 

determination to DOL and the CE issues a Recommended 

Decision (RD) to deny the claim based on NIOSH’s inability 

to complete the dose reconstruction. 

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13. Receipt of Dose Reconstruction Results from NIOSH. 

(Continued) 

The CE notes in the decision the claimant may pursue the 

SEC petition process per 42 C.F.R. Part 83.13 or 83.14. 

The claimant has the opportunity to seek administrative 

review of this result after a Final Decision to deny the 

claim. 

14. Review of Claim for Rework of Dose Reconstruction. The CE 

must compare the dose reconstruction (DR) report to the evidence 

in the case file. If there are any significant discrepancies or 

changes between the information in the case file and the DR 

report, including erroneous or incomplete information, or for 

which new information was recently received, the CE must 

determine if rework may be necessary. 

Significant discrepancies or changes would include, for example, 

additional cancer identified or changed cancer site, changed 

employment facilities or dates, different ICD-9 code, or change 

in date of cancer diagnosis. 

 

 a. Cancer Changes Rework. 

 (1) If additional cancer(s) is identified after the 

DR is performed and: 

(a) PoC is less than 50%, the CE submits a 

rework request to the DEEOIC Health Physicist. 

(b) PoC is 50% or greater, a rework is not 

required. All additional primary cancers would 

be eligible for medical benefits. The CE 

documents the newly identified cancer(s) in the 

case file and notifies the NIOSH PHA of the 

additional cancer(s) so NIOSH can update their 

records. 

(2) If two or more primary cancers are addressed in 

the DR, and it is later determined that one or more of 

the cancers should not have been included in the DR 

(e.g., the cancer was found to be a recurrent cancer or 

an erroneously reported cancer) and: 

 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

(a) PoC is less than 50%, a rework is not 

required. The PoC for the remaining cancers will 

still be below 50%. The CE should: use the PoC 

as calculated as the PoC of record and note 

appropriately; document the discrepancy between 

the cancer(s) identified in the DR and those 

determined by DOL to be cancers in the case file 

and in the RD; and notify the NIOSH PHA of the 

change to the cancer(s) status so NIOSH can 

update its records. 

(b) If PoC is 50% or greater, submit a rework 

request to the DEEOIC Health Physicist. Also, if 

a primary cancer addressed in the DR is 

subsequently found to be a secondary cancer with 

an unknown primary, or an in-situ cancer, submit 

a rework request to the DEEOIC Health Physicist. 

DOs cannot substitute newly identified cancers or 

additional cancers not used in the DR, or their 

diagnosis dates, for incorrectly reported cancers 

found in the DR. 

b. Smoking and Race/Ethnicity Changes Rework. If 

information related to race/ethnicity or smoking history 

changes after the DR is performed, the CE should re-run 

IREP using the revised information. A rework is not 

required except for the following: 

 

(1) If the PoC is initially below 45% and then 

increases above 50% or greater after re-running IREP 

using the revised information, the CE submits a rework 

request to the DEEOIC Health Physicist. 

 (2) If the PoC was above 50% and the change reduces 

the PoC below that threshold, the CE submits a rework 

request to the DEEOIC Health Physicist. 

c. ICD-9 Code Changes Rework. Changes can affect the 

internal and/or external dose models used in the DR and/or 

the IREP model. Accordingly, the CE submits a rework 

request for changes in ICD-9 codes, other than those 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

exceptions listed below, to the DEEOIC Health Physicist. 

If the ICD-9 code changes within the following series, no 

rework is required (e.g., 188.8 to 188.5): 

Series Cancer

Internal 

(IMBA) 

Organ

External 

Organ IREP Model

151 Malignant Neoplasm 

Stomach Stomach Stomach Stomach

152 Malignant Neoplasm Small 

Bowel

Small 

Intestine Stomach All digestive

154 Malignant Neoplasm 

Rectum/Anus LLI Colon Rectum

156 Malignant Gallbladder 

/Extra hepatic Gallbladder Bladder Gallbladder

157 Malignant Neoplasm 

Pancreas Pancreas Stomach Pancreas

161 Malignant Neoplasm 

Larynx

Extrathoracic 

(ET2)

Esophagus Other 

Respiratory

162 Malignant Neoplasm 

Trachea/Lung Lung Lung Lung

174 Malignant Neoplasm 

Female Breast Breast Breast Breast

175 Malignant Neoplasm 

Male Breast Breast Breast Breast

180 Malignant Neoplasm 

Cervix Uteri Uterus Uterus Female genitalia less ovary

182 Malignant Neoplasm 

Uterus Body Uterus Uterus Female genitalia less ovary

186 Malignant Neoplasm 

Testis Testes Testes All male genitalia

188 Malignant Neoplasm 

Bladder Bladder Bladder Bladder

232 Carcinoma in situ skin Skin Skin

Malignant 

Melanoma AND

Non-melanoma 

skin-Squamous 

cell

(1) For ICD-9 code 232.0, if the type of cancer is 

specified by DOL (Malignant melanoma or Non-melanoma 

skin-Squamous cell), NIOSH will use only the specified 

IREP model. If the cancer is not specified, NIOSH 

will run both IREP models and the model which results 

in the highest PoC will be used. 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

(2) This table is excerpted from NIOSH document 

ORAUT-OTIB-0005, “Internal Dosimetry Organ, External 

Dosimetry Organ, and IREP Model Selection by ICD-9 

Code”. 

d. NIOSH-IREP Changes Rework. If the ICD-9 code changes, 

but the organs used by NIOSH for calculating internal and 

external dose remain the same (only the IREP model organ 

changes), the DO should request direction by the DEEOIC 

Health Physicist for instructions to rerun IREP for the 

proper IREP cancer model (organ). 

e. Diagnosis Date Changes Rework. The net effect of a 

change in the diagnosis date depends mostly on the type of 

cancer, the worker’s age at the time of diagnosis, and 

whether or not the year of diagnosis falls within the 

latency period for development of cancer (which, in turn, 

varies by IREP cancer model). Depending on the factors 

listed above, it is possible for an earlier diagnosis date 

to result in an increase in the PoC. For changes to the 

diagnosis date: 

(1) When the PoC is less than 40% and, 

(a) The diagnosis date is in the same calendar 

year, a rework is not required. 

(b) If the diagnosis date is found to be outside 

the calendar year (either earlier or later), the 

CE submits a rework request to the DEEOIC Health 

Physicist. 

(2) When the PoC is between 40% and 49.99%, and there 

is any change to the diagnosis date, the CE submits a 

rework request to the DEEOIC Health Physicist. 

(3) When the PoC is 50% or greater, 

(a) If the diagnosis date is found to be later, 

but still within the same calendar year, a rework 

is not required. 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

(b) If the diagnosis date is found to be outside 

the calendar year (either earlier or later), the 

CE submits a rework request to the DEEOIC Health 

Physicist. 

(c) The CE documents the difference in the 

diagnosis date in the case file and ensures that 

the difference in the diagnosis date used in the 

DR is noted in the RD. 

 

(d) The CE notifies the NIOSH PHA of the change 

in the diagnosis date so NIOSH can update its 

records. 

 f. Employment Changes Rework. 

(1) If the PoC is 50% or greater and additional DOLverified employment is identified, a rework is not 

required. 

(2) If the PoC is 50% or greater and the DOL-verified 

employment is found to be less than that used in the 

DR, the CE submits a request for rework to the DEEOIC 

Health Physicist for review, and includes an 

electronic copy of the DR report.

(3) If the PoC is between 40% and 49.99%, and 

additional DOL-verified employment is identified, the 

CE submits a request for rework to the DEEOIC Health 

Physicist for review, and includes an electronic copy 

of the DR report. 

 

(4) If the PoC is less than 40%, and additional DOLverified employment is identified: 

(a) If all the additional employment falls 

within the same calendar year and the year is 

addressed in the DR, a rework is not required. 

(b) If the additional employment extends into, 

or is wholly within another calendar year not 

addressed in the DR, the CE submits a rework 

request to the DEEOIC Health Physicist. 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

(5) Some DRs contain more employment than originally 

verified by DOL in the NRSD. NIOSH may have DOE 

dosimetry or employment records for periods not 

identified by DOL, or the DR may use a continuous 

period rather than considering numerous breaks in 

employment. 

(a) If the case is likely non-compensable, NIOSH 

may add the additional time period to the DOLverified employment for the purpose of completing 

a dose reconstruction (unless it is military, 

navy nuclear or non-DOE federal service)in a 

timely manner. 

(b) If the PoC is less than 50% and the DR 

contains employment added by NIOSH, a rework is 

not required. However, the CE must write a memo 

to file that DOL did not verify part of the 

employment period assumed by NIOSH, but that the 

employment period was assumed correct for the 

purpose of completing the DR in a timely manner. 

Should new information arise to warrant 

performing the dose reconstruction again (e.g., 

additional cancer diagnosis, additional 

employment at another site), only employment 

verified by DOL will be used, which may be more 

restrictive than that allowed in the current DR. 

This must also be explained in the RD. 

If NIOSH has added employment to a claim that is 

likely compensable, NIOSH must contact the CE 

with the additional employment information for 

DOL review and verification. After verification 

the CE must submit an amended NRSD to NIOSH. 

(c) If the PoC is 50% or greater and the DR 

contains employment added by NIOSH but not 

approved by the DO, the CE submits a rework 

request to the DEEOIC Health Physicist. 

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14. Review of Claim for Rework of Dose Reconstruction. 

(Continued) 

(6) If military, navy nuclear, or non-DOE federal 

service is identified in the DR, the CE submits a 

rework request to the DEEOIC Health Physicist. 

(7) For any PoC, if changes to the employment site(s) 

are identified, the CE submits a rework request to the 

DEEOIC Health Physicist. 

(8) When a rework is not required, the CE must still 

document the changes to the employment in a memo to 

file and ensure that the difference(s) between the 

employment used in the DR compared to the DOL-verified 

employment is noted in the RD. Finally, the CE 

notifies the NIOSH PHA of the change(s) in employment 

so NIOSH can update its records. 

g. Additional Survivors (Claimants) Identified Rework. 

(1) If the PoC is 50% or greater, NIOSH does not need 

to interview any newly identified claimants. A rework 

is not required. 

(2) If the PoC is less than 50%, NIOSH will interview 

the new claimant(s), at the claimant(s)’ request, to 

determine if there is some information that could 

significantly affect the DR and therefore prompt the 

submission of a rework request to the DEEOIC Health 

Physicist. 

15. Procedures for Requesting Rework. For cases in which the 

CE determines that a rework is necessary, the CE must e-mail the 

Supervisory CE (SCE), SrCE or journey level CE with the Amended 

NRSD (ANRSD) attached, noting the issues with the DR. 

 

a. A copy of the e-mail message (printed from the sent 

file to document the date of issue) must be placed in the 

case file. 

(1) Use an e-mail subject that is specific to the 

individual rework request. For example: last four 

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15. Procedures for Requesting Rework. (Continued) 

digits of DOL ID, NIOSH ID Number, DO, and “Rework”, 

i.e., 1234-NIOSH ID #123456-Denver-Rework. 

 

(2) Briefly summarize how the current NIOSH DR was 

performed. Include the employment history used by 

NIOSH in the DR; the cancer(s), ICD-9 code(s) and 

diagnosis date(s) used in the DR, and the PoC 

resulting from this information used in the DR. 

 

(3) Describe the reason(s) for the rework request. 

For example, an additional cancer has been verified, 

the wrong cancer was reported in the NRSD, the primary 

cancer was determined for a secondary cancer reported 

as an “unknown primary,” more or less employment was 

determined, or the diagnosis date for one of the 

cancers in the DR was found to be incorrect. 

 

 (4) Determine whether the employment history and 

cancer information listed on the DR Coversheet is the 

exact information used by NIOSH in the DR. If the 

information reported in the NRSD does not match the 

information stated on the DR Coversheet, review the DR 

report, particularly in the sections “Dose 

Reconstruction Overview,” and “Information Used”, 

where NIOSH describes in more detail the information 

used to complete the DR. This text may resolve an 

apparent discrepancy. 

(5) Refer to Exhibit 6 for examples of rework requests 

and types of information needed. 

b. An amended NRSD is prepared as necessary. 

c. The PoC value is not entered in ECMS when a case is 

referred back to NIOSH. If a PoC value is already entered, 

the CE deletes the previous PoC value.

d. The DEEOIC Health Physicist serves as the central 

liaison between NIOSH and DOL on all issues related to dose 

reconstruction. If the SCE, SrCE or journey level CE 

agrees with the CE’s e-mail findings regarding rework, he 

or she must forward the CE’s e-mail along with the amended 

NRSD to the DO NIOSH liaison. In turn, the DO NIOSH 

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15. Procedures for Requesting Rework. (Continued) 

liaison sends the request along with the amended NRSD to 

the DEEOIC Health Physicist and copies the CE, SCE, SrCE or 

journey level CE, and District Director. 

 

(1) The DEEOIC Health Physicist reviews the request 

for rework and determines whether a rework is 

required. 

 

(2) If additional information is needed to make a 

determination, which may include requesting the case 

file, the DEEOIC Health Physicist contacts the CE. 

 

e. Rework Not Needed. If the DEEOIC Health Physicist 

determines that information would not change the outcome of 

the DR, he or she will send an e-mail to the DO NIOSH 

liaison, with a copy to the CE, or SCE, and District 

Director, explaining the rationale for not continuing the 

review of the DR. When the CE receives this response, he 

or she must print the e-mail for the case file and proceed 

with the IREP calculation and enter the PoC value(s) into 

ECMS. 

 

(1) Updating Records. Any changes made to a case 

with a DR, regardless of whether the case is submitted 

for a formal rework review by a DEEOIC Health 

Physicist, should be documented in the case file and 

should reference the guidelines used to make that 

determination. 

When the DO makes changes to information used in the 

NIOSH DR, and no rework is required, the DO NIOSH 

liaison or other designated person sends an e-mail to 

the appropriate NIOSH PHA. This e-mail must indicate 

what information was changed, such as the ICD-9 code, 

cancer name, employment dates, etc. 

This allows NIOSH to update its records for the case, 

which is most critical with respect to changes 

involving ICD-9 codes and PoC values different from 

those initially generated by the dose reconstruction. 

Forwarding these changes also allows NIOSH to more 

accurately compile statistics on the types of cancers 

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15. Procedures for Requesting Rework. (Continued) 

addressed in EEOICPA decisions that required a NIOSH 

DR.

If a new PoC calculation was performed using new 

information without the need for rework, the DO NIOSH 

liaison must advise the NIOSH PHA via e-mail and 

attach the new IREP summary file. For example, in a 

case with an initial PoC less that 45%, the DEEOIC 

Health Physicist determined that a change in the ICD-9 

code did not require a rework of the dose 

reconstruction, but just a different NIOSH-IREP model 

run. If the new IREP run resulted in a PoC less than 

45%, the CE may use the new IREP run and PoC as the 

value for the dose reconstruction but must advise 

NIOSH as noted above. 

(2) If the DEEOIC Health Physicist has determined 

that a rework is not necessary, but discrepancies 

appear to exist between the NIOSH dose reconstruction 

and DOL’s analysis of the DR and subsequent 

calculation of the PoC (e.g., one or more cancers were 

subsequently deemed not covered, changes in the 

diagnosis date, differences in NIOSH employment dates 

and DOL-verified employment dates) the CE addresses 

the discrepancies in the RD. 

(3) Any future DR rework based on additional verified 

cancer(s) or employment will be performed using only 

DOL-verified information, which may be more 

restrictive than information used in the previous DR 

(i.e., in some likely non-compensable cases, NIOSH may 

assume a continuous employment period rather than 

considering numerous breaks in employment for purpose 

of completing a DR in a timely manner). Therefore, it 

is possible in some cases for the subsequent PoC to 

remain the same, increase only slightly, or even 

decrease to some degree if the DR is reworked in the 

future. 

f. Rework Needed. If the DEEOIC Health Physicist 

determines that a rework is necessary, he or she will email the CE, SrCE or journey level CE, SCE, District 

Director and the DO NIOSH liaison to proceed. In certain 

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15. Procedures for Requesting Rework. (Continued) 

non-standard rework requests, the DEEOIC Health Physicist 

will also copy the designated NIOSH Office of Compensation 

Analysis and Support (OCAS) contact person(s) on the email. The CE must place a copy of the e-mail in the case 

file. 

(1) The CE must take the following actions: 

(a) Forward the amended NRSD as an electronic 

attachment via e-mail to the NIOSH PHA assigned 

to the DO. 

(b) Send a letter to the claimant (Exhibit 7) 

explaining that the case has been returned to 

NIOSH for a review of the dose reconstruction. 

(c) Send a copy of this letter to the 

appropriate NIOSH PHA along with the weekly DO 

submissions to NIOSH. The dates on the amended 

NRSD and the letter to the claimant must be the 

same, since this will be the date used for the 

new status code entry into ECMS. 

g. After a new draft dose reconstruction (DR) report is 

completed, NIOSH will send it to the claimant along with 

another Form OCAS-1. The claimant has 60 days to sign and 

return the form. 

16. Reviews of Dose Reconstruction. If the claimant objects to 

NIOSH’s decision on the results of the dose reconstruction, the 

objection must be filed with the FAB. FAB evaluates the factual 

findings upon which NIOSH based the dose reconstruction. All 

objections related to dose reconstruction must be sent to a 

DEEOIC Health Physicist for review, unless the objections are 

solely related to factual findings, i.e., whether the facts upon 

which the dose reconstruction report was based were correct. 

a. Factual Objection: If the HR or CE determines that 

the factual evidence reviewed by NIOSH was properly 

addressed, the HR or CE accepts NIOSH’s findings, in which 

case no referral to a DEEOIC Health Physicist is necessary. 

However, if the HR or CE determines that NIOSH did not 

review substantial factual evidence, he or she contacts a 

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16. Reviews of Dose Reconstruction. (Continued) 

DEEOIC Health Physicist to determine if a rework of the 

dose reconstruction is necessary. 

If the DEEOIC Health Physicist determines that a rework of 

the dose reconstruction is necessary, the HR or CE then 

remands the case to the DO for referral to NIOSH for a 

rework. 

b. Technical Objection: A technical objection may 

involve either methodology or application of methodology. 

Examples of methodology of dose reconstruction may include 

but is not limited to analyzing specific characteristics of 

the monitoring procedures in a given work setting; 

identifying events or processes that were unmonitored; 

identifying the types and quantities of radioactive 

materials involved and using current models for calculating 

internal dose. The NIOSH "efficiency" process of using 

overestimates and underestimates in dose reconstruction is 

another example of a methodology. Upon receipt of the 

technical objection(s), the HR or CE discusses it with his 

or her supervisor to obtain approval to submit the 

objection(s) for DEEOIC Health Physicist review. Following 

are steps taken to track technical objections submitted for 

DEEOIC Health Physicist review: 

(1) The HR or CE prepares a memo to the DEEOIC Health 

Physicist that identifies only the dose 

reconstruction-related technical objections (not 

including any factual objections). 

 

(2) The HR or CE attaches electronic version of the 

memo (in addition to the NIOSH dose reconstruction 

report, IREP summary for each cancer and CATI summary 

for each claimant from the NIOSH disc) to an e-mail 

message addressed to the DEEOIC Health Physicist with 

copies to the FAB supervisor and FAB support team. 

The e-mail message should contain the following 

information in the subject line: the HR or CE’s FAB 

office location; “Tech Obj”; the last 4 digits of the 

claim #; and the name of the covered facility, e.g., 

(FAB NO) Tech Obj-4112(Hanford). 

 

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16. Reviews of Dose Reconstruction. (Continued) 

(3) The HR or CE spindles the memo in the file and 

documents ECMS Notes to explain that supervisory 

approval has been granted and that the aforementioned 

actions have been completed. 

(4) Upon receipt of the technical objection(s), the 

DEEOIC Health Physicist determines whether the 

technical objection is one of application or 

methodology. Methodology used by HHS in arriving at 

reasonable estimates of the radiation doses received 

by an employee, established by regulations issued by 

HHS at 42 CFR Part 82, is binding on FAB. Objections 

concerning the application of that methodology (20 CFR 

§ 30.318) is referred by the DEEOIC Health Physicist 

to NIOSH for their opinion. NIOSH is asked to respond 

within 30 days. The DEEOIC Health Physicist then sends 

his or her written opinion (and NIOSH’s opinion, if 

any) to FAB. Upon receipt of the DEEOIC Health 

Physicist’s review of technical objections, the HR or 

CE spindles the responses in the file. If the case 

needs to be reviewed by NIOSH, the FAB will be 

instructed to remand the case back to the DO for 

referral to NIOSH. 

17. Proving Causation Between Diagnosed Non-SEC Cancer and 

Covered Employment. Under Part B, a covered employee seeking 

compensation for cancer, other than as a member of the SEC 

seeking compensation for a specified cancer, is eligible for 

compensation only if DOL determines that the cancer was "at 

least as likely as not" (that is, a 50% or greater probability) 

caused by radiation doses incurred in the performance of duty 

while working at a DOE facility and/or an Atomic Weapons 

Employer (AWE) facility. 

This includes radiation doses from medical X-rays for the preemployment physical examination, annual physical examinations, 

and a termination (exit) physical examination, but does not 

include radiation to which the employee may have been exposed 

during airline flights, as such exposures are not incurred from 

activities at the sites. 

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17. Proving Causation Between Diagnosed Non-SEC Cancer and 

Covered Employment. (Continued) 

EEOICPA does not include a requirement limiting the types of 

cancers to be considered radiogenic; CLL is considered non 

radiogenic pursuant to HHS regulation. 

a. NIOSH-IREP. The CE must use the updated version of 

radioepidemiological tables developed by the National 

Institutes of Health as a basis for determining PoC. This 

software program, named the NIOSH-Interactive 

RadioEpidemiological Program (NIOSH-IREP), is based on 

NIOSH regulations found at 42 C.F.R. Part 81. NIOSH-IREP 

allows the CE to apply the National Cancer Institute risk 

models directly to data on individual claimants. 

b. Uncertainty. NIOSH-IREP allows the CE to take into 

account uncertainty concerning the information being used 

to estimate PoC. There typically is uncertainty about the 

radiation dose levels to which a person has been exposed, 

as well as uncertainty relating to levels of dose received 

to levels of cancer risk observed in study populations. 

Accounting for uncertainty is important because it can have 

a large effect on the PoC estimates. 

c. Credibility Limit. As required by the Act at Section 

7384n(c)(3)(A), the NIOSH-IREP uses the upper 99 percent 

credibility limit to determine whether the cancers of 

employees are at least as likely as not caused by their 

occupational radiation doses. This helps minimize the 

possibility of denying compensation for those employees 

with cancers likely to have been caused by occupational 

radiation exposures. 

d. Guidelines. Specific guidelines concerning the 

calculation of the PoC for certain cancers are noted below. 

(1) Carcinoma in situ (CIS), or cancers in their 

early stages, are not specifically included in NIOSHIREP models. These lesions are becoming more 

frequently diagnosed, as the use of cancer screening 

tools, such as mammography, has increased in the 

general population. The risk factors and treatment 

for CIS are frequently similar to those for malignant 

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17. Proving Causation Between Diagnosed Non-SEC Cancer and 

Covered Employment. (Continued) 

neoplasms, and, while controversial, there is growing 

evidence that CIS represents the earliest detectable 

phase of malignancy. Therefore, for purposes of 

estimating PoC, carcinoma in situ (ICD–9 codes 230–

234) should be treated as a malignant neoplasm of the 

specified site. 

Current NIOSH guidance on which IREP models to run for 

in situ squamous cell carcinoma (SCC) skin cancer is 

contained in Table 4, “Cancer Models to be Used in the 

Calculation of Probability of Causation,” in the 

NIOSH-IREP Technical Documentation. The guidance in 

the table directs the use of two models for in situ 

skin cancer cases. For the ICD-9 code 232 series the 

CE must use the IREP models for both malignant 

melanoma and non-melanoma skin-squamous cell. 

When a physician specifically identifies the in situ 

skin cancer as squamous cell carcinoma (SCC), the IREP 

guidance in the above-mentioned tables is not 

applicable and the CE must run the SCC model only. If 

not so identified, then the CE continues to run both 

models for in situ skin cancers. 

(2) For other cancers requiring the use of NIOSHIREP, the CE must assume that neoplasms of uncertain 

behavior (ICD–9 codes 235–238) and neoplasms of 

unspecified nature (ICD–9 code 239) are malignant, for 

purposes of estimating PoC. 

e. Cancers for Which the Primary Site is Unknown. Some 

claims involve cancers identified by their secondary sites 

(sites to which a malignant cancer has spread), where the 

primary site is unknown. 

(1) This situation most commonly arises when death 

certificate information is the primary source of a 

cancer diagnosis. It is accepted that cancer-causing 

agents, such as ionizing radiation, produce primary 

cancers. In a case in which the primary site of 

cancer is unknown, this means that the primary site 

must be established by inference to estimate PoC. 

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17. Proving Causation Between Diagnosed Non-SEC Cancer and 

Covered Employment. (Continued) 

(2) For background purposes, Exhibit 8, which is 

reproduced from Table 1 in 42 C.F.R. Part 81, 

indicates, for each secondary cancer, the set of 

primary cancers producing approximately 75% of that 

secondary cancer among the U.S. population (males and 

females were considered separately). NIOSH performs 

the dose reconstruction for the cancer site that 

yields the highest PoC. 

 

If the PoC yields a PoC greater than 50%, all of the 

secondary cancers are covered for medical benefits 

even if no dose reconstruction was performed for that 

secondary cancer. 

f. Cancers of the Lymph Node. The CE must consider all 

secondary and unspecified cancers of the lymph node (ICD-9 

code 196.0) as secondary cancers (those resulting from 

metastasis of cancer from a primary site). For claims 

identifying cancers of the lymph node, Exhibit 8 provides 

guidance for assigning a primary site and calculating the 

PoC using NIOSH-IREP. 

g. Claims With Two or More Primary Cancers. For these 

claims, DOL uses NIOSH-IREP to calculate the estimated PoC 

for each cancer individually. The CE then performs an 

additional statistical procedure following the use of 

NIOSH-IREP to determine the probability that at least one 

of the cancers was caused by radiation (discussed further 

in the NIOSH-IREP procedures). This approach is important 

to the claimant because it determines a higher PoC than is 

determined for either cancer individually. 

For cases involving multiple primary cancers where the PoC 

is greater than 50%, all of the primary cancers will be 

covered for medical benefits. 

h. Claims for Leukemia. Sometimes NIOSH guidance requires 

that two or three NIOSH-IREP models be run for a particular 

cancer. This most often occurs with different types of 

leukemia. NIOSH only includes the NIOSH-IREP input and 

associated summary sheet providing the highest PoC in the 

"DR Files" on the disk sent to the DO. 

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17. Proving Causation Between Diagnosed Non-SEC Cancer and 

Covered Employment. (Continued) 

i. Claims for Chronic Lymphocytic Leukemia (CLL) Only. 

CLL is a form of leukemia not found to be radiogenic in 

studies conducted worldwide of a wide variety of radiationexposed populations. Therefore, pursuant to HHS 

regulations, the PoC for CLL is assigned a value of zero. 

The CE will insert Exhibit 9 into the file for the record. 

Exhibit 9 is a letter from NIOSH that states the Department 

of Health and Human Services (HHS) guidelines for 

determining the PoC for CLL. Since CLL has a PoC of zero, 

the CE adjudicates the claim without sending the case to 

NIOSH. The RD must contain a reference to the DHHS 

regulations and cite 42 C.F.R. § 81.30 denying compensation 

benefits under Part B of the Act. 

(1) In cases where there are multiple primary cancers 

including CLL, and the PoC is greater than 50%; 

medical benefits will be covered for CLL. When CLL is 

diagnosed after an award has been made for a greater 

than 50% PoC, medical benefits are paid for CLL. 

(2) CLL may be compensable under Part E of the Act. 

The CE must determine if causation can be established 

for CLL and exposure to toxic substances other than 

radiation under Part E. 

18. Calculation of PoC Using NIOSH-IREP Computer Program. DOL 

must calculate the PoC for all cancers, except CLL, using NIOSHIREP. The risk models developed by the National Cancer 

Institute and the Center for Disease Control for NIOSH-IREP 

provide the primary basis for developing guidelines for 

estimating PoC under EEOICPA. They directly address 33 cancers 

and most types of radiation exposure relevant to claimants 

covered by EEOICPA. 

a. NIOSH Cancer Models. The NIOSH Cancer Models take 

into account the employee’s cancer type, year of birth, 

year of cancer diagnosis, and exposure information such as 

years of exposure, as well as the dose received from gamma 

radiation, X-rays, alpha radiation, beta radiation, and 

neutrons during each year. A glossary of cancer 

descriptions for each ICD-9 code is provided in 42 C.F.R. 

Part 81 and is reproduced as Exhibit 10. 

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18. Calculation of PoC Using NIOSH-IREP Computer Program. 

(Continued) 

b. Smoking History and Racial/Ethnic Identification. The 

risk model for lung cancer takes into account smoking 

history. The risk model for skin cancer takes into account 

the race or ethnic identification of the claimant. 

(However, it does not consider exposure to sunlight, since 

sunlight is not a toxic substance.) 

None of the risk models explicitly account for exposure to 

other occupational, environmental, or dietary carcinogens. 

For cases with lung (primary or secondary, with unknown 

primary) or skin cancer, the CE must determine the smoking 

history or race or ethnic identification of the claimant. 

c. Risk Models. NIOSH-IREP is specifically designed for 

adjudication of claims under EEOICPA and incorporates 

cancer risk models that have been modified to reflect the 

radiation exposure and disease experiences of employees 

covered under EEOICPA. 

d. NIOSH-IREP Operating Guide. The CE must use 

procedures specified in the NIOSH–IREP Operating Guide to 

calculate PoC estimates under EEOICPA. 

The guide provides step-by-step instructions for the 

operation of NIOSH–IREP. The procedures include entering 

personal, diagnostic, and exposure data; setting/confirming 

appropriate values for variables used in calculations; 

conducting the calculation; and obtaining, evaluating, and 

reporting results. There are two user guides, one for 

cases with a PoC less than 45% or greater than 52%; and 

another, termed the Enterprise Edition, for cases with PoCs 

of 45% to 52%. Enterprise Edition cases can be identified 

by looking at the Excel input file name which would include 

the notation “EE.” 

(1) For cases with a PoC less than 45% or greater 

than 52%, the CE accesses NIOSH-IREP on the NIOSH 

website at http://198.144.166.6/irep_niosh/ to perform 

the PoC calculation. The CE must use data from the CD 

for the NIOSH-provided input file for each cancer. 

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18. Calculation of PoC Using NIOSH-IREP Computer Program. 

(Continued) 

After the IREP calculation is completed for each 

cancer, the CE prints out the NIOSH-IREP PoC results 

directly from the web page and retains it in the case 

file. The copy shows the web page address and date at 

the bottom, which documents that the CE independently 

ran the IREP. 

When two or more cancers are present, the CE uses the 

multiple primary cancer equation to calculate the 

total PoC, and saves this report as a hard copy. 

(2) For cases with POCs between 45% and 52%, another 

software program, called the NIOSH-IREP Enterprise 

Edition (NIOSH-IREP-EE), is used to perform the PoC 

calculation. The website address for the program, the 

User’s Manual, and the password (which NIOSH will 

change every few months), is available by contacting 

the DOL Health Physicist. 

The Enterprise Edition is used for this PoC range to 

achieve better statistical precision and further 

reduces the chance of denying a claim because of 

sampling error. 

In summary, the simulation sample size will be 

increased to 10,000; 30 additional IREP runs will be 

performed using a new random number seed for each run; 

and the average value of the upper 99% credibility 

limit (CL) of the 30 runs (PoC) will determine the 

claim outcome. 

(a) To facilitate the 30-run process, another 

Excel input file is used specifically for this 

software. This input file contains all the 

claims data found in the regular NIOSH-IREP input 

file, but are preset with 30 different random 

number seeds and a simulation sample size of 

10,000. 

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18. Calculation of PoC Using NIOSH-IREP Computer Program. 

(Continued) 

(b) NIOSH will provide this preset file (or 

files, if there is more than one primary cancer) 

for each claim that falls into the PoC range. To 

perform the required calculations, this input 

file need only be uploaded once into NIOSH-IREPEE. 

(c) After the CE uploads the file and clicks the 

“Generate 30 Results” button, the input is 

submitted to the NIOSH-IREP-EE server where the 

calculations are to be performed. Upon 

completion, the results are displayed in the form 

of IREP Summary Report. They will include the 

average value of the upper 99% CL of the PoCs for 

the 30 results. 

(d) While the CE waits for the results to be 

returned, the computer may be used for other 

tasks. However, clicking on an internet link in 

an e-mail while the file is running will disrupt 

the calculation process. To access the internet 

while waiting for the calculations to be 

performed, a new and separate instance of the 

browser should be opened. 

(e) Since some calculations could take over two 

hours to complete, it may be best to run the 

NIOSH-IREP-EE at the end of the day to allow the 

computer to process overnight. When complete, the 

calculations will remain on the CE’s screen to be 

printed and saved the next morning. 

(3) For multiple primary cancers (or secondary 

cancers with no known primary), the CE performs the 

NIOSH-IREP-EE calculation for each cancer. As with 

the standard NIOSH-IREP, the PoC results must be 

printed and placed in the case file. 

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19. Establishing Causation for Cancer Under Part E. Coverage 

under Part E is limited to confirmed DOE contractor employees or 

RECA Section 5 uranium workers who contracted any diagnosed 

illness (this Chapter focuses on cancer) after beginning 

employment at a DOE facility or a RECA Section 5 facility. 

Certain RECA Section 4 eligible claimants who have not received 

any Section 4 benefits may also be eligible for EEOICPA benefits 

if otherwise eligible under EEOICPA. To establish causation 

under Part E, evidence must show that it is “at least as likely 

as not” that the exposure to a toxic substance (which may 

include radiation) at a DOE facility or certain RECA facilities 

was a significant factor in causing, contributing to, or 

aggravating the covered illness. In certain cases, there is a 

presumption of causation under Part E. 

a. Presumption of Causation: 

1. Approved Part B Conditions. Medical conditions 

approved under Part B are given a presumption of 

causation under Part E. As such, an acceptance for a 

medical condition under Part B will correlate to an 

automatic acceptance under Part E for the same medical 

condition. 

2. DOE Physician’s Panel. If, under former Part D, a 

DOE physician’s panel finding signed by a DOE official 

provides the opinion that the employee sustained an 

illness or died due to a toxic substance at a DOE 

facility, the CE accepts the determination for 

causation under Part E. 

3. SEC Cases. A determination that an employee is 

entitled to compensation based on meeting the criteria 

required under SEC establishes causation for that 

cancer under Part E (non-SEC cancers must be developed 

for causation). However, for claims involving 

survivors, evidence must establish that the covered 

cancer was a significant factor that caused or 

contributed to the death of the employee. 

 

4. RECA Section 5. Conditions approved under Part B 

based on a RECA Section 5 awarded to a living employee 

will correlate to an automatic acceptance under Part E 

to the same living employee for the same medical 

condition. However, survivors of Section 5 RECA award 

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19. Establishing Causation for Cancer Under Part E. (Continued) 

recipients, and survivors who are award recipients in 

their own right, must submit the requisite documents 

to establish survivorship eligibility under Part E. 

All Part E survivorship rules apply to RECA survivors. 

 

b. Causation Development of Non-SEC Cancer Cases. Under 

Part E, non-SEC cancer cases without presumption of 

causation are developed for causation by evaluating the 

causal nexus between the cancer and potential occupational 

exposure to radiation and/or other toxic substances at a 

covered facility. While development actions for radiation 

and other toxic substances (non radiation) exposures have 

distinct paths, they are undertaken concurrently to 

determine whether or not a claimant meets the causation 

test under Part E. 

(1) When developing a cancer claim for causation due 

to radiation, the CE refers the case file to NIOSH for 

dose reconstruction in accordance with the 

instructions in this Chapter. The CE must determine 

whether or not the cancer is “at least as likely as 

not” related to the verified covered employment at a 

DOE or RECA facility. The “at least as likely as not” 

causation standard is met if the PoC is 50% or 

greater. 

 

Part E claims based on RECA Section 5 employment that 

are for cancers other than those accepted by DOJ 

(i.e., lung cancer) are also referred to NIOSH for 

dose reconstruction and determination of the PoC. 

 

(2) In conjunction with the dose reconstruction, the 

CE develops the Part E cancer claim for causation 

based upon toxic substance other than radiation. 

(3) A cancer claim may meet the causation test by 

either means: 

(a) If the dose reconstruction results in a PoC 

of 50% or greater, the CE issues a RD to accept 

the claim under Part B and/or Part E. In a 

survivor case, the CE must also establish that 

the covered cancer was at least as likely as not 

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19. Establishing Causation for Cancer Under Part E. (Continued) 

a significant factor that caused, contributed to 

or aggravated the death of the employee. 

(b) If the CE is able to establish toxic 

exposure causation and no Part B benefits are 

claimed, the CE renders a factual determination 

as to acceptance under Part E only and issues the 

RD. If the case is pending at NIOSH for a dose 

reconstruction, the CE pulls the case file from 

NIOSH without waiting for the dose reconstruction 

to be completed. For example, a claimant is the 

survivor of a uranium miller covered under 

Section 5 of the RECA. The claimant is seeking 

survivorship benefits under Part E based upon a 

claim of esophageal cancer. No Part B benefits 

are being sought, as the survivor was awarded 

Part B benefits as a RECA Section 5 beneficiary, 

and is not eligible for Part B benefits under the 

esophageal cancer claim. In this case only Part 

E benefits are sought for the cancer claim, and 

should the CE establish a causal link between the 

esophageal cancer and exposure to a toxic 

substance at a RECA mine, the claim can be 

immediately accepted and withdrawn from NIOSH 

without waiting for the dose reconstruction. 

If, however, Part B benefits are also claimed, 

the case file remains at NIOSH until the dose 

reconstruction is complete so a RD can be issued 

for both Parts B & E at the same time. 

 

(4) In certain instances a physician might opine that 

a claimant’s radiation and toxic substance exposure 

together worked in tandem to produce a synergistic or 

additive effect that brought about the cancer. DOL 

has not found scientific evidence establishing a 

synergistic or additive effect between radiation and 

exposure to a toxic substance, and if the physician 

presents this finding he or she must provide actual 

scientific or medical research evidence to support the 

finding before the CE may consider the assertion. 

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19. Establishing Causation for Cancer Under Part E. (Continued) 

If a physician makes this assertion, the CE requests 

that the physician provide medical evidence of a 

synergistic or additive effect and a clearly 

rationalized medical opinion as to whether or not the 

effect is significant enough to establish that the 

combination of the radiation and the exposure to a 

toxic substance was “at least as likely as not” a 

significant factor in aggravating, contributing to, or 

causing the cancer. 

If the physician provides rationalized scientific 

evidence revealing a synergistic or additive effect, 

the DO sends the case file to NO for review by a NO 

Health Physicist (HP), Toxicologist and/or the DEEOIC 

Medical Director. The HP reviews the physician’s 

report and all evidence of file and makes a 

recommendation as to causation. 

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Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

NIOSH Referral Summary Document (NRSD) 

Enter a “X” where appropriate

Initial Amendment Supplement

Remarks(if Amendment or Supplement):

1. DOL Case Number: 

Case File Contact Information 

2. Energy Employee (EE): 

a. Name (First-Middle-Last-Suffix)

b. Gender (Male or Female)

c. Date of Birth (MM/DD/YYYY)

d. Date of Death (MM/DD/YYYY)

e. Address (Street, City, State, Zip) 

f. Phone Number and Type

3. Survivor(s) (SV) (If applicable, create a table for each): 

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

e. Currently eligible survivor (Y/N)

4. Other Contact(s)(OC)(If applicable, create a table for each): 

a. Name (First-Middle-Last-Suffix)

b. Address (Street, City, State, Zip)

c. Phone Number and Type

d. Relationship to employee

EEOICPA Tr. No. 10-07 Page 1 of 3 Exhibit 1 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

_______________________________________________________________ 

Medical and Employment Information 

5. EE Covered Cancer Information (create a table for each 

cancer): 

a. Primary [ ] or Secondary (metastatic) [ ]

b. Cancer Description/Type

c. Associated ICD-9 Code

d. Date of Cancer Diagnosis 

6. Other Covered Condition: 

a. SEC Cancer Claim, but filing for Non-SEC cancer medical 

benefits [ ]

b. Other claim for benefits scenario [ ] 

c. Explain:

7. Energy Employee Verified Employment History: 

(List all breaks in employment at the DOE or AWE Facility): 

a. Employer / Facility Name

b. Start Date

c. End Date

d. Employment Badge Number

e. Dosimetry Badge No.

f. Job Title 

8. Employment Verification Information Valuable to NIOSH: 

a. DOE could not verify employment

b. Employment Verification based upon Affidavit or Other 

 Credible Evidence.

c. Worked for a contractor/sub-contractor not listed in DOE

 Office of Worker Advocacy facility online database.

EEOICPA Tr. No. 10-07 Page 2 of 3 Exhibit 1 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

_______________________________________________________________ 

9. Other information relevant to dose reconstruction, if 

required: 

a. If the claim is for 

skin cancer or a 

secondary cancer for 

which skin cancer is a 

likely primary cancer, 

list one or more of the 

following:

American Indian or Alaska Native

Asian, Native Hawaiian, or 

 Pacific Islander

 Black 

 White-Hispanic 

 White-Non-Hispanic 

Not given

b. If the claim is for 

lung cancer or a 

secondary cancer for 

which lung cancer is a 

likely primary cancer, 

select one of the 

following (Note: 

Currently refers to time 

of cancer diagnosis):

Never smoked

 Former smoker 

 Current smoker (? cig/day) 

  <10 cig/day 

  10-19 cig/day 

  20-39 cig/day 

  40+ cig/day 

10. DOL Information: 

a. District Office

b. Claims Examiner Name

c. Claims Examiner Phone Number

d. Claims Examiner email address

Reviewed by:

Claims Examiner Date

EEOICPA Tr. No. 10-07 Page 3 of 3 Exhibit 1 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

__________________________________________________________________________________________________ 

INSTRUCTIONS FOR COMPLETING THE NRSD

No. Title Description Example

N/A NRSD Type

Enter an “X” next to the type of NRSD that is being submitted. If you select Amendment or Supplement enter Remarks (the 

reason and or data that has created the need for an Amendment/Supplement. For an Initial NRSD include all sections, unless 

they will be blank (i.e. other contact if there isn’t one). For an Amendment include the employee’s name, DOL case number, 

NIOSH tracking number, the tables that include changed information, and the DOL information (including the SrCE’ or journey 

level CE signature). For Supplements, include the DOL case number, NIOSH tracking number, and employee’s name.

1 DOL Case Number Enter the 9 digit case number/social security number 123-45-6789

2 Energy Employee (EE) The employee as listed on the EE-1/EE-2.

a Name Enter the Employee’s name as it is listed in ECMS/Claim Form (First, Middle Initial, 

Last, Suffix) Fred R. Flintstone, III

b Gender Enter Male or Female as indicated in ECMS/Claim Form Male, Female

c Date of Birth Enter the date of birth in MM/DD/YYYY format 01/31/1964

d Date of Death If applicable, enter the date of death in MM/DD/YYYY format 11/01/2006

e Address

If applicable, enter the full address of the EE (Street, City, State, and zip code)

 

 

 

710 Bedrock Dr., Aiken, SC 26175-0454

f Phone Number and Type

If available/applicable, enter the employee’s 10 digit phone number. Refer to 

ECMS for the EE-2. Type can include home, work, cell, day, evening, vacation 

home, etc. 

865-123-9870 Home

3 Survivor(s) Data

If applicable, enter the survivor’s data for each survivor that has filed a Claim for Benefits, Form EE-2. If not applicable (the 

employee is living), delete these tables. If there are more than 3 survivors, copy and paste one table and add to the bottom, be 

sure to include a space between them.

a Name Enter the Survivor’s name (First, Middle Initial, Last, Suffix). Refer to ECMS for the 

EE-2 Betty D. Flintstone

b Address Enter the full address of the survivor (Street, City, State, and zip code). Refer to 

ECMS or the EE-2. 710 Bedrock Dr., Aiken, SC 26175-0454

c Phone Number and type If available, enter the survivor’s 10 digit phone number. Refer to ECMS or the EE2. Type can include home, work, cell, day, evening, vacation home, etc. 703-999-8000 Other

d Relationship to Employee Enter the survivor’s relationship to the employee as selected on the EE-2 Spouse, Child, Grandchild

e Currently eligible survivor (Yes or No)

Enter Yes or No. Entering “Yes” means the survivor has met all the requirements 

to establish survivorship. Also note if the survivor is a “Part E Only” survivor (i.e. a 

non-spousal child). In cases of multiple survivors, indicate which survivor would 

prefer to be contacted by entering “Primary Contact” in the space provided.

Yes (Part E Only/Non-spousal 

Child)/Primary Contact

4 Other Contact If applicable, enter the Authorized Representative/Power of Attorney (POA) data. If not, delete this table. If there is more than 

one contact, copy and paste the table and add to the bottom, be sure to include a space between them.

a Name Enter the Contact’s name (First, Middle Initial, Last, Suffix) Ira M. Lawyer, Jr.

b Address Enter the full address of the survivor (Street, City, State, and zip code) 710 Bedrock Dr., Aiken, SC 26175-0454

c Phone Number and Type If available, enter the survivor’s 10 digit phone number. Type can include home, 

work, cell, day, evening, vacation home, etc. 703-999-8000 Work

Helpful Hint: Adding the +4 zip code may speed up mail delivery by several days (visit 

www.usps.com to find an address’ +4 zip code). 

EEOICPA Tr. No. 10-07 Page 1 of 3 Exhibit 2 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

___________________________________________________________________________________________________ 

INSTRUCTIONS FOR COMPLETING THE NRSD

No. Title Description Example

d Relationship to employee If known, enter the contact’s relationship to the EE Lawyer

5 EE Covered Cancer Information Enter the EEs verified diagnosed cancer(s). Create a table (copy, cut, paste); for each primary cancer or secondary cancer for 

which there is an unknown primary.

a Primary or Secondary Place an “X” (by clicking) in the box that best describes the cancer (Primary or 

Secondary)

b Cancer Description/Type Enter the cancer description from the pathology/operative report, etc. Chronic monocytic leukemia, in remission

c Associated ICD-9 Code Enter the ICD-9 code that best describes the cancer 206.11

d Date of Cancer Diagnosis

Enter the date of cancer diagnosis from pathology report, operative report, death 

certificate, etc. in MM/DD/YYYY format. The entire date is not required but 

preferred. List the month and year if the full date is not available. The year of 

diagnosis is required.

01/10/2001

6 Other Covered Condition If applicable, place and “X” (by clicking) in the box(es).

a SEC Cancer Claim, but filing for NonSEC cancer medical benefits

Select this box if the claim is an employee claim or a survivor claim where the 

employee filed initially, that is being or has been accepted for an SEC cancer; and 

there is a claim for a non-SEC Cancer.

Employee is accepted for SEC lung 

cancer; and now is filing for a non-SEC 

skin cancer.

b Other claim for benefits scenario If there is any scenario not “typical” (i.e., non SEC cancer/employment) and not 

covered in 6.a, select this box by clicking.

Part B survivor case accepted for CBD. 

Under Part E, cannot establish death link 

relating to CBD; death certificate lists lung 

cancer as cause of death.

c Explain Provide a detailed/specific explanation for the reason box 6.b was selected

For the example above: “Survivor already 

compensated under Part B, Dose 

Reconstruction will be to establish death 

link for Part E only.”

7 Energy Employee Verified Employment 

History

Complete this section for all verified employment. Any breaks in employment seven days or more must be reported separately. 

Create another table by using copy, paste; remember to leave a space between them. It is not necessary to verify employment 

beyond the date of cancer diagnosis for the purposes of submitting the NRSD; however, once submitted, continue to complete 

employment verification for toxic exposure and other claimed illnesses. Remember that the verified employment may extend 

beyond the covered employment at a particular site. The CE must verify the covered dates for a site by going to the DOE Office 

of Worker Advocacy Covered Facility List (http://www.hss.energy.gov/healthsafety/fwsp/advocacy/faclist/findfacility.cfm). 

a Employer/Facility Name Enter the employer and Facility Name Union Carbide/K-25

b Start Date Enter the start date in MM/DD/YYYY Format 01/01/1956

c End Date Enter the end date in MM/DD/YYYY Format 12/31/1959

d Employment badge number If available, list the EEs employment badge number from the EE-3 or DAR. 10349

e Dosimetry Badge No. If available, list the EEs dosimetry badge number from the EE-3, DAR, or ORISE 10949

f Job Title If available, list the EEs job title (for the specific employment period) using 

information from the EE-3, DAR, or ORISE Pipefitter

8 Employment verification information 

valuable to NIOSH Select these boxes, by clicking, if applicable. 

a DOE could not verify employment Select this box if employment wasn’t verified 

EEOICPA Tr. No. 10-07 Page 2 of 3 Exhibit 2 

January 2010 

SUPERSEDED

 
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

___________________________________________________________________________________________________ 

INSTRUCTIONS FOR COMPLETING THE NRSD

No. Title Description Example

b Employment verification based on 

affidavit or other credible evidence

c 

Worked for a contractor/sub-contractor 

not listed

If the employee worked for a contractor/subcontractor not listed on the DOE Office 

of Worker Advocacy Covered Facility List, select this box. F.H. McGraw

9 Other information relevant to dose 

reconstruction For skin cancer and lung cancer cases additional information regarding the following must be provided.

a Ethnicity selection

For skin cancers, it is required that the District Office supply NIOSH with the EEs race/ethnicity. The method used to gather this 

information is EE/EN-9 (Attachment 4). If the claimant does not return the questionnaire within 60 days, the case will be 

administratively closed. However, if the CE can obtain the information from the EE’s medical information or other credible source 

(i.e. DAR), the NRSD may be completed using that information and forwarded to NIOSH with an explanation of where the 

information was acquired.

b Smoking History

For lung cancer or a secondary cancer with an unknown primary cancer that includes lung cancer as a possible primary cancer , 

the CE must request the EEs smoking history using the EE/EN-8 (Exhibit 3). If the claimant does not return the questionnaire 

within 60 days, the case will be administratively closed. However, if the CE can obtain the information from the EE’s medical 

information or other credible source (i.e. DAR), the NRSD may be completed using that information and forwarded to NIOSH with

an explanation of where the information was acquired. If the employee is a current smoker (currently refers to time of cancer 

diagnosis), then the CE must select an additional box, which indicates the amount (per day) the employee smoked at the time of 

cancer diagnosis.

10 DOL Information Enter the requested information

a District Office Enter the CE’s District Office Cleveland, Denver, Jacksonville, Seattle 

b Claims Examiner Name Enter the CE’s full name Fred C. Flintstone

c Claims Examiner Phone No. Enter the CE’s direct dial phone number (not the toll free number) (904)357-4795 x74307

d Claims Examiner email address Enter the CE’s DOL email address flinstone.fred@dol.gov

Reviewed by A SrCE or journey level CE must review the NRSD, sign, and date; affirming that to the best of her/his ability, they have reviewed 

the information provided and believe it to be accurate and correct.

Note: A complete copy of the case file (including the Part D if available) will be duplicated and sent with the NRSD to NIOSH.

EEOICPA Tr. No. 10-07 Page 3 of 3 Exhibit 2 

January 2010 

SUPERSEDED

 
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Smoking History Request, Form EE/EN-8

Dear Claimant Name: 

This letter is in regard to your claim for compensation under 

the Energy Employees Occupational Illness Compensation Program 

Act of 2000, as amended. 

We have reviewed the claim and have determined that one of the 

following potentially radiogenic cancers has been diagnosed: 

 Primary Trachea 

 Bronchus 

 Lung 

The next step in the process of determining your eligibility for 

any benefits is calculating the probability of causation. This 

is essentially a finding whether the diagnosed cancer is 

reasonably related to exposure to radioactive materials while 

employed. The calculation of probability is based on many 

factors, such as the length of exposure and proximity to 

radiological sources, the type of safety protection worn, the 

type of cancer diagnosed, etc. 

Another factor that must be included in the calculation for 

these particular cancers is the smoking history of the employee. 

In order to proceed with the calculation of probability for a 

claim involving primary trachea, bronchus, or lung cancer, we 

will need to know certain information about the employee’s 

smoking history immediately prior to the diagnosis of cancer. 

This smoking information will be used to calculate the 

probability of causation. 

Attached to this letter is an enclosure that must be completed 

in order for the claim to proceed. Please fill out the 

enclosure fully and return it to the address that appears at the 

bottom. We ask that the enclosure be returned within thirty 

(30) days so as to avoid any delay in the claims adjudication 

process. 

OMB No. 1215-0197 EE-8 Page 1 

Expiration Date: 08/31/07 

 EEOICPA Tr. No 10-07 Page 1 of 3 Exhibit 3 

 January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

The attached enclosure must be completed and returned. Without 

the completed enclosure, we will be unable to calculate the 

probability of causation in your claim. Without this 

calculation, a determination concerning your entitlement to 

monetary benefits cannot be issued. 

If you have any questions or concerns, please contact the 

District Office at toll free # or FAX to #. 

Sincerely, 

Claims Examiner 

Enclosure: EN-8 

PRIVACY ACT

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The 

Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 7384 et seq.) (EEOICPA) is 

administered by the Office of Workers’ Compensation Programs of the U.S. Department of Labor, which receives and 

maintains personal information on claimants and their immediate families. (2) Information which the Office has 

received will be used to determine eligibility for, and the amount of, benefits payable under the EEOICPA, and may 

be verified through computer matches or other appropriate means. (3) Information may be given to the Federal 

agencies or private entities that employed the claimant at the time of injury in order to verify statements made, 

answer questions concerning the status of the claim, verify billing, and to consider other relevant matters. (4) 

Information may be disclosed to physicians and other health care providers for use in providing treatment or medical 

rehabilitation, making evaluations for the Office of Workers’ Compensation Programs and for other purposes related 

to the medical management of the claim. (5) Information may be given to Federal, state, and local agencies for law 

enforcement purposes, to obtain information relevant to a decision under the EEOICPA, to determine whether 

benefits are being paid properly, including whether prohibited payments have been made, and, where appropriate, to 

pursue salary/administrative offset and debt collection actions required or permitted by the Debt Collection Act. (6) 

Disclosure of the claimant’s social security number (SSN) or tax identification number (TIN) is mandatory. The SSN 

or TIN, and other information maintained by the Office, may be used for identification, to support debt collection 

efforts carried on by the Federal government, and for other purposes required or authorized by law. (7) Failure to 

disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in 

an unfavorable decision.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of five (5) minutes to respond to this collection of information, which includes 

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection of information. If you have any comments regarding this estimate or any 

other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. 

Department of Labor, OWCP, Room S-3524, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT 

SEND THE COMPLETED FORM TO THIS ADDRESS. Persons are not required to respond to this collection of 

information unless it displays a currently valid OMB number.

 EE-8 Page 2

EEOICPA Tr. No 10-07 Page 2 of 3 Exhibit 3 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Employee: Name File Number: 

1. What is the best description for the employee named above? 

Never Smoked 

Former Smoker - The employee quit smoking more than 

five years before the date of cancer diagnosis 

Current Smoker – The employee smoked cigarettes at the 

time of the cancer diagnosis or quit smoking fewer than 

five years before the date of cancer diagnosis 

2. If you selected Current Smoker, check the box that 

corresponds with the number of cigarettes smoked per day* 

at the time of the cancer diagnosis: 

Less than 10 per day

10 - 19 per day 

20 - 39 per day

40+ per day

* Generally 20 Cigarettes Per Pack 

Any person who knowingly makes any false statement, concealment 

of fact, misrepresentation, or commits any other act of fraud to 

obtain compensation as provided under the EEOICPA or who 

knowingly accepts compensation to which that person is not 

entitled is subject to civil or administrative remedies as well 

as felony criminal prosecution and may, under appropriate 

criminal provisions, be punished by a fine or imprisonment or 

both. 

I certify that the information provided is accurate and true. 

Print Name: _______________________________________________ 

Signature: _______________________________________________ 

Date: ____________________ 

Return Form to: OFFICE OF WORKERS’ COMPENSATION PROGRAMS 

 DIVISION OF ENERGY EMPLOYEES OCCUPATIONAL 

 ILLNESS COMPENSATION 

 District Office Address 

 District Office City,State,Zip EN-8 (08/31/2007)

EEOICPA Tr. No 10-07 Page 3 of 3 Exhibit 3 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Ethnicity Request, Form EE/EN-9 

 

Dear Claimant Name: 

This letter is in regard to your claim for compensation under 

the Energy Employees Occupational Illness Compensation Program 

Act of 2000, as amended. 

We have reviewed the claim and have determined that a diagnosis 

of potentially radiogenic skin cancer has been rendered. 

The next step in the process of determining your eligibility for 

any benefits is calculating the probability of causation. This 

is essentially a finding whether the diagnosed cancer is 

reasonably related to exposure to radioactive materials while 

employed. The calculation of probability is based on many 

factors, such as the length of exposure and proximity to 

radiological sources, the type of safety protection worn, the 

type of cancer diagnosed, etc. 

For radiogenic skin cancer, the race or ethnic identification of 

the employee is required in order to determine the probability 

of causation. The information obtained will be entered into the 

computer program that we must use to determine whether or not 

the diagnosed cancer is reasonably related to employment. 

Attached to this letter is an enclosure that must be completed 

in order for the claim to proceed. Please fill out the 

enclosure fully and return it to the address that appears at the 

bottom. We ask that the enclosure be returned within thirty 

(30) days so as to avoid any delay in the claims adjudication 

process. 

OMB No. 1215-0197 EE-9 Page 1 

Expiration Date: August 31, 2007 

 

EEOICPA Tr. No 10-07 Page 1 of 3 Exhibit 4 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

The attached enclosure must be completed and returned. Without 

the completed enclosure, we will be unable to calculate the 

probability of causation in your claim. Without this 

calculation, a determination concerning your entitlement to 

monetary benefits cannot be issued. 

If you have any questions or concerns, please contact the 

District Office at (877) 336-4272 or FAX to (904) 357-4704. 

Sincerely, 

Claims Examiner 

Enclosure: EN-9 

PRIVACY ACT

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The 

Energy Employees Occupational Illness Compensation Program Act (42 U.S.C. 7384 et seq.) (EEOICPA) is 

administered by the Office of Workers’ Compensation Programs of the U.S. Department of Labor, which receives and 

maintains personal information on claimants and their immediate families. (2) Information which the Office has 

received will be used to determine eligibility for, and the amount of, benefits payable under the EEOICPA, and may 

be verified through computer matches or other appropriate means. (3) Information may be given to the Federal 

agencies or private entities that employed the claimant at the time of injury in order to verify statements made, 

answer questions concerning the status of the claim, verify billing, and to consider other relevant matters. (4) 

Information may be disclosed to physicians and other health care providers for use in providing treatment or medical 

rehabilitation, making evaluations for the Office of Workers’ Compensation Programs and for other purposes related 

to the medical management of the claim. (5) Information may be given to Federal, state, and local agencies for law 

enforcement purposes, to obtain information relevant to a decision under the EEOICPA, to determine whether 

benefits are being paid properly, including whether prohibited payments have been made, and, where appropriate, to 

pursue salary/administrative offset and debt collection actions required or permitted by the Debt Collection Act. (6) 

Disclosure of the claimant’s social security number (SSN) or tax identification number (TIN) is mandatory. The SSN 

or TIN, and other information maintained by the Office, may be used for identification, to support debt collection 

efforts carried on by the Federal government, and for other purposes required or authorized by law. (7) Failure to 

disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in 

an unfavorable decision.

PUBLIC BURDEN STATEMENT

We estimate that it will take an average of five (5) minutes to respond to this collection of information, which includes 

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection of information. If you have any comments regarding this estimate or any 

other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. 

Department of Labor, OWCP, Room S-3524, 200 Constitution Avenue, NW, Washington, DC 20210. DO NOT 

SEND THE COMPLETED FORM TO THIS ADDRESS. Persons are not required to respond to this collection of 

information unless it displays a currently valid OMB number.

 EE-9 Page 2

EEOICPA Tr. No 10-07 Page 2 of 3 Exhibit 4 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Employee: File Number: 

The National Institute for Occupational Safety and Health (NIOSH) has developed an 

Interactive Radioepidemiological Program (IREP) that is used to calculate the 

probability of causation between a diagnosed cancer and employment. More 

information can be obtained about this program by contacting NIOSH at 1-800-35-

NIOSH.

For claims involving radiogenic skin cancer, racial or ethnic identification is incorporated 

into the NIOSH-IREP calculation. It is a required element of the program. In order to 

proceed with a determination of causation, please mark the box that best matches the 

racial or ethnic identification of the employee named above:

American Indian or Alaskan Native

 

Asian, or Native Hawaiian or Other Pacific Islander

 

Black or Afro-American

 

Hispanic or Latino

 

White or Caucasian 

Any person who knowingly makes any false statement, concealment of fact, 

misrepresentation, or commits any other act of fraud to obtain compensation as 

provided under the EEOICPA or who knowingly accepts compensation to which that 

person is not entitled is subject to civil or administrative remedies as well as felony 

criminal prosecution and may, under appropriate criminal provisions, be punished by a 

fine or imprisonment or both.

I certify that the information provided is accurate and true.

Print Name: _______________________________________________

Signature: _______________________________________________

Date: ____________________

Return Form to: OFFICE OF WORKERS’ COMPENSATION PROGRAMS

 DIVISION OF ENERGY EMPLOYEES OCCUPATIONAL

ILLNESS COMPENSATION

 District Office Address

 District Office City, State, Zip code EN-9 

 August 31, 2007

EEOICPA Tr. No 10-07 Page 3 of 3 Exhibit 4 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

 NIOSH Referral Letter to Claimant 

Dear Claimant Name: 

We have received the information submitted in support of your 

claim for compensation under the Energy Employees Occupational 

Illness Compensation Program Act of 2000 (EEOICPA), as amended. 

You do not need to submit any additional evidence to us at this 

time. 

The next step in the adjudication of the claim is dose 

reconstruction. The National Institute for Occupational Safety 

and Health (NIOSH), an agency within the Department of Health 

and Human Services, administers this portion of the process. In 

order for NIOSH to evaluate the dose reconstruction, they must 

have access to your complete case record. Therefore, a copy of 

your case file is being referred to NIOSH. 

Based on our review of your claim, we will report the following 

information to NIOSH: 

Medical 

• Cancer diagnosis type (nomenclature), ICD-9 Code, and date 

of diagnosis 

Employment 

• Employer name, facility, and dates of employment (list each 

individually) 

*If the employee also had another primary cancer besides what is 

shown above, please send this District Office written medical 

records documenting an explicit diagnosis of the other cancer, 

the type of cancer, and the date of its first diagnosis as a 

cancer. Likewise, if the employee had other covered employment, 

either before or after the dates shown above, or at another 

covered facility, please send this District Office evidence to 

establish the additional employment. 

Once NIOSH receives your claim packet, they will send you a 

letter to let you know they have received your information. The 

letter will contain information on dose reconstruction and what 

to expect from NIOSH in regard to your claim. NIOSH has 

informed us that the process of dose reconstruction can be time 

EEOICPA Tr. No 10-07 Page 1 of 2 Exhibit 5 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

consuming because it relies on information that must be 

collected from a number of sources. NIOSH’s primary concern 

will be to ensure the collected information is valid and that 

the assumptions used to estimate doses are fair, consistent, and 

well grounded in the best available science. 

When NIOSH finishes its dose reconstruction and sends us the 

results, we will apply a formula using the data to determine 

whether the claimed cancer was at least as likely as not (50% or 

greater chance) related to the covered employment. We will then 

notify you in writing regarding the status of your claim. 

If you have specific questions regarding the status of the dose 

reconstruction, you may contact the NIOSH office by calling 

toll free at 1-877-222-7570. Any other questions should still 

be addressed to this district office. 

Sincerely, 

Claims Examiner 

EEOICPA Tr. No 10-07 Page 2 of 2 Exhibit 5 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Examples of Rework Request 

These examples do not cover all scenarios. Please use your 

professional judgment in conveying the most accurate and 

pertinent information necessary concerning how the DR was 

performed, and what modifications need to be made. 

1. Additional cancer reported to the DO (employment history 

unchanged): 

NIOSH DR for Karen Smith, 111-11-1111, (NIOSH 3450). Ms. Smith 

was employed at the Paducah Gaseous Diffusion Plant for several 

periods between 09/28/55 to 12/28/79. The DR was performed for 

two cancers: BCC (left preaurical area), 173.3, diagnosed on 

01/28/02; and SCC in-situ right ear, 232.2, diagnosed on 

9/17/02. The POC was 38.14%. 

 

Subsequently, the DO received evidence of an additional verified 

cancer: SCC (right posterior inferior pinna), 173.2, diagnosed 

on 07/31/03. 

2. Cancers were incorrectly reported in the NRSD (employment 

history has not changed):

John M. Jones, 222-22-2222, (NIOSH 5678). Mr. Jones was 

employed at the Nevada Test Site from (09/01/65 to 03/3/73) and 

(11/19/79 to 09/30/87). The DR was performed for two cancers: 

• Prostate cancer, 185; diagnosed on 01/01/98 

• Adenocarcinoma, Barrett’s Esophagus, 150.0, diagnosed on 

11/15/01 

The POC was 36.39%. We reviewed the case file and determined 

that the prostate diagnosis date and the Barrett’s Esophageal 

cancer were incorrectly reported. The correct cancer 

information follows: 

1. Prostate cancer, 185; diagnosed on 04/08/98 (diagnosis 4 

months later than reported) 

2. Adenocarcinoma, lower (distal) esophagus, 151.0, diagnosed 

on 11/15/01 

EEOICPA Tr. No. 10-07 Page 1 of 4 Exhibit 6 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

3. Corrections to employment (cancer unchanged) 

Mary Smith, 333-33-3333 (NIOSH 91264). Ms. Smith worked at NTS 

for four periods from the 1950’s to the 1970’s. The DR was 

performed for strocytoma, 191.3, diagnosed on 03/19/77. Based 

on the employment used in the DR, the POC was 35.57%. 

The DR used the following NTS employment dates, as reported in 

the NRSD: 

1. 04/24/57 – 06/24/57 

2. 07/09/60 – 01/18/63 

3. 01/31/63 – 07/19/65 

4. 07/26/55 – 02/01/74 

Subsequent to submitting the NRSD report, we received additional 

employment evidence to determine that employment period 4. 

above, should actually be 07/26/65 - 02/01/74, resulting in 

about 5 years less verified employment than represented in the 

current DR. 

4. Correction to cancers and employment history: 

Tom Doe, 444-44-4444 (NIOSH 23679). The DO reported that Mr. Doe 

was employed at the Tonopah Test Range and Nevada Test Site 

(NTS) from 03/27/87 to 01/22/91. The DR was performed for 

esophageal cancer, 150.9, diagnosed on 03/26/93. The POC was 

2.35%. 

We reviewed the case file and found that the cancer and the 

employment site and dates reported in the original NRSD were 

incorrect. Please replace the originally reported esophageal 

cancer, 150.9, with the following two cancers: 

• Squamous cell carcinoma of the right piriform fossa, 148.1, 

diagnosed on 01/31/90 

• Squamous cell carcinoma of the distal esophagus, 150.5, 

diagnosed on 03/25/93 

In addition, Mr. Doe was on leave without pay as of 01/22/90, 

although actual termination date was 01/22/91. Therefore, the 

correct employment is: Solely at NTS (no Tonopah employment) 

from 03/27/87 to 01/22/90, one less year than originally 

reported. 

EEOICPA Tr. No. 10-07 Page 2 of 4 Exhibit 6 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

5. Correction to reported cancers, and additional cancer (no 

changes to employment): 

DR for James Johnson, 555-55-5555 (NIOSH 0432). Mr. Johnson was 

employed at NTS intermittently from 09/07/54 to 12/31/95. The 

NRSD reported 4 primary cancer sites for dose reconstruction: 

two (2) prostate cancers (right and left lobes), and two (2) 

BCC’s, 173.3, diagnosed in 10/97 and 04/99. The resultant POC 

was 51.05%. 

 

Upon further review of the medical evidence, we determined that 

the two prostate cancers should only be reported as one, as the 

pathology report for both lobes was reported within the same two 

weeks, and there is no indication that the two lobes are 

separate primaries. We also determined that the 04/99 BCC was a 

recurrent cancer of the 10/97 BCC and should not be included in 

the DR. In addition, we received additional medical evidence of 

another verified cancer: SCC (scalp), 173.4, diagnosed on 

06/12/96. 

 

Therefore the DR should be performed for the correct cancers as 

follows: 

1. Prostate, 185, diagnosed on 10/14/84 

2. BCC (rt cheek), 173.3, diagnosed on 10/23/97 

3. SCC (scalp), 173.4, diagnosed on 06/12/96. 

6. Deletion of several cancers from a list of multiple cancers 

(no change in employment):

DR for Pete James, 666-66-6666 (NIOSH 3495). Mr. James was 

employed at the Pacific Northwest National Lab from 08/25/69 to 

06/28/87. The DR was performed for eleven (11) cancers. The 

POC was 52.1%. 

 

Upon further review of the medical evidence in the case file, we 

determined that only eight (8) of the original eleven (11) 

cancers are verifiable. Below is the list of the 11 initially 

reported cancers; the three (3) erroneous cancers are identified 

by strike through: 

 

1. Seminoma of the R. Testicle, 186.9, 06/01/77 

2. BCC R. Shoulder, 173.6, 10/30/97 

3. BCC R. Cheek, 173.3, 10/30/97 

4. SCC in situ, L. Temple, 232.3, 02/24/98 

5. SCC in situ, Scalp, 232.4, 02/24/98 

EEOICPA Tr. No. 10-07 Page 3 of 4 Exhibit 6 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

6. SCC in situ, L. Forearm, 232.6, 04/24/98 

7. SCC in Situ, L. Dorsal Forearm, 232.6, 06/23/98 

8. SCC R. Cheek, 173.3, 11/29/01 

9. BCC L. Chin, 173.3, 11/29/01 

10. BCC L. Cheek, 173.3, 02/07/02 

11. SCC in situ, L. Lateral Forearm, 232.6, 06/30/03 

 

The 8 DOL verified cancers are therefore: 

 

1. Seminoma of the R. Testicle, 186.9, 06/01/77 

2. BCC R. Cheek, 173.3, 10/30/97 

3. SCC in situ, L. Temple, 232.3, 02/24/98 

4. SCC in situ, Scalp, 232.4, 02/24/98 

5. SCC in Situ, L. Dorsal Forearm, 232.6, 06/23/98 

6. SCC R. Cheek, 173.3, 11/29/01 

7. BCC L. Chin, 173.3, 11/29/01 

8. SCC in situ, L. Lateral Forearm, 232.6, 06/30/03 

7. Additional verified employment periods (employment in NRSD 

correct): 

DR for Sam Jones, 777-77-7777 (NIOSH 3254). The DR was 

performed for liver cancer, 155.0, diagnosed on 09/03/87. The 

POC was 22%. The DR Coversheet (dated 06/02/05) notes Mr. Jones’ 

Hanford employment as: “06/29/54-07/12/77 (eleven periods of 

employment).” This is correct based on the employment 

originally reported in the NRSD by the DO. 

 

We have subsequently received evidence of additional verified 

Hanford employment periods: 

 

1. 01/01/53 to 12/31/53 

2. 08/07/53 to 06/28/54 

3. 01/30/62 to 04/15/62 

4. 01/01/79 to 12/31/79 

5. 01/01/80 to 12/31/80 

EEOICPA Tr. No. 10-07 Page 4 of 4 Exhibit 6 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Review of Dose Reconstruction Letter to Claimant 

Dear Claimant Name: 

We recently received the results of the dose reconstruction 

conducted by the National Institute for Occupational Safety and 

Health (NIOSH) in regard to your claim for compensation under the 

Energy Employees Occupational Illness Compensation Program Act. 

After review of the dose reconstruction and the evidence received 

in support of your claim, it was discovered that [insert reason]. 

We determined that your claim must be returned to NIOSH so that 

they can review and revise the dose reconstruction, as appropriate, 

to include this information. This may not affect the outcome of 

your claim, but the information used in the dose reconstruction 

must accurately reflect what is shown in the evidence received by 

the district office. Your NIOSH tracking number xxxxx will remain 

the same. Your claim will receive priority consideration by NIOSH. 

You will have the opportunity to review the revised dose 

reconstruction report, and will again be required by NIOSH to sign 

the OCAS-1 to acknowledge your receipt of the revised report and 

initial dose reconstruction results. 

When NIOSH finishes its revised study and sends us the results, we 

will apply a formula to the dose reconstruction to determine 

whether the cancer(s) was at least as likely as not (50% or greater 

chance) related to the covered employment. We will then notify you 

in writing regarding the status of your claim. 

If you have specific questions regarding the status of the dose 

reconstruction, you may contact the NIOSH office by calling toll 

free at 1-877-222-7570. Any other questions should still be 

addressed to this district office. 

Sincerely, 

Claims Examiner 

cc: NIOSH Public Health Advisor 

EEOICPA Tr. No. 10-07 Page 1 of 1 Exhibit 7 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Primary Cancer Sites 

Secondary Cancer 

(ICD-9 Code)

ICD-9 Code of Likely Primary Cancers

Lymph nodes of 

head, face and neck 

(196.0) 

141.0, 142.0(M), 146.0, 149.0(F),

161.0(M), 162.0, 172.0, 173.0, 174.0(F), 

193(F) 

Intrathoracic lymph 

nodes (196.1)

150.0(M), 162.0, 174.0(F)

Intra-abdominal 

lymph nodes (196.2) 

150.0(M), 151.0 (M), 153.0, 157.0(f),

162.0, 174.0(F), 180.0(F), 185(M), 189.0, 

202.0(F)

Lymph nodes of 

axilla and upper 

limb (196.3)

162.0, 172.0, 174.0(F)

Inguinal and lower, 

limb lymph nodes 

(196.5)

154.0(M), 162.0, 172.0, 173.0(F), 187.0(M)

Intrapelvic lymph 

nodes (196.6)

153.0(M), 154.0(F), 162.0 (M), 180.0(F),

182.0 (F), 185(M), 188.0

Lymph nodes of 

multiple sites 

(196.8)

150.0(M), 151.0(M),153.0(M),162.0,174.0 

(F) 

Lymph nodes, site 

unspecified (196.9)

150.0(M), 151.0, 153.3, 162.0, 172.0, 

174.0 (F), 185(M)

Lung (197.0) 153.0, 162.0, 172.0(M), 174.0(F),185(M),

188.0 (M), 189.0

Mediastinum (197.1) 150.0(M), 162.0,174.0 (F)

Pleura (197.2) 150.0(M), 153.0(M),162.0,174.0 (F), 183.0 

(F) 185(M), 189.0(M)

Other respiratory 

organs (197.3)

150.0, 153.0(M), 161.0, 162.0, 173.0 (M),

174.0 (F), 185(M),193

Small intestine, 

including duodenum 

(197.4)

152.0, 153.0, 157.0, 162.0, 171.0,

172.0(M), 174.0 (F), 183.0 (F), 189.0 (M) 

Large intestine and 

rectum (197.5)

153.0, 154.0, 162.0, 174.0 (F), 183.0(F),

185 (M)

Retroperitoneum and 

peritoneum (197.6)

151.0, 153.0, 154.0 (M), 157.0, 162.0 (M),

171.0, 174.0 (F), 182.0(F), 183.0(F)

Liver, specified as 

secondary (197.7)

151.0(M), 153.0, 154.0(M), 157.0, 162.0,

174.0(F)

EEOICPA Tr. No. 10-07 Page 1 of 2 Exhibit 8 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Other digestive 

organs (197.8) 

150.0 (M), 151.0, 153.0, 157.0, 162.0, 

174.0(F), 185 (M) 

Kidney (198.0) 153.0, 162.0, 174.0 (F), 180.0 (F), 185 

(M), 188.0, 189.0,202.0 (F)

Other urinary 

organs (198.1)

153.0, 174.0 (F), 180.0 (F), 183.0 (F), 

185 (M), 188.0, 189.0 (F)

Skin (198.2) 153.0, 162.0, 171.0 (M), 172.0, 173.0 (M), 

174.0 (F), 189.0 (M)

Brain and spinal 

cord (198.3)

162.0, 172.0 (M), 174.0 (F)

Other parts of 

nervous system, 

(198.4)

162.0, 172.0 (M), 174.0 (F), 185 (M), 

202.0 

Bone and bone 

marrow (198.5)

162.0, 174.0 (F), 185(M)

Ovary (198.6) 153.0 (F), 174(F), 183.0(F)

Suprarenal 

gland(198.7)

153.0 (F), 162.0, 174.0 (F)

Other specified 

sites (198.80)

153.0, 162.0, 172.0 (M), 174.0 (F), 183.0 

(F), 185 (M), 188.0 (M)

EEOICPA Tr. No. 10-07 Page 2 of 2 Exhibit 8 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

HHS Chronic Lymphocytic Leukemia Guideline Letter 

EEOICPA Tr. No. 10-07 Page 1 of 1 Exhibit 9 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

Glossary of ICD-9 Codes and Their Cancer Descriptions

ICD-9 

Code Cancer Description

140.0 Malignant neoplasm of lip

141.0 Malignant neoplasm of tongue

142.0 Malignant neoplasm of major salivary glands

143.0 Malignant neoplasm of gum

144.0 Malignant neoplasm of floor of mouth

145.0 Malignant neoplasm of other and unspecified parts of mouth

146.0 Malignant neoplasm of oropharynx

147.0 Malignant neoplasm of nasopharynx

148.0 Malignant neoplasm of hypopharynx

149.0 Malignant neoplasm of other and ill-defined sites within the 

lip, oral cavity, and pharynx

150.0 Malignant neoplasm of esophagus

151.0 Malignant neoplasm of stomach

152.0 Malignant neoplasm of small intestine, including duodenum

153.0 Malignant neoplasm of colon

154.0 Malignant neoplasm of rectum, rectosigmoid junction, and anus

155.0 Malignant neoplasm of liver and intrahepatic bile ducts

156.0 Malignant neoplasm of gall bladder and extrahepatic bile 

ducts

157.0 Malignant neoplasm of pancreas

158.0 Malignant neoplasm of retroperitoneum and peritoneum

159.0 Malignant neoplasm of other and ill-defined sites within the 

digestive organs and peritoneum

160.0 Malignant neoplasm of nasal cavities, middle ear, and 

accessory sinuses

161.0 Malignant neoplasm of larynx

162.0 Malignant neoplasm of trachea, bronchus and lung

163.0 Malignant neoplasm of pleura

164.0 Malignant neoplasm of thymus, heart, and mediastinum

165.0 Malignant neoplasm of other and ill-defined sites within the 

respiratory system and intrathoracic organs

EEOICPA Tr. No. 10-07 Page 1 of 2 Exhibit 10 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-0900 

 Eligibility Criteria for 

Part 2 - Claims Cancer and Radiation 

________________________________________________________________ 

170.0 Malignant neoplasm of bone and articular cartilage

171.0 Malignant neoplasm of connective and other soft tissue

172.0 Malignant melanoma of skin

173.0 Other malignant neoplasms of skin

174.0 Malignant neoplasm of female breast

175.0 Malignant neoplasm of male breast

179 Malignant neoplasm of uterus, part unspecified

180.0 Malignant neoplasm of cervix uteri

181.0 Malignant neoplasm of placenta

182.0 Malignant neoplasm of body of uterus

183.0 Malignant neoplasm of ovary and other uterine adnexa

184.0

Malignant neoplasm of other and unspecified female genital 

organs

185 Malignant neoplasm of prostate

186.0 Malignant neoplasm of testis

187.0 Malignant neoplasm of penis and other male genital organs

188.0 Malignant neoplasm of urinary bladder

189.0

Malignant neoplasm of kidney and other and unspecified 

urinary organs

190.0 Malignant neoplasm of eye

191.0 Malignant neoplasm of brain

192.0

Malignant neoplasm of other and unspecified parts of nervous 

system

193 Malignant neoplasm of thyroid gland

194.0

Malignant neoplasm of other endocrine glands and related 

structures

195.0 Malignant neoplasm of other and ill-defined sites

196.0

Secondary and unspecified malignant neoplasm of the lymph 

nodes

197.0

Secondary malignant neoplasm of the respiratory and 

digestive organs

198.0 Secondary malignant neoplasm of other tissue and organs

199.0 Malignant neoplasm without specification of site

200.0 Lymphosarcoma and reticulosarcoma

201.0 Hodgkin's disease

202.0 Other malignant neoplasms of lymphoid and histiocytic tissue

203.0 Multiple myeloma and other immunoproliferative neoplasms

204.0 Lymphoid leukemia

205.0 Myeloid leukemia

206.0 Monocytic leukemia

207.0 Other specified leukemia

208.0 Leukemia of unspecified cell type 

EEOICPA Tr. No. 10-07 Page 2 of 2 Exhibit 10 

January 2010 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 2-1500 

 

Part 2 - Claims Consequential Conditions 

________________________________________________________________

TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 2-1500 Consequential Conditions 

 

Table of Contents. . . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . . 1 01/10 10-07 

 2 Defining a Consequential 

 Condition. . . . . . . . . . . 1 01/10 10-07 

 3 Consequential Condition Claims . 1 01/10 10-07 

 4 Claim Development. . . . . . . . 1 01/10 10-07 

 5 Metastasized Cancer(s) . . . . . 2 01/10 10-07 

 6 Conditions Resulting from 

 Medical Treatment. . . . . . . 3 01/10 10-07 

 7 Independent Intervening 

 Causes . . . . . . . . . . . . 4 01/10 10-07 

 8 Natural Progression/Development 

 (Pathogenesis). . . . . . . . . 5 01/10 10-07 

 9 Psychological Factors. . . . . . 6 01/10 10-07 

 10 Accepting or Denying the 

 Consequential Condition. . . . 7 01/10 10-07 

 11 Impairment and Wage-Loss . . . . 7 01/10 10-07 

 12 State Workers’ Compensation (SWC) 

 Claims, Lawsuits and Fraud . . 8 01/10 10-07 

Exhibits 

 1 Medical Conditions with Likely 

 Secondary Disorders . . . . . 01/10 10-07 

 2 Conditions that Require 

 Additional Development . . . . 01/10 10-07 

EEOICPA Tr. No. 10-07 i 

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Part 2 - Claims Consequential Conditions 

________________________________________________________________

1. Purpose and Scope. This chapter discusses the Claims 

Examiner’s (CE) role when developing claims for consequential 

conditions. It also provides examples of the types of injuries, 

illnesses, impairments, or diseases that may be accepted as 

consequential conditions under EEOICPA. 

2. Defining a Consequential Condition. A consequential 

condition covered by EEOICPA is any diagnosed injury, illness, 

impairment or disease that has occurred as a result of an 

accepted occupational illness under Part B and/or covered 

illness under Part E. Consequential conditions also include 

independent incidents related to an accepted condition. 

Any illness, injury, impairment, or disease shown by medical 

evidence to be a consequence of an accepted Part B or Part E 

condition is covered for medical benefits under the Act. 

Additionally, under Part E, any illness, injury, impairment, or 

disease shown by medical evidence to be a consequence of a 

covered Part E condition may affect the calculation of an 

impairment rating and/or wage-loss. 

3. Consequential Condition Claims. The claimant must make a 

claim for a consequential condition in writing. He or she may 

use any method of written notification, including a Form EE-1/2. 

Additionally, in some situations the CE develops a potential 

consequential condition upon receipt of medical evidence that 

discusses medical conditions other than the accepted condition 

that may be consequential. 

4. Claim Development. Consequential condition(s) must be 

developed factually and medically in accordance with 20 C.F.R. 

30.114(b)(3) of the EEOICPA regulations and DEEOIC procedures 

relating to weighing medical evidence. 

There are four types of consequential conditions: 

a. Metastasized Cancer(s); 

b. Conditions resulting from medical treatment of the 

accepted condition/s; 

c. Independent incidents related to an accepted 

condition/s; 

d. Natural progression and/or development (pathogenesis). 

EEOICPA Tr. No. 10-07 1 

January, 2010 

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________________________________________________________________

5. Metastasized Cancer(s). Metastasized cancer(s) is a 

secondary cancer that originates from the primary cancer site. 

a. Assessing and Developing Medical Evidence in 

Metastasized Cancer Claims. The CE can accept a metastatic 

cancer claim, if the claimant provides medical evidence, 

including a rationalized medical report from a physician 

that identifies the metastatic cancer and links the cancer 

to a primary site that had previously been accepted. The 

evidence must also establish: 

(1) The diagnosis of a secondary cancer; and 

(2) The date of diagnosis for the secondary cancer. 

 

The date of diagnosis for the secondary cancer will 

be: a) subsequent to the date of diagnosis for the 

primary cancer; b) the same diagnosis date for the 

primary cancer; or c) before the date of diagnosis for 

the primary cancer if the primary site is not obvious. 

If the medical evidence is inconclusive and the CE is 

unable to determine if the cancer is a metastasis, the 

CE seeks clarification from the treating physician 

and/or a District Medical Consultant (DMC). 

b. Examples of Metastasized Cancers. It is widely 

accepted that certain carcinomas and/or sarcomas 

metastasize from the primary site. For example: 

(1) Carcinomas of the lung, breast, kidney, thyroid, 

and prostate tend to metastasize to the lungs, bone, 

and brain. 

(2) Carcinomas of the gastrointestinal tract, 

reproductive system, and abdomen tend to metastasize 

to the abdominal lymph nodes, liver, and lungs. Later 

in their course, these carcinomas can metastasize to 

the brain and other organs. 

(3) Sarcomas often first metastasize to the lungs and 

brain. 

EEOICPA Tr. No. 10-07 2 

January, 2010 

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________________________________________________________________

5. Metastasized Cancer(s). (Continued) 

(4) Primary malignant tumors of the brain seldom 

metastasize to other organs, but they can spread to 

the spinal cord. 

 

6. Conditions Resulting from Medical Treatment. These 

conditions require a fully rationalized medical report by a 

physician that shows the relationship between the injury, 

illness, impairment or disease and the compensable illness. 

a. Examples of Common Consequential Conditions 

Resulting from Medical Treatment for Accepted Conditions. 

As part of a patient’s medical treatment or protocol, a 

patient may undergo treatment and/or other drug therapy 

that will produce side effects that can be considered 

common consequential conditions. 

Examples of such conditions are: 

(1) Radiation pneumonitis as a result of radiation 

treatment; 

(2) Skin rashes and radiation burns because of 

radiation treatment; 

(3) Osteoporosis (which causes weakening of the bones 

and injuries such as spontaneous hip fractures) as a 

result of steroid treatment; 

(4) Chronic Pain, extreme fatigue, anemia, and 

gastrointestinal conditions such as nausea, vomiting, 

constipation, diarrhea, and weight loss are additional 

examples of side effects of medical treatment. 

b. Developing evidence for conditions resulting from 

medical treatment. When a claim is made for a 

consequential condition caused by medical treatment of the 

accepted condition, the CE investigates the submitted 

documentation to ensure the medical evidence supports the 

claim. The CE obtains the following supporting 

documentation from the claimant: 

EEOICPA Tr. No. 10-07 3 

January, 2010 

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6. Conditions Resulting from Medical Treatment. (Continued) 

(1) Medical Evidence that establishes a causal 

connection between the claimed consequential condition 

and the accepted condition. The physician discusses 

the causal relationship between the consequential 

condition and the accepted condition, and establishes 

that the prescribed treatment is a recognized medical 

response to the accepted condition. 

c. Assessing the medical evidence. The CE must use 

reasonable judgment when assessing the medical evidence 

required for a claim for a consequential condition. 

7. Independent Intervening Causes. 

a. Condition(s) resulting from an accident during travel 

to a medical appointment. If the employee sustains an 

injury in transit to or from a medical appointment or other 

necessary travel, it is considered a consequential 

condition. The CE must obtain the following factual and 

medical evidence: 

 

(1) A Personal Statement that describes the 

circumstances of the event that resulted in an injury 

during travel to or from a medical appointment. 

Examples of personal statements include: The employee 

trips down the stairs when exiting the doctor’s office 

and breaks an arm or leg. 

The employee is assaulted in the parking lot of the 

doctor’s office, and obtained bruises, cuts, possible 

concussion, etc. 

The employee is involved in a motor vehicle accident 

while en route to the doctor’s office and has 

whiplash. In this event, reasonable assessment of the 

situation is needed. If the employee’s accident 

occurred at 8 am and the doctor’s appointment was 

scheduled for 1 pm, the CE must determine the distance 

between the employee’s residence and his or her 

doctor’s office. 

EEOICPA Tr. No. 10-07 4 

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________________________________________________________________

7. Independent Intervening Causes. (Continued) 

(2) Medical Evidence must include a diagnosis of the 

condition being claimed as a consequence of a travelrelated injury and confirmation that the scheduled 

appointment was for treatment or care of a previously 

accepted covered illness. 

b. An independent intervening incident caused by, or 

attributed to the employee’s own conduct. Injuries, 

illnesses, impairments or diseases suffered as a result of 

the employee’s own actions will not be accepted as 

consequential conditions. 

8. Natural Progression/Development (Pathogenesis). There are 

medical conditions that are expected to develop due to the 

natural progression of the accepted illness. Natural progression 

is an expected measurable change in the illness that occurs with 

the passage of time. 

The CE may accept certain conditions arising as a natural 

progression of accepted condition(s) when he or she is notified 

of the existence of these secondary medical conditions. Exhibit 

1 outlines secondary conditions that are known to result from 

Chronic Beryllium Disease and Silicosis, and can be accepted 

upon the receipt of notification. Notification must be in the 

form of a well-rationalized medical report diagnosing a 

secondary condition that progressed/developed from the accepted 

condition. When notified of such a condition listed in Exhibit 

1, the CE updates ECMS and sends an appropriate letter to the 

employee. 

However, some medical conditions could develop as a result of 

either the natural progression of the accepted condition or the 

natural aging process (see Exhibit 2). Hypertension, gout, and 

heart disease are examples of medical conditions that 

potentially result from either the aging process or natural 

progression of the accepted condition. When a claimant presents 

evidence of such a medical condition, the CE assesses the 

medical evidence as described below. 

a. Assessing the medical evidence. The CE must use 

reasonable judgment when assessing the medical evidence 

required for a claim of consequential condition. In some 

EEOICPA Tr. No. 10-07 5 

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Part 2 - Claims Consequential Conditions 

________________________________________________________________

8. Natural Progression/Development (Pathogenesis). (Continued) 

instances, the CE may accept conditions caused by the 

natural progression upon receipt of the medical evidence 

describing the conditions listed in Exhibit 1. 

In other situations where the relationship is questionable, 

more medical evidence (e.g., DMC review, clarification from 

treating physician, or second opinion) may be required. 

Given that these conditions have not yet been accepted, any 

bills that are initially submitted to the medical bill 

processing agent relating to the non-accepted condition will 

suspend and/or reject until ECMS is updated. 

9. Psychological Conditions. Psychological conditions can 

arise as a consequence of the accepted condition and/or 

treatment of that condition. They can also arise with no 

physiological basis. Depression, anxiety, or chemical imbalance 

are a few examples of psychological conditions that have no 

physiological basis. In addition to a specific diagnosis, these 

conditions may be described as “psychogenic pain disorder,” 

“conversion disorder,” or “psychological syndrome.” 

However described, the symptom or pain is quite real to the 

individual involved although there is no demonstrable physical 

disorder. 

Unless expressly claimed by a claimant, the CE develops for 

psychological conditions only if the attending physician 

indicates that such a component is present and that it is 

directly related to the accepted physiological condition. In 

such cases, the CE refers the claimant to a Board-certified 

psychiatrist for evaluation and opinion concerning causal 

relationship. 

10. Accepting or Denying the Consequential Condition. The CE 

is responsible for taking the appropriate steps in developing 

any claimed consequential condition. This includes notifying the 

claimant of any deficiencies in the evidence and allowing him or 

her an opportunity to respond and submit additional evidence. 

a. Acceptances. If the consequential condition is 

accepted, the CE notifies the claimant in a letter 

decision. However, if the decision is to deny the 

EEOICPA Tr. No. 10-07 6 

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10. Accepting or Denying the Consequential Condition. 

(Continued) 

consequential condition, the CE advises the claimant of 

his/her determination by issuing a recommended decision. 

The recommended decision affords the claimant the 

opportunity to object to the determination, and present new 

evidence. 

b. Issuing the Decision. When the case is in posture for 

the CE to accept a primary covered condition and a 

potential consequential condition exists, the CE proceeds 

with the immediate release of a recommended decision for 

the primary condition. A recommended decision accepting a 

primary covered condition must not be delayed while 

developing a consequential condition. However, if the case 

is in posture to also accept the consequential condition, 

this acceptance is included in the recommended decision. 

While the case file is at the Final Adjudication Branch 

(FAB), the FAB hearing representative (HR) or CE2 Unit 

staff pursues all development regarding consequential 

conditions. A letter accepting a consequential condition 

or a recommended decision denying a consequential condition 

cannot be issued before FAB issues a final decision on the 

primary covered condition. Decisions of this nature can be 

issued concurrently. Once the case file is returned to the 

District Office, the CE can continue development on the 

consequential condition and/or issue the letter accepting 

the consequential condition or the recommended decision 

denying it. 

11. Impairment and Wage-Loss. Consequential conditions may 

cause additional impairment or wage-loss under Part E, but do 

not result in an additional lump sum award under Part B. 

a. Impairment rating. An impairment rating assesses the 

functionality of the whole organ or system. DEEOIC does 

not apportion impairment by disease (see EEOICP PM 2-1300 

for further discussion of impairment ratings). If the 

accepted condition and consequential condition affect the 

same organ or system, a rating for impairment to that organ 

or system should proceed. However, if the accepted 

condition affects one organ/system and the consequential 

condition involves another, the impairment rating on the 

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11. Impairment and Wage-Loss. (Continued) 

organ/system affected by the consequential condition could 

be developed either concurrently with the impairment for 

the primary system (if the consequential condition has been 

accepted), or later. Ideally, the CE develops the primary 

and consequential conditions concurrently; however, this 

may not be possible if, for example, the system affected by 

the consequential condition has not reached maximum medical 

improvement (see EEOICPA PM 2-1300). As soon as an 

impairment rating is completed for the primary affected 

system an impairment decision should proceed. There would 

be nothing to preclude a later decision on the impairment 

due to the consequential condition as long as the organ or 

system affected by the consequential condition was not 

rated within the past two years. After passage of two 

years, the claimant can receive an impairment rating based 

on the consequential condition affecting the same organ 

system as the accepted condition. 

b. Wage-Loss. The acceptance of a consequential condition 

may affect the claimant’s entitlement to wage-loss. Wageloss is calculated using the first day that the employee 

lost wages due to the covered illness (see EEOICPA PM 2-

1400 for further discussion of wage-loss). 

In certain instances, the consequential condition may be 

the initial cause of the employee’s wage-loss. For 

example, a claimant submits medical evidence showing that 

pulmonary hypertension caused his or her wage-loss, and 

shows a diagnosis of Chronic Beryllium Disease (CBD) three 

years thereafter. In this instance, CBD is accepted under 

Parts B and E as the primary condition and pulmonary 

hypertension is accepted as the consequential condition 

under Parts B and E. Also, the claimant may receive wageloss benefits under Part E dating from the time that the he 

or she first lost wages due to the pulmonary hypertension. 

12. State Workers’ Compensation (SWC) Claims, Lawsuits and 

Fraud. Prior to accepting a consequential condition, the CE 

collects information to determine if a claimant has filed an SWC 

claim, lawsuit, or if the claimant has been convicted of fraud 

in connection with the consequential condition. 

EEOICPA Tr. No. 10-07 8 

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________________________________________________________________

Medical Conditions with Likely Secondary Disorders 

Disorders secondary to Chronic Beryllium Disease (CBD) 

• Hypoxemia (low oxygen levels at exercise, rest or with 

sleep) 

• Airflow obstruction/wheezing (asthma-like presentation 

of CBD) 

• Right heart failure, Cor pulmonale 

• Pulmonary hypertension 

• Respiratory infections (Pneumonia,Acute Bronchitis) 

• Spontaneous Pneumothorax 

• Deconditioning secondary to chronic lung disease 

• Joint Aches (this is a symptom) 

• Hyperurecemia, Gout 

• Hypercalcemia/hypercalcuria 

• Granulomatous Hepatitis 

• Skin Nodules/Ulceration 

• Aggravation of sleep apnea due to hypoxemia of CBD 

Disorders secondary to Silicosis 

• Hypoxemia 

• Right heart failure, Cor pulmonale 

• Pulmonary Hypertension 

• Deconditioning secondary to chronic lung disease 

• Progressive Massive Fibrosis 

• Silicotuberculosis 

EEOICPA Tr. No. 10-07 Exhibit 1 

January, 2010 

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Part 2 - Claims Consequential Conditions 

________________________________________________________________

Conditions that Require Additional Development 

Disorders secondary to prednisone treatment 

• Cataracts 

• Glaucoma 

• Visual acuity changes 

• Diabetes Mellitus 

• Osteoporosis 

• Osteopenia 

• Gastric reflux 

• Peptic ulcers 

• Elevated blood pressure 

• Elevated cholesterol 

• Abnormal lipid profiles 

• Sleep disorders 

• Weight gain 

• Myopathy, dermal atrophy 

• Increased intracranial pressure 

Other disorders 

• Oral thrush and other fungal infections secondary to 

inhaled steroids, immunosuppression 

• Folic acid depletion secondary to Methotrexate 

• Infections due to immunosuppression (bacterial and 

viral) 

• Post-herpetic neuralgia secondary to Herpes Zoster 

• Flare due to immunosuppression 

EEOICPA Tr. No. 10-07 Exhibit 2 

January, 2010 

Superseded
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0100

Part 3 - Fiscal Introduction

________________________________________________________________

TABLE OF CONTENTS

Paragraph and Subject Page Date Trans. No.

Chapter 3-0100 Introduction

Table of Contents. . . . . . . i 01/10 10-07

 1 Purpose and Scope. . . . . . . 1 01/10 10-07

 2 Structure of Part 3. . . . . . 1 01/10 10-07

 3 Reference Materials. . . . . . 1 01/10 10-07

EEOICPA Tr. No. 10-07

January, 2010

i
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0100

Part 3 - Fiscal Introduction

________________________________________________________________

1. Purpose and Scope. Part 3 describes the policies and

procedures related to the financial aspects of claims under the 

EEOICPA. Topics include bills for medical care and ancillary 

medical expenses; tort offset; state workers’ compensation 

coordination; compensation for beneficiaries in disability and 

death cases; verifying continued entitlement to benefits; and 

overpayments.

Claims staff and fiscal officers are jointly involved in fiscal 

actions, and a medical bill processing agent is responsible for 

processing all medical bills. 

2. Structure of Part 3. 

a. Medical Bills. PM 3-0200 addresses medical bill 

processing in general, while PM 3-0300 addresses

entitlement to and payment for ancillary medical services. 

b. Payments and Offsets. PM 3-0400 discusses lawsuits 

and the effects of recovery from them on payments of 

benefits under EEOICPA, while PM 3-0500 addresses state 

workers’ compensation benefits and the effect of their 

receipt on EEOICPA benefits. 

PM 3-0600 discusses payment of compensation, to include 

exception processing of payments to terminal claimants;

while PM 3-0700 describes the requirements for verifying 

continued entitlement to medical benefits. 

c. Overpayments. PM 3-0800 provides an overview of the 

overpayment process and describes the actions taken when an 

overpayment is identified. PM 3-0900 addresses the debt 

collection process. 

3. Reference Materials. A list of references available to 

staff is shown in EEOICPA PM 2-0100.

EEOICPA Tr. No. 10-07

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1
FEDERAL (EEOICPA) PROCEDURE MANUAL Chapter 3-0200 

Part 3 – Fiscal Medical Bill Process 

___________________________________________________________

TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 3-0200 Medical Bill Process 

 Table of Contents. . . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . . 1 01/10 10-07 

 2 Roles and Responsibilities . . . 1 01/10 10-07 

 3 Parameters for Payment . . . . . 4 01/10 10-07 

 4 Mailbox for Medical Bill 

 Inquiries . . . . . . . . . . . 4 01/10 10-07 

 5 DMC Reviews. . . . . . . . . . . 9 01/10 10-07 

 6 Medical Records Procurement . . . 9 01/10 10-07 

 7 Psychiatric Treatment. . . . . . 10 01/10 10-07 

 8 Hearing Aids (above $5000) . . . 10 01/10 10-07 

 9 Chiropractic Services. . . . . . 11 01/10 10-07 

 10 Acupuncture Treatments . . . . . 11 01/10 10-07 

 11 Organ Transplants (Including 

 Stem Cell). . . . . . . . . . . 11 01/10 10-07 

 12 Experimental Treatment and 

 Clinical Research . . . . . . . 13 01/10 10-07 

 13 Treatment Suites . . . . . . . . 14 01/10 10-07 

 14 Eligibility Files. . . . . . . . 14 01/10 10-07 

 15 ICD-9-CM . . . . . . . . . . . . 14 01/10 10-07 

 16 Coding Software. . . . . . . . . 16 01/10 10-07 

 17 Prompt Pay . . . . . . . . . . . 16 01/10 10-07 

 18 Time Limitations for 

 Submission of Medical Bills . . 16 01/10 10-07 

 19 Fee Schedule . . . . . . . . . . 17 01/10 10-07 

 20 Fee Schedule Appeal Process. . . 17 01/10 10-07 

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1. Purpose and Scope. This chapter describes the roles 

of the Claims Examiner, Fiscal Officer, and District 

Medical Scheduler, in the medical bill process; and 

outlines the procedures for evaluating and approving 

requests from employees and their families who are in need 

of medical services, supplies, or reimbursement of expenses 

related to medical care. 

2. Roles and Responsibilities. Upon issuance of a final 

decision approving a specific medical condition, the Claims 

Examiner (CE), the Bill Processing Agent (BPA), the Fiscal 

Officer (FO), and the Medical Scheduler (MS) must ensure 

that the basic medical needs of the claimant, as they 

relate to his or her accepted medical condition, are 

reasonably provided for. 

a. Medical Bill Processing Agent (BPA). The use of 

a contractor for processing medical bills allows the 

DEEOIC to provide a high level of service to eligible 

claimants and their providers. Once a claimant has 

been accepted for a covered condition under the 

EEOICPA, an eligibility file is automatically 

generated in ECMS and sent to the BPA electronically. 

(1) When the BPA receives the eligibility file, 

the BPA sends a medical bill identification card 

(MBIC) and general information about the medical 

bill process to the claimant. 

(2) DEEOIC sends all medical bills, treatment 

notes, and requests for claimant reimbursement 

directly to the contractor for scanning and 

keying into their system. 

(3) The BPA maintains a customer call center, 

medical staff, and bill resolution units. 

b. Point of Contact Claims Examiner. The Point of 

Contact Claims Examiner (POC CE) is a specialized 

claims examiner responsible for reviewing, developing, 

and approving or denying requests for in-home health 

care. Each District Director is to appoint one to 

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2. Roles and Responsibilities. (Continued) 

three CEs (as appropriate) to serve in this role. 

c. Claims Examiner. The Claims Examiner (CE) 

considers for approval those Level 4 services (see 

Para. 3), appliances, supplies, modifications, or 

travel expenses that are recommended or prescribed by 

a licensed physician, and necessary to cure, give 

relief, or aid in reducing the overall cost of 

services required by the employee for an accepted 

condition. (Refer to EEOICPA PM 3-0300 for detailed 

information on approval of durable medical equipment, 

hospice services, in-home health care, gym 

memberships, extended medical travel, and other 

ancillary medical services.)

(1) The CE considers the level of care 

prescribed by the treating physician as it 

relates to the accepted medical condition and the 

facts of the case. The CE must then make an 

informed judgment based on the level of care 

prescribed by the doctor. 

(2) This decision must take into account the 

overall desires and needs of the patient, as well 

as those of the family. DEEOIC will not dictate 

or demand what option an employee must accept, 

nor will decisions be made based solely upon 

cost. 

The CE must also consider what level of care or 

services satisfy the patient’s needs. 

(3) The CE is responsible for communicating all 

decisions (approval/denial) to the requestor. 

(a) If a request for services or payment 

originates from the BPA, the fiscal officer 

notifies the CE via e-mail. These requests 

may come to the CE as a prior authorization 

request, or may come after submission of a 

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2. Roles and Responsibilities. (Continued) 

charge to the BPA. 

The CE’s determination are communicated via 

e-mail to the fiscal officer, input into 

ECMS notes, and communicated to the BPA via 

letter explaining the decision. 

(b) If the request originates from a 

claimant or provider, the CE immediately 

sends a copy via facsimile to the BPA, and 

concurrently begins development for approval 

or denial of the request. All approvals or 

denials are communicated to the requestor as 

outlined above. 

d. Fiscal Officer. The Fiscal Officer (FO) acts as 

liaison between the CE and the Medical BPA, serves as 

coordinator for medical bill issues between the 

District Offices and the National Office, and 

maintains a District Office record of persons 

authorized to access the BPA website. The FO does not 

determine eligibility or authorize payments. 

e. Medical Scheduler. The Medical Scheduler (MS) 

coordinates all requests for both internal and 

external District Medical Consultant reviews. The 

Medical Scheduler serves as the primary assistant to 

District Medical Consultants who are assigned to the 

District Office on a part-time basis. 

f. District Medical Consultant (DMC). The DMC 

reviews and evaluates the medical evidence of record 

and provides medical opinions about various aspects of 

cases, such as: 

(1) Causation: The DMC determines medical 

causation by reviewing medical, employment and 

exposure evidence to determine if the medical 

history is indicative of toxicity (arising out of 

exposure to a toxic substance) or of an 

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2. Roles and Responsibilities. (Continued) 

organic/other nature (arising out of a natural 

medical occurrence, such as hereditary factors, 

or a lifestyle illness). The DMC may also be 

called upon to determine the likely role of an 

accepted condition as it relates to a cause of 

death, or the appearance of secondary or 

consequential illnesses or diseases. 

(2) Explanation of treatment modalities, the 

interpretation of clinical test results, and the 

clarification of other physician’s reports. 

(3) Determining the level of impairment in a 

given case in accordance with the AMA Guides to 

the Evaluation of Permanent Impairment, 5th

Edition, subject to DEEOIC’s guidance. 

3. Parameters for Payment. OWCP procedures employ four 

levels of review in the medical bill process, only two of 

which DEEOIC currently uses. The BPA automatically 

processes charges for Level 1 services and the CE is not 

required to approve. Any higher level of service (i.e. 

two, three or four) is treated as a Level 4 service in our 

program and requires that the CE review the proposed 

procedures or service(s), the proposed charges if 

applicable, and the supporting medical documentation, prior 

to approving or denying the request. All of the following 

services (Paragraphs 4 through 11) are Level 4 services. 

4. Mailbox for Medical Bill Inquiries. The Policy, 

Regulations and Procedures Unit (PRPU) of the DEEOIC Policy 

Branch, located in the National Office (NO), has created an 

electronic mailbox (email) for use in resolving medical 

bill questions. This mailbox is to be used when submitting 

inquiries concerning medical bills, travel reimbursement, 

treatment suites, provider outreach, or policy questions 

regarding medical bill processing. 

The Fiscal Officers (FO) in each respective district office 

serve as liaison for Claims Examiners (CE) with questions 

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4. Mailbox for Medical Bill Inquiries. (Continued)

that require review by the PRPU, at the NO. CE2 staff 

submit questions to the mailbox through the CE2 Unit 

Manager. The Fiscal Officers and CE2 Unit Managers act as 

the District Office Point of Contact (DO POC) for purposes 

of communicating medical bill issues to the PRPU. A Medical 

Bill Processing POC at the National Office (Medical Bill 

POC) is responsible for routing email inquiries to the 

proper party at the NO. 

Use of this mailbox provides for expedited resolution of 

medical bill issues as they arise, and provides a more 

uniform process for responding to these questions and 

issues, program wide. The email address is 

DEEOICbillpay@dol.gov, and is to be used exclusively by the 

DO POCs, upon completion of the following steps: 

a. When a CE receives an inquiry regarding

reimbursement of a medical bill, for an accepted 

condition, the CE first reviews the bill in the 

Achieve medical bill inquiry system, and/or the Stored 

Image Retrieval(SIR)system, available at: 

http://owcp.dol.acs-inc.com/portal/main.do) in order 

to verify that the supporting medical documentation is 

on file. If, after reviewing the supporting 

documentation in the ACS web portal and in the case 

file, the CE still has questions related to medical 

bill processing, travel reimbursement, treatment 

suites, provider outreach, or a policy question 

regarding medical bill processing, additional 

assistance may be requested through the medical bill 

inquiries mailbox. 

b. The CE prepares an email to the DO POC, or the

CE2 prepares an email to the CE2 Unit Manager. In 

order to maintain consistency and to provide clarity 

in the communication process, it is imperative that 

the CEs provide sufficient information in the email, 

clearly defining the nature of the question, so that 

it can routed to the proper entity at the NO. 

Inquiries to the mailbox should be categorized using 

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4. Mailbox for Medical Bill Inquiries. (Continued) 

the subject headings below, and the subject line of 

the email must contain one of the following four 

subject headings: 

(1) Policy Questions. Questions regarding 

policy interpretation or implementation are 

answered by the Medical Bill POC. 

(2) Treatment Suites. The treatment suites and 

ICD-9 codes utilized by the DEEOIC are contained 

within a database, administered by medical 

professionals within the OWCP. This database 

compares an ICD-9 coded diagnosis, and associated 

services being billed by a provider, with a group 

(or suite) of acceptable, allowable treatments or 

services for that accepted condition. The use of 

treatment suites allows bills to be paid 

automatically when the treatment being billed is 

reasonable and customary for the accepted 

condition. Often, issues arise when a claimant is 

trying to obtain payment for a consequential 

illness and the medical bills are being denied 

because the consequential illness is not being 

recognized within the treatment suite(s) for the 

accepted condition. Inquiries of this nature 

will be directed to the Medical Bill POC, for a 

response. 

(3) Provider Outreach. Questions from medical 

providers regarding assistance with enrollment, 

submission of bill(s), or understanding DEEOIC’s 

medical billing process, must be forwarded to the 

Medical Bill POC, who will then coordinate with 

the Resource Center (RC) Manager on these issues. 

Provider outreach issues must be coordinated 

through the Medical Bill POC. 

(4) Bill Payment Processing. Questions 

regarding reimbursement of medical bills should 

use this subject heading, and will be routed to 

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4. Mailbox for Medical Bill Inquiries. (Continued) 

Payment Systems Manager for a response. 

The body of the email itself must contain the 

following information (as applicable): 

 District Office Location; 

 CE Name; 

 Employee’s Name; 

 DOL File Number(not to be used in the 

subject line); 

 Accepted Condition(s) with ICD-9 code(s); 

 Billed Amount(s); 

 Date(s) of Service(s)or Travel day(s); 

 Medical Provider Name(s); 

 Type of Service(s) (i.e., Pharmacy, In-Home 

Health); 

 Question(s) or issue(s) to be resolved. 

c. Upon receipt of an email question being posed, 

the DO POC reviews the email carefully and determines 

whether the issue warrants review by the NO. If the 

question does warrant such review, the POC forwards 

the inquiry to DEEOICbillpay@dol.gov. 

d. The Medical Bill POC reviews all submissions 

received in the medical bill inquiries email box and 

determines the proper course of action. As noted 

above, all policy, treatment suite, and medical 

provider outreach questions will be evaluated and 

answered directly by the Medical Bill POC. Issues 

related to medical bill payments will be forwarded to 

the NO Payment Systems Manager, who is responsible for 

evaluating each inquiry and providing a response. 

Some referrals to the mailbox may have elements 

related to several topics in the inquiry, and the 

Medical Bill POC ensures that the question is 

evaluated by the proper individual(s), and coordinates 

the response to the DO. 

e. In the case of a policy or treatment suite issue, 

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4. Mailbox for Medical Bill Inquiries. (Continued) 

the Medical Bill POC researches the inquiry and 

provides an answer to the requesting DO within five 

(5) business days. If a policy question requires 

additional research, a reasonable extension of time is 

granted by one of the PRPU Policy Unit Chiefs. 

Complex policy issues might require the involvement of 

the Policy Branch Chief before a response can be 

generated, and the Medical Bill POC must monitor such 

issues to ensure that they are resolved in a timely 

manner. 

f. The Medical Bill POC forwards all medical bill 

payment inquiries directly to the Payment Systems 

Manager, who assesses each question and provides an 

answer directly to the inquiring DO within five (5) 

business days of receipt of inquiry. 

g. The Medical Bill POC refers all medical inquires 

to the RC Manager for response. The RCs serve as the 

primary point of contact for DEEOIC’s provider 

enrollment inquiries. The RC Manager will provide a 

response to the Medical Bill POC within three (3) 

business days of receipt detailing the planned 

response to these types of inquiries. The Medical Bill 

POC will relay the proposed response(s) to the 

inquiring DO so the DO is aware that resolution is 

being sought. 

h. Upon receipt of inquiry responses, the DO POC 

forwards the response to appropriate CE/CE2 via email. The CE/CE2 is responsible for notifying the 

employee, claimant, authorized representative and or 

provider (if applicable), via telephone or in writing, 

of appropriate response to the issue at hand. All 

telephone activity is documented in the Energy Case 

Management System (ECMS) Telephone Management System 

(TMS) and a copy of the email response from the 

Medical Bill POC or Payment Systems Manager is placed 

in the case file. 

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4. Mailbox for Medical Bill Inquiries. (Continued) 

i. Policy decisions rendered through this process, 

which have the potential for program-wide impact, are 

treated like policy teleconference notes, and are 

placed on the shared drive for use by all DEEOIC 

staff. It is the responsibility of the Medical Bill 

POC to ensure that such issues, as identified by the 

PRPU Unit Chiefs/Policy Branch Chief, are added to the 

policy teleconference answers, on the shared drive. 

5. District Medical Consultant Reviews. For detailed 

information on the DMC referral process, refer to DEEOIC 

procedures on weighing medical evidence. 

6. Medical Records Procurement. DEEOIC pays cost 

associated with obtaining medical records regardless of 

whether a claim has been approved for benefits. This 

reimbursement is payable only to a hospital, physician’s 

office, or other medical facility that charges a fee to 

produce records. The maximum allowable reimbursement is 

$100 per employee. 

a. Form of Request. The provider provides the CE 

with the written fee request on official letterhead or 

billing statement. The request includes the tax 

identification number of the facility, total amount 

charged for the record request, and the provider 

enrollment number. If the provider is not enrolled, 

the CE forwards an enrollment package to the provider 

with a letter requesting that the provider enroll, and 

after completion of the enrollment process, the 

provider informs the CE of their new provider number. 

b. Approval of Payment. Upon receipt of the 

required information, the CE approves the payment of 

the bill by completing a Form OWCP-1500, sending an 

approval letter to the requestor, and completing ECMS 

coding as required in DEEOIC procedures. The CE then 

forwards the completed Form OWCP-1500, approval 

letter, and invoice to the Fiscal Officer for payment 

processing. 

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7. Psychiatric Treatment. Prior to approval of 

psychiatric treatment, the CE must conduct the necessary 

medical development to substantiate a psychiatric condition 

as a consequential condition of an accepted illness; and 

the consequential condition must be accepted. 

a. Expense of support groups that meet on a periodic 

basis, for individuals with a similar covered illness, 

are acceptable for reimbursement under the EEOICPA. 

b. For ongoing therapy or for personalized care for 

a psychiatric condition, the CE obtains medical 

records and reports that support the need for these 

specific services as treatment for a consequential 

condition of the covered illness. 

c. A narrative medical report from a licensed 

psychologist or psychiatrist must be submitted which 

includes: 

(1) Diagnosis (with correct code); 

(2) Medical rationale in support of how the 

psychiatric condition is related to the approved 

illness. 

d. After appropriate development the CE decides 

whether to approve a psychiatric condition as a 

consequential illness. The CE advises the claimant of 

the decision to accept (via letter) or deny (via a 

Recommended Decision followed by a Final Decision), 

and updates ECMS as appropriate. 

8. Hearing Aids (above $5000). The CE approves hearing 

aids in excess of $5,000 when hearing loss has resulted 

from an accepted illness, if the treating physician so 

recommends. DEEOIC may authorize maintenance of hearing 

aids, including batteries, repairs, and replacement as 

needed. For hearing aids under $5,000, see DEEOIC 

procedures regarding durable medical equipment. 

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9. Chiropractic Services. Chiropractic services may be 

authorized, but are limited to treatment for correction of 

a spinal subluxation, along with the tests performed or 

required by a chiropractor to diagnose such subluxation. A 

diagnosis of spinal subluxation must be documented with an 

x-ray in the chiropractor’s report prior to the CE 

considering payment. 

10. Acupuncture Treatments. Acupuncture treatments may be 

authorized when recommended by the treating physician to 

provide relief. Such treatment shall be supervised by the 

treating physician, who shall submit periodic reports to 

show progress or any relief of the symptoms. If the 

treatment continues beyond six months and/or the results 

are questionable, the case should be referred to the DEEOIC 

Medical Director. 

11. Organ Transplants (including Stem Cell). Treating 

physicians send all requests for organ transplants to 

DEEOIC’s bill processing agent (BPA) via fax, mail, or 

electronically, to begin the authorization process. The 

BPA creates an electronic record of all such requests, and 

initiates a thread to the district office FO, advising of a 

new, pending organ transplant request. The FO alerts the CE 

of the request for a transplant, and the CE ensures that 

the case file contains the necessary documentation, 

including a letter describing the necessity of the 

transplant from the treating physician, laboratory and 

diagnostic test results, CT or MRI scan results, and a 

transplant protocol. Once the CE has verified that this 

information is on file, and is contained in the thread, the 

CE forwards the information to the Medical Bill POC. The 

Medical Bill POC forwards all pertinent information to the 

DEEOIC Medical Director, who prepares a memorandum 

approving or denying the transplant for signature by the 

DEEOIC Director. The signed memorandum is returned to the 

DO following signature by the DEEOIC Director. All 

approved requests for organ transplants must be performed 

at a CMS (Center for Medicare and Medicaid Services) 

approved facility. See 

http://www.cms.hhs.gov/ApprovedTransplantCenters/

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11. Organ Transplants (including Stem Cell). (Continued) 

An organ donor is not considered an “employee” or 

“claimant” within the meaning of DEEOIC and is not entitled 

to compensation for wage-loss or permanent impairment, nor 

is a donor entitled to benefits for any complications 

resulting from the transplant. Only those medical and 

related expenses of the donor which are necessary to secure 

treatment for the employee are allowable. 

a. In-Patient or Out-Patient. Depending upon the 

transplant center, the condition of the patient, and 

geographic limitations, transplant procedures may be 

performed on an in-patient or out-patient basis. Once 

a treating physician has requested approval for an 

organ transplant of any type, the CE forwards a letter 

to the transplant center requesting a detailed 

schedule of the procedures to be performed, and 

whether the procedure(s) require in-patient stay. 

(1) Autologous transplants may be performed on 

either an in-patient or out-patient basis, 

depending upon the transplant center. This type 

of transplant requires stem cells that have been 

gathered and stored, coming directly from the 

patient. No unrelated donor, related donor, or 

cord blood search needs to be authorized. 

(2) Allogenic transplants may also be performed 

on either an in-patient or out-patient basis. 

Allogenic transplants require that donor-blood 

stem cells be drawn, stored, and then 

transplanted into the patient. 

b. Choice of Donors. 

(1) The first choice of a donor is generally a 

family member or relative. If the transplant 

facility approves a related donor, transportation 

expenses and the cost of required medical 

procedures for obtaining the organ(s) or blood 

stem cells are reimbursable. The transplant 

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11. Organ Transplants (including Stem Cell). (Continued) 

facility bills DEEOIC, referencing the employee’s 

(recipient) SSN, in addition to pertinent 

information pertaining to the donor. Travel is 

reimbursed following the same guidelines 

established for companion medical travel, and is 

paid to the employee. 

(2) If no suitable match is available through a 

relative, an unrelated donor search must be 

authorized. The transplant center coordinates 

with the National Donor Program for the testing 

of each potential donor. The transplant center 

bills for all such tests and procedures. The 

average time waiting for an unrelated donor is 

four months. Unrelated donors are not paid for 

their donation; the only coverage is for the 

medical expenses related to the organ donor 

procedure. These procedures are billed by the 

transplant facility, the same as with related 

donors, referencing the covered employee’s social 

security number on all bills. 

c. Long-Term Living Expenses. In many cases, 

transplants involve prolonged out-patient procedures 

requiring the patient to remain within a short 

distance of the transplant center. If the transplant 

procedure is authorized, and if it requires extended 

residency near the facility, lodging, per diem, 

companion, and other travel-related expenses may have 

to be authorized on a long-term basis. (Refer to 

Chapter 3-0300 for additional guidance on 

reimbursement for extended medical travel.) 

12. Experimental Treatment and Clinical Research. 

Experimental treatments, or those which are generally not 

accepted, will be considered if: the accepted condition is 

life-threatening; established therapy has been tried to no 

avail; and a significant body of data supports the view 

that the experimental procedure is indeed beneficial. 

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12. Experimental Treatment and Clinical Research. 

(Continued) 

All such requests are forwarded to the DEEOIC Medical 

Director for concurrence using the same procedures for 

organ transplants as outlined above, with the exception of 

the documents needed to approve the treatment. To request 

experimental treatment, the treating physician must send 

the treatment protocol, medical rationale, and peer 

reviewed documents supporting the treatment to the CE, to 

be forwarded to the NO for review. 

 

13. Treatment Suites. At the core of the medical bill 

reimbursement process is the use of treatment suites. The 

treatment suites used by the DEEOIC are contained in a 

database maintained by medical professionals within the 

OWCP. They compare an accepted (ICD-9 coded) diagnosis for 

which a provider has billed, with acceptable, allowable 

treatments for that condition. The use of treatment suites 

allows automatic payment of bills, for authorized services, 

when the amount billed is reasonable and customary for an 

accepted condition. 

14. Eligibility Files. In order for a claimant’s bills to 

be paid, an eligibility file is automatically generated in 

ECMS and sent to the bill processing agent once a condition 

has been accepted. This eligibility file contains the 

accepted condition for which a claimant is entitled to 

medical treatment. When the accepted condition(s) are 

coded and billed with the correct ICD-9 Code, the volume of 

suspended and denied bills is significantly reduced. 

Consequently, accurate code selection expedites provider 

reimbursement for all approved medical services rendered to 

the claimant. 

15. ICD-9-CM. The International Classification of 

Diseases, 9th Revision, and Clinical Modification, (referred 

to simply as ICD-9 codes), is a statistical classification 

and coding system used to assign appropriate codes for 

signs, symptoms, injuries, diseases, and other medical 

conditions. 

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15. ICD-9-CM. (Continued)

These codes are assigned, based on the claimants’ medical 

documentation (records), including, but not limited to 

physician notes, diagnostic tests, and surgical reports. 

ICD-9 codes are composed of numbers with 3, 4, or 5 digits. 

Three-digit category codes are generally subdivided by 

adding a fourth and/or fifth digit to further specify and 

clarify the nature of the disease or medical condition. The 

CE entering an ICD-9 code must identify and enter the code 

that references the disease, illness or medical condition 

that was reported, and should identify the organ(s) or 

portion of the body affected by the condition. 

In general, three-digit codes identify a category of 

illness, while codes with fourth digits are called 

subcategory codes, and those with fifth digits are referred 

to as sub-classifications. 

When a specific condition, illness, etc., contains a 4th or 

5th digit, the CE uses all available digits to identify the 

condition. In addition to providing further specificity of 

the anatomical site, the 4th and 5th digits also provide 

additional pertinent clinical information related to the 

injury or medical condition. Therefore, when selecting 

ICD-9 codes, the CE should always use the code that most 

specifically describes the medical condition reported. 

 a. Examples of valid 3-digit codes: 

(1) 496- Chronic Obstructive Pulmonary Disease 

(COPD). 

(2) 501- Asbestosis. 

 b. Examples of 4-digit and 5-digit codes: 

(1) 162.5- malignant neoplasm, lower lobe, 

bronchus or lung (requires a 4th digit). 

(2) 508.0- Acute pulmonary manifestation due to 

radiation (requires 4th digit). 

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15. ICD-9-CM. (Continued) 

(3) 205.10- Myeloid leukemia, chronic, in 

remission (requires a 5th digit). 

(4) If an employee was diagnosed with diabetes 

mellitus, it would be incorrect to assign code 

250, since all codes in the diabetes series (250) 

have five digits. 

16. Coding Software. Claims examiners are to utilize the 

coding software which is available at 

http://www.ingenixexpert.com/expert. This is an online tool 

that helps to identify the appropriate ICD-9-CM code. These 

guidelines are to be used as a supplement to the ICD-9-CM 

Coding books. 

17. Prompt Pay. The Prompt Payment Act requires federal 

agencies to pay vendors in a timely manner. The Act 

requires assessment of late interest penalties 

against agencies that pay vendors after a payment due date. 

The DEEOIC has identified three classes of bills that fall 

under the Prompt Pay Act: Reviews by a District Medical 

Consultant, Second Opinion/Referee Medical Examinations, 

and Impairment Rating Examinations. These bills must be 

processed within seven calendar days from date of receipt 

in the District Office. (Refer to PM 2-800 for the 

specific actions to be taken by the CE and the Medical 

Scheduler in the processing of DMC bills.) 

18. Time Limits for Submission of Medical Bills. DEEOIC 

pays providers and reimburses employees promptly for all 

bills that are properly submitted on an approved form and 

which are submitted in a timely manner. No such bill is 

paid for expenses incurred if the bill is submitted more 

than one year beyond the end of the calendar year in which 

the expense was incurred, or the service or supply was 

provided; or, more than one year beyond the end of the 

calendar year in which DEEOIC first accepted the claim, 

whichever is later. 

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19. Fee Schedule. For professional medical services, OWCP 

maintains a schedule of maximum allowable fees for 

procedures performed in a given locality. 

The schedule consists of: 

a. An assignment of a value to procedures identified 

by HCPCS/CPT code which represents the relative skill, 

effort, risk and time required to perform the 

procedure, as compared to other procedures of the same 

general class. 

b. An index based on a relative value scale that 

considers skill, labor, overhead, malpractice 

insurance and other related costs. 

c. A monetary value assignment (conversion factor) 

for one unit of value in each of the categories of 

service. 

Generally, bills submitted using HCPCS/CPT codes can not 

exceed the fee schedule. If the time, effort and skill 

required to perform a particular procedure varies widely 

from one occasion to the next, DEEOIC may choose not to 

assign a fee schedule limitation. In these cases, the 

allowable charge is set individually based on consideration 

of a detailed medical report and other evidence. At its 

discretion, DEEOIC may set fees without regard to schedule 

limits for specially authorized consultant examinations, 

and for other specially authorized services. 

20. Fee Schedule Appeal Process. As part of the medical 

bill review process, the EEOICPA regulations provide for 

the appeal of fee schedule reductions (charges by a 

provider that have been reduced in accordance with the OWCP 

fee schedule for that specific service.) In order to 

maintain consistency, record responses, and track fee 

schedule appeals, the following procedures have been 

developed to further delineate this process. 

a. When the BPA receives a fee appeal request 

letter, the BPA stores an electronic copy of the 

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20. Fee Schedule Appeal Process. (Continued) 

appeal letter in the Stored Image Retrieval system 

(SIR), linked to the remittance voucher, and sends a 

printed copy of the letter to DEEOIC Central Bill 

Processing, through the NO Payment Systems Manager 

(PSM). 

b. For each fee schedule appeal letter received, the 

PSM creates a record, and maintains them in a tracking 

system (spreadsheet or database) created for this 

purpose. 

c. The PSM reviews the fee appeal request to 

determine if the provider has met any of the 

conditions below which justify a reevaluation of the 

amount paid. These three conditions, as found in 20 

C.F.R. 30.712, are: 

(1) The service or procedure was incorrectly 

identified by the original code; or 

(2) The presence of a severe or concomitant 

medical condition made treatment especially 

difficult; or 

(3) The provider possesses unusual 

qualifications (i.e. possesses additional 

qualifications beyond board-certification in a 

medical specialty, such as professional rank or 

published articles.) 

d. Within 30 days of receiving the request for 

reconsideration, the PSM prepares a response to the 

medical provider outlining DEEOIC’s decision to 

either: 

(1) Approve an additional payment amount: In 

this instance, the PSM generates a draft letter 

for the District Director’s (DD) signature, 

informing the provider of the approval for 

additional payment. [Where an additional amount 

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20. Fee Schedule Appeal Process. (Continued) 

is found to be payable based on unusual provider 

qualifications, the DD determines whether future 

bills for the same or similar service from that 

provider should be exempt from the fee schedule.] 

The PSM also prepares a memorandum for the case 

file stating the findings and the basis for the 

approval of the additional amount, or; 

(2) Deny any additional payment: In this 

instance the PSM prepares a draft letter-decision 

for the DD’s signature, advising that additional 

payment is denied, based upon the provider’s 

failure to establish one of the conditions listed 

above, in Item c above(1,2,3). Where additional 

payment is denied, the letter decision must 

contain a notice of the provider’s right to 

further review, similar to the following: 

If you disagree with this decision, you 

may, within 30 days of the date of this 

decision, apply for additional review. The 

application may be accompanied by additional 

evidence and should be addressed to the 

Regional Director, District _________, 

Office of Workers’ Compensation Programs, 

U.S. Department of Labor, [Insert 

appropriate Regional Office address and Zip 

Code.]

e. The draft approval or denial letters are prepared 

by the PSM, for the signature of the District Director 

(DD) whose office has control of the claim file(s) 

being addressed in the decision(s). The PSM sends the 

draft letter (via email) to the District Director for 

review, signature, and mailing. The DD places a copy 

of the signed letter in the case file and also returns 

(via email) a scanned copy of the signed letter, to be 

retained by the PSM. 

f. The PSM continues to track the status of any 

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20. Fee Schedule Appeal Process. (Continued) 

fee schedule appeal case, and maintains an electronic 

copy of all correspondence. This includes a copy of 

the draft letter and a scanned copy of the signed 

letter mailed by the DD. 

g. If a denial is subsequently appealed to the 

Regional Director (RD), the RD must consult with the 

PSM to obtain copies of relevant bills and documents, 

and to discuss the appeal. The PSM also provides the 

RD with a copy of the denial letter signed by the DD. 

This can be handled via email. 

h. After consultation with the PSM, the RD prepares 

a written response to the provider within 60 days of 

receipt of the request for review. Where additional 

payment is denied at the regional level, the letter 

decision from the RD advises the provider that the 

decision is final and is not subject to further 

administrative review. The RD forwards a scanned copy 

of the signed letter decision to the PSM. The PSM also 

retains that response as part of the appeal record. 

i. The final outcome of each appeal letter is 

recorded in the PSM tracking system to indicate: 

(1) Additional payment made. 

(2) DD Denial letter. 

(3) RD Appeal letter. 

(4) Time limit (30 days) has expired for appeal 

to RD. 

(5) The final disposition date for each appeal 

letter. 

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 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

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TABLE OF CONTENTS 

Paragraph and Subject Page Date Trans. No. 

Chapter 3-0300 Ancillary Medical Services and Related Expenses 

 Table of Contents. . . . . . . i 01/10 10-07 

 1 Purpose and Scope. . . . . . . 1 01/10 10-07

 2 In-Home Health Care . . . . . 1 01/10 10-07 

 3 Attendant Services . . . . . . 13 01/10 10-07 

 4 Hospice Care . . . . . . . . . 15 01/10 10-07 

 5 Extended Care Facilities . . . 16 01/10 10-07 

 6 Durable Medical Equipment. . . 17 01/10 10-07 

 7 Vehicle Modifications 

 and Purchase . . . . . . . . 20 01/10 10-07 

 8 Housing Modifications. . . . . 26 01/10 10-07 

 9 Health Facility Membership 

 and Spa Membership . . . . . 33 01/10 10-07 

 10 Medical Alert Systems. . . . . 36 01/10 10-07 

 11 Extended Medical Travel 

 Expense Reimbursement. . . . 39 01/10 10-07 

Exhibits 

 1 Sample Initial Medical 

 Development Letter . . . . . 01/10 10-07 

 2 Sample Follow-up Development 

 Letter . . . . . . . . . . . 01/10 10-07 

 3 Sample Authorization Letter. . 01/10 10-07 

 4 Billing Codes. . . . . . . . . 01/10 10-07 

 5 Sample Recommended Decision to 

 Deny Home Health Care. . . . 01/10 10-07 

 6 Sample Travel Authorization 

 Letter . . . . . . . . . . . 01/10 10-07 

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1. Purpose and Scope. This chapter describes the 

procedures for evaluating and approving requests from 

claimants who need ancillary medical services and supplies, 

and who seek reimbursement of expenses related to ancillary 

services. The roles and responsibilities of those who 

authorize such expenses are described in EEOICPA PM 3-0200. 

2. In-Home Health Care. This section provides 

clarification with regard to the evidence needed to 

authorize in-home health care, as well as procedural 

guidance with regard to the process for review, 

development, and authorization of in-home health care 

services. 

a. All requests for in-home health care must be 

submitted to DEEOIC’s bill processing agent (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 Fiscal 

Officer (FO), advising of a new pending in-home health 

request. FO is the point of contact with DEEOIC’s BPA 

for all in-home health care requests. 

b. All requests for in-home health care require 

prior authorization from the POC Claims Examiner 

(expedient review occurs under certain emergency 

situations - see “q” below for further information), 

including authorization for initial nurse assessment. 

If a physician requests that an initial in-home 

assessment be performed to determine the need for inhome health care, the request for that initial 

assessment must be submitted to the BPA with 

appropriate supporting medical documentation. 

c. Written requests that are received in the 

district office from the claimant, the authorized 

representative, the treating physician, or a service 

provider, must be faxed by the POC CE to the BPA to 

begin the authorization process. Concurrently, the POC 

CE begins development on any such request while 

awaiting an acknowledgement from the BPA. 

d. If the POC CE receives a request for an initial 

assessment without a physician’s signature or 

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2. In-Home Health Care. (Continued) 

recommendation, the POC CE must fax it to the BPA and 

begin concurrent development, the same as in step “c” 

above. The POC CE sends a letter to the claimant 

advising that a request for an initial in-home 

assessment was received without a physician’s 

recommendation. In the letter, the POC CE provides 30 

days for receipt of a physician’s authorization or 

request for the assessment. If medical documentation 

is not received within 30 days, the POC CE denies the 

request for assessment pursuant to the instructions in 

“y” below. 

e. Telephone requests for in-home health care must 

be documented in ECMS. Except in cases of an emergency 

nature (See “r” below), the POC CE may provide 

information and answer questions pertaining to in-home 

care covered by DEEOIC, however all callers should be 

advised that they must submit their requests in 

writing before the authorization process can begin. 

Written requests must include a medical rationale and 

a detailed explanation of the type and level of 

service the patient requires. 

f. Valid requests do not always have to be initiated 

by a claimant to be considered valid requests. 

Requests for an in-home assessment of a patient’s 

needs, and/or requests for in-home care can be 

initiated by an authorized representative, or any 

licensed doctor or medical provider. 

g. Upon receipt of an authorization request for inhome health care from the BPA, the FO forwards the 

information to the appropriate POC CE for review and 

adjudication. 

h. Upon receipt of such request, the POC CE must 

determine the particular in-home health services or 

care being requested. Generally, the types of requests 

that are submitted include: a physician’s request for 

authorization of an initial in-home assessment; 

discharge summary from a hospital requesting specific 

in-home health care services; or requests from a 

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2. In-Home Health Care. (Continued) 

physician for continuing in-home health care services 

(following expiration of a previous authorization). 

i. Upon receipt of a request, the POC CE reviews the 

medical evidence to determine if the initial 

assessment or in-home health care was requested by the 

treating physician. If the request comes from the 

treating physician, or another appropriate doctor, the 

POC CE approves the initial assessment only (if 

applicable). When an initial assessment request 

precedes a request for in-home health care, the POC CE 

may not approve in-home health care until after the 

initial assessment has been completed and a plan of 

care has been submitted. Once the POC CE approves the 

initial assessment, the POC CE sends an email to the 

FO, who sends a thread to the BPA authorizing the 

request (see “p” for more information concerning 

approvals). 

j. Upon receipt of a plan of care, discharge 

summary, or physician’s recommendation delineating a 

specific request for in-home health care services, the 

CE must conduct a complete review of the case file to 

determine if there is any recent medical documentation 

from the primary care physician (or treating 

specialist for the accepted condition), describing the 

need for in-home medical care as it relates to the 

covered medical condition. The primary information 

that the treating physician must provide (often 

contained in the plan of care signed by a physician) 

should include: 

(1) Description of the in-home medical needs of 

the patient arising from the covered medical 

condition. This includes a narrative of the 

patient’s medical need for assistance while in 

the home and how this is linked to the covered 

medical condition. The physician must describe 

the findings upon physical examination, and 

provide a complete list of all medical conditions 

(those accepted by DEEOIC and those not accepted 

by DEEOIC). If a claimant has one or more noncovered conditions, medical evidence must 

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2. In-Home Health Care. (Continued) 

demonstrate how the requirement for in-home 

health care is related 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. Generally, 

approved in-home services include: 

administration of medication, medical monitoring, 

bathing and personal hygiene, meal preparation 

and feeding, wound dressing changes, and medical 

equipment checks. 

(2) Level of care required, i.e. Registered 

Nurse (RN), Licensed Practical Nurse (LPN), 

Home Health Aide (HHA), etc. The doctor 

must specify the appropriate type of 

professional who will attend to the patient. 

Services requiring specialized skills such 

as administration of medication and medical 

monitoring generally require a RN or LPN, 

while services of a general nature 

(typically referred to as activities of 

daily living), such as bathing, personal 

hygiene, and feeding are generally performed 

by home health aides and attendants. 

(3) Extent of care required (months, days, 

hours, etc). A written medical narrative 

must describe the extent of care to be 

provided in allotments of time. (Example: RN 

to administer medication and check vitals 

once a day, every three days, with a home 

health aide to assist with bathing, personal 

hygiene, and feeding, eight hours a day, 

seven days a week for three months.) 

k. If upon review the POC CE finds that the medical 

evidence is incomplete and the file does not contain 

an adequate description of the in-home health care 

needs of the patient, the POC CE prepares a letter to 

the claimant advising that the DEEOIC has received a 

request for in-home health care. In the letter to the 

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2. In-Home Health Care. (Continued) 

claimant, the POC CE advises that additional medical 

evidence is required before services can be 

authorized. Additionally, the POC CE forwards a copy 

of the claimant letter to the treating physician, 

requesting a narrative medical report that includes 

all of the information described in “j” (above). In 

addition, the physician is asked to estimate the 

length of time for which the patient will ultimately 

require in-home health care assistance. The POC CE 

advises in the letter that the medical report is 

required within 30 days. (see Exhibit 1 for sample 

letter) The POC CE also faxes a copy of the letter to 

the treating physician’s office. 

l. Upon mailing the request to the claimant (copy to 

the treating physician) the POC CE enters an ECMS note 

describing the action and inserting a 15-day call-up. 

If on the fifteenth day the physician has not 

responded, the CE contacts the physician’s office to 

inquire if the letter was received, and to ask if 

there are any questions regarding the request for 

information. The call is documented in TMS and another 

15-day call-up inserted in ECMS. 

m. After 30 days has passed with no satisfactory 

response from the treating physician, or no response 

from the claimant, the POC CE prepares a second letter 

to the claimant (accompanied by a copy of the initial 

letter), advising that following the previous letter, 

no additional information has been received from the 

treating physician. The POC CE advises that an 

additional period of 30 days will be granted for the 

submission of necessary evidence, and if the 

information is not received in that time, the request 

for in-home care may be denied by the DEEOIC (see 

Exhibit 2 for a sample letter). 

n. If the claimant or the physician does not provide 

a response to the second request for information 

within the 30-day period allowed, the POC CE issues a 

letter decision to the claimant denying the claim for 

in-home health care. (See “y” below for more details.) 

The POC CE further sends an email to the FO, who sends 

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a thread to the BPA advising that the service has been 

denied. 

o. If the claimant calls and states that he/she does 

not require in-home health care, the POC CE requests 

that the claimant put this in writing. Upon receipt 

of any written statement from the claimant stating 

that he/she is not requesting in-home health care, the 

POC CE writes a letter to the claimant with a copy to 

the treating physician advising that the claimant is 

not requesting in-home health care and thus the matter 

is closed. In this situation, the POC CE sends an 

email to the FO, who sends a thread to the BPA 

advising that this service is denied.

p. If medical evidence is received, the POC CE must 

determine if it is of sufficient probative value to 

authorize in-home health care. It is absolutely 

critical that the POC CE undertake appropriate 

analysis of any documentation pertaining to in-home 

services before authorizing such care. 

The underlying function of the POC CE is to ensure 

that the covered employee receives the necessary 

medical care for the accepted medical condition and 

that any such request for care reasonably corresponds 

with the medical evidence in the case file. If the 

physician does not provide sufficient details 

concerning the claimant’s physical condition, 

relationship to accepted conditions, or specific 

reasons for in-home health care, the POC CE must refer 

the case to a District Medical Consultant (DMC) for 

review. Upon receipt of a DMC’s opinion, the CE weighs 

the medical evidence in the file. If the DMC opinion 

is clearly in conflict with the recommendations of the 

treating physician, and the POC CE attempts to resolve 

the situation by communicating with the treating 

physician have not been successful, the POC CE is to 

arrange for a second medical opinion or referee 

evaluation, depending on the circumstances. In 

evaluating the medical evidence, the POC CE must base 

any determination solely on the weight of medical 

evidence in the case file. The POC CE must not under 

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2. In-Home Health Care. (Continued) 

any circumstances deny or reduce in-home health care 

services without a medical basis for such denial. 

q. In certain emergency claim situations (see “r” 

for a full discussion of the types of emergencies), 

the CE may authorize in-home health care for a 

preliminary 30-day period while additional development 

is undertaken. 

(1) Under these circumstances, the physician or 

hospital staff contacts DEEOIC’s BPA for 

immediate attention. The physician or hospital 

employee must notify the BPA that the situation 

is 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 documentation and assesses the 

emergency nature of the request. Once the 

medical evidence is obtained, the BPA contacts 

the FO immediately, advising of the situation and 

providing electronic copies of documentation 

obtained. The BPA does not make a decision 

regarding the request, but simply obtains the 

pertinent documentation and advises the FO of the 

emergency request. 

(2) Upon receipt of the documentation, the FO 

forwards the information to the POC CE for 

review. If discharge information from a treating 

physician supports the need for immediate 

authorization, the CE provides approval for 30 

days pending additional development. The POC CE 

concurrently sends an email to the FO advising of 

this approval. The FO sends a thread to the BPA 

with the approval information and places a 

telephone call to the BPA, alerting them of an 

impending emergency request. 

(3) After the initial approval for 30-day 

emergency care, the POC CE sends a letter to the 

treating physician with a copy to the claimant 

requesting necessary evidence to fully 

substantiate that the care being provided is 

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medically necessary to give relief for the 

accepted medical condition. This should occur 

within the preliminary 30-day authorization 

period. Extensions may be granted in increments 

of 30 days, but should generally 

never exceed a total of 120 days without the 

collection of the necessary evidence to fully 

document that the care being provided is 

medically warranted and necessitated by the 

accepted medical condition. 

(4) In some situations the request for emergency 

home health care may not be accompanied by 

evidence supporting the emergency nature of the 

request. For example, the claimant’s condition 

may be stable, or he/she is not being discharged 

from a hospital. In these situations, the POC CE 

sends a letter to the claimant, with a faxed copy 

to the requestor if other than the claimant. The 

letter advises that no evidence was submitted to 

support the request for emergency care, and that 

additional medical evidence is required. In 

addition, the POC CE sends an email to the FO 

advising that the request for emergency care is 

under development. The FO sends a thread to the 

BPA advising of this determination and places a 

telephone call to the BPA, alerting them of an 

impending emergency request. 

r. Emergency situations warranting short-term 

preliminary authorization for in-home health care 

include: 

(1) Requests for in-home health care for 

terminal patients with six months or less to 

live. Terminal status must be based on the 

opinion of a physician. 

(2) Patients discharged from in-patient hospital 

care with need for assistance. The CE must 

carefully evaluate these situations to ensure the 

medical documentation clearly indicates that the 

patient’s care and well-being is dependent on the 

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2. In-Home Health Care. (Continued) 

assignment of a medical professional in the home, 

(normally following a hospital stay). If the BPA 

has not already obtained this, the POC CE 

requests the attending physician discharge 

summary and discharge planning summary, which is 

normally available within 72 hours of discharge. 

When pre-authorization of emergency in-home care is to 

be granted, the POC CE prepares a memorandum for the 

case file documenting the rationale applied in 

authorizing care. For each subsequent 30-day preauthorization granted, a new memo is prepared 

outlining the basis for such authorization. In 

addition, the POC CE notifies the claimant and 

provider in writing of additional periods of 

authorization. The POC CE sends an email to the FO 

advising of any authorizations, and the FO forwards 

the information to the BPA in the form of a thread. 

s. For all requests, if upon review of the medical 

evidence the POC CE decides that in-home health care 

is required, authorization is to be granted. The POC 

CE prepares a letter notifying the claimant and the 

home health care provider of the decision, and 

delineating the following information (see Exhibit 3 

for a sample authorization letter): 

(1) Covered medical condition(s) for which 

care is being authorized. 

(2) A specific narrative description of the 

service approved (e.g. in-home assistance in 

administering medicine, monitoring accepted 

conditions, assistance in/out of bed, 

preparing meals and feeding, and medical 

equipment checks). 

(3) Level and duration of the specialized 

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 3 months. 

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(4) Authorized billing codes relevant to 

the level of authorization (see Exhibit 4 

for a description of the pertinent codes). 

(5) Period of authorization with specific 

start and end dates. 

t. The authorization must be limited to in-home 

medical services that are reasonably necessary for the 

treatment or care of the patient’s covered medical 

condition. These services generally include: Home 

Health Aide or attendant for mobility, food 

preparation, feeding and dressing; skilled nursing 

should be limited to the scope of practice of an RN or 

LPN, as long as there is medical evidence of such. 

The POC CE may not authorize a lower level of care 

than that requested by the physician unless the weight 

of medical evidence supports a lower level of care and 

the claimant has been provided the right to a 

recommended decision. 

u. Once the responsible POC CE sends the letter of 

authorization to the claimant and the provider, the 

POC CE prepares an email to the fiscal officer (FO). 

In the email, the POC CE advises the FO of the precise 

level of care, billing codes, and time period of 

authorization. The POC CE is not required to advise 

the FO of the number of correlating units per billing 

codes. In assigning billing codes, the POC CE 

references Exhibit 4. 

v. Once the email authorizing the services has been 

sent, the POC CE enters a note into ECMS detailing the 

level of service and time period of authorization. In 

addition, the POC CE enters a call-up note into ECMS 

for 30 days prior to the expiration date for which 

services have been authorized. 

w. If no request for additional authorization for 

in-home health care is received prior to the date of 

the call-up, the POC CE sends a letter to the 

provider, with a copy to the claimant. In the letter, 

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the provider is notified of the expiration date of the 

in-home health care services. The provider is further 

advised of the medical evidence required if additional 

services are necessary. If the POC CE does not 

receive an additional request, further action is 

unnecessary. However, if the provider or the claimant 

submits an additional request for ongoing services, 

the POC CE evaluates the evidence as above. 

x. Upon receipt of the email authorization from the 

POC CE, the FO prepares a thread to the BPA 

authorizing the specific level of care, billing codes 

(with units), and period of authorization. The FO 

calculates the authorized number of units based upon 

the POC CEs description of the level of care, weekly 

authorized amount for each level of care, and the time 

period of authorization. 

y. If upon review of the medical evidence in the 

file, and if after appropriate development as outlined 

above, the POC CE determines that there is 

insufficient evidence to warrant authorization of inhome health care, the POC CE sends a detailed letterdecision to the claimant (with a copy to the in-home 

provider). 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. 

z. In the event that the claimant does request a 

Recommended Decision, the POC CE prepares a 

Recommended Decision (see Exhibit 5 for a sample 

decision). 

aa. At any time after a period of authorized services 

and after the POC CE has undertaken any medical 

development (i.e. letter to the claimant requesting 

additional documentation, referral to DMC or second 

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2. In-Home Health Care. (Continued) 

opinion) the POC CE may receive new medical evidence 

that warrants a change in the level of in-home care 

currently authorized. If this occurs, the POC CE must 

review that evidence, employing the same decisionmaking process described in “p.” If the new medical 

evidence supports a denial of services, or reduction 

in the level of services currently being authorized, 

that reduction or denial must be communicated to the 

claimant in a detailed letter as discussed in “y”, 

(with a copy to the in-home care provider) explaining 

the change. 

bb. Letters that advise of a reduction or termination 

of services must be copied to the in-home care 

provider and must specifically advise the claimant 

that: 

(1) Any reduction in the current level of 

service being provided will occur 15 days 

from the date of the letter. This letter 

must also contain information describing the 

new level of care being authorized; or, 

(2) Any termination of services will occur 

30 days from the date of the letter. 

cc. After the expiration of the 15 or 30 day periods, 

the POC CE sends a letter-decision to the claimant 

advising as to the final action taken on the request 

for in-home health care services. In this letter the 

POC CE advises the claimant of his/her rights of 

action as delineated in action item “y” above. 

In addition, the POC CE sends an email to the FO 

advising of the new level of care or the termination 

of current level of services. The FO then sends a 

thread to the BPA advising of the determination. It 

is very important for the POC CE to note that only a 

single authorization can exist at any one time. If 

the POC CE has authorized a certain level of care that 

subsequently changes, it is essential that this 

information be clearly communicated in an email to the 

FO. The FO sends a thread to the BPA advising of any 

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2. In-Home Health Care. (Continued) 

change in the level of care being authorized, or of 

any additional period of authorization beyond the 

existing expiration date. The POC CE must also 

document the information in the notes section of ECMS 

when a thread is sent to the BPA. 

dd. If the claimant requests a recommended decision 

on a termination of services, the POC CE proceeds 

with a recommended decision. If the claimant 

requests a recommended decision on a reduction in 

the level of care, the POC CE proceeds with a 

recommended decision. 

ee. If, after initial approval of services, the 

claimant’s treating physician sends in medical 

documentation (without prior POC CE development) 

recommending a lower level of care, the POC CE 

authorizes the new level of care via letter to the 

claimant (with a copy to the provider). Since the new 

level of care is requested by the treating physician 

without development by the POC CE, the POC CE does not 

need to provide the claimant with a right to a 

recommended decision. The POC CE concurrently sends 

an email to the FO advising of the new level of care. 

The FO sends a thread to the BPA advising of this 

change. 

(1) Period of Service. In-home health care may be 

authorized for a period of up to six months. 

Recertification is required for any period of 

time beyond six months. Recertification should 

be completed before the current authorization 

expires, to allow for care to continue 

uninterrupted. 

 

3. Attendant Services. This section provides 

clarification with regard to the evidence needed to 

authorize attendant services. Refer to item 2 of this 

chapter for guidance regarding development of attendant 

services. 

a. Section 7384t of the EEOICPA authorizes payment 

for personal care services whether or not such care 

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3. Attendant Services. (Continued) 

includes medical services, as long as the personal 

care services have been determined to be medically 

necessary and are provided by a home health aide, 

licensed practical nurse, or similarly trained 

individual. 

(1) Attendant services are non-skilled services 

routinely provided in an in-home setting. These 

services assist claimants with activities of 

daily living (i.e. bathing, feeding, dressing, 

etc). Attendant services must be provided by a 

trained individual.

(2) The POC CE may authorize attendant services 

to a claimant when a treating physician 

determines that these services are required for 

an accepted condition. The physician must provide 

a written statement, prescription or plan of care 

to that effect. 

b. A claimant’s relative may provide attendant care 

(if properly trained), but may not be reimbursed for 

care that falls within the scope of household duties 

and other services normally provided by a relative. 

Duties such as maintaining a household, washing 

clothes, or running errands are not considered 

attendant services, and will not be authorized. A

claimant’s relative who provides attendant care 

services to a claimant can be authorized for 

reimbursement up to 12 hours per day.

c. All requests for attendant services 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 new, and pending 

attendant service requests. Upon receipt of an 

authorization request for attendant services from the 

BPA, the FO forwards the information to the 

appropriate POC CE for review and adjudication.

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3. Attendant Services. (Continued) 

(1) Period of Service. Attendant services may 

be authorized up to six months. Recertification 

is required for any period of time beyond six 

months. Recertification should be completed 

before the current authorization expires, to 

allow for care to continue uninterrupted. 

(2) Billing. Attendant care services should be 

billed weekly or monthly. Supporting 

documentation (i.e., weekly or monthly notes) 

must be submitted with the bill to the DEEOIC’s 

BPA. The DEEOIC’s BPA then forwards 

weekly/monthly notes to the district office for 

review. In assigning billing codes, the POC CE 

references Exhibit 4. 

4. Hospice Care. This section provides clarification 

with regard to the evidence needed to authorize hospice 

care services. Refer to item 2 for guidance regarding the 

development of hospice care. 

a. Hospice care is generally requested and 

authorized when a claimant is determined to be 

terminally ill and has no more than six months to one 

year of life remaining. 

(1) When a treating physician determines that 

hospice care is required for an accepted 

condition and provides a written statement, 

prescription or plan of care to that effect, the 

CE may authorize the services. 

(2) Hospice, once authorized, is responsible for 

assessing the claimant’s needs and providing all 

levels of care to the claimant. 

b. All requests for hospice care in the home 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, pending hospice 

request. All requests for hospice care require prior 

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4. Hospice Care. (Continued) 

authorization from the CE. Upon receipt of an 

authorization request for hospice care from the BPA, 

the FO forwards the information to the appropriate CE 

for review and adjudication. 

(1) Period of Service. Hospice services may be 

authorized for up to six months. Recertification 

is required for any period of time beyond six 

months. Recertification should be completed 

before the current authorization expires, to 

allow for care to continue uninterrupted. 

(2) Billing. Supporting documentation (i.e., 

medical notes) must be submitted with the bill to 

the DEEOIC’s BPA. The DEEOIC’s BPA then forwards 

monthly notes to the district office for review. 

In assigning billing codes, the CE references 

Exhibit 4. 

5. Extended Care Facilities. This section provides 

clarification with regard to the evidence needed to 

authorize placement in an extended care facility. 

a. Care in a nursing home, skilled nursing facility 

and assisted living facility may be authorized when 

the claimant does not need acute care but does require 

medical services and assistance with daily activities 

of living. 

b. All requests for extended care 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, pending extended care facility 

request. All requests for extended care require prior 

authorization from the CE. Upon receipt of an 

authorization request for extended care from the BPA, 

the FO forwards the information to the appropriate CE 

for review and adjudication. 

When a treating physician determines that extended 

care is required for an accepted condition, and 

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5. Extended Care Facilities. (Continued) 

provides a written statement to that effect, the CE 

may authorize the services. The claimant should remain 

under continuing medical supervision of a physician 

while residing in an extended care facility. 

(1) Period of Service. Extended Care facilities 

may be authorized up to six months. 

Recertification is required for any period of 

time beyond six months. Recertification should 

be completed before the current authorization 

expires, to allow for care to continue 

uninterrupted. 

(2) Billing. Supporting documentation (i.e., 

medical notes and itemization of charges,) must 

be submitted with the bill to the DEEOIC’s BPA. 

The DEEOIC’s BPA then forwards supporting 

documentation to the district office for review. 

DEEOIC will reimburse the rates for standard 

accommodations according to the requirements of 

the medical condition. In assigning billing 

codes, the CE references the Current Procedural 

Terminology (CPT) manual. 

6. Durable Medical Equipment. This section describes 

procedures to be followed when a claimant requests 

authorization for durable medical equipment (DME), 

appliances and supplies. All DME, appliances, and or 

supplies must be purchased from a DME supplier. 

a. DME is primarily and customarily used to serve a 

medical purpose only. DME can withstand repeated use, 

and is appropriate for use in the home. Some examples 

of DME include hospital beds, walkers, wheel chairs, 

and oxygen tents. 

b. The District Office has broad discretion in 

approving DME, appliances, or supplies provided under 

the EEOICPA. 

(1) Most appliances, supplies and or DME 

purchases under $5,000.00 do not need CE approval 

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and are automatically paid by the DEEOIC’s BPA in 

accordance with the OWCP fee schedule. 

(2) Requests for DME, appliances and or supplies 

equal to or over $5,000 (excluding mobility 

devices) must be approved by the CE, and that 

approval must be communicated to DEEOIC’s BPA 

through the FO. 

(3) Requests for mobility devices, such as a 

scooter or a motorized wheelchair, including its 

components and accessories, which are medically 

necessary to provide basic mobility, under 

$10,000, do not need approval and are paid 

automatically by DEEOIC’s BPA. 

(4) Requests for mobility devices equal to or 

over $10,000 must be approved by the CE, and that 

approval must be communicated to DEEOIC’s BPA 

through the FO. 

c. When authorizing purchase requests for DME 

equipment equal to or over $5,000 and mobility devices 

equal to or over $ 10,000, the CE must obtain the 

following information: 

(1) From the treating physician: 

(a) The treating physician must provide 

either a detailed letter of medical 

necessity or another means of justification 

for the medical equipment required, relating 

the need to the accepted condition. 

(b) A full, specific description of the 

basic equipment. 

(c) The anticipated duration of the need 

for the item (to determine whether rental or 

purchase is appropriate). 

(d) The full name and address of two 

suppliers. 

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6. Durable Medical Equipment. (Continued) 

(2) Claimant: 

(a) Claimant must submit two estimates from 

two different DME suppliers. These estimates 

must be for exactly the same type of DME 

appliances and or supplies. 

(3) From the Supplier: 

(a) From each potential supplier, a signed 

statement describing in detail the DME 

equipment item, a breakdown of all costs 

including delivery and installation, and the 

current Healthcare Common Procedure System 

(HCPCS) code for each DME item needed. 

e. Estimates. The CE must authorize the lowest 

estimate provided that no exceptional circumstances 

warrant the higher estimate, (e.g., inability to 

provide the equipment in a timely fashion). 

f. Repair/Maintenance Cost: Cost for repairs and 

maintenance to DME equipment is covered. 

g. DME add-ons or Upgrades: Add-ons or upgrades are 

not covered; when they are intended primarily for the 

claimant’s convenience, and do not significantly 

enhance DME functionality. 

h. Communicating the decision. Upon receiving a 

request for DME, appliances or supplies, the CE takes 

one of the actions below: 

(1) Approval: If the CE approves the request, 

he/she writes a letter to the claimant 

advising him/her of the decision. The letter 

includes the following: the date DO received the 

request; the type of service or appliance being 

approved; and a statement that the reimbursement 

amount will be based on the OWCP fee schedule. 

The CE also communicates this decision to the 

DEEOIC’s BPA, through the fiscal officer. The 

claimant should be instructed to submit a copy of 

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this approval letter, along with the request for 

reimbursement or payment, to the DEEOIC’s BPA. 

(2) Additional Information: If upon review the 

CE determines that additional information is 

necessary, he/she writes to the claimant 

requesting specific documentation that is 

necessary to continue the processing of the 

payment. 

(3) Follow-up. If the provider and/or claimant do 

not respond to the development letter, or if 

he/she fails to provide sufficient documentation 

to support their request, the CE has the 

discretion to either take additional steps to 

develop the evidence, or to deny the request. 

The CE must review the evidence in accordance 

with the guidance in this chapter, properly 

weighing the medical rationale provided. 

 (4) Denials. If the CE denies the request 

he/she writes a detailed letter decision to the 

claimant detailing the reason(s) for the denial. 

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. 

(5) Recommended Decision. If the claimant 

requests a recommended decision, the CE 

proceeds with a recommended decision. 

7. Vehicle Modifications and Purchases. This section 

provides clarification with regard to the evidence needed 

to approve vehicle modifications and purchases; as well as 

procedural guidance with regard to the process for review, 

development, and authorization of vehicle modifications and 

purchases. 

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7. Vehicle Modifications and Purchases. (Continued) 

a. When it becomes necessary to provide the claimant 

with some form of private transportation, other than 

taxis or hired services, modification to, or 

replacement of the claimant’s privately owned vehicle 

can be approved. Upon receipt of a letter of medical 

necessity from the treating physician, detailing the 

physical limitations involved, and the specific 

transportations needs of the claimant as related to 

the accepted medical condition. The CE must gather two 

estimates from certified or licensed dealers for the 

cost of vehicle modifications recommended by the 

claimant’s treating physician. The CE has the latitude 

to approve an estimate that the claimant favors, if 

the estimates are reasonably similar in scope and 

cost. 

(1) Criteria for Modifications. If the 

claimant’s transportation needs can be met by 

modifying or adding accessories and equipment to 

the claimant’s present vehicle, the CE explores 

this option first, before consideration is given 

to replacing the existing vehicle. When 

considering modifications to an existing vehicle, 

the CE takes into consideration the type of 

vehicle currently owned, its age, and condition. 

Modifications must be consistent with the 

claimant’s pre-injury standard of living and 

should approximate that standard insofar as is 

practical. 

(2) Proposals. If the CE determines that the 

claimant’s needs warrant vehicle modification, 

the CE advises the claimant in writing to submit 

a detailed written proposal containing the 

following information: 

(a) The year, make, model, and body style 

of the vehicle to be modified, as well as 

current mileage, description of general 

mechanical condition, and any repairs 

currently needed or anticipated. The same 

applies regardless of whether the vehicle to 

be modified is new or used. 

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7. Vehicle Modifications and Purchases. (Continued) 

(b) An itemization of all vehicle 

modifications proposed, to include parts, 

labor and their respective costs. The 

itemization should also specify the amount 

of time required for the modifications. 

(3) After considering the proposal for 

modification to an existing vehicle, the CE 

accepts or rejects the proposal, in writing, 

within a reasonable time frame. 

(4) Approval. If upon review of the evidence 

the CE approves the request, the CE writes a 

detailed letter decision to the claimant advising 

of the approval. 

(5) Notifying the BPA. Once the CE sends the 

letter of approval to the claimant, the CE 

prepares an email to the FO. In the email, the CE 

advises the FO of the approval, citing the 

appropriate homegrown code (e.g. VHMDF, VHPUM) 

for a vehicle modification or purchase and the 

amount approved. The fiscal officer communicates 

this approval to DEEOIC’s BPA. 

(6) Additional Information. If the CE 

determines that additional information is 

necessary, the CE sends a letter to the claimant 

requesting additional documentation that is 

necessary to continue with the review process. 

(7) Follow-up. If the claimant does not respond 

to the development letter, or if he or she fails 

to provide sufficient documentation to support 

the request, after considering all relevant 

evidence, the CE issues a detailed letter 

decision informing the claimant of the denial. 

The CE also informs DEEOIC’s BPA through the FO 

of this denial. 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 

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7. Vehicle Modifications and Purchases. (Continued)

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. 

(8) Recommended Decision. If the claimant 

requests a recommended decision, the CE 

proceeds with a recommended decision. 

(9) Purchase. If it is established that the 

claimant’s currently owned vehicle is no longer 

acceptable for his or her transportation needs, 

and if modifications to that vehicle are not 

possible or practical, then the CE reviews the 

case with a supervisor and may authorize the 

purchase of a suitable replacement vehicle, 

taking credit (see (e) below) for the value of 

the claimant’s existing vehicle. Purchase options 

include the following:

(a) Purchase of a used vehicle, similar in 

quality to the claimant’s existing vehicle, 

which is already equipped to accommodate the 

claimant’s disability and transportation 

needs. 

(b) Purchase of a used vehicle that is 

suitable for modification as described above. 

(c) Purchase of a new vehicle, modified, or 

suitable for modification, to meet the 

transportation needs of the claimant, 

arising from an accepted condition. 

(d) Whether a new or used vehicle is 

purchased, it must be a vehicle of similar 

quality as the vehicle that the claimant 

already owns (i.e. a vehicle in a price 

range that closely approximates the level of 

income and/or standard of living of the 

claimant). 

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7. Vehicle Modifications and Purchases. (Continued) 

For example if the claimant owns a midpriced Chevrolet, Ford, Honda or Toyota, 

purchase of a Cadillac or Lincoln SUV, to be 

modified for their needs, would not be of 

comparable value. A vehicle of comparable 

value would have to be selected. Once the 

baseline cost of a comparable quality 

vehicle has been established, the claimant 

may (at his or her option) choose to upgrade 

the baseline model, by adding additional 

equipment, with the difference in cost being 

paid for by the claimant. 

(e) After determining the baseline cost of 

a comparable vehicle, the CE must take 

credit for (deduct) the wholesale value of 

the claimant’s existing car, when 

determining the allowance to be paid for a 

replacement vehicle. The wholesale value of 

the existing vehicle can be determined 

through a number of internet websites that 

make this information available free-ofcharge. The CE should advise the claimant of 

the source of their information, once the 

wholesale value of the claimant’s current 

vehicle has been determined. 

(f) Sales Tax: State sales tax should be 

included in the cost of obtaining a 

replacement vehicle. 

(g) Equipment that is medically necessary 

for the accepted condition should be 

factory-installed whenever possible. 

(10) Maintenance Costs. The CE authorizes 

necessary maintenance on the specialized 

equipment in a modified vehicle, whether 

installed in a new or used vehicle. 

a) Replacement cost of the specialized 

equipment, due to normal wear and tear, may 

be considered as well. Other parts of the 

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7. Vehicle Modifications and Purchases. (Continued) 

vehicle will be maintained at the owner’s 

expense, even if the vehicle purchase was 

reimbursed by DEEOIC. 

(b) Replacement of the vehicle, and all 

authorized equipment, can be considered if 

the claimant can establish that the age, 

mileage, and condition of the vehicle 

warrant such replacement. Any residual 

value remaining in the vehicle to be 

replaced would be applied as a credit toward 

the cost of a replacement vehicle. 

(11) Proof of Insurance. The claimant is 

required to obtain adequate insurance and to 

maintain current registration of the vehicle in 

the state of residence. Claimants are required 

to carry comprehensive (fire, theft, vandalism, 

etc.) and collision insurance on any vehicle for 

which DEEOIC has authorized reimbursement, unless 

the fair market value of the vehicle and its 

equipment is less than $2,500. The claimant may 

select the deductible of the insurance policy but 

will be responsible for any such deductible 

should an accident occur. 

(12) Vehicle No Longer Needed. When the claimant 

no longer needs the vehicle, DEEOIC is entitled 

to recover the fair market value of the modified 

vehicle, less any percentage contribution the 

claimant made to the overall purchase price of 

the vehicle and its modifications. If the fair 

market value of the modified vehicle is less than 

$5,000, no reimbursement will be due DEEOIC. 

(a) Example 1. The claimant owns a $10,000 

vehicle that is not suitable for 

modification. The purchase price of a 

suitable replacement vehicle is $30,000. The 

claimant contributes $10,000 toward the 

purchase of the new $30,000 vehicle, as this 

represents the value of the vehicle he or 

she owned, which is being replaced. DEEOIC 

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7. Vehicle Modifications and Purchases. (Continued) 

then pays an additional $20,000 in 

reimbursement toward the purchase price of 

the modified vehicle. 

(b) Example 2. The claimant has a $30,000 

vehicle, for which he or she has contributed 

one-third of the purchase price. At the time 

of sale, the claimant would be entitled to 

one-third of the proceeds and DEEOIC would 

recover two-thirds. However, if at the time 

of sale, the fair market value was 

determined to be $4,995 (less than $5000); 

the DEEOIC would recover zero dollars. 

8. Housing Modifications. This section provides 

clarification with regard to the evidence needed to approve 

housing modifications, as well as procedural guidance with 

regard to the process for review, development, and 

authorization of housing modifications. 

a. Modifications must be prescribed by a treating 

physician whose medical specialty qualifies him or her 

to offer a medical opinion on the specific 

architectural needs of a medically disabled person. 

Modifications must be in conformity with applicable 

building codes and must conform to the standard of 

décor that existed prior to the disability. 

(1) Modifications to Owned Property. 

Modifications to a house must be consistent with 

the claimant’s pre-injury standard of living and 

should approximate that standard insofar as 

practical, with respect to the quality of 

construction materials and workmanship. 

(a) Modifications may include certain 

additions where warranted. For example, if 

a ground-floor recreation room is converted 

to a bedroom, to accommodate a wheelchairbound individual, and if no ground-floor 

bathroom facilities exist, then the addition 

of a bathroom on the ground floor could be 

approved. Similarly, if there is no suitable 

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8. Housing Modifications. (Continued) 

space for conversion to a bedroom on the 

ground floor, then the addition of a bedroom 

on the ground floor could be approved, if no 

other reasonable alternative exists. 

(b) Modifications may include certain 

accessories. The addition of appliances 

such as air conditioning or air filtration 

equipment can be considered, if found to be 

medically necessary for the relief of 

certain accepted medical conditions. 

For example, if the claimant suffers from 

respiratory or cardiac conditions that have 

been accepted, his or her physician may 

order that the claimant be kept in an air 

conditioned environment, in which case the 

expense for these modifications would be 

allowed. 

(c) Maintenance expenses. The CE approves 

maintenance expenses for equipment furnished 

to the claimant, as well as replacement 

costs after normal wear and tear. 

(d) The Government is entitled to 

reimbursement for the value of any special 

equipment that can be removed and sold 

separately, when no longer needed by the 

claimant. Reimbursement shall also be owed 

for any increase in overall value of the 

property resulting from permanently 

installed special equipment, or for any 

architectural modifications of a permanent 

nature, that improve the value of the 

property. 

The value of such permanent equipment or 

modifications may be determined in any 

reasonable, equitable manner, such as 

written estimates from real estate sources, 

or by comparing the recent sales prices of 

similar houses without the special 

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8. Housing Modifications. (Continued) 

equipment. No reimbursement to the claimant 

should be considered for any reduction in 

the value of the property resulting from 

modifications which may inconvenience 

prospective purchasers. 

(2) Modifications to Non-Owned Property. Any 

modifications to property not owned by the 

claimant and his or her family are subject to 

approval by the landlord or owner. This is in 

addition to the preceding guidelines established 

for owned property. When presented with a 

request for modifications to non-owned property, 

the CE considers the following points: 

(a) Rental property may be subject to 

federal (Americans with Disabilities Act), 

state or local statutes that mandate 

barrier-free accessibility for persons with 

disabilities. The claimant should discuss 

any change in housing needs with his or her 

landlord, who may be able to offer 

modifications or alternative accommodations 

better suited to the needs of the 

individual. 

(b) If the landlord is unable or unwilling 

to pay for modifications, or offer other 

suitable accommodations, approval must still 

be obtained from the landlord prior to 

making any changes or alternations to the 

non-owned property. Any such changes must 

be made at the claimant’s expense, and are 

subject to review and approval by DEEOIC, 

prior to any reimbursement. 

(c) If the landlord/owner will not permit 

modifications, or if the costs are 

excessive, and if suitable housing 

arrangements are available elsewhere, it may 

be more cost-effective to consider paying 

relocation expenses rather than paying for 

modifications at the current location. If 

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8. Housing Modifications. (Continued) 

changing locations is the most costeffective alternative, the CE may authorize 

a subsidy for any increase in rent, if 

warranted, in addition to the relocation 

expense. For example, if the claimant lives 

in an apartment with stairs, and is no 

longer able to climb stairs due to his or 

her accepted condition(s), DEEOIC would 

reimburse the claimant for the most nearly 

comparable apartment available that offers 

an elevator and any other accommodations 

required to fulfill the claimant’s medical 

needs arising from the claimant’s accepted 

condition(s). 

(d) The Government is entitled to 

reimbursement only for the value of special 

equipment that can be removed and sold 

separately, once the claimant no longer 

needs that equipment. Improvements or 

modifications, and any increase in property 

value resulting from such changes, accrue to 

the benefit of the owner. 

(3) Proposals. If the CE determines that the 

claimant is eligible for housing modifications, 

the CE asks the claimant to submit a detailed 

written proposal for review and consideration. 

The CE advises the claimant that the proposed 

housing modifications should be of a quality and 

finish consistent with his or her present 

residence, not superior to it. Further, the 

claimant should be cautioned that structural 

modifications must not compromise the integrity 

of the existing structure. 

While the choice of modifications remains with 

the claimant, the CE does not authorize payment 

for any modifications that are structurally 

unsound. 

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8. Housing Modifications. (Continued) 

Modifications will be no more expensive than 

necessary to accomplish the required purpose. For 

example, when remodeling a bathroom, it may be 

feasible to re-install an existing sink at 

wheelchair height, for less than the cost of 

discarding the sink and buying a new one. 

Conversely, modifications must be in keeping with 

the standard of the décor of the current or preillness accommodations. For example, if the 

claimant’s dwelling (owned or rented) requires 

that a sink or commode be changed for handicap 

accessibility, and if it is necessary to tear out 

and replace tile, then the tile in the entire 

bathroom or kitchen may have to be replaced with 

similar quality tile in order to maintain the 

architectural décor of the room. 

Proposals must include the following information: 

(a) A medical report detailing the physical 

limitations for which the requested 

modifications are necessary. This report 

should be prepared by a physician who is a 

recognized authority in the appropriate 

medical specialty. Reports from physical or 

occupational therapists may also be helpful 

in determining the nature of the 

modifications required. 

(b) An itemization of all modifications 

proposed. Where substantial modifications 

are required, the detailed changes should be 

recommended by a medical or rehabilitation 

professional familiar with the needs of the 

disabled. 

(c) If the claimant lives in a rented or 

non-owned premise, a written statement from 

the landlord/owner must be obtained, 

approving and authorizing the specific plans 

and proposed modifications. 

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8. Housing Modifications. (Continued) 

(d) The CE reviews the itemized proposal 

and determines if the specified 

modifications are warranted. If the CE 

identifies technical issues regarding 

implementation, the CE develops the issue 

further to identify alternate solutions. 

b. Fees and Bids. 

(1) Reasonable fees may be paid for the medical 

or rehabilitation professional’s visit to the 

site, and for the preparation of the detailed 

report. The same applies to any architectural 

drawings that are required for significant 

structural changes. 

(2) No fee will be paid for attorneys or similar 

representatives engaged by the claimant to assist 

with the proposal. Any fee charged by an 

Approved Representative remains the claimant’s 

obligation. 

(3) Two or more bids must be obtained by the CE 

for the proposed changes from licensed and/or 

certified contractors. These bids must be for 

exactly the same modifications so that a true 

comparison of the competitive bids can be 

obtained. 

(a) If construction work is required, the 

bids obtained must be for binding estimates 

of the cost. No fees will be paid for the 

bids or estimates. 

(b) If special accessories or devices are 

required, the CE stipulates that the price 

quoted by the vendor includes any necessary 

installation. 

(4) The CE reviews the bids and selects the one 

which combines any acceptable alternative means 

of achieving the desired results with the lowest 

cost, unless there is a sound reason for a 

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8. Housing Modifications. (Continued) 

higher-cost alternative, such as increased 

durability. 

(5) Approval. If upon review of the evidence 

the CE approves the request, the CE writes a 

detailed letter decision to the claimant advising 

of the approval. 

(6) Notifying the BPA. Once the CE sends the 

letter of approval to the claimant, the CE 

prepares an email to the FO. In the email, the CE 

advises the FO of the approval, citing the 

homegrown code (e.g. HSMDF) for housing 

modifications and the amount approved. The 

fiscal officer communicates this approval to 

DEEOIC’s BPA. 

(7) Additional Information. If the CE 

determines that additional information is 

necessary, the CE sends a letter to the claimant 

requesting additional documentation that is 

necessary to continue with the review process. 

(8) Follow-up. If the claimant does not respond 

to the development letter, or if he or she fails 

to provide sufficient documentation to support 

the request, after considering all relevant 

evidence, the CE issues a detailed letter 

decision informing the claimant of the denial. 

The CE also informs DEEOIC’s BPA through the FO 

of this denial. 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. 

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8. Housing Modifications. (Continued) 

(10) Recommended Decision. If the claimant 

requests a recommended decision, the CE 

proceeds with a recommended decision. 

9. Health Facility Membership/Spa Membership. This 

section describes procedures to be followed when a claimant 

requests authorization for reimbursement of fees to join a 

commercial health club or spa. 

a. Authorization. Membership in a health club or 

exercise facility, or treatment at a spa, may be 

authorized when recommended by the treating physician 

as likely to treat the effects, cure or give relief 

from a covered illness. All requests for reimbursement 

of health facility and spa fees require prior 

authorization from the CE. 

In all cases where such membership is requested, the 

CE determines whether the membership is likely to be 

effective and cost-efficient. 

b. Payment. Whenever a request for payment of 

health club/spa membership is received, the CE obtains 

the following information: 

(1) Information from Physician. The CE obtains 

the following information from the treating 

physician: 

(a) A description of the specific therapy 

and or exercise routine needed to address 

the effects of the covered illness, 

including the frequency with which the 

exercises should be performed. 

(b) The anticipated duration of the 

recommended regimen (i.e. weeks, months, 

etc.). 

(c) An opinion as to the actual/anticipated 

effectiveness of the regimen, treatment, 

goals attained/sought, and frequency of 

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9. Health Facility Membership/Spa Membership. (Continued) 

examinations to assess the continuing need 

for the regimen. 

(d) A description/list of the specific 

equipment and or facilities needed to safely 

perform the regimen. 

(e) The nature and extent of supervision, 

if any, required for the safety of the 

claimant while performing the exercises. 

(f) An opinion stating whether exercise can 

be performed at home, as part of a home 

exercise program, or a recommendation as to 

what kind of public or commercial facility 

could provide the prescribed exercise 

routine. 

(2) Information from Claimant. In addition, the 

CE obtains the following information from the 

claimant: 

(a) The full name, address, and distance 

from the claimant’s home or work location, 

of any public facilities (no membership 

required) and those commercial facilities 

(membership required) able to accommodate 

the prescribed regimen. 

(b) If applicable, the specific reason(s) 

membership in a commercial health club/spa 

is required when public facilities are 

available, and or where the doctor indicates 

the regimen can be performed at home. 

(c) A signed statement from the health 

club/spa manager stating that the club/spa 

can fully provide the exercise regimen 

prescribed by the treating physician, and a 

breakdown of the fees and charges for 

various membership options and terms. The 

statement should describe all facilities, 

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9. Health Facility Membership/Spa Membership. (Continued) 

services, and special charges not included 

in the membership fee. 

c. Approval. 

(1) For all requests, if upon review of the 

evidence the CE approves the request, CE must 

write a letter to the claimant advising of the 

approval. The letter must include the following:

(a) The date the DO received the request. 

(b) The period of time which the approval 

will cover. 

(c) The amount approved (i.e. monthly or 

annual fee, etc.). 

(d) The type of membership approved. 

(e) Two copies of a blank OWCP-957 

 

(2) Notifying the BPA. Once the CE sends the 

letter of approval to the claimant, the CE 

prepares an email to the FO. In the email, the CE 

advises the FO of the specific services being 

approved, citing the homegrown code (i.e. GYMME) 

and the amount to be reimbursed. The FO 

communicates this approval to DEEOIC’s BPA. 

d. Additional Information. If the CE determines 

that additional information is necessary, the CE sends 

a letter to the claimant (with a copy to the treating 

physician) requesting additional documentation that is 

necessary to continue with the review process. In the 

letter, the CE provides 30 days for receipt of the 

requested information. 

e. Follow-up. If the claimant does not respond to 

the development letter, or if he or she fails to 

provide sufficient documentation to support the 

request, after considering all relevant evidence, the 

CE issues a detailed letter decision informing the 

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9. Health Facility Membership/Spa Membership. (Continued) 

claimant of the denial. The CE also informs DEEOIC’s 

BPA through the FO of this denial. The letterdecision 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. 

f. Recommended Decision. If the claimant 

requests a recommended decision, the CE 

proceeds with a recommended decision. 

g. Reimbursement Request. If a request for 

reimbursement of a health facility membership or spa 

membership, not previously approved, is submitted for 

payment to DEEOIC’s BPA, the DEEOIC’s BPA communicates 

this to the DO through the FO, and waits for approval 

from the CE. 

h. Period of Service. Health facility membership 

may be authorized for up to twelve months. 

Recertification is required for any period of time 

beyond twelve months. 

10. Medical Alert Systems. This section describes 

procedures to be followed when a claimant requests 

authorization for medical alert system. 

a. Definition. A Medical Alert system is an 

electronic device connected to a telephone line. In an 

emergency, the system can be activated by either 

pushing a small button on a pendant or pressing the 

help button on the console unit. When the device is 

activated, a person from the 24 hour central 

monitoring station answers the call, speaks to the 

claimant via the console unit, assesses the need for 

help, and takes appropriate action. A medical 

communication system qualifies as a Medical Alert 

system if it includes the following requirements: 

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10. Medical Alert Systems. (Continued) 

(1) An in-home medical communications 

transceiver; 

(2) A remote, portable activator (Personal 

Pendant, etc.); 

(3) A central monitoring station staffed by 

trained attendants 24 hours a day, seven days a 

week (optional). 

b. Authorization. All requests for medical alert 

systems require prior authorization from the CE. A 

request for a medical alert system must be documented 

with a letter of medical necessity from the treating 

physician, linked to the accepted condition, which 

includes a statement that the claimant has an acute or 

chronic condition which can require urgent or 

emergency care. 

(1) Period of Service. The CE may authorize the 

medical alert system for up to twelve months at a 

time. The need for such equipment should be 

recertified by the prescribing physician prior to 

the expiration of the authorization period. 

(2) Billing. Systems that require a one-time 

connection fee and monthly monitoring fee may be 

approved, based on the claimant’s needs and the 

medical justification. The equipment provided is 

leased and must be returned when no longer needed 

to avoid further charges. DEEOIC is not 

responsible for any additional charges incurred 

for failure to return equipment or failure to 

timely return the equipment in a timely manner. 

c. Approval. 

(1) For all requests, if upon review of the 

evidence the CE approves the request, the CE 

writes a letter to the claimant advising of the 

approval. The letter includes the following: 

(a) The date the DO received the request; 

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10. Medical Alert Systems. (Continued) 

(b) The period of time which the approval 

will cover; 

(c) The amount approved. 

(2) Notifying the BPA. Once the CE sends the 

letter of approval to the claimant, the CE 

prepares an email to the FO. In the email, the CE 

advises the FO of the approval, citing the HCPS 

code for a medical alert system and the amount 

approved. The fiscal officer communicates this 

approval to DEEOIC’s BPA. 

d. Additional Information. If the CE determines 

that additional information is necessary, the CE sends 

a letter to the claimant (with a copy to the treating 

physician) requesting specific documentation that is 

necessary to continue with the approval process. In 

the letter, the CE provides 30 days for receipt of the 

requested information. 

e. Follow-up. If the claimant does not respond to 

the development letter, or if he or she fails to 

provide sufficient medical documentation to support 

the request, the POC CE sends a detailed letter 

decision to the claimant. The CE also informs DEEOIC’s 

BPA through the FO of this denial. 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. 

f. Recommended Decision. If the claimant requests a 

recommended decision, the CE proceeds with a 

recommended decision. 

g. Reimbursement Request. If a request for 

reimbursement of a medical alert system not previously 

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10. Medical Alert Systems. (Continued) 

approved is submitted for payment to DEEOIC’s BPA, the 

DEEOIC BPA communicates this to the DO through the FO, and 

awaits approval from the CE.

11. Medical Expense Reimbursement for Extended Travel. 

This section describes procedures to be followed for 

authorizing medical travel requests over 200 miles round 

trip, and the process for approving claims for 

reimbursement, regardless of whether the claimant obtained 

prior approval for the trip. 

a. Travel Claims. All claims for travel 

reimbursement must be sent to DEEOIC’s BPA. Should 

the CE receive a reimbursement request directly from 

the claimant for an authorized trip, the CE forwards 

it immediately to DEEOIC’s BPA to begin the 

reimbursement process. In the event the CE receives a 

claim for travel reimbursement that was not approved 

in advance, the CE immediately forwards the claim to 

the DEEOIC’s BPA, and concurrently begins the process 

of approving or denying the trip. This ensures that 

all claims are adjudicated promptly and are properly 

recorded and tracked by DEEOIC’s BPA, throughout the 

reimbursement process. 

b. Authorization. DEEOIC requires pre-authorization 

for reimbursement of transportation, lodging, meals, 

and incidental expenses incurred when a claimant 

travels in excess of 200 miles round trip for medical 

care of an approved condition. DEEOIC’s BPA processes 

reimbursement claims for claimant travel without preauthorization when travel is less than 200 miles round 

trip.

c. Processing. DEEOIC’s BPA processes reimbursement 

claims in accordance with GSA travel guidelines. Per 

diem rates for overnight stay and mileage 

reimbursement rates are published on GSA’s website, 

and air fare reimbursement is based on actual ticket 

cost up to the amount of a refundable coach ticket (YClass airfare). 

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11. Medical Expense Reimbursement for Extended Travel. 

(Continued) 

d. Approval. Upon acceptance of a medical 

condition, the claimant receives a medical benefits 

package from the DEEOIC that includes instructions on 

how to submit a written request for prior approval of 

medical travel when such extended travel (over 200 

miles round trip) is required. Despite these 

instructions, it is not uncommon for claimants to 

submit their request for reimbursement after a trip 

has been completed, and without having obtained prior 

approval. 

e. Travel Exceeding 200 Miles. Medical expense 

reimbursement for travel exceeding 200 miles round 

trip must be authorized by the CE. Claims that are 

submitted to DEEOIC’s BPA, for reimbursement of travel 

expenses arising from medical travel in excess of 200 

miles roundtrip, will not be processed for payment 

unless authorization has been provided by the district 

office. 

(1) Requests. Upon receipt of a travel 

authorization request from the claimant, the 

claims examiner (CE) takes immediate action to 

ensure that the request meets one basic 

requirement: that the medical treatment or 

service is for the claimant’s approved medical 

condition(s). The medical provider’s enrollment 

in the DEEOIC program is not a prerequisite to 

approving medical travel if the claimant chooses 

to receive medical services from a non-enrolled 

provider. 

(2) Companion. If the travel request involves 

authorization for a companion to accompany the 

claimant, the claimant must provide medical 

justification from a physician. That 

justification must be in written form, relating 

the treatment to the accepted condition and 

rationalizing the need for the companion. If the 

doctor confirms that a companion is medically 

necessary, and provides satisfactory rationale, 

then the CE may approve companion travel. In the 

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11. Medical Expense Reimbursement for Extended Travel. 

(Continued) 

alternative, the CE can authorize the claimant to 

stay overnight in a hospital or medical facility, 

and can approve payment for a nurse or home 

health aide if a companion is not available. The 

CE must use discretion when authorizing such 

requests and may approve one of the above 

alternatives when there is a definite medical 

need, accompanied by written justification from 

the physician. 

(3) Mode of Travel. The claimant is allowed to 

specify his/her desired mode of travel. It is 

the CE’s role to authorize the desired mode of 

travel for the time period(s) requested. When a 

request is received from the claimant that does 

not identify the mode of transportation, the CE 

contacts the claimant by telephone and assists in 

determining the desired mode of travel. 

(Resource Center staff may be assist in this 

process.) 

f. Approval. Once the basic requirements for travel 

over 200 miles are met, as outlined above, the CE 

prepares and sends the claimant a travel authorization 

letter following the guidelines below. The CE may 

approve an individual trip, or any number of trips 

within a specified date range, all in one letter to 

the claimant. Once an initial authorization letter has 

been sent, future visits to the same doctor or 

facility may be approved by telephone, and confirmed 

by a follow-up letter. 

g. Authorization Letter. The authorization letter 

delineates the specifics of the trip being authorized, 

based upon the mode of travel the claimant has 

selected. In the travel authorization letter, the CE 

advises the claimant that travel costs are 

reimbursable only to the extent that the travel is 

related to obtaining medical treatment. In the letter 

CE also invites the claimant to contact the nearest 

Resource Center for assistance prior to or upon 

completing any trip and to complete Form OWCP-957, 

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11. Medical Expense Reimbursement for Extended Travel. 

(Continued) 

Request for Reimbursement, in accordance with the 

information and conditions as outlined in Exhibit 6. 

h. Adjudication. When adjudicating claims submitted 

after the trip has been completed, but for which prior 

approval was not obtained, the CE follows the same 

steps as for pre-authorized trips, to the point of 

sending an authorization package. At that point the CE 

sends only the authorization (or denial) letter to the 

claimant, not an entire authorization package. 

i. Denials. If a travel request is denied (either 

before or after a trip), the CE notifies the 

claimant in writing, detailing the reason(s) for 

the denial. The CE’s unit supervisor must 

provide sign-off for all denials of claimant 

travel before the denial letter is sent to the 

claimant. The following wording is included in 

the denial letter: “This is the final Program 

decision on your request for approval of travel 

expense reimbursement. 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.”

j. Recommended Decision. If the claimant requests a 

recommended decision, the CE proceeds with a 

recommended decision. 

k. Notifying the BPA. In conjunction with sending 

the claimant an approval or denial of a travel 

request, the CE conveys his/her decision to DEEOIC’s 

BPA via the office’s Fiscal Officer (FO), who is the 

point of contact with DEEOIC’s BPA for such issues. 

The CE prepares an email to the FO, who in turn 

generates an electronic thread to the BPA. In the 

email the CE provides the information specified below. 

The CE must also enter this information into the case 

notes field of ECMS (Select the note type of “T” for 

Travel Authorization): 

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11. Medical Expense Reimbursement for Extended Travel. 

(Continued) 

(1) Approved dates for a single trip or in the 

alternative, a date range and number of trips 

authorized within that time frame. 

(2) Approved mode of transportation 

(3) Starting point and destination, e.g., 

claimant address and provider address (city & 

state at a minimum). 

(4) Authorization for rental car reimbursement, 

if appropriate. 

(5) Companion travel if approved. 

l. Approval Package. The approval package must 

include the following: 

(1) Two copies of the detailed 

authorization letter. 

(2) Two copies of a blank OWCP-957. 

(3) A prepaid express mail envelope, 

addressed to DEEOIC’s BPA, for the 

claimant’s use. 

m. Prompt Pay. DEEOIC’s BPA promptly pays any 

approved claims directly to the claimant, not to any 

other party. However, if the claimant completes the 

form in error or neglects to submit the proper 

information, DEEOIC’s BPA attempts to resolve the 

issue by accessing the authorization letter or the 

pre-approval notification (thread) from the FO. If 

DEEOIC’s BPA is unable to issue payment based on 

information provided in one of these two sources, 

DEEOIC’s BPA contacts the FO, requesting clarification 

and/or assistance. 

n. DO Review. The FO and responsible CE take 

immediate action to review the claim as submitted, 

contact the claimant when appropriate, make a 

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11. Medical Expense Reimbursement for Extended Travel. 

(Continued) 

determination as to the correct amount of 

reimbursement or denial, and send an authorization 

notification or correction (electronic thread) back to 

DEEOIC’s BPA. 

o. District office CEs and FOs responsible for 

travel authorization processing must keep management 

apprised of issues impacting prompt and accurate 

processing of travel authorizations and 

reimbursements. Claims staff should be especially 

vigilant to identify any real or perceived problems 

with the processing interfaces between and among the 

district office, the Resource Center and DEEOIC’s BPA. 

Problems must be elevated (reported via email) 

immediately to the National Office to the attention of 

the Branch Chief for Policy, with a copy of the 

notification to the Branch Chief for the Branch of ADP 

Systems (responsible for oversight of DEEOIC’s BPA). 

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SAMPLE INITIAL MEDICAL DEVELOPMENT LETTER 

Date: 

Claimant Name (or auth rep) File Number 

Street Address Accepted Conditions 

City, State, Zip 

Dear Claimant Name: 

I am writing to you concerning your benefits under the 

Energy Employees Occupational Illness Compensation Program 

Act (EEOICPA). We have received a request to provide you 

with in-home medical care. In order to properly evaluate 

and respond to this request, we need additional medical 

evidence. 

Please have your treating physician prepare a written 

narrative report, providing our office with detailed 

information describing findings upon physical examination, 

your medical needs, the specific level of in-home nursing 

care required, the time period for which services are 

requested and a description of the specific services that 

the home health care provider is expected to provide. 

Additionally, the physician should provide medical 

rationale for the recommended care, relating the requested 

services to the accepted medical condition(s) listed above. 

The following is an example of a narrative describing the 

type of care required: For the medical condition of (fill 

in the blank), the claimant requires the care of an RN or 

LPN, three times weekly to administer and/or monitor 

medications and medical equipment, and to assist in 

respiration therapy for the next 3 months. The claimant 

also requires the daily services of a home health aide 

during waking hours (total of 16 hours per day) to assist 

in ambulating, dressing, bathing and trips to the toilet. 

This service is required for the next 3 months, at which 

time the claimant’s physical condition will be reevaluated. 

By copy of this letter, your physician is requested to 

contact this office immediately if there are any problems 

with our request. If you (or your physician) already have 

the name of an in-home medical services provider you wish 

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to have perform the initial assessment, please provide me 

with that information. 

In the interest of expediting the request for care, by 

copy of this letter your physician is requested to 

please fax and mail a response to my office within 30 

days, or contact me sooner if there are questions 

regarding this request. 

If for any reason you are not requesting in-home health 

care, please advise me immediately in writing. 

Thank you for your assistance. Please contact me at 

the number listed below if you have additional 

questions or concerns. 

Sincerely, 

(Insert PoC CE Name and Signature) 

Insert PoC CE telephone & fax numbers

Cc: (Physician’s name and address) 

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SAMPLE FOLLOW-UP DEVELOPMENT LETTER 

Date: 

Claimant Name (or auth rep) File Number 

Street Address Accepted Conditions 

City, State, ZIP

Dear Claimant Name: 

This letter affects medical benefits you have requested and 

requires your immediate attention and response. 

We have received a request to provide you (or the claimant 

that you represent) with in-home medical care for the 

accepted condition(s) shown above, arising out of your 

claim with the Energy Employees Occupational Illness 

Compensation Program (EEOICP), administered by the Division 

of Energy Employees Occupational Illness Compensation 

(DEEOIC). We are currently evaluating this request. In a 

letter dated (date of first letter) we requested additional 

medical information. As of this date, we have not received 

a response. 

Without the additional information your request for home 

health care may be denied. It is imperative that we receive 

a response from your doctor. We need an updated 

verification of the type and level of in-home care that you 

require, and verification that this care is for the 

accepted condition(s) that have been approved for benefits 

through the EEOICP. 

Please contact your treating physician’s office 

immediately, and ask your doctor to provide us with this 

information. Extra copies of our previous letter 

concerning this matter are attached for your use. This 

information must be received within 30 days or the request 

for in-home health care may be denied. If you are unable 

to contact your doctor, and/or if you have questions 

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regarding this verification process, you may call me at the 

telephone number listed below. 

Sincerely, 

(Insert PoC CE Name, Signature and Telephone Number) 

Enclosure 

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SAMPLE AUTHORIZATION LETTER 

Date: 

Claimant Name (or auth rep) 

Street Address 

City, State, ZIP 

 Re: Claim Number (Insert Claim Number)

Dear(Insert Claimant or Auth Rep Name): 

This letter is in reference to your claim for compensation 

under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA). 

The Division of Energy Employees Occupational Illness 

Compensation (DEEOIC) recently received a request for 

authorization of in-home medical care for the following 

covered medical conditions: 

Pulmonary Fibrosis 

Silicosis 

Chronic Obstructive Pulmonary Disease (COPD) 

After a thorough review of your case file including 

communication with your treating physician [if applicable] 

the following authorization is granted for the period of 

December 4, 2006 through June 4, 2007: 

 Registered Nurse [Billing Codes T1030 (per diem) 

and S9123 (hourly)] to administer medication and 

conduct physical evaluation 1 hour per day, every 5 

days. 

 Home Health Aid or equivalent [Billing Codes 

S5126 (per diem) and S9122 (hourly)], 16 hours per 

day, seven days per week, to assist with ambulating, 

bathing, general personal hygiene, food preparation 

and feeding, and oxygen canister replacement. 

You are free to select any licensed provider willing to 

perform the authorized services; however, the DEEOIC 

requires that the provider be enrolled in our medical bill 

payment system. Providers may call toll free 1-866-272-

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2682 for program enrollment information or for answers to 

payment questions. If you have any questions or concerns 

regarding this authorization please call your claims 

examiner at (XXX) XXX-XXXX. 

Sincerely, 

(Insert PoC CE Name) 

DEEOIC Claims Examiner 

cc: Provider 

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Billing Codes

T1001: Nursing Assessment in-home Initial Evaluation: 

A physician’s written report and a Claims Examiner’s 

prior authorization is required before the in-home 

assessment is conducted. Typically only one (1) inhome initial evaluation is authorized for a claimant. 

Once an authorization is approved by the DEEOIC, an 

assessment can be performed. 

 

T1017: Targeted Case Management Per Unit (15 minutes 

= 1 Unit): This service requires prior authorization 

from the DEEOIC Claims Examiner for a Registered Nurse 

to perform targeted case management. This is limited 

to the clinical impact of a claimant’s accepted workrelated condition on his/her current medical status. 

The skill level of a Registered Nurse is required for 

this targeted case management activity. The Claims 

Examiner’s authorization will specify the number of 

hours authorized for a case management visit. Each 

unit of a T1017 code is equal to 15 minutes; 

therefore, if a nurse case manager is at the 

claimant’s home for an assessment for one hour, the 

proper number of units to bill for this T1017 code is 

4 units. 

 

T1019: Personal Care Services (PCA) Per Unit (15 

Minutes = 1 Unit): This service requires prior 

authorization from the Claims Examiner. Attendant 

services are non-skilled services routinely provided 

in an in-home setting. These services assist 

claimants with activities of daily living (i.e. 

bathing, feeding, dressing, etc). Attendant services 

must be provided by a home health aide, licensed 

practical nurse, or similarly trained individual. A 

family member who is also a trained personal care 

attendant can only be approved for up to 12 hours of 

care per day. 

An attendant can only be approved for care if there is 

sufficient medical rationale from a physician 

stipulating the specific need for personal care 

services related to the accepted work related 

condition that requires an attendant. 

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Each unit of a T1019 code is equal to 15 minutes; 

therefore, if an attendant provides services for one 

hour, the proper number of units to bill for this 

T1019 code is 4 units. 

T1020: Personal Care Services (PCA) Per Diem (8 hrs): 

This service requires prior authorization from the 

DEEOIC Claims Examiner. Attendant services are nonskilled services routinely provided in an in-home 

setting. These services assist claimants with 

activities of daily living (i.e. bathing, feeding, 

dressing, etc). Attendant services must be provided 

by a home health aide, licensed practical nurse, or 

similarly trained individual. A family member who is 

also a trained personal care attendant can only be 

approved for up to 12 hours of care per day. 

An attendant can only be approved for care if there is 

sufficient medical rationale from a physician 

stipulating the specific need for personal care 

services related to the accepted work related 

condition that requires an attendant. 

12-hour care: For personal care services approved 

for 12 hour care, the bill must be submitted with 

one unit of a T1020 code, which covers the 8-hour 

period of provided services, and 16 units T1019 

which cover the 4-hour period of provided services. 

Under no circumstance should a per diem code be used 

for less than 8 hours of care. 

T1030: Nursing Care, in-home, by Registered Nurse 

(RN), Per Diem (8 Hour Shift): This service requires 

prior authorization from the DEEIOC Claims Examiner 

for a Registered Nurse to perform in home health care 

(per 8 hour shift). An RN can only be approved for 

ongoing care if there is sufficient medical rationale 

from a physician stipulating the specific medical 

services related to the accepted work-related 

condition that require an RN for an 8 hour shift(s). 

24-hour care: If this code is approved for 24 hour 

care, the bill must be submitted with 3 units of a 

T1030 code which covers the 24 hour period of 

provided services, regardless of the number of RNs 

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assigned. For example, if two nurses are utilized 

for two 12 hour shifts, the bill must reflect three 

units of the authorized T1030 code. Under no 

circumstances should a per diem code be used for 

less than 8 hours of care. 

T1031: Nursing Care, in-home, by Licensed Practical 

Nurse (LPN) Per Diem (8 Hour Shifts): This service 

requires prior authorization from the DEEOIC Claims 

Examiner for a Licensed Practical Nurse to perform inhome health care (per 8 hour shift). An LPN can only 

be approved for ongoing care if there is sufficient 

medical rationale from a physician stipulating the 

specific medical services related to the accepted 

work-related condition that require an LPN for an 8 

hour shift(s). 

24-hour care: If this CPT code is approved for 24 

hour care, the bill must be submitted with 3 units 

of a T1031 code which covers the 24 hour period of 

provided services, regardless of the number of LPNs 

assigned. For example, if two nurses are utilized 

for two 12 hour shifts, the bill must reflect three 

units of the authorized T1031 code. Under no 

circumstances should a per diem code be used for 

less than 8 hours of care. 

S5126: Attendant: Home Health Aide (HHA), Certified 

Nurse Assistant (CNA), Per Diem (8 Hour Shift): This 

service requires prior authorization from the DEEIOC 

Claims Examiner. A HHA/CNA can only be authorized for 

care if there is sufficient medical rationale from a 

physician documenting the medical necessity of the 

service for the accepted work-related condition. If a 

HHA/CNA is authorized and a RN/LPN is utilized, bills 

should be submitted with the S5126 code. 

24-hour care: If this CPT code is approved for 24 

hour care and the care is provided, the bill must be 

submitted for 3 units which cover the 24 hour period 

of provided services, regardless of the number of 

HHA/CNAs assigned. For example, if two HHA/CNAs are 

utilized for two 12 hour shifts, the service 

provided still covers the authorized three 8 hour 

shifts and the bill should reflect 3 units of the 

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authorized S5126 code. Under no circumstances should 

a per diem code be used for less than 8 hours of 

care. 

S9122: Home Health Aide (HHA) or Certified Nurse 

Assistant (CNA) Hourly Code (less than 8 hour care): 

This service requires prior authorization from the 

DEEOIC Claims Examiner for a HHA or CNA to perform in 

home health care (per hour code only). A HHA or CNA 

can be approved if there is sufficient medical 

rationale from a physician stipulating the specific 

medical services related to the accepted work-related 

condition that requires a HHA or CNA. 

S9123: Nursing Care in-home Registered Nurse (RN) 

Hourly Code (less than 8 hour care): This service 

requires prior authorization from the DEEOIC Claims 

Examiner for a RN to perform in home care (per hour 

code only). A RN can only be approved for ongoing 

care if there is sufficient medical rationale from a 

physician stipulating the specific medical services 

related to the accepted work-related condition that 

requires a RN. 

S9124: Nursing Care in-home License Practical Nurse 

(LPN) Hourly Rate (less than 8 hour care): This 

service requires prior authorization from the Claims 

Examiner for a LPN to perform in home care (per hour 

code only). A LPN can only be approved for ongoing 

care if there is sufficient medical rationale from a 

physician stipulating the specific medical services 

related to the accepted work-related condition that 

requires a LPN. 

S9126: Hospice Care, in the home, Per Diem (8 Hour 

Shifts): This service requires prior authorization 

from the DEEOIC Claims Examiner. Hospice care is 

generally requested and authorized when an employee is 

determined to be terminally ill. Once approved, 

hospice is responsible for assessing the claimant’s 

needs and providing all levels of care to maintain the 

comfort of the claimant.

 

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SAMPLE RECOMMENDED DECISION TO DENY HOME HEALTH CARE 

EMPLOYEE: John Doe 

FILE NUMBER: 123-00-4567 

NOTICE OF RECOMMENDED DECISION 

(MEDICAL BENEFITS ONLY) 

This is the Recommended Decision of the [applicable 

district office] District Office regarding the request for 

in-home medical services filed by you under the Energy 

Employees Occupational Illness Compensation Program Act

(EEOICPA or the Act). The [appropriate] District Office 

recommends the request be denied for the reasons set forth 

below. 

STATEMENT OF THE CASE 

You filed a claim on (Insert Date), seeking benefits under 

the Act. On (Insert Date) the Final Adjudication Branch 

issued a final decision accepting the claim and awarding 

medical benefits for the condition of lung cancer. 

On (Insert Date) the (appropriate) District Office received 

a request for in-home skilled nursing care. The level of 

care and/or type of service to be provided was specified in 

a (Plan of Care or doctor’s letter – fill in the blank), 

dated (Insert Date). 

Upon review and consideration of the request for in-home 

skilled nursing services it was determined that there is 

insufficient medical evidence to support that the nursing 

care services are required for the treatment of your 

accepted conditions. [This paragraph is only to be used if 

that is the reason for the denial. Other reasons may 

include that the weight of medical evidence is with the DMC 

or second opinion, lack of any medical evidence. The 

decision should specifically discuss the medical evidence 

in the case file related to the issue.] On (Insert 

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Date) the district office claims examiner (CE) sent a 

letter to you with a copy to your physician, requesting 

detailed information regarding the type and level of care 

required for the accepted condition(s). Your doctor did 

not respond to this letter. On (Insert Date), the CE called 

Dr. (Insert Name)’s office to confirm that he received the 

(Insert Date) letter, and the CE questioned the doctor 

regarding the level of care you required. By follow-up 

letter dated (Insert Date) you were requested to provide 

the needed medical evidence. As of this date, we have not 

received medical evidence sufficient to establish that the 

request for in-home health care services is required as a 

result of your accepted condition under the EEOICPA. 

FINDINGS OF FACT 

1. You filed a claim under the EEOICPA on (Insert 

Date). 

2. On (Insert Date), the FAB issued a decision 

awarding you compensation in the amount of (Fill in 

amount) and medical benefits for the treatment of your 

[accepted condition]. 

3. On (Insert Date), the district office received a 

request for in-home medical care. 

CONCLUSIONS OF LAW 

You do qualify as an “individual with cancer” [if 

applicable] as defined in 42 U.S.C. § 7384l (9) (B) (or 

Insert Appropriate Illness and Statutory Citation.) 

42 U.S.C. § 7384t states that The United States shall 

furnish, to an individual receiving medical benefits under 

this section for an illness, the services, appliances, and 

supplies prescribed or recommended by a qualified physician 

for that illness which the President considers likely to 

cure, give relief, or reduce the degree or the period of 

the illness; 

and 

20 CFR Part 30 § 30.403 states that OWCP will authorize 

payment for personal care services under section 7384t of 

the Act, whether or not such care includes medical 

services, as long as the personal care services have been 

determined to be medically necessary and are provided by a 

home health aide, licensed practical nurse, or similarly 

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trained individual. The Office of Workers Compensation 

Programs (OWCP) will make the determination if personal 

care services are or are not medically necessary. 

Sufficient medical evidence, necessary to make a 

determination as to the type of services and/or the level 

of care to be provided, has not been forthcoming from your 

treating doctor. Without this medical evidence, your 

request for in-home medical care cannot be granted. 

Therefore, the claim for in-home medical services is 

denied. 

 

{Note: Depending upon the circumstances, the language in 

this sample decision can be modified for use in reducing or 

limiting services currently being provided, or in denying 

new requests for in-home care. The usual cover letter for 

recommended denials should be used, which outlines the 

claimant’s rights following such a decision.) 

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Prepared by: 

_____________________ _____________ 

(Name) Date 

Claims Examiner 

Reviewed and Certified by: 

______________________ _____________ 

(Name) Date 

Senior Claims Examiner

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[Sample Travel Authorization Letter]

Date: 

Claimant Name(or auth rep) 

Street Address 

City, State, Zip 

Dear Claimant Name(or auth rep): 

This letter is in reference to your request for medical 

travel authorization under the Energy Employees 

Occupational Illness Compensation Program Act. You (or you 

and your companion) are authorized to travel for medical 

treatment with (Insert name of doctor or medical facility) 

in (City / State). Outlined below are the itemized travel 

allowances approved for your trip: 

• Dates of Trip: (Insert authorized travel dates)

[Or in the alternative] 

• Multiple Trips Authorized (Insert Authorized 

travel date range)

• Trip Origin & Destination: (Insert starting 

City/State and ending points) 

• Authorized mode of travel (Insert approved 

mode: auto, air, etc.) 

• Meals & Incidental Expenses (M&IE) See below. 

• Lodging (single or double occupancy) See 

below.

• Airfare allowance See below. 

• Mileage allowance for personal vehicle (Insert 

appropriate mileage rate or N/A)

• Companion approved to travel: (Insert name of 

companion or N/A] 

• Rental car reimbursement Indicate “YES” or N/A]

Companion Travel: If you have been authorized a companion 

to accompany you on this trip, you will be reimbursed at 

twice the daily M&IE rate and lodging will be based upon 

double-occupancy, unless otherwise approved. If travel is 

by commercial airline, then the companion airfare will be 

reimbursed as well. The expenses for your companion will 

be paid to you; not to the companion or any other party. 

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Travel Changes: We understand your travel may not happen 

as originally planned. If you encounter a change in your 

travel plans (such as an extended stay) that may result in 

additional expenses, please contact me or the DEEOIC 

Resource Center identified below at your earliest 

convenience to let us know the specific changes. We will 

be glad to assist you with any adjustments to your 

authorization so you won’t encounter any delays in your 

reimbursement. 

How to File for Travel Reimbursement: Reimbursement 

requests must be submitted using the enclosed Form OWCP957. Only travel costs that are directly related to 

obtaining medical treatment for your accepted condition(s) 

will be reimbursed. Receipts are required for all lodging, 

airfare, rental car (if authorized), and gasoline purchases 

(for approved rental car only). Any other expenses under 

$75.00 do not require receipts. The OWCP-957 form includes 

an instruction sheet; however, I would like to provide you 

with some additional information to help you with your 

reimbursement request: 

M&IE: Itemization of expenses and submission of 

receipts is not required for meals and incidental 

expenses (MIE). The MIE expenses are reimbursed as a 

fixed-rate, daily allowance, regardless of what you 

actually spend, and are determined by the Government 

Services Administration (GSA) published rate for the 

geographic location of your stay on any given day. 

By GSA rule, reimbursement for the first and last days 

of travel is 75% of the daily fixed-rate for MIE.

Lodging: Daily lodging rates are also based on 

applicable GSA rates for the location of your stay and 

may change due to seasonal fluctuations so be sure to 

check the current rates. State and local lodging 

taxes are not included in the daily lodging rate and 

will be reimbursed separately. All receipts must be 

submitted. 

Rental Car: When a rental car has been approved, 

reimbursement will be based upon an economy-sized 

vehicle, unless otherwise approved. Gasoline 

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purchases for the rental car are reimbursable. All 

receipts must be submitted. 

Airfare: Airfare reimbursement will be based upon the 

actual cost incurred, but not to exceed the cost of a 

refundable coach or economy class fare (Y-Class 

airfare). All receipts must be submitted. 

GSA Rates: The daily allowances for MIE and lodging 

are determined by GSA, for specific cities and 

geographic areas around the country, and they vary by 

region. These rates are revised occasionally by GSA. 

For more information on these GSA-published rates, 

please visit the GSA Website at: www.gsa.gov ; or 

contact your nearest resource center for assistance. 

Where to Send Your Reimbursement Forms: Send a copy of 

this authorization letter, along with your itemized Form 

OWCP-957, along with any required receipts, to our bill 

processing agent. For your convenience, I have enclosed a 

pre-paid envelope and an extra copy of this authorization 

letter. Please send your information to: 

(Insert Name and Address of the DEEOIC Bill Processing 

Agent)

Where to go for Help: For assistance in completing your 

travel reimbursement form, or in determining applicable MIE 

and lodging rates, or if you need other assistance related 

to this travel authorization or reimbursement process, 

please contact your nearest DEEOIC Resource Center, or call 

me. Below is the address of your nearest Resource Center. 

Insert complete RC address 

Telephone Number 

Additional information and forms are also available on our 

website at: http://www.dol.gov/esa/.Please have a safe trip 

and let me know if you have any other concerns that are not 

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addressed in this letter. I can be reached, toll free, at: 

(Insert toll free number). 

Sincerely, 

John Doe 

Claims Examiner 

Enc: OWCP-957 (2 blank forms) 

Prepaid envelope addressed to bill processing agent 

Copy of Authorization Letter (2 copies) 

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