OFFICE OF WORKERS' COMPENSATION PROGRAMS

Ambulatory Surgical Centers should bill for facility charges on the OWCP-1500 using the appropriate AMA CPT® code(s) for the primary, secondary, tertiary, etc. procedures and should use the "SG" modifier with each CPT® code.

Effective October 1, 2022, Outpatient UB-04 billed lines submitted with both the Revenue Center Code (RCC) and a CPT/HCPCS/OWCP procedure code will be priced based on the procedure code fee schedule. This pricing update will apply to bills submitted for DFEC, DEEOIC, and DCMWC.

Please note that there will be no changes for RCC pricing for lines billed without a procedure code.

In addition, this pricing update will not affect the RCC Codes requiring CPT/HCPCS/OWCP Codes for Outpatient Hospital Services, per the OWCP Fee Schedule.

It also will not affect Outpatient Bills (13x or 14x) that are priced via OPPS for DFEC and DEEOIC Programs, or implant lines billed with RCC 0274 – 0279 that require a manufacturer’s invoice for reimbursement (DFEC program only).

Please click this link to visit the OWCP Fee Schedule page for more information.

For additional information, you may contact our Call Center at the number listed below, where a Call Center representative will be happy to assist you.

• Division of Coal Mine Workers’ Compensation (DCMWC) 1-800-638-7072
• Division of Energy Employees' Occupational Illness Compensation (DEEOIC) 1-866-272-2682
• Division of Federal Employees' Compensation (DFEC) 1-844-493-1966

Effective October 1, 2022, DEEOIC will implement process improvements for submitting Durable Medical Equipment (DME) and for Rehabilitative Therapies (Rehab) authorization requests.

Improvements include:

• Providers will be able to submit corrections to approved Rehab request authorizations.
• Providers will be able to view the line status of an Authorization Request, including the new status of “Processed - Awaiting Decision” when the authorization line is under DEEOIC review. The status will be updated when a decision has been made by DEEOIC.

Please note that if any changes are necessary for DME authorization, then the provider can submit a new Authorization Request.

For additional information, you may contact our Call Center at the number listed below, where a Call Center representative will be happy to assist you.

• Division of Energy Employees' Occupational Illness Compensation (DEEOIC) 1-866-272-2682

The Division of Coal Mine Workers' Compensation, or Federal Black Lung Program, requires prior approval of the pre-transplant evaluation for lung transplants and the lung transplant itself for Black Lung beneficiaries (20 C.F.R. § 725.705).

Information about an individual's general eligibility for medical benefits may be obtained by calling the District Office where the patient's claim file is located, or by calling the Black Lung toll-free number at (800) 638-7072. Eligibility for medical benefits does not automatically include approval for a pre-transplant evaluation or a lung transplant.

Before seeking approval for a pre-transplant evaluation or a lung transplant, a medical center must be approved as a lung transplant center by the Center for Medicare and Medicaid Services (CMS), or the request will automatically be denied. The list of approved transplant centers is available at:

https://qcor.cms.gov/default.jsp?referer=http://qcor.cms.gov/main.jsp

After reaching the homepage, select the “Resources” link on the upper right hand of the page. A pop-up window will open. Select link for “List of CMS-Approved Organ Transplant Programs”. This will open an excel spreadsheet which contains certification information for all Medicare-certified transplant programs, organized by State. Please refer to the approved lung transplant programs.

Approved lung transplant centers must determine if the patient's medical benefits are the responsibility of a coal mine operator or insurer or the Black Lung Disability Trust Fund. The patient should have this information. For a pre-transplant evaluation or transplant to be considered, it must be necessitated by the coal miner's black lung condition and directly related conditions. If the patient is covered by an insurer or coal mine operator, the company's approval must be obtained prior to a pre-transplant evaluation or transplant. Pre-transplant evaluation and transplant coverage is decided on a case-by-case basis. The Federal Black Lung Program expects coal mine operators or insurers to provide the same coverage that it does. The documentation that coal mine operators or insurers require to determine whether or not they will approve coverage may vary.

If the patient is covered by the Black Lung Disability Trust Fund, the approval process must be initiated by emailing the request to https://owcpmed.dol.gov or by calling the toll-free number (800) 638-7072.

Requests for pre-transplant evaluations and lung transplants should include basic information including the patient's name and date of birth, as well as the name of the facility performing the evaluation or transplant.

Additionally, a request for a pre-transplant evaluation must include a physician's letter of justification. A physician's letter of medical justification is a well-rationalized narrative statement, prepared by a qualified physician who has been actively treating the patient for their pulmonary condition. The letter of medical justification represents the physician's independent assessment and opinion and must include a brief review of the claimant's pertinent medical history, a brief statement regarding the claimant's current medical condition, and explanation of the claimant's medical need for a lung transplant evaluation.

Requests for lung transplants must include the medical facility's lung transplant protocols and all medical records produced for the pre-transplant evaluation, including the results of all tests, consultations, and narrative reports.

After the Federal Black Lung Program evaluates the information submitted, it will notify the requestor of a determination regarding coverage. Any pre-transplant evaluation or transplant performed prior to receiving prior approval by the Federal Black Lung Program will be denied.

Any questions about pre-transplant evaluations or transplants should be directed to the Division of Coal Mine Workers' Compensation at efax-maos-transplant@dol.gov or by calling the toll-free number (800) 347-2502.

Effective August 20, 2022, the DFEC program will be implementing new utilization review (UR) for psychological exam and evaluation procedure codes. This change will impact professional, outpatient, and prompt pay bills.

Please refer to the DFEC Bulletin at this link for more information.

You may also contact our Call Center at the number listed below, where a Call Center representative will be happy to assist you.

Division of Federal Employees’ Compensation (DFEC): 1-844-493-1966

As of July 9, 2022, OWCP will implement enhancements to Surgical Package Authorization and Bill Processing for DFEC. Updates will be made to better reflect the providers involved in providing the surgical procedure.

Enhancements will include:

• Adding new Professional Type for Co-Surgeon for both online and paper authorization requests
• Allowing the same surgical package authorization request to cover all Professional Types
• Enhancing the authorization utilization and bill history screen to include Professional Type

You may also contact our Call Center at the number(s) listed below where a Call Center representative will be happy to assist you.

Division of Federal Employees' Compensation (DFEC) 1-844-493-1966

Effective January 1, 2022, in accordance with guidance set forth by the Centers for Medicare and Medicaid Services (CMS), DCMWC introduced two new pulmonary rehabilitation procedure codes, 94625 and 94626, to be billed for pulmonary rehabilitation services.

Effective July 1, 2022, the Healthcare Common Procedure Coding System (HCPCS) pulmonary rehabilitation procedure code G0424, will no longer be covered.

Please note that DCMWC will not pay for at-home pulmonary rehabilitation services.

Preauthorization is not required for in-facility pulmonary rehabilitation services.

Pulmonary rehabilitation providers must be enrolled in the DCMWC provider network to treat miners and receive payment for services. To enroll as a DCMWC provider, please access: the Web Bill Processing Portal<https://owcpmed.dol.gov/portal/> for enrollment instructions.

All bills for pulmonary rehabilitation services must be submitted on the OWCP-1500 claim form. A downloadable OWCP-1500 form<https://www.dol.gov/sites/dolgov/files/owcp/dfec/regs/compliance/owcp-1500.pdf> is available. Providers must use current procedure codes 94625 and 94626 when billing for pulmonary rehabilitation services. A bill for pulmonary rehabilitation services must include at least one of the following mandatory components:

1. Physician-prescribed exercise;
2. Education or training;
3. Psychosocial assessment;
4. Outcome's assessment; or
5. An individualized treatment plan.

DCMWC will pay for up to a maximum of 60 one-hour treatment sessions during any 90-day period; or a maximum of 90 one-hour sessions during any 12-month period. Lifetime maximums may also apply.

In accordance with 20 CFR 725.707(b), DCMWC may require reports of treatment from time to time, including an individualized treatment plan for each patient.

There is no change in the procedures for billing for other medical services that may be related to pulmonary rehabilitation services. For example, bills for established patient office visits and pulmonary function tests still do not require a Certificate Medical Necessity (CMN) and can be billed separately as they are now. There is also no change in the procedures for prescriptions for durable medical equipment (DME) or home nursing care, which will require a CMN.

All medical bills should be sent to:

DCMWC/Federal Black Lung Program
P.O. Box 8302
London, KY 40742-8302

Effective May 28, 2022, DEEOIC Home Health Requests for authorizations submitted by the provider will be combined into a single Authorization Request number to align to the authorization decisions made by the DEEOIC Program.

Additional improvements include:

• Providers will be able to submit corrections to approved Home Health request authorizations.
• Providers will be able to view the line status of an Authorization Request, including the new status of "Processed - Awaiting Decision" when the authorization line is under DEEOIC review. The status will be updated when a decision has been made by DEEOIC.

For additional information, you may contact our Call Center at the number listed below, where a Call Center representative will be happy to assist you.

• Division of Energy Employees' Occupational Illness Compensation (DEEOIC) 1-866-272-2682

In order to process prescriptions for DOL's FECA program, pharmacies MUST be part of the Optum/Tmesys Retail Network, process real time, and adjudicate electronically. The FECA program stopped accepting batch pharmacy bills in December, 2017 as a step toward this point-of-sale requirement, and the new PBM is the final step.

Effective 4/30/2021, you MUST submit all pharmacy bills point of sale, regardless of date of service, through the Optum network. Thus, ALL pharmacy paper bills must be submitted before 4/30/2021. As of 4/30/2021, DOL will no longer accept pharmacy paper bills for workers compensation medications covered under the OWCP FECA program. All medications must be processed at the point of sale with our PBM or home delivery program contractor, Optum Workers Compensation

In February 2021, the U.S. Department of Labor (DOL) began the implementation of a new contract to provide Pharmacy Benefit Management (PBM) services to the Office of Workers' Compensation Programs' Federal Employees Program for claims covered under the Federal Employees' Compensation Act (FECA).  DOL’s new PBM contractor is PMSI, LLC d.b.a Optum Workers’ Compensation Services of Florida (“Optum”).

Optum/FECA pharmacy cards and welcome letters will be mailed to injured federal employees in a phased approach. Before April 1, 2021 welcome packets will be mailed to claimants who have been prescribed opioid medication(s) with daily dosages exceeding the 90 MED (Morphine Equivalent Dose) due to urgent safety concerns. Presently, these claimants receive pharmacy services through First Script/Coventry and will need to transition to Optum.  Before April 30, 2021, welcome packets for all other FECA claimants will be mailed.

The use of the Optum/FECA pharmacy program is mandatory for ALL FECA claimants. Prescriptions will not be authorized at the pharmacy on or after the effective date printed on the recipient's card unless the card is presented at a participating pharmacy. If claimants have refills available at a non-participating pharmacy, an Optum/FECA network pharmacy may be able to transfer and receive the remaining refills.

Claimants can search for participating pharmacies on the web (ecomp.dol.gov) or by contacting Optum at 1-833-FECA-PBM (1-833-332-2726). If a pharmacy provider would like to join Optum’s network they should contact Optum at 855-264-8815 or email tmesys.network@optum.com.

OWCP has allowed for the provision of telehealth services without interruption and will continue to do so. However, due to the increased use of telehealth, and to ensure consistency and appropriate billing for such services, the Federal Employees’ Program issued a new policy on 10/22/2020 applicable to injured workers receiving medical care via telemedicine for an accepted work related injury.

FECA Bulletin 21-02 (https://www.dol.gov/agencies/owcp/dfec/regs/compliance/DFECfolio/FECABulletins) establishes the routine medical services that are eligible to be provided by telemedicine, and the specific provider types eligible for reimbursement for these services. Covered telemedicine services are analogous with services payable by the Centers for Medicare & Medicaid Services (CMS) but are not inclusive of all CMS approved services. When billed, correct modifiers and place of service indicators are required. In addition, along with the bill for services, appointment notes articulating the method of telemedicine employed, the length of the visit, any information collected, and the need and benefit derived from the appointment must be submitted at the time the bill is submitted for payment.

Effective April 25, 2019, the Division of Energy Employees Occupational Illness Compensation (DEEOIC) released a new policy regarding Targeted Case Management (TCM). TCM authorization requests submitted prior to April 25, 2019, are not impacted by the new policy.

Targeted Case Management (TCM) can occur when a claimant is prescribed multiple types or levels of care related to their covered condition(s). TCM is the coordination of different care providers (such a Home Health Aids, RNs, Therapists, etc.), and the different treatments being provided to assure that the medical care is appropriately scheduled, and that treatments don't inappropriately overlap or have unintended negative impacts on the claimant's health. This process facilitates services provided and assists claimants in gaining access to needed medical, social, educational, and other services directly related to their DEEOIC accepted condition(s).

DEEOIC does not reimburse for the supervision and monitoring of staff by RNs or other higher credentialed individuals. DEEOIC considers the supervision of home health care staff to be the inherent responsibility of the medical provider that the claimant chooses to provide health care services. The training or continuing education of health care personnel is also not considered TCM or reimbursed.

See the EEOICPA circular on Targeted Case Management for Home Health Care.

A regulatory change to the EEOICPA Final Rule was published on February 8, 2019, and went into effect April 9, 2019. This change made OMB forms EE-17A and EE-17B required for initiating initial (claimant has never received services through EEOICPA) authorization requests for home health care, hospice, assisted living, and nursing home care. Upon implementation of the forms on June 3, 2019, medical providers will no longer submit authorization request forms to Conduent to initiate care for the aforementioned service types when the claimant requests care for the first time. However, the authorization details (approved, denied, or pending) concerning these requests will continue to be processed and transmitted to Conduent. All emergency temporary authorization requests, or requests for reauthorization, or requests for an amended level of care will continue to be submitted to Conduent using the existing processes.

Review the EE-17A and EE-17B forms.
 

Notice of Final Rule
The Office of Workers' Compensation Programs has issued a Final Rule governing the Black Lung Disability Trust Fund's payment of medical benefits under the Black Lung Benefits Act. The Final Rule:

1. Adopts modern payment formulas for physicians, hospitals and other providers that are derived from the formulas used in the Medicare program. These formulas are also similar to those used by other OWCP programs (e.g., Federal Employees Compensation and Energy Employees Occupational Illness Compensation programs).
2. Codifies the black lung program's current practices for the payment of prescription drugs and the submission of medical bills for payment.
3. Provides greater clarity about fees paid to providers, which should speed processing and payment of benefits as well as make it easier for the Trust Fund to obtain reimbursement from coal companies.
4. Prohibits providers from seeking additional payments from miners for covered services that have been paid by the Trust Fund.

Miners will not see any change in the medical care they receive to treat their black lung disease.
The regulations will be effective August 31, 2018. The rules will apply to medical equipment, prescription drugs, and inpatient medical services provided or rendered after that date. The rules governing payment of professional medical services and outpatient medical services have a delayed application date and will apply to services rendered after April 27, 2020.

The Final Rule is available for public inspection today on the Federal Register's website at: https://www.federalregister.gov/documents/2018/06/14/2018-12418/black-lung-benefits-act-medical-benefit-payments. The Federal Register published the rule on June 14, 2018. The published version is available online at the same website location.

On June 14, 2018, the Office of Workers' Compensation Programs Division of Coal Mine Workers' Compensation issued a final rule governing the Black Lung Disability Trust Fund's payment of medical benefits under the Black Lung Benefits Act. The revised regulations became effective on August 31, 2018. Most of them, including those governing payments for medical equipment, prescription drugs, and inpatient medical services, applied immediately. However, the regulations governing payment of professional medical services and outpatient medical services had a later applicability date of November 30, 2019, so that a new computer system could be developed to process these bills. OWCP is delaying the applicability date of the regulations governing payments for professional medical services and hospital outpatient services from November 30, 2019, to April 26, 2020, due to unforeseen delays in developing the computer system. More information is available at: https://www.dol.gov/owcp/dcmwc/