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U.S. Department of Labor Office of Workers’ Compensation Programs

Division of Energy Employees Occupational

Illness Compensation 

Washington, DC 20210 

RELEASE – TRANSMISSION OF FEDERAL (EEOICPA) PROCEDURE MANUAL 

VERSION 4.3: 

EEOICPA TRANSMITTAL NO. 20-04 September 14, 2020 

EXPLANATION OF MATERIAL TRANSMITTED:

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is issuing this 

transmittal to notify staff of the publication of Federal (EEOICPA) Procedure Manual (PM)

Version 4.3 (v4.3) which replaces v4.2, effective the date of publication of this transmittal.

Following are the content edits that make up PM v4.3: 

• Chapter 2 – The EEOICPA

o Ch. 2.6 has been updated to reflect the current distribution method for initial case

assignments. The language in v4.2 previously read:

6. Jurisdiction. This paragraph describes the jurisdiction of the four DEEOIC

DOs. The DO that handles a claim is determined by where the employee last worked as a

covered employee. A DO acquires jurisdiction if the last covered facility is/was located

within the geographical area it serves.

a. Survivor Claims. This rule applies to claims from survivors as well as

those brought by the employee.

b. Uranium Workers. All claims for uranium workers (or their survivors)

who may have been awarded benefits under Section 4 or 5 of RECA are

within the jurisdiction of the Denver DO.

It has been updated in v4.3 to: 

6. Jurisdiction. Employee and survivor claims filed with the DEEOIC are assigned

to a CE within one of the four district offices on a rotational basis to maintain an equal

distribution of work, relative to the experience level of the CE.

o Exhibit 2-1, Jurisdictional Map, that was previously included in v4.2, has been

removed from v4.3, as this exhibit was outdated. As such, the remaining exhibits of

Chapter 2 has been renumbered accordingly.
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• Chapter 6 – Processing Mail

o Ch. 6.7i has been updated to remove all references to the Regional Director and to 

communicate a uniform procedure for reporting PII violations. The language in v4.2 

previously read:

i. Improper Release of Protected PII. If protected PII is improperly release to 

an incorrect individual, or documentation sent to the correct individual 

contains protected PII of another individual that was not redacted, DEEOIC 

staff must:

(1) Contact the individual via telephone and registered mail to request the 

return of the document. The DEEOIC staff member provides a selfaddressed, stamped envelope for the return of the material directly to 

the DEEOIC;

(2) Immediately notify Appropriate Management (DD, FAB Manager or

FAB Branch Chief) who in turn notifies the Regional Director or NO, 

who complies with established departmental reporting requirements, 

documenting the type of PII disclosure, the circumstances surrounding 

the disclosure, how it was discovered, the appropriate actions taken to 

recover the document in question, and the disposition of the recovery 

effort; and

(3) Track each PII recapture request within the Regional or FAB Office.

(a) If the recapture of the PII documentation is successful, the 

incident becomes closed with the incident record filed and 

maintained in OWCP.

(b) If the third party in possession of the improperly released 

documentation refuses to return it, the DEEOIC staff member 

reports the situation through the appropriate management, 

through the Regional Director (except FAB), to the NO, who 

will provide guidance.

It has been updated in v4.3 to:

i. Improper Release of Protected PII. If protected PII is improperly released to 

an incorrect individual, or documentation sent to the correct individual 

contains protected PII of another individual that was not redacted, DEEOIC 

staff must notify their supervisor who will follow the standard department 

protocols for reporting PII violations.
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o Exhibit 6-1, OIS Subjects and Categories, that was previously included in v4.2, has 

been removed from v4.3, as this Exhibit was outdated. As such, the remaining 

exhibits of Chapter 6 have been renumbered accordingly.

• Chapter 7 – Case Creation

o Ch. 7.4 has been updated to remove references to claims assignments based on 

jurisdictional locations. The language in v4.2 previously read:

4. Assignment of Claims to a DO. The assignment of a claim to a particular DO 

occurs based on the state where the employee’s most recent location of covered 

employment occurred, as listed on Form EE-3. Each DO is responsible for claims 

originating from a state for which it has jurisdictional responsibility. Information 

regarding DO jurisdictional boundaries is located on the DEEOIC main webpage. If the 

claimant does not submit a Form EE-3 with his claim, the CCC uses the claimant’s state 

of residence to make a DO assignment. Each DO is to provide the CCC with an up to 

date case create digit assignment list so that upon creation, the CCC directs the claim to 

appropriate CE. When CE digit assignments change, the DD or a designee is to email 

the updated list to zzOWCP-DEEOIC-Centralized Case Create Group.

It has been updated in v4.3 to:

4. Assignment of Claims to a DO. The assignment of a claim to a particular DO 

occurs on a rotational basis to maintain an equal distribution of work, relative to the 

experience level of the CE. 

o Ch. 7.7a has been updated to remove reference to the Resource Center (RC) verifying 

employment using ORISE, as this function is now performed by the assigned district 

office Claims Examiner (CE). The language in v4.2 previously read:

a. Consideration of Employment. In addition to considering the claimed medical 

condition(s), claimed employment is also considered. Part B of the EEOICPA 

covers employees of the DOE, its contractors and subcontractors, beryllium 

vendors, AWEs and eligible survivors. Part E offers benefits to DOE contractors, 

subcontractors and their eligible survivors. 

For claims filed at the RC, the RC verifies employment through the Oak Ridge 

Institute for Science and Education (ORISE) and/or clarifies the nature of 

claimed employment.

It has been updated in v4.3 to: 

a. Consideration of Employment. In addition to considering the claimed medical 

condition(s), claimed employment is also considered. Part B of the EEOICPA 

covers employees of the DOE, its contractors and subcontractors, beryllium 
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vendors, AWEs and eligible survivors. Part E offers benefits to DOE contractors, 

subcontractors and their eligible survivors. 

Upon receipt of a claim filed at the RC, the District Office CE will perform all 

necessary actions to verify claimed employment, including review of the Oak 

Ridge Institute for Science and Education (ORISE) database information.

• Chapter 9 – Transfers and Loans

o Ch. 9.3c has been updated to remove language related to case transfers based on the 

last place of covered employment. The language in v4.2 previously read:

c. DOs may transfer case files to other jurisdictions permanently, based upon the 

employee’s last verified covered employment. Alternatively, management 

decisions may lead to changes in case allocations amongst the district or FAB 

offices.

It has been updated in v4.3 to: 

c. DOs may transfer case files to other jurisdictions permanently, based on 

management decisions regarding case allocations amongst the district or FAB 

offices. 

• Chapter 10 – Resource Centers

o Chapter 10 has been replaced in its entirety to update the functions of the Resource 

Center and their role in occupational history development.

o Exhibit 10-1, Occupational History Interview, has been updated.

o Exhibit 10-2, RECA Occupational History Interview, that was previously included in 

v4.2, has been removed from v4.3, as this Exhibit was outdated.

o Accordingly, what was Exhibit 10-3, Interview Confirmation Letter, in v4.2, has been 

updated and renumbered as Exhibit 10-2 in v4.3. 

• Chapter 11 – Initial Development

o Ch. 11.9 has been added to include a description of the Correspondence Creation and 

Tracking System (CCAT) and an overview of the forms and letters contained therein. 

The new section contained in v4.3 reads:

9. Correspondence Creation and Tracking System (CCAT.) CCAT is an internal 

form and correspondence generator within ECS that is used to generate certain 

standardized forms and correspondence letters. The system populates various fields with 

information already contained within ECS, such as names and addresses, while allowing 
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the user to input other claim-specific information. In addition, CCAT also contains 

samples of these forms and letters.

a. Below, in alphabetical order, are the forms and letters currently available 

in CCAT:

(1) Alternative Filing Acknowledgement Letter

(2) AR Acknowledgement Letter

(3) Change of Address Acknowledgement Letter

(4) Claim Acknowledgement Letter

(5) DEEOIC Case Transfer Sheet

(6) DME Authorization Letter

(7) EE-8 and EN-8 Smoking History Questionnaire

(8) EE-9 and EN-9 Race/Ethnicity Questionnaire

(9) EE-10 and EN-10 Claim for Additional Wage-Loss and/or 

Impairment Benefits under the EEOICPA

(10) EE-11A and EN-11A Form (Impairment)

(11) EE-16 and EN-16 Form

(12) Hearing Request Acknowledgement Letter

(13) Hearing Transcript Letter

(14) HHC Authorization Letter

(15) Home Hospice Authorization Letter

(16) Letter to DOJ for RECA Award Confirmation
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(17) Lump Sum Payment Acknowledgement Letter

(18) Medical Travel Reimbursement Authorization Letter

(19) Not Claiming Impairment and/or Wage-Loss Letter

(20) Physician Letter

(21) Rehabilitative Service Authorization Letter

(22) Residential Care Facility Authorization Letter

(23) Review of Written Record Acknowledgement Letter

(24) Untimely Hearing Request Letter

o In conjunction with the above change, the following exhibits that were previously 

included in v4.2 and are now available through CCAT, have been removed from v4.3, 

and the remaining exhibits of the affected chapters have been renumbered 

accordingly:

 Exhibit 7-1: Sample Acknowledgement Letter 

 Exhibit 12-3: Notification to Representative 

 Exhibit 19-1: Letter to DOJ for RECA Award Confirmation 

 Exhibit 19-2: Alternate Letter to DOJ for RECA Award Confirmation 

 Exhibit 20-2: Sample Alternative Filing Letter

 Exhibit 21-2: Not Claiming Impairment Letter 

 Exhibit 22-2: Not Claiming Wage-Loss Letter

 Exhibit 25-1: Sample Acknowledgment Letter, Review of Witten Record 

 Exhibit 25-2: Sample Acknowledgement Letter, Hearing

 Exhibit 29-3: Sample Ancillary Medical Services Authorization Letter 

 Exhibit 29-4: Sample Authorization Letter

 Exhibit 29-7: Sample Travel Authorization Letter 

• Chapter 14 – Establishing Special Exposure Cohort Status

o Chapter 14.6 has been updated to reflect additional guidance for calculating workday 

requirements in instances where evidence supports an onsite presence at a designated 

Special Exposure Cohort (SEC) facility for 24 hours. The language in v4.2 

previously read:
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6. Workday Requirement. Eligibility under the SEC provision typically requires 250 

workdays of eligible employment at one or more SEC worksites. 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, and 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 (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 workdays 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 worksite 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 worksite. There may be breaks in employment, but 

the workdays may only be accumulated at eligible SEC worksites.

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 be 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) 

e. Where records of an employee’s earnings are available, such as a 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 
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earned at the SEC worksite 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 NO Policy Unit may be required.

It has been updated in v4.3 to:

6. Workday Requirement. Eligibility under the SEC provision typically requires 250 

workdays of eligible employment at one or more SEC worksites. 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, and 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 (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.

(1) If evidence exists establishing an employee’s onsite presence at a 

designated SEC facility for 24 hours, including time spent working 

or living at the facility, the employee will be credited for 3 work 

shifts (i.e. 3 workdays) towards the 250-work day requirement. In 

such instances, the 250-work day requirement will be satisfied if 

the evidence establishes the employee’s onsite residential presence 

at a designated SEC facility for 83 days, which a CE may consider 

as the equivalent of 250 workdays.

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

holidays, 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 worksite 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 worksite. There may be breaks in employment, but 

the workdays may only be accumulated at eligible SEC worksites.
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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 be 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

24 hours per day of residential onsite presence for 83 days

One month = 21 days (if evidence indicates six-day weeks, 25 days) 

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 worksite 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 NO Policy Unit may be required.

o Exhibit 14-1, List of SEC Designated Classes, has been updated to include the 

following EEOICPA Circulars:

 Circular 20-01: West Valley Demonstration Project SEC (01/01/69 – 12/31/73)

 Circular 20-02: Y-12 Plant SEC (01/01/77 – 07/31/79)

o Exhibit 14-2, SEC Class Screening Worksheet, which was previously included in 

v4.2, has been removed from v4.3. As such, the remaining exhibits of Chapter 14 

have been renumbered accordingly.
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• Chapter 15 – Establishing Toxic Substance Exposure and Causation

o Exhibit 15-4: Exposure and Causation Presumptions with Development Guidance for 

Certain Conditions, has been updated. 

 Exhibit 15-4.1b, regarding Angiosarcoma, has been amended. The language in 

v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to polyvinyl chloride for at 

least 250 aggregate work days. This can be determined by an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant polyvinyl chloride 

exposure. This can be determined by an IH assessment. 

 Exhibit 15-4.4b, regarding Asbestosis, has been amended. The language in v4.2 

previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to asbestos for at least 250 

aggregate work days. This can be determined by existing asbestos exposure 

presumptions or an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant asbestos exposure. This 

can be determined by existing asbestos exposure presumptions or an IH 

assessment.

 Exhibit 15-4.6c, regarding Bladder Cancer, has been amended. The language in 

v4.2 previously read:

c. Causation: For employees with demonstrated regular, routine exposure at 

significant levels (as opined by an Industrial Hygienist) to one of these substances 

for a full, consecutive working year, causation is presumed.

It has been updated in v4.3 to:

c. Causation: For those employees who were employed consecutively for a 

full working year in a position that would have involved significant exposure to 

one of the toxins identified in (b)(1-5) (as opined by an Industrial Hygienist), 

causation is presumed.
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 Exhibit 15-4.7b(1), regarding Chronic Obstructive Pulmonary Disease, has been 

amended. The language in v4.2 previously read:

(1) The employee was employed in any of the labor categories that are listed 

in Exhibit 15-4.3a(1) for an aggregate of 20 years prior to and including 

December 31, 1986.

It has been updated in v4.3 to:

(1) The employee was employed in any of the labor categories that are listed 

in Exhibit 15-4.3a(1) for an aggregate of 20 years prior to and including 

December 31, 1995.

 Exhibit 15-4.9b, regarding Kidney Cancer, has been amended. The language in 

v4.2 previously read:

b. Exposure: An employee who was employed for 5 or more consecutive

years prior to 1990 and had significant exposure to trichloroethylene (TCE). This 

can be determined by an IH assessment or without the review of an IH if the 

employee meets all of the following employment criteria (exposure presumption):

It has been updated in v4.3 to:

b. Exposure: An employee must have been employed for 5 or more 

consecutive years prior to 1990 in a position that would have had significant 

trichloroethylene (TCE) exposure. This can be determined by an IH assessment 

or without the review of an IH if the employee meets all of the following 

employment criteria (exposure presumption): 

 Exhibit 15-4.10b, regarding Laryngeal Cancer, has been amended. The language 

in v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to asbestos for at least 250 

aggregate work days. This can be determined by existing asbestos exposure 

presumptions or an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant asbestos exposure. This 

can be determined by existing asbestos exposure presumptions or an IH 

assessment. 

 Exhibit 15-4.11b, regarding Leukemia, has been amended. The language in v4.2 

previously read:
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b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to benzene for at least 250 

aggregate work days. This can be determined by an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant benzene exposure. This 

can be determined by an IH assessment. 

 Exhibit 15-4.12b, regarding Lung Cancer, has been amended. The language in 

v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to asbestos for at least 250 

aggregate work days. This can be determined by existing asbestos exposure 

presumptions or an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant asbestos exposure. This 

can be determined by existing asbestos exposure presumptions or an IH 

assessment. 

 Exhibit 15-4.15b, regarding Non-Hodgkin’s Lymphoma, has been amended. The 

language in v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure with lindane (1,2,3,4,5,6-

Hexachlorocyclohexane) for at least 56 days.

or

The employee was employed in a job that would have brought the employee into 

contact with significant exposure with pentachlorophenol for at least 2 years.

It has been updated in v4.3 to:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure with lindane (1,2,3,4,5,6-

Hexachlorocyclohexane) for at least 56 days.

or
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The employee was employed for an aggregate of 2 years in a position that would 

have had significant pentachlorophenol exposure. 

 Exhibit 15-4.16b, regarding Ovarian Cancer, has been amended. The language in 

v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to asbestos for at least 250 

aggregate work days. This can be determined by existing asbestos exposure 

presumptions or an IH assessment

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant asbestos exposure. This 

can be determined by existing asbestos exposure presumptions or an IH 

assessment.

 Exhibit 15-4.18b, regarding Pleural Plaques, has been amended. The language in 

v4.2 previously read:

b. Exposure: The employee was employed in a job that would have brought 

the employee into contact with significant exposure to asbestos for at least 250 

aggregate work days. This can be determined by existing asbestos exposure 

presumptions or an IH assessment.

It has been updated in v4.3 to:

b. Exposure: The employee must have been employed for an aggregate of 

250 days in a position that would have had significant asbestos exposure. This 

can be determined by existing asbestos exposure presumptions or an IH 

assessment.

• Chapter 18 – Eligibility Criteria for Non-Cancerous Conditions

o Ch. 18.19 has been edited to comply with the removal of Exhibit 18-1. The language 

in v4.2 previously read:

19. Other Conditions. Like asbestosis and the lung ailment COPD, there are a host 

of other non-cancerous conditions potentially covered under Part E that are not covered 

under Part B. With the wide variety of conditions claimed under Part E, this chapter 

cannot address diagnostic requirements of all possible conditions. However, the 

matrices in Exhibit 18-1 have been created to provide information relating to the 

assessment of the following conditions: kidney disease; occupational asthma; toxic 

neuropathy; and chronic toxic encephalopathy. Ultimately, the CE uses his or her best 

judgment in reviewing and evaluating the probative value of the medical evidence.
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It has been updated in v4.3 to:

19. Other Conditions. With the wide variety of conditions claimed under Part E, this 

chapter cannot address all common diagnostic or clinical characteristics for every 

particular diagnosis. Ultimately, the CE uses his or her best judgment in weighing the 

probative value of available medical evidence to ascertain a diagnosis. The 

establishment of a diagnosis requires that a qualified physician apply sound medical 

reasoning to interpret available clinical or diagnostic evidence to identify a disease or 

disorder. In those instances where the CE cannot establish that the weight of medical 

evidence supports a diagnosis, the CE is to seek clarification from the claimant’s treating 

physician. If the CE is unable to obtain clarification from the treating physician or in 

instances where the claimant is not currently under the care of a physician, the CE may 

seek clarification of a medical diagnosis from a CMC.

o Exhibit 18-1: Matrix for Confirming Sufficient Evidence of Non-Cancerous Covered 

Illness, has been deleted based on input from the Advisory Board on Toxic 

Substances and Worker Health.

• Chapter 19 – Eligibility Requirements for Certain Uranium Workers

o Ch. 19.3a and Ch. 19.3b, pertaining to RECA claims being solely adjudicated by the 

Denver District Office, have been removed.

• Chapter 20 – Establishing Survivorship

o Chapter 20.12b has been amended to clarify that a survivor electing to receive Part E 

monetary benefits which an employee would have been eligible to receive will have 

to have those monetary benefits coordinated if the employee received benefits as part 

of a State Workers’ Compensation (SWC) claim. The language in v4.2 previously 

read:

b. Death Due to Non-Covered Illness, Part E. If a covered Part E employee dies 

after filing a claim but before the claimed payment is received, and if the 

employee’s death was caused solely by a non-covered illness, the survivor(s) has 

the option to elect to receive the payment that the covered Part E employee would 

have received, had he/she not died prior to payment, rather than survivor 

benefits. It is not necessary for the employee to have filed a claim specifically for 

wage-loss or impairment benefits for the election option to be available to the 

survivor(s). As long as the employee filed a Part E claim, claims for wage-loss 

and impairment benefits are presumed. The earlier receipt by the employee of 

monetary benefits under Part E for wage-loss and/or impairment does not negate 

the availability of this election for any subsequent amount of monetary benefits 

claimed by the survivor.

It has been updated in v4.3 to:
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b. Death Due to Non-Covered Illness, Part E. If a covered Part E employee dies 

after filing a claim, but before the monetary benefits are paid, and if the 

employee’s death was caused solely by a non-covered illness, the survivor(s) has 

the option to elect to receive the payment that the covered Part E employee would 

have received had he/she not died prior to payment. This would be in lieu of the 

survivor lump-sum compensation payable under Part E. 

It is not necessary for the employee to have filed a claim specifically for wageloss or impairment benefits for the election option to be available to the 

survivor(s). As long as the employee filed a Part E claim, claims for wage-loss 

and impairment benefits are presumed. The earlier receipt by the employee of 

monetary benefits under Part E for wage-loss and/or impairment does not negate 

the availability of this election for any remaining balance of Part E lump-sum 

compensation available to a survivor under Part E should they make an election.

Once a survivor makes an election to receive a payment that the covered Part E 

employee would have received, the survivor is treated the same as the employee in 

determining whether the payment is subject to state workers’ compensation 

(SWC) coordination. For example, if the employee received SWC benefits for 

asbestosis and the survivor elected to receive what the deceased employee would 

have received under EEOICPA based on asbestosis, the CE must coordinate the 

amount payable to the survivor with the amount of those SWC benefits. (See PM 

Chapter 32, Coordinating State Workers’ Compensation Benefits).

• Chapter 22 – Wage-Loss Determinations

o Exhibit 22-4, SSA Contact Numbers, which was previously included in v4.2, has 

been removed from v4.3, as it is duplicative with Exhibit 13-1. As such, the 

remaining exhibits of Chapter 22 have been renumbered accordingly.

• Chapter 24 – Recommended Decisions

o Ch. 24.7a has been edited for clarity. The language in v4.2 previously read:

a. Written Decision. The written decision is comprised of an Introduction, a 

Statement of the Case, Explanation of Findings, and Conclusions of Law. 

Exhibit 24-1 and Exhibit 24-2 provide sample RDs. 

(1) Introduction. This portion of a RD succinctly summarizes what benefit 

entitlement is being recommended for acceptance, denial or deferral. 

Distinction is made between benefits addressed under Part B vs. Part 

E. 

It has been updated in v4.3 to:
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a. Written Decision. The written decision is comprised of an introductory 

statement, a Statement of the Case, Explanation of Findings, and Conclusions 

of Law. Exhibit 24-1 and Exhibit 24-2 provide sample RDs. 

(1) Introductory Statement. This is a statement written following the title 

“Recommended Decision” that summarizes what benefit entitlement is 

being recommended for acceptance, denial or deferral. Distinction is 

made between benefits addressed under Part B vs. Part E. 

o Exhibit 24-1 has been modified to align with the text of Ch. 24.7; specifically, the 

header “Notice of Recommended Decision” has been changed to “Recommended 

Decision. 

o Exhibit 24-2 has been modified to align with the text of Ch. 24.7; specifically, the 

header “Notice of Recommended Decision” has been changed to “Recommended 

Decision. 

o Exhibit 24-3, Notice of Recommended Decision, has been updated to include new 

language to clarify reporting requirements for recommended acceptances. 

• Chapter 26 – FAB Decisions

o The final paragraph of Ch. 26.3a has been updated to clarify the requirement that two 

EN-20s are to be included with each final decision acceptance. The language in v4.2 

previously read:

An acceptance may include two other components: (1) a medical benefits letter 

explaining entitlement to medical benefits for an accepted condition (Exhibit 26-2); 

and/or (2) an Acceptance of Payment form (EN-20), which is required before payment 

can be issued.

It has been updated in v4.3 to:

An acceptance may include two other components: (1) a medical benefits letter 

explaining entitlement to medical benefits for an accepted condition (Exhibit 26-2); 

and/or (2) two Acceptance of Payment forms (EN-20), one of which must be properly 

completed and returned before payment can be issued.

o Ch. 26.5c has been edited to remove outdated reference to Co-Located Unit. The 

language in v4.2 previously read:

c. Claimant Cannot be Located. When a RD is returned by the Postal Service and a 

current address for the claimant cannot be obtained by the Co-Located Unit 

within a reasonable period of time, the FAB administratively closes the claim and 

returns the case file to the DO. In situations involving multiple claimants, the 

FAB issues a FD to the remaining survivors, denoting the administrative closure 
17

of the claimant whose address could not be determined, and outlining that the 

share of compensation of the claimant whose claim has been administratively 

closed will be held in abeyance.

It has been updated in v4.3 to:

c. Claimant Cannot be Located. When a RD is returned by the Postal Service and a 

current address for the claimant cannot be obtained within a reasonable period of 

time, the FAB administratively closes the claim and returns the case file to the 

DO. In situations involving multiple claimants, the FAB issues a FD to the 

remaining survivors, denoting the administrative closure of the claimant whose 

address could not be determined, and outlining that the share of compensation of 

the claimant whose claim has been administratively closed will be held in 

abeyance.

o Exhibit 26-2, Medical Benefits Letter, has been updated to include language 

regarding the U.S. Department of Treasury’s direct deposit program, and the 

inclusion of SF 1199A, Direct Deposit Sign-Up Form.

• Chapter 28 – Medical Bill Process

o Ch. 28.13 has been amended to reflect existing practices related to the OWCP fee 

schedule review process. The language in v4.2 previously read:

13. Fee Schedule Appeal Process. As part of the medical bill review process, 

program 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 appeal letter in the XTCM Image Retrieval system, 

linked to the remittance voucher if submitted by the provider, and sends an 

email to the MBPU for review.

b. For each fee schedule appeal letter received, the MBPU creates a record, 

and maintains it in a tracking system (spreadsheet or database) created 

for this purpose.

c. The MBPU POC 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:
18

(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 15 days of receiving the request for reconsideration, the MBPU 

prepares a response to the medical provider outlining DEEOIC’s decision 

to either:

(1) Approve an additional payment amount: In this instance, the 

MBPU generates a draft letter for DD signature, informing the 

provider of the approval for additional payment. Where an 

additional amount 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 MBPU 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 MBPU 

prepares a draft letter-decision for DD signature, advising that 

additional payment is denied, based upon the provider’s inability 

to establish one of the conditions listed above in Item c (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 must 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 MBPU, for the 

signature of the DD whose office has control of the claim file(s) being 

addressed in the decision(s). The MBPU sends the draft letter (via email) 

to the DD for review, signature, and mailing. The DD places a copy of the 
19

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 MBPU continues to track the status of any 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 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 MBPU 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.

 

It has been updated in v4.3 to:

13. Fee Schedule Review Process. As part of the medical bill review process, 

program regulations provide for the reconsideration of fee schedule reductions (charges 

by a provider that have been reduced in accordance with the OWCP fee schedule for that 

specific service). A provider whose charge OWCP partially pays under the fee schedule 

has 30 days to request reconsideration of the fee determination. 

a. Fee reconsideration circumstances. A medical provider may contest a 

payment under the OWCP fee schedule under the following 

circumstances:
20

(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.) 

b. A provider is to submit a fee schedule reconsideration involving a 

DEEOIC claim to the BPA at the medical bill processing mailing address. 

The fee reconsideration request is to communicate clearly that the 

provider is contesting a payment under the fee schedule relating to a 

DEEOIC case file and the applicable fee reconsideration circumstance the 

provider is pursuing. The provider is to attach any remittance voucher or 

other accompanying material the provider is using to support the fee 

reconsideration request. 

c. Once received, the BPA will register the fee reconsideration request and 

forward it to the MBPU. MBPU will coordinate with the DO with 

jurisdiction over the claim to assess the reconsideration request. Within 

30 days of receiving a fee reconsideration, the responsible DD is to issue 

a written determination on the reconsideration request. The DD’s written 

determination is to state whether or not an additional amount will be 

allowable as reasonable considering the information submitted in the 

reconsideration request. If the DD decides to deny the reconsideration 

request, the DD is to include the following notice within the written 

decision:

If you disagree with this decision, you may, within 

30 days of the date of this decision, apply for 

additional review. Direct any request for additional 

review to the National Administrator for Field 

Operations (NAFO). You may submit with the 

application any additional information you wish the 

NAFO to consider. Mail your application for 

additional review to the DEEOIC BPA at the 

following address:

<Insert BPA Mailing Address>

d. If a provider seeks further review of a denied reconsideration request, the 

DEEOIC BPA will coordinate with the MBPU to direct the request to the 

NAFO. The NAFO performs the same functions as, and serves as the 

equivalent of, a Regional Director, which the regulations reference as 
21

having to conduct this review. DEEOIC reorganized its regional offices 

into National Field Operations, so the position of Regional Director no 

longer exists. The NAFO will seek any information to allow for a 

comprehensive review of the application, including review of any 

information supplied by the provider or maintained by DEEOIC regarding 

the case file. Once the NAFO completes a review of the application and 

relevant documentation, the NAFO will prepare a written response to the 

provider within 60 days of the receipt of the request for further review. 

The decision will communicate whether or not an additional amount is 

allowable. If the NAFO denies an additional amount, the NAFO’s 

decision to communicate to the provider that the decision is final and is 

not subject to further administrative review.

• Chapter 29 – Ancillary Medical Benefits and Related Services

o Ch. 29.13 has been updated to provide additional guidance regarding the evaluation 

of claimant requests for vehicle modification, and removes language pertaining to 

vehicle purchases. The language in v4.2 previously read:

13. Vehicle Modifications and Purchases. This section provides clarification with 

regard to the evidence needed to approve vehicle modifications and purchases, and 

provides procedural guidance with regard to the process for review, development, and 

authorization of such requests.

a. Criteria for Modifications. Upon receipt of a LMN describing a medical 

need for vehicle modification, and if the claimant’s medical needs can be 

met by modifying or adding accessories/equipment to the claimant’s 

present vehicle, the MBE explores that option first, before considering 

replacement of the existing vehicle. When considering modifications to an 

existing vehicle, the MBE 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 practical.

b. Proposals. If the MBE determines that the claimant’s medical needs 

warrant vehicle modification, the MBE advises the claimant in writing to 

submit a detailed written proposal containing the following information:

(1) 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 modifications currently needed or 

anticipated. The same applies regardless of whether the vehicle to 

be modified is new or used.

(2) Detailed written estimates from two licensed automobile dealers, 

or custom alteration facilities, itemizing the proposed vehicle 
22

modifications necessary to comply with the treating physician’s 

LMN. Estimates must include a breakdown of all parts, labor, and 

the respective costs associated with each item. The estimates 

should also state the amount of time required to perform the 

modifications.

c. Acceptance by the MBE. The MBE has the latitude to approve an estimate 

that the claimant favors, if the estimates are reasonably similar in scope 

and cost.

(1) Approval or Denial. Upon review of the evidence, the MBE 

approves or denies the request by sending a letter decision to the 

claimant advising of the approval, or reason(s) for denial of the 

request. 

(2) Additional Information. If the MBE determines that additional 

information is necessary, the MBE sends a letter to the claimant 

requesting the additional documentation that is necessary to 

continue with the review process.

(3) Inadequate response. If the claimant does not respond to the 

development letter, or does not provide sufficient documentation to 

support the request, after considering all relevant evidence, the 

MBE issues a letter decision informing the claimant of the 

authorization denial. 

d. Vehicle Purchase. If the claimant provides a LMN establishing that 

modifications to his or her currently owned vehicle are not feasible or 

practical, and that a substitute vehicle is required for the claimant to 

operate, the MBE reviews the case with a supervisor and the NO FO, and 

may authorize the purchase of a suitable replacement vehicle. Under 

these circumstances, credit must be taken for the value of the claimant’s 

existing vehicle. Purchase options include the following:

(1) Purchase of a used vehicle, (similar in quality to the claimant’s 

existing vehicle), equipped to accommodate the claimant’s 

disability and transportation needs.

(2) Purchase of a used vehicle that is suitable for modification as 

described above.

(3) Purchase of a new vehicle, modified, or suitable for modification, 

to meet the needs of the claimant, arising from an accepted 

condition.
23

(4) Whether a new or used vehicle is purchased, it must be a vehicle of 

comparable value as the vehicle currently owned and operated by 

the claimant (i.e.; a vehicle in a price range that closely 

approximates the level of income and/or standard of living of the 

claimant). For example, if the claimant owns a mid-priced 

Chevrolet, Ford, Honda or Toyota; purchase of a Cadillac, 

Lincoln, or Lexus SUV, would not represent a vehicle of 

comparable value. 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.

(5) After determining the baseline cost of a comparable vehicle, the 

MBE 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-of-charge. The MBE 

should advise the claimant of the source of their information, once 

the wholesale value of the claimant’s current vehicle has been 

determined.

(6) Sales Tax. State sales tax should be included in the cost of 

obtaining a replacement vehicle.

(7) Equipment that is medically necessary for the accepted 

condition should be factory-installed whenever possible.

(8) Maintenance Costs. The MBE 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 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.
24

(9) Proof of Insurance. The claimant bears the cost of obtaining 

automobile insurance and maintaining current vehicular 

registration in conformance with the laws of the state within which 

the claimant resides. Claimants are required to carry 

comprehensive (fire, theft, vandalism) 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.

(10) Vehicle No Longer Needed. If the MBE obtains information that a 

vehicle purchased by DEEOIC is no longer needed, the MBE will 

send an email to the DEEOIC Bill Pay Box Mailbox alerting 

MBPU of the situation. DEEOIC is entitled to recover the fair 

market value of the purchased vehicle, less any percentage 

contribution the claimant made to the overall purchase price of the 

vehicle and its modifications. The MBPU will undertake 

appropriate action to attempt recovery of any funds collectable 

through sale of a DEEOIC purchased vehicle no longer needed by 

a claimant. 

It has been updated in v4.3 to:

13. Vehicle Modifications. DEEOIC requires claimants to obtain prior authorization 

for reimbursement of modifications to their vehicle to accommodate the effect(s) of an 

accepted, work-related medical condition, as they relate to the use of that vehicle for 

purposes of medical transportation. It is the role of the Medical Benefits Examiner 

(MBE) to evaluate such claims and to grant authorization for reimbursement of those 

vehicle modification costs that are determined to be medically necessary and reasonable 

in cost. For the purposes of claim processing under the DEEOIC, a medically necessary 

vehicle modification means a mechanical alteration or addition to a vehicle, owned and 

operated by the claimant, necessary for purposes of medical transportation. 

a. Vehicle Modification Claim Submissions. For the MBE to assess a claim 

for vehicle modification, a claimant is responsible for submitting medical 

and factual documentation necessary to support an authorization for 

reimbursement. 

(1) Letter of Medical Necessity (LMN). The claimant must provide a 

LMN from a qualified physician who has conducted a face-to-face 

examination with the patient, prescribing vehicle modifications to 

address the effect of a work-related illness or injury, and providing 

a medical rationale for how those modifications relate to an 

accepted medical condition. The face-to-face examination must 

occur within 60 days of the date of the LMN. Specifically, the 
25

LMN must provide an explanation as to how the prescribed 

modification to the claimant’s vehicle will accommodate the 

claimant’s need for medical transportation.

(2) Evidentiary Requirements. Evidence supporting the need for 

specific vehicle modifications must include a description of the 

required equipment and/or labor operations necessary to modify 

the claimant’s current vehicle, along with product information 

such as pamphlets, or technical diagrams, depicting the 

materials/equipment being proposed as part of the modification 

process. (For example: the claimant might provide a product 

brochure with photographs and technical information describing 

the installation of a lift device, designed for the purpose of 

transporting the claimant’s DEEOIC prescribed mobility device.) 

The product information may be included with the submission of 

written estimates, or submitted separately to DEEOIC. Any unique 

or exceptional circumstances, regarding the nature of the 

requested modification and estimates for the cost of installation or 

modifications, are to be explained by the claimant, in a written 

statement, with supporting documentation, if applicable. 

(3) Competitive Estimates. The claimant must obtain and submit 

three, independent, written estimates from appropriately licensed 

businesses or DEEOIC enrolled providers, detailing the proposed 

modifications that align with the medical rationale supplied by the 

claimant’s physician. The scope of the estimates must identify the 

same equipment and/or alterations specified in the LMN. Labor 

charges for modification of the existing vehicle and/or installation 

of DME are to be identified separately on the estimate. (This is 

important, as claims for DME purchase, and labor charges for 

installation, must be itemized separately when submitting claim 

forms for reimbursement.) 

(a) Estimates for equipment added to a vehicle (e.g., scooter 

lift platform, motorized wheelchair lift platform, etc.) must 

specifically identify the description of the durable medical 

equipment (DME) being purchased. Information must 

include manufacturer or brand name, model number, and 

any other identifying information unique to the item 

described in the estimate. 

(b) Estimates for installation costs (labor and materials), for 

the permanent attachment of DME to the claimant’s vehicle 

(e.g., receiver or other permanent mounting devices 

attached to the vehicle for mounting purposes) must be 

provided in separate estimates. 
26

b. MBE Assessment of Medical Evidence. Upon receipt of medical evidence 

supporting a claim for vehicle modification, the MBE conducts a review to 

ensure that the weight of medical evidence supports the medical necessity 

for making modifications to a claimant’s vehicle to facilitate the use of 

that vehicle for the purpose of medical transportation.

(1) Initial Review of the LMN. The MBE reviews the LMN to 

determine whether it documents a face-to-face examination 

between the claimant’s treating physician and the employee, within 

60 days of the LMN. Moreover, the MBE screens the LMN to 

ensure that the requested vehicle modification is linked to a 

DEEOIC accepted medical condition(s). If, upon review, either of 

these conditions are not satisfied, the MBE undertakes 

development with the claimant and the treating physician seeking 

the necessary evidence. 

(2) The MBE must evaluate the weight of medical evidence to 

determine if the physician’s LMN provides a sufficiently supported 

medical justification for the requested vehicle modification. The 

MBE may consider multiple factors when assessing the available 

evidence and in reaching a decision. The LMN should reflect the 

physician’s accurate and comprehensive knowledge of the 

claimant’s medical history, diagnostic, and clinical status.

(a) In situations where the MBE determines additional 

information is needed to explain the medical necessity of a 

vehicle modification, the MBE initiates development with 

the claimant’s treating physician. The treating physician is 

the principle point of contact for obtaining medical input. 

The MBE allows the claimant’s physician the opportunity 

to respond to, or provide clarification with respect to, any 

development issue identified by the MBE. Additionally, the 

MBE may make referrals to DEEOIC nurse consultants, 

during the development process, for assistance in clarifying 

issues, obtaining information, or in seeking 

recommendations for additional development. 

(b) In those instances, where development occurs with the 

treating physician, the MBE allots 30 days for the 

submission of necessary evidence to support a vehicle 

modification claim. For an initial request, the MBE allots 

15 days to allow for a response. If the MBE does not 

receive the requested evidence within the 15-day period, 

the MBE sends a second development letter, providing an 

additional 15 days for submission of the requested 

evidence.
27

(c) When development with the prescribing physician does not 

produce evidence necessary to establish the medical 

appropriateness of the prescribed vehicle modification, the 

MBE refers the case for a Second Opinion (SECOP) 

medical examination. The function of the SECOP 

examination is to obtain an independent assessment of the 

medical need for the requested vehicle modification. Upon 

receipt of the SECOP results, the MBE reviews the SECOP 

report and conducts a full examination of the case 

evidence, including any medical evidence submitted by the 

treating physician. If the SECOP examination results in a 

validation of the need for a vehicle modification, as 

prescribed by the claimant’s physician, the MBE proceeds 

with a review of the cost estimates for the modifications. 

If the SECOP examination results in an opinion that differs 

from that of the claimant’s physician, the MBE weighs the 

opinions of the two physicians. If the MBE determines that 

the opinion of the SECOP physician is of greater weight 

than that of the treating physician, the MBE proceeds with 

the claim, based on the recommendation of the SECOP, 

and issues a recommended decision; or, the MBE can 

request that the claimant revise and resubmit any requested 

vehicle modification. If, for whatever reason, including 

receipt of new evidence from the prescribing physician, the 

MBE determines that the weight of medical evidence is the 

same between the treating physician and the Second 

Opinion physician, and there is a conflict regarding the 

medical need for a vehicle modification, the MBE proceeds 

with a referral for a referee examination. The MBE is to 

consider the opinion of a referee medical physician as 

possessing special weight in resolving conflicting medical 

opinions.

(d) Depending on the outcome of medical development, the 

MBE proceeds with adjudication of the claim. Where the 

medical evidence establishes the necessity for a vehicle 

modification, the MBE proceeds with collection, and/or 

review of any competitive estimates for the validated 

modification. If the weight of medical evidence does not 

support the medical necessity for a vehicle modification, 

the MBE issues a recommended decision denying the claim. 

c. MBE Assessment of Competitive Estimates. Once the MBE establishes 

that the weight of medical evidence warrants a vehicle modification, the 

MBE reviews the competitive estimates from the claimant. It is the 
28

responsibility of the claimant to produce valid, complete, and accurate 

competitive estimates that reflect only the work necessary to accommodate 

the claimant’s need for medical transportation. Unless exceptional 

reasons exist, that can be adequately explained, the claimant is to submit a 

minimum of three competitive estimates. The MBE assesses the estimates 

to determine if the scope of the requested modification(s) reasonably 

aligns with the modifications prescribed in the physician’s LMN. The 

MBE may seek consultative advice from DEEOIC nurse consultants for 

input as to whether the written estimates reflect a medically necessary 

accommodation of the claimant’s transportation needs. MBEs may also 

request input from nurse consultants regarding alternatives for 

accommodating the claimant’s medical transportation needs. 

(1) Comparing Competitive Estimates. The MBE examines the 

estimates to determine whether the scope of the proposed vehicle 

modification aligns with the physician’s opinion of medical 

necessity. Each estimate must represent a proposal from a 

separate and distinct bidder desiring to perform the medically 

necessary vehicle modification. Estimates must be similar in their 

description of the equipment to be installed or work to be 

performed. For modifications to the existing vehicle, such as hand 

controls, modified driver seat, etc., the estimates must provide an 

itemization of the cost of materials, and the associated labor 

charge for each operation performed. As outlined above, DME, 

and the cost of modifying the vehicle to accommodate the DME, 

must be itemized in separate estimates. Unusual or exceptional 

circumstances, associated with the requested modification, must be 

clearly described in the estimate. The MBE is to undertake a 

careful, comparative analysis to determine if each estimate 

represents a viable proposal for completing a cost-effective 

modification consistent with the physician’s LMN. The MBE may 

consider any input that the claimant wishes to express regarding a 

preference for a particular service provider, or any other factors 

that relate to the requested modification. 

(2) Undertaking Development. If, during the examination of each bid, 

the MBE determines the scope of the work, detailed in the 

contractor bids, is inconsistent with either the LMN or the 

condition (i.e., year, make, model) of the claimant’s owned vehicle, 

or, if a viable alternative modification, or alternative 

transportation option exists, the MBE prepares a letter to the 

claimant. The letter should outline the deficiency(ies) in what is 

being claimed, and specifically describe the evidence needed from 

the claimant to support further assessment of the claim. This could 

include a request for resubmission of a modified estimate or 

estimates. It may be helpful, in some instances, for the MBE to 
29

contact the claimant directly, to explain a problem and describe 

the necessary steps for submission of needed evidence. When a 

development letter is necessary, the MBE allots the claimant a 

total of 30 days for the submission of the requested evidence. For 

initial requests, the MBE allots 15 days to allow for the submission 

of responsive documentation. If the requested evidence is not 

received within the initial 15-day period, the MBE sends a second 

development letter, allotting an additional 15 days for a response.

(a) Once all development actions are complete, the MBE must 

carefully weigh the totality of available evidence and 

assign the greatest weight to the estimate that represents 

the most qualified and cost-effective proposal for 

accomplishing the medically necessary vehicle 

modification. While cost is a factor in the MBE’s analysis, 

it is not the sole determiner in the selection process. Each 

estimate must be assessed on its merits, along with any 

input from the claimant, in order to identify the estimate 

with the greatest weight. 

(b) If a deficiency is found to exist, with a request for prior 

authorization of reimbursement for a vehicle modification, 

and the claimant is unable to produce evidence or 

information that addresses the deficiency, the MBE 

determines whether the deficiency prevents the MBE from 

proceeding with consideration of the reasonably 

comparable estimates. If the determination is that the MBE 

cannot proceed because of that deficiency, the MBE 

proceeds with the issuance of a recommended decision 

denying the request for prior authorization of 

reimbursement. In the recommended decision, the MBE 

must clearly explain the specific deficiency(ies) in the 

evidence resulting in an inability to grant prior 

authorization of the reimbursement request. 

(3) Issuing Authorization Decisions. Upon reaching a decision to 

grant a request for prior authorization of reimbursement, the MBE 

writes a detailed letter-decision to the claimant advising of the 

approval. The letter should specifically describe the 

modification(s) being approved and should include a blank Form 

OWCP-915 with instructions to use that form when submitting 

reimbursement requests. For approvals involving the installation 

of DME on a vehicle, the approval letter should instruct the 

claimant to separately list the purchased DME from labor charges 

necessary to complete the installation. 
30

d. Retroactive Requests for Reimbursement. In those instances, where a 

claimant did not request prior authorization from DEEOIC and 

subsequently submits a request for reimbursement for work already 

performed, the MBE conducts a review of the evidence to determine the 

amount, if any, that can be authorized for reimbursement. The claimant 

must provide an LMN that meets the same evidentiary requirements as a 

prior authorization request, i.e., it must be sufficient for the MBE to make 

a determination regarding the medical necessity of a modification to the 

claimant’s vehicle. If necessary, the MBE conducts development to obtain 

sufficient medical evidence supporting the claimant’s request. 

(1) Calculating Costs to Determine a Reimbursable Amount. Once the 

MBE establishes the medical necessity of a request for retroactive 

reimbursement for a vehicle modification, the MBE collects all 

available information from the claimant regarding the completed 

modification. With the exception of requiring three estimates, the 

evidentiary requirements for a retroactive review are no different 

than those previously outlined for prior authorization requests. 

The MBE reviews the available evidence to determine if the 

claimed expenses appear reasonably in line with similar 

modification requests. The MBE calculates and deducts any costs 

for materials and/or labor not related to, or not necessary to 

complete the requisite vehicle modification. Upon completion of a 

thorough review, the MBE prepares a memo to file outlining any 

calculations performed and provides an explanation as to how the 

MBE arrived at a final cost for approval of any reasonable and 

medically necessary vehicle modifications.

(2) Issuing a Decision. Having determined that reimbursement is 

appropriate, the MBE issues a letter decision authorizing 

reimbursement for the claimed amount. If the MBE’s final 

calculations of documented and/or reasonable costs represent an 

amount less than the amount claimed, or if the MBE recommends a 

denial of the requested amount, the MBE issues a recommended 

decision. In that decision, the MBE must fully explain the analysis 

of available evidence and how the MBE arrived at the 

recommended amount of reimbursement. This explanation must 

include any reference materials or other information, utilized by 

the MBE, to calculate the reimbursable amount.

o Ch. 29.14 has been updated to provide clear guidance for assessing the medical 

necessity of a claim for home modification. The language in v4.2 previously read:

14. Housing Modifications. This section provides clarification with regard to the 

evidence needed to approve housing modifications, and provides procedural guidance 

with regard to the process for review, development, and authorization of housing 
31

modifications. The MBE considers home modification only when deemed medically 

necessary due to an accepted condition. A MBE’s responsibility is to grant authorization 

to modify an existing structure to accommodate the claimant’s medical needs. The 

treating physician must describe in a LMN the particular home modifications needed to 

accommodate the claimant’s work-related illness. 

a. 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.

(1) Modifications may include certain additions where warranted. 

For example, if a ground-floor recreation room is converted to a 

bedroom, to accommodate a wheelchair-bound 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 space for conversion of 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.

(2) Modifications may include certain appliances, such as air 

conditioning or air filtration equipment, if deemed to be medically 

necessary by the treating physician, and necessary for the relief of 

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.

(3) When considering modification requests, the MBE should consider 

whether a portion of a home can be modified, as compared to a 

whole-house modification. An example of this would be one or 

two room air conditioning units, versus installing a whole-house 

air conditioning system.

(4) Maintenance expenses. The MBE approves maintenance expenses 

for equipment furnished to the claimant, as well as replacement 

costs, after the normal life expectancy of the appliance. 

b. 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 MBE considers the following 

points:
32

(1) Rental property may be subject to federal Americans with 

Disabilities Act (ADA), 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.

(2) 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.

(3) If the landlord/owner will not permit modifications, or if the costs 

are excessive, and if suitable housing arrangements are available 

elsewhere, within the same geographic area, it may be more costeffective to consider paying relocation expenses rather than paying 

for modifications at the current location. If changing locations is 

the most cost-effective alternative, the MBE 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).

(4) 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.

c. Proposals. If the MBE determines that the claimant is eligible for housing 

modifications, the MBE asks the claimant to submit a detailed written 

proposal for review and consideration. The MBE advises the claimant 

that the proposed housing modifications should be of a quality and grade 

consistent with the existing architecture and construction materials, not 

superior to them. Further, the claimant should be cautioned that 

structural modifications must not compromise the integrity of the existing 

structure. 

Modifications will be no more expensive than necessary to accomplish the 

required purpose. For example, when remodeling a bathroom, it may be 
33

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 pre-illness accommodations. For example, if the 

claimant’s dwelling 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:

(1) 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. 

(2) 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.

(3) 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.

(4) The MBE reviews the itemized proposal and determines if the 

specified modifications are warranted. If the MBE identifies 

technical issues regarding implementation, the MBE develops the 

issue further to identify alternate solutions.

d. 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 AR remains the claimant’s obligation.

(3) The claimant must provide two or more bids for the proposed 

changes from licensed and/or certified contractors. The bids 
34

submitted must be for exactly the same modifications so that 

comparison of the competitive bids can be made.

(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 MBE 

stipulates that the price quoted by the vendor includes any 

necessary installation.

(4) The MBE reviews the bids to determine that the same workmanship 

and materials are specified in the competitive bids, and normally 

selects the lowest cost bid, unless there is a sound reason for a 

higher-cost alternative, such as increased durability. If the MBE 

selects a bid other than the lowest-cost bid, a memorandum to the 

file is required, explaining any variance or the justification for 

accepting a higher bid.

(5) Additional Information. If the MBE determines that additional 

information is necessary, the MBE sends a letter to the claimant 

requesting additional documentation that is necessary to continue 

with the review process.

e. Approval and Payment Options. Upon approval of the request, the MBE 

writes a detailed letter decision to the claimant advising of the approval 

(Exhibit 29-6 provides a sample of the home modification approval letter.) 

The approval letter is to include guidance to the claimant of the payment 

options available and requests that the claimant respond in writing, 

indicating his/her preferred payment option. For payment of home 

modification, the following is necessary:

(1) The claimant submits medical evidence and two proposals for 

home modifications. Upon review the MBE approves the lower 

cost bid proposal and sends a letter to claimant stating DEEOIC 

agrees to the approved scope and cost of repairs, and, at the 

claimant’s request, will make direct payment to the enrolled 

contractor, once the agreed upon work has been completed. The 

letter states that upon completion of the agreed-upon work, the 

claimant must submit a written attestation to DEEOIC stating that 

the agreed upon work has been completed by the contractor, to the 

claimant’s satisfaction, and requesting that payment be made to 

the contractor. The MBE sends a courtesy copy of this letter to the 

contractor.
35

(2) Upon receipt of the claimant’s attestation and request to pay the 

contractor, the MBE acknowledges the claimant letter and advises 

that the enrolled contractor should submit Form OWCP- 1500, 

along with a final invoice, in order to receive payment of the 

agreed upon price. The OWCP Code for HOME MODIFICATION 

- HSMDF is used, when preparing the Form OWCP-1500. 

(3) In certain situations, the MBE may authorize payment of a preconstruction deposit if required by the contractor whose bid has 

been accepted by the MBE. In these situations, the contractor is to 

specify the total cost for specified home modification, along with 

the amount of any deposit (up to one-third of the total cost) 

required to initiate work. With MBE approval, the contractor may 

then submit Form OWCP-1500, to receive partial payment for the 

deposit amount of the estimated cost. The OWCP code for HOME 

MODIFICATION - HSMDF is used when preparing the Form 

OWCP-1500. Upon completion of the work, the claimant must 

submit a written attestation to DEEOIC stating that the agreed 

upon work has been completed by the contractor, to the claimant’s 

satisfaction, and requesting that final payment be made to the 

contractor. The contractor submits a separate Form OWCP-1500, 

requesting payment of the balance of the agreed upon amount. 

(4) For guidance regarding problems encountered during the course 

of home modifications, or for other billing questions, (e.g.; billing 

difficulties, disputes or other irregularities), the MBE should 

contact the NO Policy Branch for assistance.

It has been updated in v4.3 to:

14. Housing Modifications. DEEOIC requires claimants to obtain prior authorization 

for reimbursement of modifications to their residence to accommodate the effect(s) of an 

accepted, work-related illness. It is the role of the Medical Benefits Examiner (MBE) to 

evaluate such claims and to grant authorization for reimbursement of those home 

modification costs that are determined to be medically necessary. For the purposes of 

claim processing under the DEEOIC, a medically necessary home modification means an 

alteration, addition to, or repair of an existing residential structure to overcome a 

deficiency limiting or preventing the claimant, with an accepted, work-related illness, from 

performing activities of daily living.

a. Home Modification Claims Submissions. For the MBE to assess a claim 

for home modification, a claimant is responsible for submitting medical 

and factual documentation necessary to support an authorization for 

reimbursement. 
36

(1) Letter of Medical Necessity (LMN). A qualified physician who has 

conducted a face-to-face examination with the patient is to submit 

a LMN prescribing home modifications to address the effect of a 

work-related illness or injury, and how those modifications relate 

to an accepted condition. The face-to-face examination must occur 

within 60 days of the date of the LMN. The LMN must provide the 

physician’s rationale justifying the medical need for a modification 

to the claimant’s residential structure. Specifically, within the 

narrative of the LMN, the physician has to explain the reasons for 

a home modification and how the modification will serve to 

overcome an established inability of the claimant to perform an 

activity of daily living arising from an accepted medical condition. 

(2) Evidentiary Requirements. The claimant must submit evidence 

substantiating the need for home modifications, including a 

description of the required modifications, digital photographs of 

the existing areas requiring modification, and any other plans, 

drawings, or documentation, supporting the required 

modifications. This information should clearly depict the area or 

areas requiring modification and should show evidence of the 

existing grade and quality of construction in the home. The 

claimant my include this information with the initial submission of 

written estimates, or submit it separately. Any unique or 

exceptional circumstances regarding the nature of the requested 

modification and the competitive estimates are to be explained by 

the claimant in a written statement with accompanying supportive 

documentation, if applicable. Any modification to property not 

owned by the claimant is subject to approval by the landlord or 

owner. 

(3) Competitive Estimates. The claimant must obtain and submit 

three, independent written estimates, from appropriately licensed 

contractors or vendors, detailing the proposed modifications that 

align with the medical rationale supplied by the claimant’s 

physician. The estimates must include the same alterations, 

additions, or repairs as specified in the LMN. These estimates are 

to include itemized unit costs, broken down into materials and 

labor, for each operation (e.g. number of square feet of drywall or 

flooring, with the associated cost of materials and labor per 

square foot). Construction estimates are to include the grade of 

proposed construction materials and contain specifics describing 

the type and manufacturer of fixtures and appliances (such as 

sinks, cabinets, bathtubs, flooring materials, etc.). Building 

materials and construction quality, described in the construction 

estimates for a medically necessary home modification, must 

conform to the same construction quality as the existing structure. 
37

Any additional services, improvements, or upgrades, desired by the 

claimant, which are not within the scope of medically necessary 

modifications, are to be itemized distinctly and separately in the 

estimate. Such services, improvements, or upgrades are not 

reimbursable as a medically necessary home modification.

b. MBE Assessment of Medical Evidence. Upon receipt of the evidence 

supporting a claim for home modification, the MBE first conducts a 

review and assessment of the medical evidence. The function of this 

review is to ensure that the weight of medical evidence supports the 

medical necessity for making modifications to a claimant’s residence to 

accommodate the effects of a work-related illness on the employee’s 

ability to perform activities of daily living. 

(1) Initial Review of the LMN. The MBE reviews the LMN to 

determine whether it documents a face-to-face examination 

between the claimant and the treating physician, within 60 days of 

the LMN. Moreover, the MBE screens the LMN to ensure that the 

requested home modification is linked to the DEEOIC accepted 

medical conditions. If, upon review, either of these conditions is 

not satisfied, the MBE undertakes development with the claimant 

and the treating physician, seeking the necessary evidence. 

(2) The MBE must evaluate the weight of medical evidence to 

determine if the physician’s LMN provides a sufficiently supported 

medical justification for the requested home modification. The 

MBE may consider multiple factors when assessing the available 

evidence and in reaching a decision. The LMN should reflect the 

following: the physician’s accurate and comprehensive knowledge 

of the claimant’s medical history; diagnostic and clinical status; 

living circumstances; and functional capacities. The LMN should 

include the physician’s consideration of such information and how

the physician relates the need for, and the scope of any home 

modification, to an established deficiency in the claimant’s 

capacity to perform activities of daily living arising from an 

accepted, work-related illness. 

(a) In those situations, where the MBE determines that 

additional information is necessary to explain the medical 

necessity of a home modification, the MBE is to initiate 

development with the claimant’s treating physician as the 

principle point of contact for obtaining medical input. 

Moreover, the MBE is to allow the claimant’s physician the 

opportunity to respond to, or provide clarification with 

respect to, the development issue identified by the MBE. At 

any time in this process, the MBE may make referrals to 
38

DEEOIC nurse consultants for assistance in clarifying 

issues, obtaining information, or recommending additional 

development. 

(b) In those instances, where development occurs with the 

treating physician, the MBE should allot 30 days for the 

submission of necessary evidence to support a home 

modification claim. For an initial request for evidence, the 

MBE is to grant a period of 15 days to allow for the 

submission of responsive documentation. If the requested 

evidence is not received within the 15-day period, the MBE 

sends a second development letter providing an additional 

15 days to submit the requested documentation. No further 

time will be granted for a response from the treating 

physician, unless extenuating circumstances exist and are 

documented.

(c) When development with the prescribing physician does not 

produce evidence necessary to establish the medical 

appropriateness of the prescribed home modification 

during the allotted 30 days, the MBE is to refer the case for 

a Second Opinion (SECOP) medical examination. The 

function of the SECOP examination is to obtain an 

independent assessment of the medical need for the 

requested home modification. 

Once the SECOP medical examination is complete, the 

MBE will need to review the SECOP report and conduct a 

full examination of the case evidence including any medical 

evidence submitted by the treating physician. If the SECOP 

examination results in a validation of the need for a home 

modification, as prescribed by the claimant’s physician, the 

MBE is to proceed with a review of the cost estimates for 

the modifications. 

If the SECOP examination results in an opinion that differs 

from that of the claimant’s physician, the MBE weighs the 

opinions of the two physicians. If the MBE determines that 

the opinion of the SECOP physician is of greater weight 

than that of the treating physician, the MBE proceeds with 

the claim, based on the recommendation of the SECOP, 

and issues a recommended decision. In the alternative, the 

MBE can request that the claimant revise and resubmit any 

planned home modification. If, for whatever reason, 

including receipt of new evidence from the prescribing 

physician, the MBE determines that the weight of medical 
39

evidence is the same between the treating physician and the 

Second Opinion physician, and there is a conflict regarding 

the medical need for a home modification, the MBE is to 

proceed with a referral for a referee examination. The 

MBE is to consider the opinion of a referee medical 

physician as possessing special weight in resolving a 

conflict of medical opinion.

(d) Depending on the outcome of medical development, the 

MBE will proceed with adjudication of the claim. Once the 

medical necessity of a home modification is established by 

the weight of medical evidence, the MBE proceeds with 

collection, and/or review of any competitive estimates for

the validated modification. If the weight of medical 

evidence does not support the medical necessity of a home 

modification, the MBE is to issue a recommended decision 

denying the claim. 

c. MBE Assessment of Competitive Estimates. Once the MBE establishes 

that the weight of medical evidence warrants a home modification to 

accommodate the claimant’s inability to perform an activity of daily 

living, the MBE reviews competitive estimates, submitted by the claimant, 

to accomplish the proposed home modification. The claimant is 

responsible for producing valid, complete, and accurate, competitive 

estimates that reflect the work to be done to accommodate a medically 

necessary modification. Unless exceptional reasons exist that can be 

adequately explained, the claimant is to submit a minimum of three 

competitive estimates. The MBE assesses the three estimates to determine 

if the scope of the requested modification(s) reasonably aligns with the 

information supplied in the physician’s LMN. If necessary, the MBE may 

seek consultative advice from DEEOIC nurse consultants for input as to 

whether the proposals reflect a medically necessary accommodation of the 

claimant’s needs and whether those modifications align with the treating 

physician’s LMN. MBEs may also request input from nurse consultants 

regarding medically feasible options or alternatives for accommodating a 

medical need. If a claimant chooses to also have improvements outside 

the scope of medical necessity performed at the same time, the bids should 

provide a distinction between the medically necessary portion of the work 

and the personal improvements requested by the claimant.

(1) Comparing Competitive Estimates. The MBE examines the 

contractor estimates to determine whether the scope of the 

proposed home modifications aligns with the physician’s opinion of 

medical necessity. Each bid must represent a proposal from a 

separate and distinct contractor, desiring to perform the medically 

necessary home modifications as spelled out in the LMN, which will 
40

serve to accommodate the claimant’s medical need. Estimates must 

be similar in their description of the operations to be performed. 

Further, estimates must contain an itemization of the cost of 

materials and the associated labor charge for each operation 

performed. All estimates must reflect the use of construction 

materials comparable to the existing quality or grade of the 

structure to be modified. Unusual or exceptional circumstances 

associated with the requested modification must be clearly 

described in the estimate. The MBE is to undertake a careful 

comparative analysis to determine if each estimate represents a 

viable proposal for completing a cost-effective modification to the 

claimant’s residence to accommodate an established medical need. 

The MBE may consider any input that the claimant wishes to 

express regarding a preference for a particular contractor, or any 

other factors that relate to the requested modification. 

(2) Undertaking Development. If, during the examination of each bid, 

the MBE determines the scope of the work detailed in the contractor 

bids is inconsistent with either the LMN or the existing grade and 

quality of the claimant’s dwelling; or if viable alternative 

modification options exist, the MBE prepares a letter to the 

claimant. The letter should outline any deficiencies, and 

specifically describe the evidence needed from the claimant to 

support further assessment of the request. This could include a 

request for resubmission of a modified estimate or estimates. It 

may be helpful, in some instances, for the MBE to contact the 

claimant directly, to explain a problem, and describe the necessary 

steps for submission of needed evidence. In those instances in 

which the MBE issues a development letter to the claimant, the 

MBE allots 30 days for the submission of the necessary evidence. 

For an initial request for evidence, the MBE is to grant a period of 

15 days to allow for the submission of responsive documentation. If 

the requested evidence is not received within the 15-day period 

provided, the MBE sends a second development letter providing an 

additional 15 days to submit the requested documentation. No 

further time will be granted for the submission of this 

documentation, unless extenuating circumstances exist and are 

documented. 

(a) Once all development actions are complete, the MBE must 

carefully weigh the totality of available evidence and 

assign the greatest weight to the estimate that represents 

the most qualified and cost-effective proposal for 

accomplishing the medically necessary home modification. 

While cost is a factor in the MBE’s analysis, it is not the 

sole determiner in the selection process. Each estimate 
41

must be assessed on its merits, along with any input from 

the claimant, in order to identify the estimate with the 

greatest weight. 

(b) If a deficiency is found to exist, and the claimant is unable 

to overcome it, the MBE is to issue a recommended 

decision denying the request for home modification 

reimbursement. In the recommended decision, the MBE 

clearly explains the specific deficiencies in the evidence. 

(3) Issuing Authorization Decisions. Upon reaching a decision to 

grant prior authorization of a reimbursement request, the MBE 

writes a detailed letter decision to the claimant advising of the 

approval. (Exhibit 29-4 provides a sample of the home 

modification approval letter.) In the letter, the MBE provides 

guidance to the claimant regarding the payment options 

available (as detailed in the exhibit letter) and requests that the 

claimant respond in writing, indicating the preferred payment 

option. 

d. Retroactive Requests for Reimbursement. In those instances where a 

claimant did not request prior authorization from DEEOIC, and 

subsequently submits a request for reimbursement for work already 

performed, the MBE conducts a review of the evidence to determine the 

amount, if any, that can be authorized for reimbursement. The claimant 

must provide a LMN that is sufficient for the MBE to make a 

determination regarding the medical necessity of a modification to the 

claimant’s residence. If necessary, the MBE conducts development to 

obtain sufficient medical evidence supporting the claimant’s request. 

(1) Calculating Costs to Determine a Reimbursable Amount. Once the 

MBE establishes the medical necessity of a request for retroactive 

reimbursement of a home modification, the MBE must collect all 

available information from the claimant about the home 

modification that occurred. With the exception of requiring three 

estimates, the evidentiary requirements are no different from those 

previously outlined for prior authorization requests, and the 

burden of proving reasonableness of cost remains with the 

claimant. Supportive evidence could include diagrams, blueprints 

or floor plans, pictures, written descriptions, manufacturer and 

model number of appliances or fixtures, invoices, estimates, paid 

receipts, or other descriptive information. To the extent possible, 

the claimant must also document the pre-modification condition of 

the residence including photographic evidence and a description of 

preexisting structural grade and quality. In assessing a 

reimbursable amount, the MBE is to evaluate all the available 
42

evidence to ascertain only those materials and labor expenses that 

reasonably align with the cost of completing a medically necessary 

modification. The MBE must exclude any costs associated with 

materials and/or labor not necessary to complete the requisite 

home modification. Moreover, the MBE may calculate and deduct 

adjusted costs for any building materials or labor charges 

determined to exceed the pre-modification construction grade or 

quality of the residence. Once the MBE has conducted a thorough 

consideration of the available evidence and calculated the 

reasonably necessary cost required to accomplish the medically 

necessary modification (s), the MBE is to complete a memo to file, 

outlining in detail the analysis performed and calculations used in 

arriving at the reimbursable amount. 

(2) Issuing a decision. Once the MBE has determined that 

reimbursement to the claimant is appropriate, the MBE issues a 

letter decision authorizing reimbursement for the claimed amount. 

If the MBE is unable to obtain evidence supporting reimbursement 

at the claimed amount, or if the MBE’s calculation of allowable 

costs represents a figure that is less than the amount claimed, the 

MBE will issue a recommended decision. Within the content of the 

recommendation, the MBE is to provide a detailed accounting of 

the MBE’s analysis of available evidence and how the MBE 

determined the reimbursable amount. This includes any reference 

materials or other tools utilized to calculate those costs that are 

attributable to modifying the claimant’s residence at a cost 

comparable to the existing grade and quality of construction. 

• Chapter 32 – Coordinating State Workers’ Compensation Benefits

o Chapter 32.4 has been edited to clarify the circumstances under which coordination is 

required as it relates to an election of employee benefits by a survivor. The language 

in v4.2 previously read:

4. When Coordination is Required. Coordination of Part E benefits (there is no 

coordination of Part B benefits) is required only if the EEOICPA beneficiary received 

benefits through a SWC program for the same covered illness for which that same 

EEOICPA beneficiary is eligible to receive benefits under Part E. This means the CE 

first determines the employee/survivor’s eligibility to receive Part E benefits, then 

determines who the beneficiary of the SWC benefits was before determining whether 

coordination is required. For example, if the employee settles a SWC claim for 

asbestosis and the accepted covered illness for which the employee is entitled to Part E 

benefits is also asbestosis, coordination of the Part E award is required to reflect the 

amount of SWC benefits the employee has received.
43

Similarly, in cases where the employee had filed a Part E claim but died before payment 

could be issued, Part E medical benefits through the date of employee’s death awarded to 

the survivor requires coordination if the employee had received SWC benefits for the 

same covered illness. Coordination of medical benefits is required in this case because 

the Part E medical benefits were based on the employee’s entitlement to Part E benefits 

and the same employee received SWC benefits for the same covered illness.

However, if the employee or the deceased employee’s estate (considered same as the 

employee) receives SWC benefits for asbestosis and the accepted covered illness for 

which the survivor is entitled to Part E benefits is also asbestosis, the CE will not 

consider this claim for coordination (unless that survivor also received some form of 

SWC benefits for asbestosis, such as death benefits).

It has been updated in v4.3 to:

4. When Coordination is Required. Coordination of Part E benefits (there is no 

coordination of Part B benefits) is required only if the EEOICPA beneficiary receives 

benefits through a SWC program for the same covered illness for which that same 

EEOICPA beneficiary is eligible to receive benefits under Part E. This means the CE 

first determines the employee/survivor’s eligibility to receive Part E benefits, and then 

determines who the beneficiary of the SWC benefits was before determining whether 

coordination is required. For example, if the employee settles a SWC claim for 

asbestosis and the accepted covered illness for which the employee is entitled to Part E 

benefits is asbestosis, coordination of the Part E award is required to reflect the amount 

of SWC benefits the employee has received.

Similarly, where there is an election to receive the employee’s benefits by the survivor 

(refer to Chapter 20.12b for specific requirements for a survivor who elects to receive the 

employee’s benefits rather than survivor benefits), coordination is required if the

employee received SWC benefits for the same covered illness. Coordination is required 

because the survivor is taking the place of the employee in this situation. For example, if 

the employee received a SWC payment for asbestosis and the survivor elects to receive 

what the deceased employee would have received under EEOICPA based on asbestosis, 

the CE must coordinate the benefits payable to the survivor.

In cases where the employee had filed a Part E claim but died before payment could be 

issued, Part E medical benefits awarded to the survivor through the date of the 

employee’s death are subject to coordination if the employee had received SWC benefits 

for the same covered illness. Coordination of medical benefits is required in this case 

because the Part E medical benefits were based on the employee’s entitlement to Part E 

benefits and the same employee received SWC benefits for the same covered illness.
44

o Chapter 32.5 has been edited to add a new exception to coordination of SWC 

benefits. The language in v4.2 previously read:

5. Exceptions. The following are exceptions to the coordination requirement. 

Review Exhibit 32-1 for additional scenarios and determination as to whether 

coordination is required. 

a. Multiple illnesses. If the claimant receives SWC benefits for a noncovered illness, or for both a covered and a non-covered illness arising 

out of and in the course of the same work-related exposure, the CE does 

not coordinate the Part E award. 

For example, if the claimant settles a SWC claim for asbestosis and 

silicosis arising out of the same exposure and the amounts are not 

apportioned between the two illnesses, and the accepted covered illness 

for which the claimant is entitled to Part E benefits is only asbestosis, 

coordination of the Part E benefits is not required. 

b. Covered illness. Because a “covered illness” is an illness resulting from 

exposure to a toxic substance, the same medical condition accepted by 

DEEOIC and a SWC program may not require coordination. For 

example, if the claimant settles a SWC claim for asbestosis in a non-DOE 

facility and is entitled to Part E benefits for asbestosis based on a separate 

and distinct exposure to asbestos at a DOE facility, coordination of the 

Part E benefits is not required because it is not the same covered illness 

(not resulting from the same toxic exposure).

c. Waivers. DEEOIC may waive the requirement to coordinate Part E 

benefits with benefits paid under a SWC program, if it is determined that 

the administrative costs and burdens of coordinating Part E benefits in a 

particular case or class of cases justifies the waiver. A waiver is 

automatically granted if the total amount of SWC benefits the claimant 

received is under $200.

If a waiver is to be granted, the CE prepares a memo to the file, approved 

by the DD, explaining that the requirement to coordinate the benefits is 

waived due to the dollar amount of the SWC benefits the claimant 

received. 

d. Medical or Vocational Benefits Only Claims. Medical or vocational 

benefits paid by a SWC program do not require any coordination of 

benefits.

It has been updated in v4.3 to:
45

5. Exceptions. The following are exceptions to the coordination requirement. 

Review Exhibit 32-1 for additional scenarios and determination as to whether 

coordination is required. 

a. Multiple illnesses. If the claimant receives SWC benefits for a noncovered illness, or for both a covered and a non-covered illness arising 

out of and in the course of the same work-related exposure, the CE does 

not coordinate the Part E award. 

For example, if the claimant settles a SWC claim for asbestosis and 

silicosis arising out of the same exposure and the amounts are not 

apportioned between the two illnesses, and the accepted covered illness 

for which the claimant is entitled to Part E benefits is only asbestosis, 

coordination of the Part E benefits is not required. 

b. Covered illness. Because a “covered illness” is an illness resulting from 

exposure to a toxic substance, the same medical condition accepted by 

DEEOIC and a SWC program may not require coordination. For 

example, if the claimant settles a SWC claim for asbestosis in a non-DOE 

facility and is entitled to Part E benefits for asbestosis based on a separate 

and distinct exposure to asbestos at a DOE facility, coordination of the 

Part E benefits is not required because it is not the same covered illness 

(not resulting from the same toxic exposure). 

c. Waivers. DEEOIC may waive the requirement to coordinate Part E 

benefits with benefits paid under a SWC program, if it is determined that 

the administrative costs and burdens of coordinating Part E benefits in a 

particular case or class of cases justifies the waiver. A waiver is 

automatically granted if the total amount of SWC benefits the claimant 

received is under $200. 

If a waiver is to be granted, the CE prepares a memo to the file, approved 

by the DD, explaining that the requirement to coordinate the benefits is 

waived due to the dollar amount of the SWC benefits the claimant 

received. 

d. Medical or Vocational Benefits Only Claims. Medical or vocational 

benefits paid by a SWC program do not require any coordination of 

benefits.

e. Survivor Claim. In a survivor claim (except as noted in Section 4), the CE 

does not coordinate even if the employee or the deceased employee’s 

estate received SWC benefits based on the same covered illness as the 

survivor’s Part E claim (unless that survivor also received some form of 

SWC benefits, such as death benefits). For example, if the employee 

received a SWC payment based on asbestosis and the survivor Part E 
46

claim was also based on asbestosis, the CE will not consider this claim for 

coordination because the survivor did not receive the SWC benefits.

RACHEL D. POND

Director, Division of 

Energy Employees Occupational Illness Compensation