Source: https://www.dol.gov/owcp/dfec/regs/compliance/DFECfolio/bctfy12/
Timestamp: 2019-04-26 05:39:06+00:00

Document:
Bill Pay - Revision in the Reimbursement Rates Payable for the Use of Privately-Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: The Defense Base Act (DBA) provides a workers' compensation system for workers injured or killed while performing work for government contractors outside the United States. Liable carriers under the DBA are generally required to pay periodic compensation benefits to the injured employee or to his/her survivors. However, the DBA provides that in cases involving non-citizens and non-residents of the United States and Canada, after the entry of a compensation order, the carrier may request the responsible Longshore District Director overseeing the DBA claim to commute the award of benefits, resulting in one lump-sum payment. Under the DBA, the District Director is required to act on such a request. It is a common practice of carriers to request commutation of a DBA award for these claimants residing overseas, obviating the time and expense of making periodic payments.
Where the DBA-covered injury or death results from a war risk hazard, the carrier may then seek reimbursement for its payments under the War Hazards Compensation Act (WHCA). The WHCA, administered by the Division of Federal Employees' Compensation (DFEC), provides a compensation system under which the United States reimburses a contractor or its insurance carrier liable under the DBA for the payment of benefits resulting from an injury or death caused by a "war risk hazard."
The WHCA also provides that an employer or its carrier seeking reimbursement may recover "reasonable and necessary" claims expenses. See 42 U.S.C. 1704(a)(3). Under the WHCA's implementing regulations at 20 CFR Part 61, reasonable and necessary claims expenses are divided into two types of expenses (allocated and unallocated) incurred in connection with a case for which reimbursement is claimed. The regulations define "unallocated claims expenses" as costs that are incurred in processing a claim but cannot be specifically itemized or documented. The regulations generally provide that "[a] carrier may receive reimbursement of unallocated claims expenses in the amount of to 15% of the sum of the reimbursable payments" made under the DBA. See 20 CFR 61.104(c).
Purpose: To address the current practice of reimbursing carriers for unallocated claims expenses under the WHCA.
In addition to providing a general "15%" rule for reimbursing unallocated claims expenses as described above, the regulations also provide authority to vary that calculation, providing that "if this method of computing unallocated claims expenses would not result in reimbursement of reasonable and necessary claims expenses, the Office may, in its discretion, determine an amount that fairly represents the expenses incurred." Thus, while the 15% payment provides a general rule of thumb, ultimately the payment of unallocated costs should be a reasonable measure of unallocated expenses incurred. Although this regulation could be applied in the context of increasing the amount of unallocated expenses, given the language of the provision, it is equally applicable to circumstances where unallocated expenses should be less.
Under current practices, if the carrier requests the 15% payment, the DFEC routinely pays this 15% allotment in virtually all reimbursement cases. This has been deemed reasonable in cases where the carrier (or self-insured employer) is merely seeking reimbursement for past periodic expenses. However, one subset of cases where the practice of routinely calculating unallocated claims expenses as 15% of the claimed reimbursement for benefits merits re-examination. In certain cases, the carrier commutes its future DBA liability and, therefore, the payments for which it seeks reimbursement will include both its past payments of periodic liability and the commuted payment for future DBA liability. Although it does not appear possible that the carrier will have incurred reasonable or necessary costs for these commuted benefits in any amount over and above what has already been documented and is reimbursable as an allocated expense, the current practice provides that the calculation of the unallocated claims expenses includes this commuted amount of future DBA payments.
In such instances, the payment of 15% of the commuted amount constitutes an unjustified payment to the carrier, since it is not reasonably related to the expenses in handling the DBA claim. Since the regulations grant considerable discretion in reimbursing unallocated costs, the DFEC will exercise this authority and use an alternative approach to calculating a reasonable and appropriate measure of unallocated costs in the case of the commuted award. In circumstances where the carrier has had the benefit commutated and seeks reimbursement, the DFEC will reimburse unallocated costs equaling 15% of the payments it has made up until the time the award is commuted. DFEC will exclude from the calculation the payment of the commuted amount that represents payment of future liability, as no unallocated costs have been incurred in the payment of these benefits.
Because the authority for exercising this discretion in reimbursing unallocated claims expenses already exists in the regulations, this approach to payment of unallocated claims expenses in cases with commuted awards by insurance carriers applies to all pending and future claims for reimbursement under the WHCA.
Disposition: This bulletin is to be retained until the FECA PM has been updated.
Subject: Life Insurance - Optional Life Insurance Rates Change Effective January 1, 2012, and Other Life Insurance Information.
Background: While in receipt of compensation benefits, claimants are entitled to remain enrolled in the Federal Employees' Group Life Insurance (FEGLI) program. To continue this coverage, enrollees for Optional Life Insurance (OLI) coverage must have the appropriate withholdings made from their compensation payments. OLI includes three options - Option A (Standard), Option B (Additional), and Option C (Family).
An enrollee may have any combination of the options. The various combinations are known as "classes". Exhibit 1 of this Bulletin is a listing of these life insurance combinations by "class code". These are the codes that are provided by the employing agency on Form CA-7, Claim for Compensation, and we are required to make the appropriate premium deductions in the Compensation application of the Integrated Federal Employees Compensation System (iFECS). When the class code and the yearly salary are keyed during data entry in iFECS, the system will calculate the appropriate withholdings.
The withholdings are based on the age band of the insured, defined by the age of the enrollee. The enrollee is considered to have attained the age of a particular band as of the first pay period subsequent to his or her birthday. All withholdings for OLI usually stop on the first compensation period to occur after the enrollee reaches their 65th birthday. However, a notice is sent to claimants 60 days prior to their 65th birthday, informing them of their option to continue life insurance. The claimant must contact the Office of Personnel Management (OPM) to make the election, and OPM will inform OWCP as to what level of coverage is to be maintained.
In order for an enrollee to have OLI coverage, they must also have Basic Life Insurance (BLI). Prior to January 1, 1990, BLI was free of charge, and no deductions are required for any OWCP claimants with a date of injury prior to that date. For all claims with a date of injury after January 1, 1990, OWCP is also required to withhold premiums for the Basic Life Insurance coverage. The enrollee may also elect Post-Retirement Basic Life Insurance (PRBLI) should they wish to continue their BLI coverage past age 65. PRBLI is mandatory for any enrollee that carries OLI past age 65.
At the time of an enrollee's death, OPM will send an inquiry to OWCP concerning life insurance withholdings during the enrollee's receipt of compensation benefits. It is imperative that OWCP verify the fact that premiums were or were not withheld from compensation benefits. Timely verification is extremely important as no action may be taken by either OPM or FEGLI until OWCP's verification is received.
The previous rate changes for life insurance coverage were effective January 12, 2005, updating the rates for enrollees over the age of 65.
Purpose: To inform the appropriate personnel of the new premium rates for life insurance coverage effective January 1, 2012. The new rates are lower for some age bands in Option B, Option C, as well as the amounts withheld for the Post-Retirement Basic Life Insurance coverage.
There is no change in premiums for BLI or Option A coverage.
References: Office of Personnel Management (OPM), Benefits Administration Letter, No. 11-205, dated November 10, 2011.
1. The new rates were available in iFECS on January 5, 2012.
2. iFECS has been updated as of the periodic disability payroll for the period effective January 15, 2012 through February 11, 2012. Cases with gross overrides should be recalculated to reflect the new rates for life insurance coverage.
3. There will be no notices sent to the enrollees receiving an adjustment on the periodic disability payroll. Please note that changes in the net compensation amount paid after February 11, 2012 can be the result of one or more of the following factors: health insurance premiums adjustments; life insurance premium adjustments (both for rate or age band changes); or Min/Max salary adjustments.
5. Post-Retirement Basic Life Insurance Coverage.
The rates for the PRBLI coverage have also reduced. Exhibit 12 is a complete list of the PRBLI rates and effective dates for this coverage. This coverage is elected at time of the claimant's retirement (or at age 65 if they are on the OWCP rolls) and determines the rate at which BLI will decline in value during the life of the claimant. Exhibit 13 lists the BLI rates and effective dates.
PRBLI coverage involves one of three choices affecting the original BLI coverage. The claimant may elect reductions in the amount of BLI coverage at the time of retirement of 75 percent, 50 percent, or No Reduction (i.e. maintaining 100% of BLI coverage). When the election is made, OPM will advise OWCP of the election, the date to commence withholdings, and the salary upon which the withholdings should be calculated.
There is no cost or withholdings for the 75 percent reduction. Withholdings for the 50 percent and no reduction are withheld from compensation benefits effective the date the enrollee "retires" for life insurance purposes. Withholdings continue for life, or until the coverage is either cancelled or otherwise discontinued.
The per annum salary provided by OPM will be the base upon which to calculate the biweekly withholdings. It is generally a different amount from that upon which the salary for wage-loss compensation is calculated. This is due to the fact that optional life insurance coverage is withheld during the entire period compensation, is paid up to age 65, and is based on the salary at time of disability or date of recurrence. PRBLI coverage must be withheld from date of retirement, though it can be elected prior to that time. Withholdings for PRBLI are based on the final salary as reported by OPM.
In iFECS, the premiums will change the first periodic pay cycle following the age event (i.e. the claimant's birthday when they move into a new age bracket for life insurance). If the enrollee elects to continue coverage after age 65, premiums will continue for life.
PLEASE NOTE: Premiums are based on the per annum salary ofthe claimant at retirement. OPM must advise OWCP ofthe coverage, and will provide the effective date and the per annum salary.
PLEASE NOTE: Premiums are only withheld until age 65. Premiums are calculated using the "BASE" pay on which compensation is computed. This amount is rounded-up to the nearest $1,000 and an additional $2,000 is added.
Subject: Compensation Pay - Consumer Price Index (CPI) Cost-of-Living Adjustments for March 1, 2012.
Reference: FECA Consumer Price Index (CPI) Amendment, dated January 6, 1981; Bureau of Labor Statistics Consumer Price Index Publication for December 2009 (USDL-10-0011).
Purpose: To furnish information on the CPI adjustment process for March 1, 2012.
The cost-of-living adjustments granted to a compensation recipient under the FECA are based on the "Consumer Price Index for Urban Wage-Earners and Clerical Workers" (CPI-W) figures published by the Bureau of Labor Statistics (BLS). The annual cost-of-living increase is calculated by comparing the base month from the prior year to the base month of the current year, with the percentage of increase adjusted to the nearest one-tenth of 1 percent. 5 U.S.C. 8146(a) establishes the base month for the FECA CPI as December.
December 2010 had a CPI-W level of 215.262, and the December 2011 level was reported by BLS as 222.166. This means that the new CPI increase, adjusted to the nearest one-tenth of one percent, is 3.2 percent. The increase is effective March 1, 2012, and is applicable where disability or death occurred before March 1, 2011. In addition, the new base month for calculating the future CPI is December 2011.
Action: National Office Production staff will update the iFECS CPI tables and have all payment records re-calculated when the iFECS system is not in use by District Office personnel. This will occur on or about March 1, 2012. The March 10, 2012 check will be paid at the 2011 rate but will include the supplemental CPI payment for the period of March 1st to March 10th. The following periodic roll check will reflect the updated 2012 28-day amount. Please note that if there are any cases with fixed gross overrides, there will be no supplemental record created. These cases must be reviewed to determine if CPI adjustments are necessary, and, if so, a manual calculation will be required. If the gross override payment is in fact eligible for annual CPI increases, the payment plate should be adjusted in the iFECS system to pay as a "Gross Override with CPI."
1. Minimum and Maximum Adjustments Listings. Form CA-841, Cost-of-Living Adjustments; Form CA-842, Minimum Compensation Rates; and Form CA-843, Maximum Compensation Rates, should be updated to indicate the increase for 2012. Attached to this directive is a complete list of all the CPI increases and effective dates since October 1, 1966 (through March 1, 2012) for reference.
a. All claimants will be provided a notice with their Benefit Statements indicating the amount of this year's increase. The Treasury will include this notice as a "stuffer card" with every Benefit Statement issued for the March 10, 2012 rolls.
b. If claimants write or call for verification of the amount of compensation paid (possibly for mortgage verification; insurance verification; loan application; etc.), please continue to provide this data in letter form from the district office. Many times a Benefit Statement may not reach the addressee and regeneration of the form is not possible. A letter indicating the amount of compensation paid every four weeks will be an adequate substitute for this purpose.
Prior to September 7, 1974, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis, or the nearest multiple of $.23 on a weekly basis ($.23, $.46, $.69, or $.92). After September 7, 1974, the new compensation after adding the CPI is rounded to the nearest $1.00 on a monthly basis, or the nearest $.25 on a weekly basis ($.25, $.50, $.75, or $1.00).
1 Per Executive Order 13561 signed by President Obama on December 22, 2010, the GS pay schedules for Federal civilian employees will remain at 2010 levels for 2011 and 2012.
Reference: Memorandum for Executive Heads of Departments and Agencies dated December 22, 2010; and the attachment for the 2012 General Schedule.
Background: On December 22, 2010, the President signed Executive Order 13561 implementing a salary freeze for the General Schedule basic pay. The rates of pay established for the 2010 GS Pay Schedule are to remain in effect through 2012. Normally, the applicability under 5 U.S.C. 8112 only includes an increase in the basic General Schedule, so no increase to the minimum or maximum rates of compensation will be afforded this year. Any additional increase for locality-based pay is excluded as always.
Purpose: To inform the appropriate personnel of the minimum/maximum rates of compensation and the adjustment procedures for affected cases on the periodic disability and death payrolls.
The maximum compensation rate payable is based on the scheduled salary of a GS-15, step 10, which remains $129,517 per annum. The basis for the minimum compensation rate is the salary of a GS-2, Step 1, which remains $20,017 per annum. The actual rates are outlined below.
Action: The Integrated Federal Employees' Compensation System (iFECS) will not require updates to the periodic disability and death payrolls, as the rates have not changed since the prior adjustments were made.
Background: The Office of Workers' Compensation Programs' (OWCP) Division of Federal Employees' Compensation (DFEC) has long been committed to facilitating effective communication with claimants and employing agencies regarding decisions and other actions in each individual case. Consistent with its responsibilities under applicable Federal disability nondiscrimination laws, with its mission, and with the additional emphasis on the employment of individuals with disabilities as reflected in Executive Order 13548 (issued July 26, 2010), OWCP is issuing this Bulletin to inform DFEC officials and personnel of their responsibilities under federal disability nondiscrimination law (including but not limited to Rehabilitation Act Section 504 obligations, which applies to Federally-conducted programs or activities). The Bulletin explains the type of notice OWCP will require DFEC to provide to claimants about its responsibilities under federal disability nondiscrimination law. The Bulletin also describes the procedures that must be used for handling requests from claimants needing communication assistance, or reasonable accommodations/modifications (see explanation in Section III below), in the claims process. Finally, it sets forth requirements regarding conducting hearings, medical appointments, and other in-person interactions in accessible facilities.
The district office should handle virtually all requests for communication assistance or reasonable accommodations/modifications for claimants with disabilities immediately in the manner in which the claimant requests. Because OWCP bears a high burden for justifying any failure to provide requested assistance, a district office should immediately contact the National Office if it has questions or concerns regarding how to comply with the applicable requirements.
In addition to its duty to provide communication aids and services and reasonable accommodations for persons with disabilities, OWCP must reasonably modify its policies, practices, and procedures when necessary to avoid discrimination on the basis of disability. It is also obligated to conduct its programs and activities so that each part of a program or activity is accessible to individuals with disabilities.
Communicating effectively with, providing other types of appropriate assistance and accommodations/modifications for, and ensuring that all aspects of the claims process are accessible to, claimants with varying types of disabilities (including visual impairments) are not only consistent with the non-adversary nature of the FECA adjudicatory process, but are also required by Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794) (Section 504), which applies to Federally-conducted programs or activities. In addition, in the Americans with Disabilities Act Amendments Act of 2008 (ADAAA), which amended the Rehabilitation Act as well as other Federal disability nondiscrimination laws, Congress emphasized that the definition of disability "shall be construed in favor of broad coverage of individuals . . . to the maximum extent permitted by [the terms of the applicable law]," and generally shall not require extensive analysis. Therefore, when responding to a request for assistance, OWCP should focus its attention primarily on how to assist the claimant (or other individual with a disability) most effectively, rather than on whether the individual is, in effect, "disabled enough" to deserve the assistance.
Both applicable law and Department of Labor policy require OWCP to communicate as effectively with persons who have disabilities as the agency communicates with other persons. OWCP bears the general responsibility for providing communication aids and services for claimants with disabilities and for ensuring that the aids and services provided to each individual claimant with a disability are effective for that particular claimant. The obligation to provide equally effective communications applies to the written letters and decisions that OWCP generally provides in paper format telephonic communications, and all other modes of communication.
Finally, the legal duty to provide accommodations/modifications, and to conduct hearings and other in-person interactions in accessible facilities, applies to all phases of the claims process.
Applicability: All National and District Office personnel, field nurses, vocational rehabilitation counselors, medical billing processors and employing agencies.
References: 29 U.S.C. § 794; 29 U.S.C. § 705; 42 U.S.C. § 12102. Note that the ADAAA amended the statutory definition of "disability" for purposes of disability nondiscrimination law (referred to in the Background section above) to broaden that definition and provide rules for construing it. See 29 U.S.C. § 705(20)(B), incorporating by reference the definition of "disability" set forth in 42 U.S.C. § 12102.
The EEOC published a Final Rule in March 2011 that explains in detail how to interpret the definition of "disability" and its component elements; it has also published a fact sheet and Questions and Answers sheets regarding the provisions of the Final Rule. These documents are available at the EEOC web page cited above. Please note that although the EEOC regulations are not directly applicable to FECA, DOL's interpretation of the disability nondiscrimination laws it enforces must be consistent with EEOC's interpretation of Title I of the Americans with Disabilities Act (ADA); therefore, EEOC's regulations and guidance documents are useful tools for learning about DFEC's and OWCP's disability-related legal obligations.
Purpose: To advise OWCP and related personnel of their responsibilities, and of OWCP procedures, for taking certain actions related to disability. These actions include responding to requests by claimants and others for auxiliary aids and services to ensure equally effective communication ("communication aids and services"), or for reasonable accommodations/modifications, on the basis of disability. They also include taking appropriate steps to ensure that all in-person interactions are accessible to persons with disabilities.
Although this Bulletin primarily addresses requests from claimants needing communication assistance and/or accommodations/modifications under applicable Federal disability nondiscrimination laws, these instructions also apply where an employing agency official (for example, injury compensation specialist), a representative, or anyone else legitimately associated with the claims process requires communication aids and services, or reasonable accommodations/modifications.
1. All OWCP/DFEC personnel must be sensitive to the potential needs of the claimant population and must realize that the law permits claimants to request communication aids and services, and/or reasonable accommodations/modifications, at any stage of the claims process. A claimant who did not need such aids, services, or accommodations/modifications at the initial stages of a claim may later develop a disability requiring one or more of these types of assistance. Under the law as amended by the ADAAA, a person who does not have an actual, current disability, but who has a record of a disability (for example, someone who has recovered from cancer or heart disease), is entitled to reasonable accommodations under appropriate circumstances.
2. Because the same medical condition may affect each person differently, requests for communication aids and services and/or accommodations/modifications must be analyzed on a case-by-case basis, and actions appropriate to each individual person with a disability will vary. For example, not every person who is deaf understands American Sign Language (ASL). Some deaf persons rely on lip reading, frequently combined with computer-assisted real-time (CART) transcription; others understand Signed English (which has a different syntax from ASL); and still others understand other sign languages, such as Spanish Sign Language. Information on how to respond to each type of request (for communication aids and services, and for accommodations/modifications) appears in Section III below.
3. Upon receipt of a request for disability-related communication aids and services or reasonable accommodations/modifications, action must be taken immediately. Once OWCP determines that accommodation is required under the particular circumstances, the background color of the header in the Integrated Federal Employees' Compensation System (iFECS) will be changed to purple, so that anyone reviewing the case will immediately understand that special handling is required.
All OWCP/DFEC personnel should know the procedures for responding to requests for communication aids and services and/or accommodations/modifications. Each District Office should have at least one designated point of contact who is responsible for helping with responses to such requests, and who is knowledgeable about the relevant procedures, law and policy. Any personnel within that District Office should reach out to the designated point of contact should a question arise. As needed, DFEC personnel may also consult with the Branch of Regulations and Procedures and the Branch of Technical Assistance, which may seek out resources available in other Department of Labor agencies or other appropriate federal agencies. For example, DOL's Office of Disability Employment Policy (ODEP) has a Technical Assistance Center called the Job Accommodation Network (JAN) which may be able to assist with interactive services to help determine what accommodations are appropriate for a specific person. Contact with JAN should be handled through the National Office.
1. Federal disability nondiscrimination law defines a "disability" as a physical impairment (such as cancer, diabetes, or epilepsy) or a mental impairment (such as autism, bipolar disorder or post-traumatic stress disorder) that substantially limits one or more of the person's major life activities. DFEC will provide notice to claimants that: if they have such a disability, they may request that DFEC provide them with communication aids and services and/or accommodations/modifications; a claimant who has a record of such a disability is also entitled to receive reasonable accommodations under appropriate circumstances; and DFEC will respond to all requests for the above types of assistance as required by Federal law. A sample notice that provides the above information is attached to this Bulletin.
3. Communications from DFEC to the claimant will include either this notice or a similar notice that provides the same information, and will also include information about how and where to request communications aids and services and/or accommodations/modifications.
This section explains how to respond to two different types of requests. Subsection A addresses requests for auxiliary (communication) aids and services, while Subsection B addresses other types of requests for individualized assistance. Requests in the latter category should be considered requests for reasonable accommodations and/or modifications, as explained in subsection B.
DFEC will provide appropriate communication assistance for claimants with disabilities at all stages of the claims process. The circumstances under which communication assistance must be provided extends to claimants' interactions with physicians, field nurses, vocational rehabilitation counselors, or other health providers, and DFEC staff. Appropriate assistance is to be provided regardless of the method of contact -- whether by telephone, postal mail, in person, or some other method.
The type of communication aids or services necessary to ensure effective communication will vary with the type of communication used by the individual with a disability; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place. When deciding what communication aids or services to provide in response to a request from a claimant or other person with a disability, DFEC must honor the choice of the person with a disability, unless DFEC can demonstrate that either: (a) another means of communication exists that will be effective for the particular person with a disability, or (b) use of the means chosen by the person with a disability would result in a fundamental alteration in the nature of the DFEC or OWCP program. In addition, in order to be effective, communication aids and services must be provided by methods that are usable and/or understandable by the individual with a disability; in a timely manner; and in such a way as to protect the privacy and independence of the individual with a disability.
Each DFEC office should be prepared to provide documents in each of the above formats when requested. DFEC will identify one or more sources for producing documents in Braille and, if appropriate, on audio CD, and will inform each district office of the turnaround time and procedures for submitting such requests. If the district office plans to supply its own large-print or high-contrast documents, it should ensure that enough staff members know the appropriate computer and printer settings to permit such documents to be produced at any time, without delay. If the district office plans to create its own audio or text CDs, it should keep the appropriate types of blank CDs in stock.
If a person with a visual impairment requests that a document be provided in Braille, audio CD, or data CD/Microsoft Word on CD, the document should be provided both in the usual format (paper or imaged file) and the requested alternate format.
In-person contacts: If sign language interpreting services are necessary, they may be provided in person or through remote Video Interpreting Services.
Interpreters must be qualified. Under Federal disability nondiscrimination law, an interpreter is qualified if s/he is able to interpret effectively accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. The law prohibits DFEC from requiring an individual with a disability to bring another person to interpret for him/her, whether that individual is a claimant, an employing agency official, a representative, or someone else who is legitimately associated with the claims process.
In circumstances in which it is permissible for a claimant or other individual with a disability to be accompanied by another adult during in-person contacts, DFEC must not rely on that adult to interpret, or to otherwise facilitate communication, except: in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available; or where the individual with a disability specifically requests that the accompanying adult interpret or facilitate communication; the accompanying adult agrees to provide such assistance; and reliance on that adult for such assistance is appropriate under the circumstances.
Hearings. The Branch of Hearings & Review (BHR) is responsible for providing appropriate communication aids and services for hearings, and for notifying claimants and other appropriate parties that such aids and services are available. For example, for in-person oral hearings before a BHR representative, BHR must provide sign language interpreters, CART transcription services, or other types of communication assistance upon request. For telephonic hearings, BHR must provide TTY or other types of relay services. As with other DFEC branches, when deciding what type of communication aids or services to provide, BHR must give primary consideration to the request of the individual with a disability.
Claimants and other persons associated with the claims process who have disabilities may request a wide range of adjustments or changes to the process because of their disabilities. Such requests constitute requests for reasonable accommodation or modification; they automatically trigger DFEC's or OWCP's duty to act.
a. To request an accommodation or modification, all that the individual with a disability (or someone acting on his/her behalf) must do is notify the claims examiner, hearing representative, or someone else associated with DFEC or OWCP, that s/he needs an adjustment or change in the claims processing procedures for a reason related to a disability.
Note: A request for disability-related parking assistance, such as for an accessible parking space within the building where a hearing or other in-person meeting is scheduled, is a request for a reasonable accommodation and should be treated as such.
b. The individual may use "plain English": s/he need not mention disability law or use technical language such as "reasonable accommodation" or "reasonable modification of policies, practices, or procedures."
c. The request does not need to be in writing: it may be made during a conversation, or through any other mode of communication. DFEC staff should be alert to such requests, and should recognize their legal and practical significance. The law permits DFEC personnel to write a memorandum or letter confirming the individual's request, or to ask the individual to submit the request in writing. However, the initial request triggers DFEC's and OWCP's duty to take action, and cannot be ignored pending receipt, completion, or processing of written confirmation.
2. When DFEC receives a request for an accommodation/modification as described above, it may simply provide the requested assistance. Otherwise, DFEC personnel should engage in an informal dialogue with the individual with a disability (and/or his/her representative) to clarify what the individual needs and identify the appropriate reasonable accommodation/ modification. The exact nature of the dialogue will vary depending upon the circumstances.
a. In many instances, both the disability and the type of accommodation/modification required will be obvious; thus, there may be little or no need to engage in any discussion.
b. In other cases, DFEC may need to ask questions concerning the nature of the disability and the individual's functional limitations in order to identify an effective accommodation or modification.
c. The individual with a disability does not have to be able to specify the precise accommodation or modification needed. However, s/he (or his/her representative) does need to describe the barriers s/he is encountering in the claims process or the way it is implemented.
d. Even if the individual with a disability cannot identify a specific accommodation or modification, s/he may be able to offer suggestions about the type, or general characteristics, of reasonable accommodations/modifications that will help overcome the barrier.
e. Once the interactive dialogue has enabled the district office to ascertain the specific limitations imposed by the disability and barriers imposed by the claims process, where neither the individual nor DFEC is familiar with possible accommodations or modifications, the district office may contact the National Office for assistance from an accommodations expert.
3. Under the law, DFEC is permitted to ask for documentation to support a request for accommodation/modification only in the following circumstances: either the disability itself or the need for an accommodation/modification is not obvious, and the information already in DFEC's possession is insufficient to confirm that the individual has a substantially limiting impairment or needs an accommodation or modification (in the case of a claimant, the information already in the individual's file).
4. In some circumstances, it will be appropriate for DFEC to make adjustments or provide assistance without waiting for a specific request. For example, if DFEC knows that a claimant has mobility impairments (for example, uses a wheelchair, walks only short distances with the use of a cane or walker, or has respiratory or cardiac-related restrictions on walking), it is entirely appropriate -- as well as good customer service -- for the DFEC staffer to take the initiative to schedule in-person meetings with the claimant in locations that minimize the distance the claimant must walk or propel his/her chair.
DFEC and OWCP are obligated to conduct their programs and activities so that when each part of a program or activity is viewed as a whole, that part is fully accessible to individuals with disabilities, including those with mobility impairments. Because not every facility associated with the claims process is required to satisfy the full panoply of accessibility standards adopted by the General Services Administration (GSA) for Federal facilities, OWCP DFEC is implementing the following accessibility-related policy: ALL IN-PERSON INTERACTIONS MUST BE HELD IN ACCESSIBLE LOCATIONS. Such interactions include, but are not limited to: any meetings with the field nurse or vocational rehabilitation counselor; medical examinations; and all in-person hearings before DFEC Branch of Hearings & Review.
Whether a particular location or facility may be considered "accessible" will be determined pursuant to the accessibility standards that are applicable to Federal facilities (as well as to facilities designed, built, altered, or leased with Federal financial assistance). See http://www.access-board.gov/aba/index.htm.
Upon receipt of this Bulletin, District Directors will share this information and these procedures with district office staff, discuss, and provide guidance as needed. District Directors will consult with the National Office as necessary. District Directors will update staff as procedures are refined and revised.
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from DFEC in the form of communication assistance, accommodation and modification to aid you in the FECA claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.
If you have a disability (a substantially limiting physical or mental impairment), please contact our office/claims examiner for information about the kinds of help available, such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications.
Effective December 1, 2011, benefits issued by the Social Security Administration (SSA) were increased by 3.6%. This requires the amount of the Federal Employees' Retirement System (FERS) Dual Benefits deduction to be increased by the same amount, to ensure the dollar-for-dollar offset remains current.
This adjustment will be made from the National Office for all cases that were correctly entered into the Compensation application of the Integrated Federal Employees Compensation System (iFECS). The adjustment will be effective with the periodic roll cycle beginning December 18, 2011. There will be no adjustment or overpayment declared for the period of December 1, 2011 through December 17, 2011.
PURPOSE: Because of continued heightened concerns over disclosure of personal information, the Office of Workers' Compensation Programs (OWCP) is instituting this formal policy on AQS access.
While OWCP realizes that AQS information could be useful to other entities such as pharmacy providers, OWCP believes that the very limited information needed by these entities is available through other means, such as the bill pay portal.
1. AQS is a secure internet site that provides access to certain information on Federal Employees' Compensation Act (FECA) claims to authorized personnel from federal agencies. The information available includes the claimant's name, social security number, home address, current claim status, compensation payment history, medical bill payment history, and COP Nurse assignment information.
2. Within each federal agency, there is a designated Intra-Agency Coordinator (IAC) recognized by DFEC as the sole point of contact for AQS user access within that particular agency. Any employing agency personnel who contact DFEC directly for AQS access are routed to the applicable IAC. The IAC then contacts the Division of Federal Employees' Compensation (DFEC) to gain permission for that user. A specific user name is assigned to that user; access is password protected.
3. Access to AQS cannot be granted on a case-by-case basis, nor can AQS data fields be limited by user. Access is granted based on employing agency chargeback codes.
4. All records relating to claims for FECA benefits are covered by the government-wide Privacy Act system of records entitled DOL/GOVT-1. Information from the FECA file may only be released pursuant to a need to know (applicable only to disclosures within the Department of Labor), a published routine use, a signed Privacy Act waiver, or a court order from a court of competent jurisdiction. Release of information in accordance with a routine use must be consistent with the purpose for which the file was created; that purpose is the administration of the FECA claim. The FECA regulations at 20 C.F.R. §10.11 make clear that the protection, release, inspection, and copying of records covered by DOL/GOVT-1 should be carried out in accordance with the rules, guidelines, and provisions of Subpart A of the FECA regulations, as well as those contained in 29 C.F.R. parts 70 and 71, which are the Department of Labor's regulations implementing the Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C. 552a) respectively, as well as with the notice of system of records and routine uses published in the Federal Register.
5. A "routine use" authorizes disclosing information from the FECA claim file without first obtaining the claimant's permission. Such disclosure is acceptable because the routine use is listed and published in the Privacy Act Systems Notice for DOL/GOVT-1; because OWCP has concluded that disclosure in the particular circumstance is compatible with the routine use; and because the anticipated use of the information is consistent with the purpose for which the information was collected. A listing of the universal routine uses which apply to all Department of Labor (DOL) systems of records can be found at http://www.dol.gov/sol/privacy/intro.htm. A listing of the routine uses specific to DOL/GOVT-1 can be found at http://www.dol.gov/sol/privacy/dol-govt-1.htm. [See DOL Privacy Act System of Record Notices, 67 FR 16825, at 16827-16828 (April 8, 2002).] Further guidance can also be found at http://www.dol.gov/sol/privacy/intro.htm.
1. A routine use published in the Federal Register permits disclosure to "federal agencies that employed the claimant at the time of the occurrence or recurrence of the injury or occupational illness in order to verify billing, to assist in administering the FECA, to answer questions about the status of the claim, to consider rehire, retention or other actions the agency may be required to take with regard to the claim, or to permit the agency to evaluate its safety and health program." This, combined with another routine use, permits access to contractors performing workers' compensation functions for agencies, e.g. federal contractors retained to provide claims filing, case management and return to work services. In limited circumstances, other individuals may be granted access based on a particular routine use.
2. Based on DOL OWCP's responsibility to protect the information that resides in a Privacy Act System of Records, AQS access must be limited to authorized users in federal agencies (and, where appropriate, contractor employees) who are performing activities authorized by the language in the routine use above. Examples of such authorized users include agency injury compensation specialists. Other employing agency personnel (such as immediate supervisors, safety and health officials without any workers' compensation duties, and Accident Review Panels) generally do not have a sufficient business reason for access to this level of personal information and will not qualify as authorized users.
3. DOL does not consider medical providers and entities that perform ancillary functions (for example, pharmacy billing and management) authorized users, as AQS provides a level of detail and personal information far beyond what is needed by those entities. If such providers and entities need information on a particular claim, other methods for accessing the more limited information needed by them are available through the billing portal or from the agency, but direct access to AQS will not be authorized.
4. Agencies may wish to encourage their employees to utilize the Claimant Query System as an additional resource to meet their needs.
1. FECA Circular 08-04 (DFEC Protocol Statement - OIG Audits, Evaluations and Investigations) was released in response to the increased number of requests for information received from the Office of Inspector General (OIG) community as they performed audits, evaluations, inspections and investigations. DFEC recognizes that employing agencies and their respective OIG offices have an interest in reducing costs, returning people to work, and identifying and preventing fraud. In an effort to fully cooperate with the OIG community, while simultaneously coordinating the interaction in a way that would not interfere with our ability to perform our mission, DFEC outlined a specific protocol that would be used to respond to such requests that would preserve program resources and avoid duplication of effort. This circular detailed that when an employing agency OIG investigator requests to view a case record, he/she will be required to sign a brief statement prior to gaining access to the file indicating that access to the file is being requested based on an investigation into a potential violation of law. The guidance provided in FECA Circular 08-04 has not changed.
2. FECA Circular 09-05 (Release of Documents from Federal Employees' Compensation Act (FECA) Files) was released to provide District Offices guidance in situations where information or copies of documents are requested from a claimant's FECA case file. The circular focused on such requests made by employing agencies and clearly outlined that all records relating to claims for FECA benefits are covered by the government-wide Privacy Act system of records entitled DOL/GOVT-1. Specifically, this circular provided that DFEC may grant requests from employing agencies for records pertaining to their employees as a permitted routine use, but that blanket release of the entire case record is not appropriate, except to an investigative body. This circular also outlined that a request from the employing agency for copies of documents contained in the FECA case record must contain a reason for the request, and that the use of these copies must be consistent with the reason the information was collected (connected in some way with the compensation claim). The guidance provided in FECA Circular 09-05 has not changed.
3. Employing agency OIG access to information in the FECA file is permitted by the first sentence of routine use b of DOL/GOVT-1- the same routine use that permits the employing agency to receive information about specific cases of its own employees. However, DFEC's experience with providing employing agencies access to the AQS system has demonstrated that the current structure, which establishes the use of the agency IAC to provide the appropriate level of access to AQS for each individual within that agency who seeks access, has worked effectively and efficiently. For this reason, any request for independent AQS access received from a non-DOL employing agency OIG, or other investigative body, will not be granted. Access to the AQS system for any agency personnel, including any OIG offices or other agency investigative body, must be coordinated with and channeled through the agency IAC who has been recognized by DFEC. Separate access, outside that designated IAC channel, will not be granted by DFEC.
4. Upon receipt and review of a written request delineating in detail the need for such access and the specific timeframe requested, an exception to the access procedure in #3 above may be granted only by the Deputy Director for Federal Employees' Compensation.
The interest rate to be assessed for the prompt payment bills is 2.0 percent for the period of January 1, 2012 through December 31, 2012. This new rate has been updated in the Central Bill Payment system tables.
The rate for assessing interest charges on debts due the government has not been changed. The interest rate for assessing interest charges on debts due the government remains 1.0 percent for the period of January 1, 2012 through December 31, 2012.
Ordinarily, the rate of interest charged on debts due the U.S. Government is only changed in January and is effective for the entire year. However, the rate may be changed in July if there is a difference in the Current Value of Funds (CVF) interest rate of more than two percent. The rate will be reviewed on July 1, 2012 to determine if the Treasury has changed the rate.
Attached to this Circular is an updated listing of both the Prompt Payment and Debt Management interest rates from January 1, 1985 through the current date.
SUBJECT: Bill Pay - Revision in the Reimbursement Rates Payable for the Use of Privately-Owned Automobiles Necessary to Secure Medical Examination and Treatment.
Background: Effective April 17, 2012, the mileage rate for reimbursement to Federal employees traveling by privately-owned automobile was increased to 55.5 cents per mile by GSA. No restriction is made as to the number of miles that can be traveled. As in the past, determination has been made to apply the applicable rate to disabled FECA beneficiaries traveling to secure necessary medical examination and treatment.
Reference: Chapter 5-0204, Principles of Bill Adjudication, Part 5, Benefit Payments, Federal (FECA) Procedure Manual and 5 U.S.C. 8103.
Action: The Central Bill Pay (CBP) facility has updated its system to reflect the new rates. Since there is no action required at the District Office level, the rates are being provided for informational purposes only.
DispositionThis Bulletin should be retained in Chapter 5-0204, Principles of Bill Adjudication, Federal (FECA) Procedure Manual.
This circular is being issued to provide supplemental guidance on the effective date of insurance deductions. It updates the information previously contained in Federal Employees' Compensation Act (FECA) Circular 09 - 04 (Health Benefits Insurance and Life Insurance - General Guidance), issued June 1, 2009.
When a Federal employee enters a leave without pay (LWOP) status, the employing agency is no longer able to deduct for health benefits and life insurance premiums. If compensation for wage loss is payable under the FECA, the responsibility for making those deductions transfers to the Office of Workers' Compensation Programs (OWCP).
As noted in Circular 09-04, OWCP deductions for health benefits and life insurance become effective on the first day of LWOP status. Historically, OWCP did not actually begin making the deductions until the claimant has been in receipt of compensation for 28 days. Once the claimant had received compensation for more than 28 days, deductions were made retroactively to the date compensation began.
Beginning in August, 2010, OWCP discontinued the practice of delaying deductions for that 28-day period and instead began the deductions effective the first day of LWOP. Beginning deductions promptly, rather than making a retroactive deduction at a later date, enables OWCP to provide continuity of payment for the injured worker with no interruptions in insurance deductions.
Note - Insurance deductions are not made for intermittent hours or days within a pay period.
This circular is being issued to document certain current billing practices and restrictions for the Division of Federal Employees' Compensation (DFEC) under the Federal Employees' Compensation Act (FECA). See 5 U.S.C. 8103. 20 C.F.R. Part 10, in particular Subpart I, also provides additional details concerning the responsibilities of claimants and providers in regard to medical billing and reimbursement.
20 CFR §10.809, which was updated effective August 29, 2011, outlines how payments are made for medication. This regulation specifically states that, "Payment for medicinal drugs prescribed by physicians shall not exceed the amount derived by multiplying the average wholesale price, or as otherwise specified by OWCP, of the medication by the quantity or amount provided, plus a dispensing fee."
Effective June 17, 2012, any bill submitted on a Form OWCP-1500 for the payment of medications dispensed in the office using one of the unlisted HCPC "J" codes (J3490, J8499, J8999 and J9999) will be paid based on the Average Wholesale Price or the Medispan Average Wholesale Price. The reimbursement will be determined based on the date of service and the price for the National Drug Code (NDC), which accompanied the unlisted drug code, as outlined below.
1.	Providers submit bills for payment of medications dispensed in the office on an OWCP-1500 billing form. The bills for these services contain one of the following unlisted HCPC "J" codes: J3490, J8499, J8999, and/or J9999. These codes are accompanied with an NDC code and the day's supply, which are key factors for determining the payment amount.
2. The pharmacy system, using the billed diagnosis, will validate the appropriateness of the NDC with the claimant's accepted condition. If the medication is not payable in accordance with the claimant's accepted conditions, the bill will be denied. If the NDC code is payable and appropriate for the claimant's accepted condition, the bill will be paid.
3.	The pharmacy system, based on the date of service, will systematically perform the pricing of the medication based on the date of service. If the date of service is prior to 09/30/2011, the pharmacy system will calculate the payment using the Average Wholesale Price (AWP). If the date of service is after 09/30/2011, the pharmacy system will calculate the payment using the Medispan Average Wholesale Price (MAW).
4.	Similarly, if a bill is received with procedure code 99070 and the description of services is equal to "Dispensing Fee" and/or "Discount" (or any other description that represents a charge associated with the payment of medication), the line will be denied. If this procedure code is billed with a valid and appropriate supply description (tray, bandages, etc.), the line will be paid. Additionally, if the provider bills an NDC under this procedure code (99070), the NDC will be evaluated to determine payment just like the "J" code.
20 CFR §10.809(c) provides that, "With respect to prescribed medications, OWCP may require the use of generic equivalents where they are available." This regulation was effective August 29, 2011. As the prior regulations already provided full authority for OWCP to require the use of generics, the most recent regulatory update did not alter DFEC's policy regarding generic medication. The regulatory update only moved the language referenced to a different section, as the same exact language now found in 20 CFR §10.809(c) was previously found in 20 CFR §10.310(b).
Generic drugs will be selected automatically even when brand is available unless one of these DAW codes is present.
DFEC continues to use these criteria for medication authorizations.
On May 3, 2011, DFEC implemented a new policy and program to monitor and closely manage the use of fast-acting fentanyl products such as Actiq and Fentora and the prescribing of parenteral fentanyl products. An automatic processing rule was implemented whereby new prescriptions for fast-acting fentanyl products would be denied unless the claimant had an accepted work-related condition of cancer. See FECA Bulletin 11-05.
Pursuant to 5 U.S.C. 8103 and 20 CFR §10.315, the employee is entitled to reimbursement of reasonable and necessary expenses, including transportation needed to obtain authorized medical services, appliances or supplies. In reviewing requests for reimbursement, OWCP considers the availability of services, the employee's condition, and the means of transportation. See also 3-0400 of the FECA Procedure Manual. Effective October 30, 2011, a new bill payment restriction was added such that any single claim in excess of 200 miles is rejected by the automated system so that it can be reviewed manually for approval. Prior to this change, the restriction was for any travel greater than 500 miles. Other restrictions, as outlined below, are also active.
1.	Claimants submit claims for reimbursement for travel expenses on Form OWCP-957. Items 5, 6 and 7 of this form are used to claim reimbursement for specific dates of travel. Data required to process such reimbursement is designated by specific alpha designated blocks for each date of service.
2.	Only one date of travel will be accepted in block A (Date of Travel). Date ranges will not be accepted and will be returned to the claimant.
3.	A Trip Code (one way or round trip) must be checked in block B. If not present, it will be returned to the claimant.
4.	A departure and destination must be checked in elected blocks C (Travel From) and D (Travel To). If not present, it will be returned to the claimant.
5.	The complete address of the facility to which the claimant traveled must be present in block E (Medical Facility Name and Address). If not present, the bill will be returned to the claimant. Note, however, this information is not required for travel to a pharmacy/medical supply facility.
6.	Block F (Total Expenses/Cost) is used to claim reimbursement for items related to travel, other than the mileage. These items are listed below with applicable codes.
If the claimant requests reimbursement for any of these services, and the charges exceed $75.00, a receipt must accompany the reimbursement claim. Manual review is also required, and the Central Bill Payment Facility will seek approval and authorization to pay the services from the Claims Examiner. If the claim is less than or equal to $75.00, receipts are not required, and the service will pay without any manual review.
7.	Block G (Private Auto Only Miles Traveled) is used to specify the number of miles claimed for reimbursement. Applicable codes are A0080 and A0090. If the mileage billed in block G is greater than 200 miles per day, manual review is required, and the Central Bill Payment Facility will seek approval from the Claims Examiner. If the mileage billed in block G is less than or equal to 200 miles per day, the reimbursement claim will be paid without manual review.
8.	Reminder – Reimbursement for travel expenses related to medical treatment/evaluation in DFEC claims is generally based on GSA requirements for travel. As such, DFEC will not pay for meals or lodging unless the travel requires more than 12 hours to complete.
1.	Providers submit bills for travel-related expenses on Form OWCP-1500.
2.	Providers billing for mileage (codes A0080 and A0090) will be paid based on the General Services Administration (GSA) mileage rate. Payment will be calculated based on the number of units billed in Block 24-G of the OWCP-1500 billing form.
3.	If the service exceeds 200 miles per day, prior authorization is required. If there is no such authorization on file when the bill is received, the bill will be denied and the provider will be directed to complete the Medical Authorization – Transportation and Travel Authorization template, which can be found on the Central Bill Payment contractor's website. If the service is billed at 200 miles or less, the service will pay without prior approval.
4.	A provider may also use Block 24-D of the OWCP-1500 to bill for services related to travel, other than the mileage. These items are listed below with applicable codes.
Prior authorization for any of these services is required if the charge will be more than $75.00. If the provider submits a bill for any of these services, and the charges exceed $75.00, prior authorization is required, and an invoice showing the Departure and Destination of the trip must accompany the bill or be reflected on the bill when submitted. If there is no attachment showing proof of the trip, or the information is not contained within the bill, it will be denied. If the bill does contain sufficient detail regarding the trip, and prior authorization is not on record, the bill will be denied, requesting the submission of the Medical Authorization – Transportation and Travel template. If the bill is for less than or equal to $75.00, documentation of the trip details is not required, and the service will pay without any manual review.
Effective 12/05/10, updates were made to the anesthesia fee schedule. Effective this date, the fee schedule allowance for anesthesia services was based upon the formula: (Time Units + Base Units) x Conversion Factor. In addition, every anesthesia procedure billed to OWCP required one of the following modifiers: AA, QY, QK, AD, QX, or QZ.
When multiple procedures are performed during a single anesthetic administration, reimbursement is based on the line item representing the most complex procedure.
Effective 07/01/2010, DFEC no longer utilized DOL homegrown procedure code RP100 (Pain Management). Effective that date, when rendering pain management services, providers were required to bill and/or submit for prior authorizations the appropriate HCPCS/CPT codes applicable for the services.
Effective March 1, 2010 DFEC no longer accepted the use of the AMA/CPT consultation codes ranges 99241-99245 and 99251-99255 for outpatient and office settings. This policy adhered to the decision made by the Center of Medicare and Medicaid (CMS) announced in MLN Matters, #MM6740.
Effective 07/15/2010, DFEC required the place of service to be present on the OWCP-1500 (Box 24b). This requirement, however, did not affect any facility services billed on a Form UB04 or professional services billed for third party carriers, billing agents, contract nurses, second opinion contractors, and vocational rehabilitation services.
Chapter 2-0601 has been revised in its entirety. This chapter now provides an overview of the goals and coding associated with the entire Disability Management (DM) process. The coding applies to both the Quality Case Management (QCM) and Periodic Roll Management (PRM) portions of DM; therefore, the chapter has been renamed Disability Management Tracking.
Paragraph 1 outlines the purpose and scope of the chapter, and provides related references to Chapter 2-0600 (Disability Management), Chapter 2-0810 (Developing and Evaluating Medical Evidence), Chapter 2-0811 (Nurse Case Management) and Chapter 2-0813 (Vocational Rehabilitation Services).
Paragraph 2 provides an overview of the DM process and the differences between QCM and PRM. This paragraph also stresses the importance of consistent and accurate coding in the DM Tracking application for proper analysis and measurement of actions taken during the DM process.
Paragraph 3 outlines the two primary goals of Disability Management - return to work and resolution - and how these goals are measured.
Paragraph 4 discusses the actual DM records, including when to create a record, the meaning of a Track Date vs. a Start Date and how to maintain a DM record.
Paragraph 5 discusses the various DM categories and their meanings.
Paragraph 6 outlines the differences between mandatory and optional codes, and how and why the RMV code should be used to remove a record from DM Tracking.
Paragraph 7 outlines the mandatory Claims Examiner (CE) Intervention codes and when they should be used.
Paragraph 8 discusses the mandatory codes to be used during the Nurse Intervention Phase of DM.
Paragraph 9 discusses the codes that are used to designate that a case has a dual tracking effort with both a Field Nurse (FN) and a Rehabilitation Counselor (RC).
Paragraph 10 focuses on the various codes that are used during the Vocational Rehabilitation portion of DM.
Paragraph 11 details when and how the return-to-work (RTW) codes are to be used.
Paragraph 12 outlines the optional codes that are available for use and how they can assist the CE with management of the DM record.
Paragraph 13 provides guidance on the use of closure codes and the interplay between closure codes and resolutions. This paragraph outlines which closure codes count as resolutions and the differences depending on whether the case is in the QCM or PRM portion of DM.
Paragraph 14 acknowledges that some DM codes have become obsolete; therefore, when reviewing previous coding in a DM record some codes may appear that are no longer available for use.
The following chapter is being updated in its entirety. Because transmittal of the FECA Procedure Manual is primarily electronic, DFEC has discontinued the practice of inserting page numbers when an entire chapter is reissued.
Chapter 2-1601 has been revised in its entirety to reflect changes that have taken place both throughout the Division of Federal Employees' Compensation (DFEC) and specifically within the Branch of Hearings and Review.
References to case files being transferred upon request of a hearing have been removed. Several changes have been made to the sections on arranging for and conducting hearings due to the fact that most hearings are no longer held in-person but are conducted electronically via telephone or videoconference. Other changes were made in response to the changes in the Code of Federal Regulations (20 CFR §§ 10.615 through 10.622) published on June 28, 2011, effective August 29, 2011.
Chapter 2-1602 has been revised in its entirety. The chapter has been streamlined and updated to include new language, and the structure of the chapter has been changed. Many of the paragraphs have been reordered, consolidated, and updated to reflect the reconsideration process in its entirety. Exhibits 1-6 have been deleted.
Paragraph 5 "Special Evidence or Argument" has been moved and incorporated into a new paragraph 3 titled "Preliminary Processing."
Paragraphs 4 "Evidence or Argument Required" and 7 "Evaluating Sufficiency of Evidence" have been moved and incorporated into a new paragraph 6 titled "Timely Applications."
Paragraphs 6 "Prima Facie Denials" and 9 "Protecting Claimant's Further Appeal Rights" are now incorporated into a new paragraph 7 titled "Non-Merit Decisions."
Other changes were made in response to the changes in the Code of Federal Regulations (20 CFR §§ 10.605 through 10.610) published on June 28, 2011 and effective August 29, 2011. These changes include a distinction in the requirement regarding when a reconsideration request must be sent to the employing agency. Where there is a legal argument or factual basis for a merit review, the application together with copies of pertinent supporting documentation should be sent to the employing agency, and the employing agency is provided with 20 days to submit comments or documentation. Medical evidence submitted with the request, however, shall not be furnished to the employing agency since it does not constitute documentation that is pertinent for review and comment by the employing agency. Therefore, where a reconsideration request pertains only to a medical issue, the employing agency should be notified that a request for reconsideration has been received, but OWCP is not required to wait 20 days for comment before reaching a determination, except when that claimant is deployed in an area of armed conflict.
The other significant change is to the timeliness standards for reconsideration requests. The regulations at §10.607 now provide that the request for reconsideration must be received within one year, which is a change from the prior standard for timeliness (that an application for reconsideration must be sent within one year).
The chapter is being updated in its entirety. Because transmittal of the FECA Procedure Manual is primarily electronic, DFEC is discontinuing the practice of inserting page numbers when an entire chapter is reissued.
The Division of Federal Employees' Compensation (DFEC) has at times used specific case numbering series to designate cases that are related to a particular event. DFEC will no longer use numbering series and will instead now use 3-character case designations within the Integrated Federal Employees Compensation System (iFECS). The exhibit outlining the prefixes and the previously-used numbering series has, therefore, been updated. Also, since case prefixes are part of the case number itself, whereas case designations are only viewable in iFECS, the one exhibit has been split into two.
Exhibit 1 now lists the prefixes used for FECA cases. The prefixes are reflected in the case number.
Exhibit 2 now lists the case designations used for FECA cases. The designations are viewable only in iFECS. Also, two additional case types were added. Although never given a special numbering series and never listed in a previous exhibit, cases associated with the bombing of the United States embassy in Nairobi on August 7, 1998 and the Alfred P. Murrah Federal Building in Oklahoma City on April 19, 1995 were identified. They were provided with a case designation in the new scheme, OKC and NAI respectively, so these case types are now specifically listed in the exhibit.
Chapter 3-0300 has been revised in its entirety. The chapter includes new language and updated references throughout. Other updates have been made based on changes in the regulations. On August 13, 2010, the Office of Workers' Compensation Programs (OWCP) published in the Federal Register a proposal to amend the regulations governing the administration of the Federal Employees' Compensation Act (FECA). On June 28, 2011, the new Regulations became final with an effective date of August 29, 2011. The regulations pertaining to medical and related benefits in Section 10.300 through 10.315 had minimal changes; some of those changes are reflected in this chapter. Also, exhibit 1 (a copy of the CA-16) has been deleted.
Paragraph 1 outlines the purpose of the chapter, which is to describe the circumstances under which OWCP or, in some instances, the employing agency, may authorize medical services for injured claimants.
Paragraph 2 provides an overview of the authorization process and specifies that the majority of such requests are received initially by the Office of Workers' Compensation Programs' (OWCP) designated bill processing agent. The paragraph also discusses the types of treatment requested. Changes made based on the updated regulation at 20 CFR §10.310 include the following: specifically noting OWCP's authority to utilize field nurses in facilitating and coordinating medical care; clearly stating that certain non-physician providers (physicians' assistants, nurse practitioners and physical therapists) may provide authorized services to injured employees, to the extent allowed under Federal and state law, including licensure by any appropriate regulating body for that profession; and clarifying that for a chiropractor's service to be considered under the direction of a qualified physician, a physician must actually prescribe those services.
Paragraph 3 discusses the CA-16, Authorization for Examination and/or Treatment, which is the vehicle by which the employing agency authorizes initial examination and/or medical treatment for an employee who sustains a traumatic injury at OWCP expense. Based on the updated regulation at 20 CFR §10.300, Form CA-16 authorizes treatment for 60 days from the date of injury, not the date the form is signed.
Paragraph 4 briefly outlines the various types of prohibited authorizations, including excluded providers, issuance to oneself, issuance to minors, etc.
Paragraph 5 outlines the various types of medical facilities where care may be authorized, such as physicians' offices, hospitals, and federal medical facilities. This paragraph also stipulates that ordinarily the physician selected for treatment should be located within a reasonable distance of the employee's home or place of employment, and travel should be undertaken by the shortest route, and, if practical, by public conveyance. Per 20 CFR §10.315, a "reasonable distance of travel" is further defined as a roundtrip distance of up to 100 miles.
Paragraph 6 discusses transfer of termination of medical care and outlines the procedures for making these decisions.
Paragraph 7 focuses on Peace Corps cases and entitlement to medical care for these specific injured workers based on their status with the Peace Corps, both prior to and after separation. Information regarding Peace Corps cases is also contained in PM 2-1700-4, and some of the information in Paragraph 7 of this chapter is duplicative. Specifically, 2-1400-4c(2)(d) discusses that the Peace Corps will, at its discretion, pay medical costs directly for treatment of certain specified service-related medical conditions or injuries costing less than $1,000. Conditions covered by this provision are listed in 2-1400-4c(2)(d), and they are also listed in this chapter. The list in this chapter, however, has been updated to include additional conditions in which Peace Corps and OWCP have agreed that Peace Corps can cover costs directly. These new conditions include the following: vaginal yeast infections (candidiasis); acute otitis media; acute sinusitis; constipation; and hemorrhoids. This paragraph also now specifically notes that injury due to assault or sexual assault (including treatment for sexually transmitted disease and mental health treatment) are covered under the FECA.
FECA PM Chapter 2-0812 has been updated and revised.
Updates were made based on the changes in the Code of Federal Regulations (20 CFR §§ 10.417 and 10.537) effective August 29, 2011. These regulations outline the reporting requirements for students and dependents over the age of 18 who are incapable of self support.
Updates were also made as a result of an updated Social Security Administration Form SSA-581. The new version of this form, which was approved by the Office of Management and Budget, is now in such a format (with bar codes and fill in boxes) that the Division of Federal Employees' Compensation (DFEC) can no longer automatically generate this form with the annual Form CA-1032 that is sent to the claimant. Therefore, rather than automatically issuing the form with every Form CA-1032 issued, the Claims Examiner should selectively request submission of the form when there is any evidence of earnings or employment.
Form CA-0936 (the cover letter to the claimant asking for completion of Form SSA-581) can still be found in Correspondence Library. Form SSA-581 can be found on DFEC's intranet site. The CE should write the claimant's case number on the SSA-581 before it is mailed to the claimant.
The chapter was also reorganized to more closely tailor the evidence review required with the annual Form CA-1032 (with EN-1032 attachment). Further detail was also added with regard to the information provided to the claimant and requested by the claimant on Form EN-1032.
Lastly, the section on Forfeiture was deleted from Chapter 2-812 and a new chapter devoted entirely to Forfeiture, Chapter 2-1402, was created.
Paragraph 1, Purpose and Scope, was updated slightly to cross-reference the new chapter 2-1402, and also to make it clear that the purpose of this chapter was to discuss the periodic review of the medical evidence, as well as the key factual elements to review in conjunction with the annual CA-1032 form.
No changes were made to paragraph 2, Statutory Provisions.
Paragraph 3, Burden of Proof for Terminating Benefits, was modified only slightly to include a cross reference to FECA PM 2-810-13 when discussing grounds for suspension of benefits under section 8123 of the FECA.
The information contained in the prior paragraph 4 was split into two distinct paragraphs (4 and 5). Paragraph 4, Placement on the Periodic Roll, reminds CEs that when the medical evidence indicates that disability is expected to continue for more than 60-90 days, compensation should usually be paid on the periodic roll, and that the CE should advise the claimant when such payments are initiated.
Paragraph 5, Monitoring Claims on the Periodic Roll, outlines the necessary elements for review in general terms and establishes the timeframe guidelines (based on case status) that should be used when determining the adequacy of medical evidence in the file.
Paragraph 6, Medical Elements of Review, outlines the elements of the medical review for periodic roll cases, including the expected content of the medical report, necessary follow-up actions, and guidance regarding changes in medical status and review of existing attendant allowances. Chapter 2-0810, Developing and Evaluating Medical Evidence, should also be consulted for a more detailed discussion of reviewing medical evidence.
Paragraphs 7 through 12 correspond with topics covered on Form EN-1032.
Paragraph 7, Employment and Earnings, reminds CEs that if there is any evidence on Form EN-1032 that the claimant has any type of employment or earnings, further action is warranted. Further information can be obtained directly from the claimant, and issues to be developed are provided based on whether the work activity is characterized as a sole proprietorship, a partnership or a corporation. Information can also be obtained from the Social Security Administration (SSA) if the claimant completes Form SSA-581; benefits may not be suspended for failure to complete Form SSA-581, however, as authorization to obtain reports from the SSA is not a requirement for receipt of compensation.
Paragraph 8, Dependents, outlines the criteria to review when the claimant is receiving augmented compensation based on one or more dependents. This paragraph includes updated material based on the new criteria in 20 CFR §§ 10.417 and 10.537 for reporting requirements for dependents. References to the CA-1615 and CA-1618 letters were deleted, since these letters no longer exist; the Student Dependency letter is now the letter to use. For students, the reporting requirement has been changed from twice-yearly to annually. The claimant, however, is required to report any changes to student status in the interim. For dependents over the age of 18 but incapable of self support, a review is also required annually. However, if the status of such a dependent is unlikely to change, the claimant may establish the permanency of the condition by submitting a well rationalized medical report which describes that condition and the ongoing prognosis of that condition. Once the permanency of the condition is established, the CE does not need to seek further information regarding that condition; however, if there is a change in that condition, the claimant is required to immediately report that change to OWCP. If the permanency of such a condition is established, the CE should prepare a memorandum to the file for concurrence by the Supervisory Claims Examiner.
Paragraph 9, Dual Benefits, provides the basic criteria to review to determine if the claimant is in receipt of benefits from other Federal agencies such as the Office of Personnel Management, Social Security Administration, or the Department of Veterans' Affairs, as receipt of one of these benefits may require an election or offset. FECA PM Chapter 2-1000 has a detailed discussion of dual benefits, but this paragraph now clearly notes that the CE should review the case for a possible SSA/FERS dual benefit regardless of the claimant's response to the relevant question on the EN-1032.
Paragraph 10, Third Party Settlements, reminds CEs to refer any case in which a new settlement has been made or reported to the Office of the Solicitor.
Paragraph 11, Fraud and Felony Conviction, outlines that if a claimant is convicted of fraud in connection with the application for or receipt of benefits under the FECA, 5 U.S.C. 8148(a) requires termination of all future benefits, including medical benefits. And if a claimant is imprisoned based on a felony conviction unrelated to the FECA claim, 5 U.S.C. 8148(b) requires suspension of benefits to the claimant, but allows payment of benefits to eligible dependents during the time that the claimant is imprisoned.
Paragraph 12, Address Changes, simply reminds CEs to be sure that any address change is updated in the case management system.
Paragraph 13, Actions Based on Form EN-1032 Responses, emphasizes that follow-up action in response to an outstanding issue on Form EN-1032 should be taken promptly in order to avoid or minimize any improper payment.
Paragraph 14, Suspension of Compensation, outlines the process for suspending compensation for non-receipt of the Form EN-1032.
Paragraph 15, Periodic Entitlement Review (PER) Codes, outlines how these codes are used for documenting the periodic entitlement review that is to take place on an annual basis in conjunction with the release of Form CA-1032.
Paragraph 16, Disability Management (DM) Status Codes, outlines that DM codes are used to document actions that may coincide with the development undertaken as the result of a PER review or a final PER action, but that a PER action or closure code will not always coincide with a DM status code, since the PER application is distinct from DM Tracking, each serving a unique purpose. For a complete explanation of DM coding, see FECA PM Chapter 2-0601.
No changes were made to Exhibit 1, PN Memo Example, but the remaining exhibits were deleted.
Paragraph 1, Purpose and Scope, outlines the limited scope of this chapter and cross references FECA PM 2-0812 for a more detailed discussion of reviewing cases on the periodic roll.
Paragraph 2, Statutory Provisions, provides the reference to Section 8106(b) of the FECA and clarifies that the statutory authority for forfeiture applies to the omission or understatement of earnings and work activity; it does not apply to similar misrepresentations of dependent status, receipt of dual benefits, etc.
Paragraph 3, Periodic Roll Review, sets the foundation for reviewing periodic roll cases in conjunction with the release of the annual Form CA-1032.
Paragraph 4, CA-1032 Reporting Requirements, provides an overview of the specific directions provided to the claimant when responding to the questions regarding work and volunteer activity.
Paragraph 5, Key Elements of a Forfeiture Decision, clarifies that there are two key requirements for a finding of forfeiture under Section 8106(b)(2): 1) whether the claimant failed to report earnings; and 2) whether he/she did so knowingly. It is not enough to merely establish that there were unreported earnings. The evidence must demonstrate the claimant knowingly failed to report the earnings or activity.
Paragraph 6, Definition of Earnings, provides the regulatory references for the definition of earnings and the requirements for reporting volunteer activity.
Paragraph 7, Definition of Knowingly, provides the regulatory definition for the term, as well as discussion regarding what to look for when making this determination. Relevant decisions of the Employees' Compensation Appeals Board (ECAB) are also included.
Paragraph 8, Penalty Decision, discusses the formal decision and the necessary elements, as well as direction on issuing the simultaneous overpayment decision.
Paragraph 9, Form CA-7, Claim for Compensation, provides guidance on issuing a forfeiture decision based on a Form CA-7, as opposed to the Form EN-1032, with the essential difference being that a forfeiture in this instance is based only on the period claimed on the form, rather than the 15-month period prior to the signature date on the Form EN-1032.
Chapter 2-0807 has been revised in its entirety. The chapter has been streamlined and updated to include new language, and the structure of the chapter has been changed. Many of the paragraphs have been reordered, renamed, consolidated, and updated to reflect the Continuation of Pay (COP) process in its entirety. The number of paragraphs in the chapter has been reduced from 17 to 15.
The amendment to the Federal Employees' Compensation Act (FECA), which moved the 3-day waiting period for US Postal Service workers to the beginning of the COP period, rather than the period after COP, has also been incorporated. This amendment was Title IX of the Postal Service Accountability and Enhancement Act, effective 12/20/06.
No substantive changes were made to paragraph 1, but the title was updated to Purpose and Scope.
Paragraph 2 was renamed Statutory Authority and has been updated to include a reference to Title IX of the Postal Service Accountability and Enhancement Act.
Paragraph 3, COP Defined, has been amended to include that COP is allowable for time lost for medical care.
Prior paragraph 5, Employee Status, was moved to paragraph 4 and retained the same name and information.
Paragraph 5, Employee Responsibilities, is a compilation of the information contained in previous paragraphs 4 and 7.
Paragraph 6, Employing Agency Responsibilities, contains essentially the same information as the prior paragraph 8.
Paragraph 7, Controversion of COP, contains essentially the same information as the prior paragraph 9, but the reasons for controverting COP have been reorganized based on the applicable regulatory references.
Paragraph 8, Counting COP Days, is a compilation and reorganization of the information previously found in paragraph 6 (Period of Entitlement), paragraph 12 (Delayed Disability), and paragraph 13 (Recurrence of Disability).
Paragraph 9, Interruption and Suspension of COP, and paragraph 10, Termination of COP, provide the information previously found in paragraph 14.
Paragraph 11, COP and Modified Duty Assignments, covers the information found previously in paragraph 16 and includes additional guidance.
Paragraph 12, Payment of COP, provides details regarding the three-day waiting period before COP may be granted to Postal employees. 20. C.F.R. §10.200(c) also reflects this statutory change to 5 U.S.C 8117 (per Title IX of the Postal Service Accountability and Enhancement Act, effective 12/20/06), which provides that Postal Service employees are not entitled to continuation of pay for the first 3 days of temporary disability unless that disability exceeds 14 days or is followed by permanent disability.
Paragraph 13, COP and Leave Election, contains essentially the same information contained in prior paragraph 15, but the information has been reorganized and supplemented.
Paragraph 14, Formal Adjudication of COP, discusses the information contained in the prior paragraph 10, and also provides more detailed information regarding the development, approval, and denial of COP.
Paragraph 15, Initial Claims for Compensation Following COP, updates the information previously found in paragraph 15 and emphasizes the commitment of the Division of Federal Employees' Compensation (DFEC) that claimants are not without income during the period immediately following the expiration of COP. This paragraph outlines how the initial payment should be made. The examiner is then directed to FECA Procedure Manual Chapter 2-901 for further guidance regarding ongoing payments.
Chapter 2-1200 has been updated and revised in its entirety. Some changes were made based on the updates in the Code of Federal Regulations, effective August 29, 2011. The chapter name has also been updated to REPRESENTATIVES' SERVICES, rather than Fees for Representatives' Services, since the chapter discusses more than just fee approval.
Paragraph 1, Purpose and Scope, outlines that the chapter covers both communication with representatives as well as instructions for fee approval.
Paragraph 2, Authority and Citations, includes both statutory and regulatory references pertaining to authorized representatives. This paragraph also provides information regarding who may act as an authorized representative, including when a federal employee may do so, and the regulatory reference that provides that OWCP may communicate with any member of an authorized attorney's law firm.
Paragraph 3, Corresponding with Representatives, outlines the actions that should be taken upon receipt of a claimant's signed authorization, and provides a detailed discussion of what correspondence should be sent to an authorized representative.
Prior paragraph 4, How Fees for Services are Paid, outlines that the claimant is solely responsible for paying the fee and other applicable charges, and that OWCP will not reimburse a claimant, nor is OWCP in any way liable for the cost of the representation.
Paragraph 5, Fees Which May Not Be Approved, explains that fees for service in matters which have no relation to the claim should not be approved. This paragraph also provides a discussion of contingency fees and reiterates that "contingency fees are not allowed in any form." 20 C.F.R. §10.702(a).
Paragraph 6, Fee Approval, discusses the entire fee application and approval process. This paragraph includes a discussion regarding the necessary elements of a fee application, what to do if information is missing from the fee application submission, how to develop and review disputed applications, and how to issue a formal decision regarding a fee reduction.
Paragraph 7, Authority to Approve Fees, lists the authority to approve disputed fee requests by position and dollar amount.
Paragraph 8, Timely Case Action, outlines that where the representative has submitted an application for fee approval prior to or at the time of submission of the evidence needed to reach a decision in the case, the CE should issue the notification of case acceptance, the notice of payment of compensation or notice of award, along with the ruling on the fee request, when possible. This paragraph also reminds CEs that compensation checks should usually not be forwarded to a representative, even with the claimant's approval.
Paragraph 9, Fee Requests in Disallowed Claims, explains that where a compensation claim is disallowed, a formal decision should still be made on the representative's fee application.
Paragraph 10, Inquiries From State Bar Associations Relating to FECA Representative, outlines that where an inquiry is received from a State Bar Association relating to a FECA representative's conduct, the CE should provide the applicable citations to regulations and procedures concerning representative fees, but exercise the utmost care regarding the disclosure of evidence from the FECA file.
The prior Exhibit 1, Sample Formal Decision, has been deleted.
Chapter 7-0100, Introduction to Nurse Intervention, is a new chapter in a completely new part of the FECA Procedure Manual, Part 7 – Nurse Intervention.
FECA PM 2-0600, Disability Management, and FECA PM 2-0811, Nurse Case Management, discuss the role of nurse case management during the early phases of a disability claim. These chapters focus on disability management and nurse intervention from a Claims Examiner's perspective. Currently, OWCP's Nurse Intervention Program is also discussed in Part 3 of the FECA PM, in FECA PM 3-0201, Staff Nurse Services, and in FECA PM 3-202, Contract Field Nurse Certification. The chapters in Part 3 provide information pertaining to the nurse intervention from the Staff Nurse and contract nurse perspective.
OWCP's Nurse Intervention Program is in integral piece of the overall disability management process and, as such, it has been decided that moving information pertaining to this program to an entirely new Part of the PM is warranted. In doing so, procedures will be updated and expanded to reflect DFEC's most recent revisions to the use of contract nurses in our disability management protocols, many of which are already outlined in the Part 2 chapters noted above. The relevant Part 3 chapters will remain until all information has been updated and absorbed into Part 7; however, since Part 7 will contain the most recent guidance and procedures, Part 7 should be consulted first (prior to the part 3 chapters) and, if questions arise, the Part 7 guidance should be followed.
Paragraph 1, OWCP Objectives, lays the foundation for the Nurse Intervention Program by clearly conveying OWCP's commitment to seeing that benefits for compensation and medical services are appropriately and timely provided, and reiterating our commitment to assisting injured workers in obtaining a successful medical recovery and minimizing the period of disability from work.
Paragraph 2, Scope, notes that this chapter focuses only on the objectives and purpose of nurse intervention and the types of nurses involved, and then references the Part 2 chapters noted above as additional resources. This paragraph also provides the regulatory authority (20 C.F.R. §10.310(a)) for using field nurses to facilitate and coordinate medical care.
Paragraph 3, Purpose, discusses how nurse intervention has been incorporated into the Quality Case Management (QCM) portion of the Disability Management process, and how involving nurses in the early stages of disability cases facilitates expedited medical care and recovery and can result in shortening the length of disability from work.
Paragraph 4, National Office Nurse Consultant, outlines the role and some of the duties of the National Coordinator for the nurse program, which include planning and developing methods for the assessment of the OWCP nurse program and serving as a resource for the District Office Staff Nurses.
Paragraph 5, District Office Staff Nurses, outlines the critical role of the Staff Nurse in the overall success of the nurse intervention program and provides an overview of the duties, which include the following: coordinating the assignment of contract nurses for specific cases; monitoring contract nurses' performance in correlation to both contract specifications and quality of services provided; reviewing nurse reports for completeness and timeliness prior to authorizing payment of bills; and communicating with the CE as needed with regard to issues that arise during the nurse intervention phase.
Paragraph 6, Continuation of Pay (COP) Nurses, outlines that COP Nurses are contracted nurses assigned in traumatic injury cases where the injured worker has immediate disability and has not returned to work within 7 days following the date of work stoppage. The expectations of the CN are outlined, and it is noted that CNs only have a role during the COP period in traumatic injury cases and are strictly triage nurses whose work is performed telephonically.
Paragraph 7, Field Nurses, explains that Field Nurses are contracted registered nurses whose contact is generally in person, and that assignment of Field Nurses should occur as soon as possible after the injury occurs and the claim has been approved for a work-related injury. An overview of the FN duties is also provided.
The chapter is an entirely new chapter in a new part of the PM. Because transmittal of the FECA Procedure Manual is primarily electronic, DFEC is discontinuing the practice of inserting page numbers when an entirely new chapter is issued.
Chapter 2-0803 has been updated and revised in its entirety. The chapter has been updated to include new language, and the structure of the chapter has been changed.
Paragraph 1, Purpose and Scope, outlines that the chapter will discuss the guidelines for determining whether the third basic element of a claim, Fact of Injury (FOI), has been met. It also references FECA PM Chapter 2-0800 (Development of Claims) as a source for further information pertaining to how to properly develop claims.
Paragraph 2, Components of Fact of Injury, discusses the two components of this element: Fact of Injury-Factual and Fact of Injury-Medical. This paragraph also makes it clear that both of these criteria must be satisfied before proceeding to consider the fourth basic element of a claim, performance of duty.
Paragraph 3, Fact of Injury – Factual, provides a description of the evidence that should be reviewed to determine whether FOI-Factual has been satisfied. The paragraph also discusses sources of evidence and outlines some issues that the CE may need to develop.
Paragraph 4, FOI-Medical, discusses the criteria for determining whether FOI-Medical has been satisfied, and indicates that the CE should develop the case if a medical diagnosis in connection with the claimed injury is not present.
Paragraph 5, Denial Reason, discusses on what basis to deny the case if one or both of these essential elements of Fact of Injury have not been met.
Chapter 7-0300, Continuation of Pay (COP) Nurses, is a new chapter in the FECA Procedure Manual (PM), Part 7 – Nurse Intervention.
FECA PM 2-0600, Disability Management, and FECA PM 2-0811, Nurse Case Management, discuss the role of nurse case management during the early phases of a disability claim. These chapters focus on disability management and nurse intervention from a Claims Examiner's perspective. Currently, OWCP's Nurse Intervention Program is also discussed in Part 3 of the FECA PM. The chapters in Part 3 provide information pertaining to the nurse intervention from the Staff Nurse and contract nurse perspective.
As outlined in FECA Transmittal No. 12-09, it has been decided that moving information pertaining to the Nurse Intervention Program to an entirely new Part of the PM is warranted. The relevant Part 3 chapters will remain until all information has been updated and absorbed into Part 7; however, since Part 7 will contain the most recent guidance and procedures, Part 7 should be consulted first (prior to the Part 3 chapters), and if questions arise, the Part 7 guidance should be followed.
This new chapter, 7-0300, discusses the COP Nurse phase of the Nurse Intervention Program. Involving COP Nurses in certain traumatic injury disability cases during the 45-day COP period allows for expedited adjudication efforts, thus resulting in earlier disability case management activities which assist in the medical recovery and return to work of injured employees.
Paragraph 1, Background, lays the foundation for the implementation of the COP Nurse intervention program and provides historically related references to FECA Bulletin 00-15, FECA Bulletin 01-09, and FECA Bulletin 10-04.
Paragraph 2, Purpose and Scope, outlines the purpose and scope of the chapter, providing related references to FECA PM 2-0600 (Disability Management) and 2-0811 (Nurse Case Management).
Paragraph 3, Introduction, defines the role of the COP Nurse and the benefits obtained from the COP Nurse intervention activities.
Paragraph 4, Identification of Cases for Assignment of COP Nurse, details how certain traumatic injury disability cases are identified for COP Nurse assignment eligibility.
Paragraph 5, COP Nurse Intervention Actions, provides an overview of the nurse intervention activities to be provided and the timeframes allowed for the completion of such activities.
Paragraph 6, COP Nurse Reimbursement, specifies that when the COP Nurse closes a case, the Staff Nurse reviews the closure for appropriateness and accuracy, and then, after approval, the closure report is generated and the bill is sent for processing.
Paragraph 7, Claims Examiner Action Upon COP Nurse Closure, outlines the case management expectations after the Claims Examiner receives the completed COP Nurse closure report.
Paragraph 8, COP Nurse Closure Codes, specifies the various types of closure codes used to triage the disability status of the traumatic injury cases assigned for COP Nurse intervention.
The chapter is an entirely new chapter in a new part of the PM. Because transmittal of the FECA Procedure Manual is primarily electronic, the DFEC is discontinuing the practice of inserting page numbers when an entirely new chapter is issued.
Chapter 8-0100, Introduction to Rehabilitation, is a new chapter in a new part of the FECA Procedure Manual, Part 8 – Rehabilitation.
FECA PM 2-0600, Disability Management, and FECA PM 2-0813, Vocational Rehabilitation Services, discuss the role of rehabilitation in a disability claim. These chapters focus on disability management and vocational rehabilitation from a Claims Examiner's (CE's) perspective. Currently, DFEC's Rehabilitation Program is also discussed in Part 3 of the OWCP PM. The chapters in Part 3 provide information pertaining to rehabilitation from the Rehabilitation Specialist (RS) and contract Rehabilitation Counselor (RC) perspective.
Vocational Rehabilitation is in integral piece of the overall disability management process, and, as such, it has been decided that moving information pertaining to this program to an entirely new Part of the FECA PM is warranted. In doing so, procedures will be updated and expanded to reflect DFEC's most recent revisions to the use of contract RCs in our disability management protocols, many of which are already outlined in the Part 2 chapters noted above. The OWCP PM chapter will remain; however, since Part 8 of the FECA PM will contain the most current guidance and procedures, the FECA PM should be consulted first (prior to the OWCP PM), and if questions arise, the FECA PM guidance should be followed.
Paragraph 1, OWCP Objectives, lays the foundation for the vocational rehabilitation program by clearly conveying OWCP's commitment to seeing that benefits for compensation and medical services are appropriately and timely provided, and reiterating our commitment to assisting injured workers in obtaining a successful medical recovery and minimizing the period of disability from work.
Paragraph 2, Purpose, discusses how vocational rehabilitation is part of DFEC's disability management process, and outlines two underlying themes that are core components of the rehabilitation portion of disability management: (1) close coordination of CE and RS/RC actions; and (2) a clear, consistent message to the injured worker that return to some kind of work is expected as soon as the worker is medically ready.
Paragraph 3, Scope, notes that this chapter focuses only on the objectives and purpose of vocational rehabilitation, including the legislative and regulatory authority under which such services are provided, and then references the OWCP PM and the relevant FECA Part 2 chapters as additional resources.
Paragraph 4, Statutory, Regulatory and Program Requirements, provides the authority for DFEC's vocational rehabilitation program.
Paragraph 5, Roles and Responsibilities, describes the roles of the relevant participants, and then references FECA PM 2-0813 as an additional resource.
Paragraph 6, Compensation Entitlement During and After Vocational Rehabilitation, discusses how compensation is paid during the vocational rehabilitation effort, identifies the bars to receipt of such compensation, and explains how compensation is reduced following the completion of rehabilitation services.
Paragraph 7, Restoration Rights with the Federal Government, provides the authority by which an injured worker who has either fully or partially recovered may return to duty with the previous employer. This provision is administered by the Office of Personnel Management.
Paragraph 8, Available Services, outlines the various medical and vocational rehabilitation services available to an injured worker and identifies which of those services are considered substantial services for the purpose of successful rehabilitation closure.
The chapter is a new chapter in a completely new part of the FECA Procedure Manual, Part 8 – Rehabilitation. Because transmittal of the FECA Procedure Manual is primarily electronic, DFEC is discontinuing the practice of inserting page numbers when an entire chapter is issued or reissued.
A minor update is being made to Chapter 2-0900, paragraph 8 (Applying Increments of Pay).
Paragraph 8(a) previously indicated that Sunday premium pay should be requested for the year prior to the pay rate effective date; however, this is not necessary if the worker regularly worked on Sundays. If an additional amount or percentage was paid for Sunday work, and the file contains no evidence showing that this amount varied or was paid irregularly, the CE may add the indicated amount or percentage to the base pay reported without further inquiry. If the evidence shows, however, that the amount or percentage paid for Sundays varied or was paid irregularly, the CE should determine the amount of additional pay received during that year and add it to the reported base pay.
Chapter 8-0800, Assisted Reemployment, is a new chapter in FECA Procedure Manual (PM), Part 8 – Vocational Rehabilitation Intervention.
Currently, Assisted Reemployment is discussed in Part 3 of the OWCP PM, Chapter 3-0401. As outlined in FECA Transmittal No. 12-12, however, it has been decided that moving information pertaining to DFEC's Rehabilitation Program into the FECA PM is warranted. The OWCP PM chapter will remain, and that chapter may be referenced for a historical perspective, but since it has not been recently updated, this new chapter (FECA PM 8-0800) should be consulted for any Assisted Reemployment issue, since it contains the most current policies and procedures for DFEC.
Paragraph 1, Purpose and Scope, defines Assisted Reemployment as a temporary subsidy designed to encourage employers to choose qualified rehabilitated workers, thereby increasing the number of job offers made by private employers.
Paragraph 2, Background, describes the inception of Assisted Reemployment in FY 1992.
Paragraph 3, Funding Authority, provides a reference to the authority that allows DFEC to use the FECA fund to pay a portion of the salary of a newly reemployed Federal worker (who is eligible for disability benefits under the FECA) via Assisted Reemployment.
Paragraph 4, Eligible Employers, outlines that Assisted Reemployment salary reimbursement may be offered to employers in the private sector, but not to a business owned or managed by the injured worker, the injured worker's relatives, an employee of OWCP (or his/her family), or an OWCP vocational rehabilitation counselor (or his/her family).
Paragraph 5, Reimbursement Parameters, discusses that the rate and duration of Assisted Reemployment salary reimbursement offered should be negotiated separately with each employer, depending on the nature of the job market and the particular circumstances in the case. The paragraph then lists the restrictions and parameters for payment of the subsidy.
Paragraph 6, Eligible Cases, explains that a Claims Examiner (CE), a Rehabilitation Specialist (RS), or a Rehabilitation Counselor (RC) may propose Assisted Reemployment for an injured worker during Plan Development, or at any time during Placement, especially if it seems that it may be difficult to place the injured worker, but cautions that such subsidies should not be considered in instances where the claimant is not putting forth a good-faith effort in the return-to-work process or has demonstrated non-cooperative behavior.
Before proceeding with AR, the file should reflect that the Employing Agency (EA) has declined or failed to offer appropriate modified employment.
Paragraph 7, Assisted Reemployment Initiation, discusses the first steps the RS and RC should take when it has been decided to pursue Assisted Reemployment as part of the vocational rehabilitation plan.
Paragraph 8, Placement Phase, outlines the steps the RS and RC should take during the placement phase, including: contacts by the RC; reporting outcomes of such contacts in the monthly reports; and possibly informal conferences with potential employers who are interested in Assisted Reemployment.
Paragraph 9, Assisted Reemployment Approval, discusses the Assisted Reemployment Memorandum of Agreement that is used to record the terms of the wage subsidy once an arrangement has been finalized. This paragraph also references the shell AR Agreement, available in Correspondence Library, but cautions the RS to tailor the agreement for the particular circumstances of the case but not alter any of the essential elements.
Paragraph 10, Case Closure, explains that a worker may be considered successfully rehabilitated when employed for more than 60 days without interruption (due to the disability), and that the same basic principle applies to cases with Assisted Reemployment subsidies, except that wage reimbursement payments will be made on the injured worker's behalf for up to three years after the return to work, and post-employment services may be provided throughout this entire period.
Paragraph 11, Post-Employment Services, discusses how these services are authorized and the time frames involved.
Paragraph 12, Payment of Assisted Reemployment Subsidies, outlines how employers submit claims for reimbursement (via Form CA-2231), and the steps the RS takes when reviewing these submissions for payment authorization.
Exhibit 1, Assisted Reemployment Memorandum of Agreement, is the shell agreement that is to be used when approving an Assisted Reemployment subsidy.
The chapter is completely new. Because transmittal of the FECA Procedure Manual is primarily electronic, DFEC is discontinuing the practice of inserting page numbers when an entire chapter is issued.
Subject: War Hazards Compensation Act (WHCA) and Defense Base Act (DBA) - Ongoing handling of DBA cases accepted for reimbursement under 42 U.S.C. § 1704(a)(1) in which the Division of Federal Employees' Compensation (DFEC) has chosen to pay benefits directly to the entitled beneficiary in lieu of reimbursing the DBA carrier ("direct payment") as authorized by 42 U.S.C. § 1704(a)(3) and described in 20 CFR 61.105.
References: This bulletin supplements the information contained in the Federal Employees' Compensation Act (FECA) Procedure Manual (PM) 4-0300 and OWCP Bulletin 05-01.
Background: After accepting a claim for reimbursement under 42 U.S.C. § 1704(a) of the WHCA, DFEC may pay benefits directly to an entitled beneficiary, in lieu of reimbursement to a carrier in accordance with 42 U.S.C. 1704(a)(3) and 20 CFR § 61.105. The regulations at 20 C.F.R. § 61.105(c) provide that DFEC will not assume direct payment unless the rate of compensation and the period of payment have become relatively fixed and known. OWCP has further determined in OWCP Bulletin 05-01, that only a formal compensation order by the Division of Longshore and Harbor Workers' Compensation (DLHWC) will meet the regulation's requirement of being relatively fixed and known (absent extraordinary circumstances). Even if DFEC assumes direct payment, under the regulations DFEC maintains the right to transfer any case back to the carrier for it to pay benefits. 20 C.F.R. §61.105(f). Nevertheless, as a practical matter, if a compensation order under the DBA awards continuing compensation benefits (either due to disability or death), and DFEC accepts the case for reimbursement under the WHCA, DFEC usually assumes direct payment of compensation.
20 CFR 61.105(d) outlines that in such direct payment cases, "medical care for the effects of a war risk may be furnished in a manner consistent with the regulations governing the furnishing of medical care under the Federal Employees' Compensation Act." Part (e), however, clearly specifies that, "the transfer of a case to the Office [DFEC] for direct payment does not affect the hearing or adjudicatory rights of a beneficiary or carrier as established under the Defense Base Act or other applicable workers' compensation law." The regulations reflect that direct payment cases continue to be DBA cases subject to all the provisions of the Longshore and Harbor Workers' Compensation Act (LHWCA).
Due to the increased number of cases where benefits are being paid directly by DFEC to an injured worker or a survivor under 42 U.S.C. § 1704(a)(3) of the WHCA, generally pursuant to a compensation order issued under the DBA, it is necessary to outline a protocol for handling directly paid WHCA reimbursement cases.
Purpose: To provide specific guidance on the interplay between DFEC and DLHWC, and the responsibilities of each program in the administration of DBA/WHCA reimbursement cases with ongoing entitlement.
Applicability: All National Office staff and District Office claims personnel for the Division of Federal Employees' Compensation (DFEC) and the Division of Longshore and Harbor Workers' Compensation (DLHWC).
1. The notification and interaction described in this bulletin will occur at the District Office level for both DFEC and DLHWC, but the District Offices may seek additional guidance from the respective Branches of Regulations and Procedures and appropriate Office of the Solicitor divisions as needed.
2. Any written clarification between the two divisions should be included in the applicable case files maintained by each office.
On occasion, prior to DFEC accepting the claim for direct payment, clarification of the DLHWC Informal Conference Memorandum or Compensation Order may be required.
1. If clarification regarding the award amount is needed prior to assuming direct payment, the District Director for the DFEC Special Claims District Office will seek guidance concerning the terms of the order directly from the DLHWC District Director who filed the order. Such a request will be made in writing with copies provided to the claimant, the insured, and their legal representatives, if any. If a new order is issued, it will be made part of the case file maintained by DFEC, as well as DLHWC's case file.
2. If a compensation order awards benefits for more than one injury, and some, but not all of the injuries for which benefits are awarded qualify for reimbursement under the WHCA, DFEC will request clarification from the carrier submitting the reimbursement request to determine how much of the compensation due is attributable to each injury. The carrier will be asked to substantiate which portions of the compensation due are attributable to each injury. It is the carrier's responsibility to submit proof of how much of what was paid is directly attributable to the WHCA injury or injuries; this must be established to DFEC's satisfaction.
As a general matter the findings in a compensation order are accepted and no additional review is done by DFEC. (20 C.F.R. § 61.102(c), OWCP Bulletin 05-01) However, if after a case has been assumed for direct payment DFEC has reason to believe that there was a mistake in determination of fact in the DBA compensation order or the circumstances existing at the time the DBA compensation order issued have changed, e.g. payment of total disability for a period in which earnings were present, DFEC, after appropriate development, should notify the DLHWC District Director that modification of the compensation order may be warranted [See Parts V and VI below for further discussion on changes in compensation after the case has been assumed for direct payment].
1. DFEC will notify DLHWC in writing and provide supportive documentation, if applicable.
2. If DLHWC agrees that modification is warranted, it will initiate modification proceedings under Section 22 of the LHWCA, as incorporated. If DLHWC disagrees with DFEC that modification is warranted, it will so notify DFEC.
3. Reimbursement for the stated period and/or assumption of direct payment may be delayed pending receipt of a response from DLHWC. If a modification proceeding is commenced, DFEC may consider terminating direct payment and transfer the case back to the carrier for it to pay subject to reimbursement.
As outlined in 20 CFR 61.105(d), in reimbursement cases where DFEC takes over direct payment of DBA benefits, the furnishing of medical treatment may be provided in a manner consistent with the regulations governing the furnishing of medical treatment under the FECA. The DFEC Procedure Manual provides that it will utilize these regulations, and therefore, medical treatment in reimbursement cases where DFEC has taken over direct payment will be authorized and paid for by DFEC in accordance with its regulations and procedures in administering the FECA.
DFEC contracts it medical billing services and this system is premised on the conditions specifically accepted by DFEC in adjudicating a FECA claim. It is recognized that compensation orders and decisions issued under the DBA do not necessarily identify the specific medical conditions associated with the DBA claim. To the extent that stipulations can be reached to identify these conditions when carriers and claimants are seeking compensation orders from DLHWC District Directors or litigating cases before the Office of Administrative Law Judge, it is recommended that they do so. In addition, when an application for reimbursement is submitted which is likely to result in direct payment by DFEC, the applicant should include a list of conditions that it believes are related to the DBA claim. At the time of acceptance for direct payment, DFEC will list these conditions as those accepted for medical treatment which will be entered into its electronic claims processing system (iFECS) for the purpose of medical bill payments.
1. If the claimant requests treatment for a consequential condition (a condition that flows as a natural consequence from the covered injury), DFEC should develop the medical evidence to determine whether it is a consequential condition stemming from the compensable injury.
a. If such development substantiates that the new condition is related, DFEC may authorize necessary treatment without input from DLHWC, but DLHWC and the carrier will be notified of that determination along with the claimant.
b. If such development does not substantiate that the new condition is related to the already covered conditions, DFEC will outline the rationale for its determination in a letter to the claimant, attach any applicable medical documentation, and advise the claimant to seek an adjudicatory decision from DLHWC. DLHWC and the carrier will be notified of this determination as well.
Note - A condition that DFEC accepts as consequential for purposes of authorizing medical treatment may also give rise to a change in the level or duration of disability benefits. In such instance, DFEC should direct the claimant to DLHWC for initiation of modification proceedings. See Part V. 1.
2. If the claimant requests treatment for or acceptance of a completely new condition not readily identifiable in the DLHWC compensation order (e.g. DLHWC issued a decision finding an injury to the arm and the claimant seeks treatment for the ankle), DFEC will direct the claimant to file a claim for medical benefits or, if appropriate, seek a modification of the compensation order from DLHWC; DLHWC and the carrier will receive copies of this correspondence as well. DFEC will not take any development action in such a case and will await the outcome of claimant's request for modification. DLHWC will initiate modification proceedings under Section 22 of the LHWCA, as incorporated. The employer and/or the carrier, as well as the claimant, will be the parties to such proceedings. The carrier is reminded that a failure to present any and all viable defenses to such claim may result in a subsequent denial of its reimbursement claim under the WHCA. The carrier should also be put on notice that the new claim, if accepted, will not be covered under the WHCA absent a subsequent request by the carrier and determination by DFEC.
3. If the claimant requests a change in treating physician, DFEC will consider such factors as the reason for the request, the appropriateness of current care, and other circumstances (e.g. whether the current treating physician has retired, the claimant has moved, etc.).
a. If a change in the treating physician is clearly warranted (such as a change due to a geographical move or to an appropriate medical specialist), DFEC will authorize the change without input from DLHWC, and DLHWC and the carrier will be notified of such approval along with the claimant.
b. If it appears such change may not be warranted, DFEC will outline the rationale for its determination in a letter to the claimant, attach any applicable medical documentation, and advise the claimant to seek an adjudicatory decision from DLHWC. DLHWC and the carrier will be notified of this determination as well. DLHWC will take necessary action to resolve the medical dispute, including an informal conference and an independent medical examination as necessary. The DLHWC District Director may issue an Order for Medical Treatment under certain circumstances. If a factual dispute exists that cannot be resolved at the district office, the case will be referred to the Office of Administrative Law Judges for formal adjudication. The employer and/or the carrier, as well as the claimant, will be the parties to such proceedings.
In cases where DFEC has taken over direct payment and for which regular periodic payments are being made for disability, DFEC pays compensation as specified by the DBA compensation order. A change in benefit level or amount of the award cannot be made by DFEC without modification of the order.
1. If a claimant requests a change in benefit level, e.g. an increased schedule award or total disability benefits in lieu of partial disability benefits, DFEC will advise the claimant to seek such modification from DLHWC. DLHWC and the carrier will be copied on this notification. If DFEC disagrees with the claimant's request for change in the benefit level at that time, DFEC will outline the rationale for its disagreement and attach any applicable documentation.
Note -- If a claimant initially seeks modification directly from DLHWC, DLHWC should provide notice of the request to DFEC.
2. If DFEC obtains evidence that it believes warrants a change in benefit level (i.e. partial disability benefits in lieu of total disability benefits), DFEC will, after appropriate development of the case, notify DLHWC in writing that modification of the order may be warranted. DFEC will include any supporting documentation and request a review of the benefit level. If DLHWC agrees that modification is warranted, it will initiate modification proceedings. If DLHWC disagrees with DFEC that modification is warranted, it will so notify DFEC.
4. DFEC can request periodic medical updates to substantiate continued disability. Generally, this will occur once every three years, unless more frequent reports are needed to monitor medical care and support the payment of medical bills. A yearly inquiry will also be sent to the claimant to verify the current address, continuing receipt of benefits, and employment.
If the claimant does not submit the requested medical evidence, DFEC may arrange for an examination under Sections 7 and 19(h) of the LHWCA, as incorporated. If the claimant fails to submit the required medical evidence, fails to attend the examination, or fails to return the yearly benefit verification statement, DFEC will provide written notice to DLHWC, with any supporting documentation, and request appropriate modification of the order, which may include suspension, reduction, or termination of benefits. The claimant and the carrier will also be advised of this request for modification of the benefit level.
5. DFEC will on a yearly basis send Form LS-200 to claimants receiving compensation for total or partial disability, requesting a report of their earnings from employment or self-employment. However, because disability compensation is payable under the DBA at a rate of two-thirds of average weekly wage (for total disability) and is not subject to augmentation of the compensation rate similar to that allowed under the FECA, information about a disabled employee's marital status or dependents need not be requested as the presence or absence of a spouse or dependent children has no effect on compensation rates for disability under the DBA. However, that information is germane and should be obtained in death benefit cases - see Part VI below.
In cases where DFEC has taken over direct payment and for which regular periodic payments are being made for the death of an employee, DFEC pays death benefits as specified by the DBA compensation order. DFEC cannot terminate such benefits without a modified award by DLHWC, except in certain specific circumstances.
1. In DBA reimbursement cases for which benefits are being paid to the spouse of a deceased employee, a yearly inquiry will be made to verify that there has been no change in the marital status of the widow or widower. DFEC will use Form LS-267 for this purpose. If the widow/widower fails to return the yearly benefit verification statement, DFEC will provide written notice to DLHWC, with any supporting documentation, and request a review of the ongoing benefit payments and/or consideration of suspension of benefits. The widow/widower and the carrier will also be advised of this request for a review of ongoing benefit payments.
Note - DFEC cannot stop benefit payments in this instance, but must await a determination by DLHWC. If benefits are ultimately suspended and the widow then submits the required information, DFEC will reinstate benefits and notify DLHWC.
2. If a widow/widower notifies DFEC that he/she has remarried, or if DFEC obtains evidence that a widow/widower has remarried, DFEC will immediately stop ongoing payments and compute a two-year, lump-sum payment representing two years of compensation. DFEC will pay the lump sum, taking credit for any amount paid since the remarriage in order to avoid an overpayment, and notify the beneficiary of the payment amount. DLHWC and the carrier will also be advised, but this action can be taken without input from DLHWC as the remarriage itself extinguishes any order issued by DLHWC. This procedure is currently set forth in the FECA Procedure Manual. See FECA PM 4-300-15(b).
Note - If the beneficiary has already received compensation in excess of the two-year, lump-sum amount at the time of notification/verification, DLHWC and the carrier should be advised along with the beneficiary, but no action can be taken with regard to any overpayment, as an overpayment under the FECA cannot be declared.
3. If benefits are being paid to a minor child, DFEC must monitor the age/status of that child and adjust beneficiary benefit levels in a timely manner to avoid any excess compensation payments. Compensation may continue after a child's 18th birthday if he/she meets the definition of a student. The requirements for student status are the same as those under the FECA, and DFEC should request the necessary documentation needed for verification of student status prior to the child's 18th birthday, and on a periodic basis thereafter. DFEC will use Form LS-266 for this purpose. DFEC should promptly terminate compensation payments for a child when he/she turns 18 years of age if full-time student status is not established or if the evidence on file no longer supports student status after initially established.
Note - If the beneficiary has already received excess compensation at the time of the cessation of compensation, DLHWC and the carrier should be advised along with the beneficiary, but no action can be taken with regard to any overpayment, as an overpayment cannot be declared. Credit can be taken, however, if the child subsequently becomes eligible again, based on the same injury or death, e.g. a student.
4. In DBA reimbursement cases where benefits are being paid to an employee who subsequently dies, DFEC will direct any potential survivor to file a death benefits claim with DLHWC; DLHWC and the carrier will receive copies of this correspondence as well. DFEC will not take any development action in such a case and will await a determination on the death benefits claim. The carrier's failure to present any and all viable defenses to such claim may result in a subsequent denial of its reimbursement claim under the WHCA. Upon approval of the death benefits claim, DLHWC should instruct the carrier of its responsibility to initiate timely payment on the DBA order. The carrier may subsequently seek reimbursement from DFEC under the WHCA.
Once DLHWC receives a request for modification, either from the claimant or from DFEC, DLHWC will take appropriate action required under the DBA. Given that DFEC has assumed responsibility for direct payments, however, DFEC should maintain active oversight of that claim and will provide any information or assistance requested by DLHWC to determine claimant entitlement or resolve claim disputes.
1. DLHWC will seek input from DFEC, as it would from the claimant and the carrier, and DFEC will provide written or verbal input as requested.
2. The DFEC Special Claims District Director, or his/her designee, will usually be the point of contact for DFEC in proceedings before the DLHWC District Director. He/she may request assistance as needed from the Branch of Regulations and Procedures and/or the Office of the Solicitor. In some instances a representative from the Branch of Regulations and Procedures and/or the Office of the Solicitor will act as DFEC's point of contact in a DLHWC District Director proceeding, in lieu of or along with the Special Claims District Director, or his/her designee.
1. Generally, DLHWC may only issue an order resolving an issue based on the agreement of the claimant and the employer/carrier.
2. If no agreement is reached, any party may seek adjudication of the issue through formal hearing and the various levels of review established under the LHWCA/DBA -- Office of the Administrative Law Judge (OALJ), the Benefits Review Board (BRB) and federal courts. FECA appeal rights are not applicable in these cases.
3. Any of those adjudicatory bodies may issue a decision and order that is effective upon filing or issuance and which will become final once the time to appeal to a higher body has passed.
4. Once an order on an issue outlined in this bulletin is filed, it is binding and DFEC must proceed accordingly, e.g. increasing the benefit level, paying an additional award, accepting a new medical condition, etc.
5. If payment of compensation is due, it must be paid within 10 calendar days of the DLHWC District Director's filing of the order or additional compensation is also owed in the amount of twenty percent (20%) of the accrued amount of compensation due.
6. Any request for payment of additional compensation due to a late payment should be made to DLHWC. If DLHWC determines that additional compensation is payable, DFEC will be so notified along with the claimant and carrier, and DFEC will process any necessary payment.
The LHWCA/DBA requires approval of any claimant's attorney fee by the body before whom the work was performed, e.g. the DLHWC District Director, the OALJ, the BRB, or the federal courts. Therefore, if a fee petition is received by DFEC due to an issue outlined in this bulletin (or any other reason), DFEC will direct the representative to seek approval from the appropriate body. DFEC can object to the requested fee, and will submit its response to the fee request to the appropriate body when necessary. DFEC will not review such fee petitions in accordance with FECA standards.
DFEC will send a letter to the employer/carrier, and to their attorney, containing all relevant information and/or proposed actions to be implemented.
The letter should also contain the caveat that the employer/carrier will be deemed to have consented to the action proposed unless it files an objection to such action with the DLHWC within 15 days.
If the employer/carrier does object, it is incumbent upon it to take the appropriate action in furtherance of its objection.
1. DFEC requires, before acceptance of any WHCA reimbursement claim, that the employer/carrier has made only reasonable and prudent efforts in presenting all meritorious defenses against a DBA claim without regard to whether the case is eligible for WHCA reimbursement. An employer/carrier's inadequate or overly zealous representation in defending against a DBA claim may be grounds for denying all or some portion of a request for WHCA reimbursement.
2. DFEC'S development of any aspect of a claim may include communication with the claimant and his legal counsel, as the situation dictates.
Disposition: This bulletin is to be retained until the FECA and LHWCA Procedure Manuals have been updated.

References: § 794
 § 794
 § 705
 § 12102
 § 705
 § 12102
 §10
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 §10
 §10
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 §10
 §10
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 § 1704
 § 1704
 § 1704
 § 61
 § 61
 §61
 § 1704
 § 61
 V.