PART E IMPAIRMENT BENEFITS SESSION - DOLInstructor Guide Page 1 . PART E IMPAIRMENT BENEFITS SESSION . Basic Claims Examiner Training Course Impairment Benefits Session Instructor

Basic Claims Examiner Training Course Impairment Benefits Session

Instructor Guide Page 1

PART E IMPAIRMENT BENEFITS

SESSION



SESSION BACKGROUND INFORMATION

Session Title Part E Impairment Benefits

Instructional Time

90 minutes

Session Description

This session focuses on the development of impairment benefits. It addresses the requirements to substantiate an impairment claim through two options – either the claimant’s physician or the DMC. It also covers how to calculate the actual impairment award and concludes with what must be contained in the recommended decision as well as how this is handled during FAB review.

Instructional Objectives

• Explain the conditions under which a survivor or an employee may claim impairment benefits

• Define ‘maximum medical improvement’ • Identify the standard used for impairment rating • Explain the two options that a claimant may pursue in order to claim

impairment benefits • Identify what the impairment evaluation must provide

Instructor Materials

For this session, the following materials are required:

ImpairmentSession.PPT

Trainee Handouts

PM 2-1300

Participant Guide

Impairment Session tab

Case Study After slide #39, proceed to the case study activity and then continue with the remainder of the slide presentation.



IMPAIRMENT BENEFITS SESSION INSTRUCTIONAL CONTENT

#1

Part EImpairment Benefits

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#2

Introduction Another benefit available to Employees (and in one

instance to survivors) under the EEOICPA is Impairment.

This presentation will discuss • New procedures implemented to streamline process and

speed up benefit disbursement• Benefits available• The impairment claim process

2



IMPAIRMENT BENEFITS SESSION INSTRUCTIONAL CONTENT, CONTINUED

#3

Who can file a claim for Impairment Benefits? Employee:

• Covered Part E employee found to have contracted a covered illness through exposure to a toxic substance at a DOE facility or RECA section 5 facility

Survivor:• If a survivor is not entitled to the lump sum $125,000 entitlement

payment, he/she may elect to receive compensation that otherwise would have been paid to the covered employee

• Note: The employee must have filed a claim underPart E and then died from a non-covered condition prior to receiving compensation

3

#4

Overview of Impairment Benefits Performed on a covered illness that has reached

maximum medical improvement (MMI) or if the employee is terminal

Impairment is established by use of current medical evidence (within last 12 months)

Performed by a qualified physician using the 5th Edition of the AMA’s Guides

As a result of an impairment rating, the claimants may receive $2,500 per percentage point ($2,500 x 1% = $2,500.00)

4




Instructor NOTE

The scope of this presentation is to help the CE better understand impairment and the impairment rating process. This will be discussed throughout this session.

#5

Impairment RatingBased upon the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides), a rating is a percentage that represents the extent of whole-person impairment of the employee, based on the organ(s) or system(s) affected by all the employee’s covered illnesses

5

(Currently, the 5th edition is being used) - The 6th edition has been released but we require that the physicians use the 5th edition.

The American Medical Association Guides to the Evaluation of Permanent Impairment (Guides) is the most widely used basis for determining impairment. They are used in state workers’ compensation systems, federal systems, automobile casualty and personal injury.

Impairment and Disability are not the same thing. The AMA Guides define disability “as an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment.” Impairment is “a loss, loss of use, or derangement of any body part, organ system, or organ function.” In essence you can be impaired without being disabled. However, you can’t be disabled without being impaired. When discussing impairment with claimants, the CE should be sure to make this distinction.




#6

Maximum Medical ImprovementThe medical evidence must show that the employee’s covered illness has reached maximum medical improvement (MMI), which means the condition is unlikely to improve substantially with or without medical treatment

• An exception is if the employee, based on the medical evidence, is terminal

6

If the medical records show the employee’s covered illnesses have reached MMI, or if you are unable to determine that MMI has been reached, or if the employee is terminal, the CE moves forward with soliciting a claim.




#7

Not at MMI

In most cases, a determination of MMI is based on a physician’s evaluation and/or conclusion

If the employee has not reached MMI or is not terminal:• CE sends a letter to the employee informing him/her that

an impairment rating cannot be made until MMI is reached and the claim is administratively closed. CE also advises the employee to notify the DO when the covered illness is at MMI

• The CE codes ECMS - C10 Partial Claim Closure code (reason code – NM ‘Not at MMI’)

7

If the employee’s treating physician states that the employee is not at MMI and recommends treatment that could improve the condition, the CE should contact the employee to determine if he/she is undergoing the recommended treatment and how long the treatment will last. If the employee is undergoing this treatment, the CE can administratively close the claim. However, if the employee chooses to forgo the recommended treatment, he/she must notify the District Office in writing. Upon receipt of the employee’s choice to forgo the recommended treatment, the CE may proceed with an impairment determination.

Once medical evidence is received in the DO indicating that the employee is at MMI, development is resumed and an “RD” [Reopened – Development Resumed] code is entered into ECMS. The status effective date is the date the evidence of MMI is received in the DO.

In a case of multiple covered illnesses where one condition is at MMI and another is not, the CE should proceed with a determination regarding impairment for the condition(s) at MMI. If different covered illnesses affect the same organ, and one condition is not at MMI, the CE cannot proceed with an impairment rating until all conditions in that organ have reached MMI.




General Process The CE is now responsible for developing impairment and/or wage-loss claims by engaging in outreach efforts and educating covered employees on the requirements for filing and obtaining impairment and/or wage-loss benefits. This outreach effort takes place after the issuance of a Part E final decision to an employee with a positive causation determination and there is no indication that a claim has already been made for wage-loss and/or impairment. It will also include cases where the two year re-filing mark for impairment claims is reached and cases where the one year mark following issuance of the last wage-loss award has elapsed.

Upon receipt of the final decision from FAB, the CE telephonically contacts the eligible employee. The purpose of the call is to solicit claims by providing information about the potential wage-loss and/or impairment benefits available, explaining eligibility requirements or program procedures, and responding to questions. During the telephone call, the CE requests that the employee submits a signed letter stating whether or not he or she intends to pursue either impairment and/or wage-loss benefits. The CE then prepares an initial development letter for impairment and/or wage-loss benefits, sends it to the employee and enters the appropriate claim status code in ECMS (DO-IM, DO-WL or DO-WI). Examples of the initial development letters for impairment benefits are included in PM 2-1300 and initial development letters for wage-loss benefits are included in PM 2-1400. All discussions with the employee about wage-loss and/or impairment must be documented in the ECMS via the Telephone Management System (TMS) screen. ECMS code is applicable whenever the employee informs the DEEOIC in writing of his or her intention to claim wage-loss and/or impairment benefits. Conversely, if the CE is unable to contact the employee after a reasonable amount of time (3 separate attempts) and has determined that further attempts will not be productive, then no further follow-up actions are necessary. The CE memorializes the telephone call in the ECMS via the TMS screen but no ECMS code is applicable. The CE continues to develop for wage-loss and/or impairment claims in accordance with the established policy in the PM 2-1300 and PM 2-1400.

Taken from Policy Guidance in an email dated February 24, 2010 from Carol Campbell, Policy Unit chief to District Directors.




#8

Developing for Impairment Benefits The CE must develop for impairment benefits, when

applicable If solicitation is applicable, the CE sends initial

development letter Impairment development does not delay the issuance of

a recommended decision to accept on other issues of the claim

FAB advises the employee of his/her right to claim impairment in the final decision cover letter

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#9

Initial Development LetterCE informs the employee in a letter:

• To select either their Own Physician or the District Medical Consultant (DMC) to perform the impairment rating evaluation, in writingo If electing Own Physician, the physician’s contact information must be

providedo If electing a DMC, current medical records and Activities of Daily Living

(ADLs) will be required• If he/she does not wish to file a claim for impairment at this time,

they may decline offer in writing and file at a later date• To provide a response in writing within 60 days with follow-up at

the 1st 30 day interval

9

Participant Guide Pages

A copy of the initial development letter template for impairment benefits is included in this session of the Participant Guide.




#10

Development Option 1 and 2 are no longer applicable

Claimant can still choose, but if impairment is claimed and the claimant does not choose his/her physician then the CE can proceed to obtain a rating based upon the evidence of file

Expedited handling is the goal

10

#11

Impairment Solicitation (No Response)If employee does not respond to impairment solicitation within 60 days (2 - 30 day letters). The CE can assume impairment is not being claimed

• The CE sends an impairment development letter to the employee advising that a claim for impairment will not be developed at this time and advises of the right to claim impairment in the future

• CE enters ECMS code - NIM ‘Not claiming Impairment’ –the status effective date is the date a letter is sent to the employee acknowledging that they do not wish to file a claim for impairment (after the expiration of 60 days)

11




#12

Impairment Solicitation (Negative response)If the employee advises the District Office that they do not wish to claim impairment benefits:

• The CE advises the employee by letter of his/her right to file a claim for impairment benefits in the future

• CE enters ECMS code–NIM ‘Not claiming Impairment’ –the status effective date is the date the response was received from the employee

12

#13

Impairment Withdrawal (Partial Claim Closure)If the employee files a claim for impairment benefits and then withdraws the claim in writing prior to issuance of a recommended decision, the CE will enter ECMS code:

• C10 (reason code ‘ICW - Impairment Claim Withdrawn’ –the status effective date = the date the withdraw letter was received by the DO or FAB

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#14

Impairment (Partial Claim Closure) The C10 code must never be used to “stop the clock”

while waiting for impairment evidence

If impairment is claimed and the employee is unresponsive to development the claim must be denied, not closed!

14

#15

Impairment Claim Input the “IC” – Impairment Claimed code into ECMS when a

claim is received in writing Status effective date = postmark date of the letter, if

available, or the date the letter is received in the DO/FAB If impairment is claimed multiple times, “IC” code only needs

to be entered once – earliest one (unless impairment is claimed again after the final decision)

If the employee submits an impairment rating performed by his/her personal physician without filing, this is treated as a claim for impairment and the “IC” code is entered

15




#16

Employee Elects Own Physician If employee elects his/her own treating physician to perform the impairment evaluation:

• CE sends letter to the physician providing the:o Covered illness(es)o ICD-9 code(s)o Physician requirementso Evaluation criteriao Procedures for submitting charges

• CE also advises the physician that the impairment evaluation, along with tests needed to perform the evaluation will be paid by DOL if it meets specific criteria

16

#17 Physician Requirements for Employee’s Own Physician The physician must hold:

• A valid medical license and a Board certification/eligibility in the appropriate field of expertise (i.e. toxicology, pulmonary, occupational medicine, etc.)

The physician must meet at least one of the following:• Certified by the American Board of Independent Medical Examiners (ABIME)

and/or the American Academy of Disability Evaluating Physicians (AADEP)• If not ABIME or AADEP certified, may possess the requisite professional

experience and background in interpreting the AMA’s Guides to provide such ratings. He/she must include in a report a written certification identifying the specific expertise and knowledge of the AMA’s Guides (i.e. years performing ratings, entities for which ratings were performed, etc.).

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If the employee wants his/her physician to do the impairment rating and it is determined that the physician does not meet the above criteria, the employee may contact the CE for a listing of physicians that are qualified to perform impairment ratings and are enrolled in the program.

Qualifications may be determined by the submission of a letter or a resume which demonstrates that the physician is licensed and meets the requisite program requirements; no copies of medical licenses or certificates are needed.

If questions arise as to the competency of a physician to conduct such a rating, this matter will be forwarded to National Office for consideration.

#18

Procedures For Submitting Charges (Employee’s Own Physician)In a letter, the CE must provide to the employee’s physician:

• OWCP-1168 Provider Enrollment Form (unless the physician is already enrolled)

• OWCP-1500 - clearly marked on top of the form in red ink “Prompt Pay”. The CE also completes:o Sections 1a, 2, 3, & 5 (File No., name, address, birth date, and sex)o Section 12 & 13 should contain “signature on file”o Section 21 should contain V70.9

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#19

OWCP-1168 and OWCP-1500

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Participant Guide Page

Copies of the OWCP-1168 and the OWCP-1500 are included in this session of the Participant Guide.




#20

Employee Elects DMC If employee elects a District Medical Consultant (DMC) to perform

the impairment evaluation:• CE must reference the required medical evidence for the specific ICD-9 Code

of the covered illness(es) • CE must determine if the medical evidence is current (dated within the last

12 months) and includes the employee’s ADLs

If the medical evidence is sufficient, CE prepares a DMC referral package. The referral package, along with the appropriate medical evidence is forwarded to an approved DMC via the District OfficeMedical Scheduler

If medical evidence is insufficient, CE sends letter to claimant requesting additional specific evidence/test results

20

Note that the DMCs are qualified to perform impairment ratings; therefore, the CE will not request the physician’s medicals and licensing.




#21

Employee Elects DMC, continued The CE requests that the employee provide current medical evidence (within last

12 months); however, if the employee states in writing (or after two letters requesting medicals with no response) that he/she has provided all medical evidence, the CE should proceed with a DMC referral if applicable testing is in the file.

Examples of applicable testing include:• PFTs for lung conditions• Measured creatine clearance testing for kidney diseases• Stress testing for heart conditions• Blood count for blood disorders• Audiograms for hearing loss• Range of motion for accepted conditions affecting limb use, i.e., breast cancer• Gait for peripheral neuropathy• Vision tests for accepted vision defects, e.g., cataracts, macular degeneration

When an employee is in the advanced stages of his/her accepted cancer, it is imperative that the employee’s physician submit detailed ADL’s so that the DMC can make a fair assessment.

21

To be claimant favorable, if the medical evidence appears to be lacking the specific testing for certain conditions, the CE should check with the DMC to determine if an impairment evaluation can be completed prior to denying the claim.




#22

Required Medical for Specified ICD-9 Code

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#23

Activities of Daily Living (ADLs)

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A copy of the ADL is included in this session of the Participant Guide.

If an impairment claim is received for breast cancer or skin cancer and the employee is selecting the DMC to complete the impairment evaluation, these two pages along with the specific ADL’s for breast cancer or skin cancer must be sent to the employee so that the employee can have his/her treating physician complete them.

#24

Activities of Daily Living (ADLs) – Breast Cancer

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If an employee is claiming impairment for breast cancer, this sheet along with the 2-page general ADLs must be sent to the employee so that the employee can have his/her treating physician complete them.


A copy of the Breast Cancer ADL is included in this session of the Participant Guide.




#25

Activities of Daily Living (ADLs) – Skin Cancer

25

If an employee is claiming impairment for skin cancer, this sheet along with the 2-page general ADL’s must be sent to the employee so that the employee can have his/her treating physician complete them.


A copy of the Skin Cancer ADL is included in this session of the Participant Guide.




#26

Impairment Claimed – Rating Option not Chosen If the employee responds in writing that he/she

wishes to claim impairment but does not indicate who should perform the impairment evaluation, the CE will assume that the employee wishes to have the DMC complete the impairment evaluation and will evaluate the case for DMC referral.

If more medical is required, contact claimant

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#27

Employee Deemed as Terminal (or End Stage)When an employee is considered TERMINAL, the CE should do everything within their power to make sure the case progresses as quickly as possible.

• The CE should provide the employee and/or their authorized representative all necessary documentation to complete the impairment evaluation.

• While the employee may choose their personal physician to complete the evaluation, the CE should encourage the employee to select the DMC so that the process can be expedited at the DO level.

• If the employee elects their own physician, the CE should contact the physician immediately and fax all pertinent documentation to the physician.

• In some situations, the Resource Centers may be used when waivers and forms, e.g., EN-20, ADLs, etc., need to be signed quickly due to the health of the employee an the possibility that the benefit may be extinguished due to the employee’s death.

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Terminal status allows for an exemption of the 2 year waiting period for an increase in impairment. Policy Call 9/10/08, #8

“If there is sufficient evidence to determine that the employee is terminal and there are no new covered/consequential illnesses, the employee would be eligible for a new early impairment evaluation.”

#28

Impairment Ratings for Certain ConditionsMental Disorders

• The CE must determine whether the claimed impairment originates from a documented physical dysfunction of the nervous system.

• If the mental impairment originates from a documented physical dysfunction of the nervous system, an impairment evaluation can be obtained based on Table 13-8 of Chapter 13 in the 5th Edition of the AMA’s Guides.

• If the mental impairment is not related to a documented physical dysfunction of the nervous system, it cannot be assigned a numerical percentage using the AMA Guides.

• The CE sends a letter to the employee and provides 30 days to submit documentation from a physician if the employee believes there is a link between the exposure to a toxic substance at a covered facility and the development of a mental impairment.

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The physician’s report must contain rationalized medical evidence establishing that the mental impairment is related to neurological damage due to a named toxic exposure.

Speculation or unequivocal statements from the physician reduce the probative value of a physician’s report, and, in such cases, the CE may find it necessary to refer the case to a DMC or a DEEOIC toxicologist.




#29 Impairment Ratings for Certain Conditions, continuedBreast Cancer

• Once an impairment claim is received in the DO for breast cancer, either male or female, the CE submits a request to the physicianperforming the evaluation explaining all the criteria that must be considered and referenced in the final report.

• For females, child bearing age will not be a determining factor when issuing an impairment rating, as the AMA’s Guides do not define “child bearing age.”

• Upon receipt of the completed impairment evaluation, the CE reviews the report to ensure that the physician comprehensively addressed each of the factors necessary for an acceptable rating.

• If the physician has not provided a complete rating for the breast, the CE sends a follow-up letter to the physician. The CE notes the deficiency in the assessment and that the purpose for obtaining a complete response is to ensure the employee receives the maximumallowable rating provided by the AMA’s Guides.

29

The physician should address the following in his/her report:

1. The presence or absence of the breast(s),

2. The loss of function of the upper extremity (or extremities if there is absence of both breasts due to cancer),

3. Skin disfigurement, and

4. Other physical impairments resulting from the breast cancer.




#30

DMC Referral PackageIf the medical is sufficient for an impairment evaluation by the DMC, the CE prepares a referral package (requesting appropriate specialist), which includes:

• District Medical Consultant Referral Form • A Statement of Accepted Facts (SOAF)• Questions to the DMC• Form OWCP-1500. The CE completes:

o Sections 1a, 2, 3, & 5 (File No., name, address, birth date, and sex)o Sections 12 & 13 (should contain “signature on file”)o Section 21 (should contain V70.9)

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On the day that the Medical Scheduler mails the DMC referral package (date of the cover letter), the CE enters “MS/IM” in ECMS E.




#31

SOAF & DMC Questions SOAF includes:

• Employee Name• File No.• Covered employment• Covered illness(es)• Current Height/Weight• Adjudication of the case• Decisions issued on case to

date (Final Decision - Part E)

DMC Questions – specific, non-general• Has the employee reached

MMI? • If the employee’s condition has

reached MMI, what is the percentage of whole person impairment?

• Provide the pages and tables of the AMA’s Guide used in performing the impairment evaluation.

31

Current height is needed when evaluating lung conditions which require PFT results.

Current height/weight is needed when evaluating digestive conditions.

DEEOIC requires that the DMCs use the 5th edition of the AMA Guides.




#32

Impairment EvaluationsThe Impairment evaluation should:

• Note if the employee’s covered illness has reached MMI• Provide a percentage point that represents the extent of whole

person impairment, based on the organ/system affected by the covered illness(es) only

• Provide a combined total percentage point, if the physician performed a rating on more than one organ or system

• Be clearly rationalized and grounded in sound medical opinion, referencing the pages and tables used

• Be based on the AMA’s guides (5th Edition)

32

If the DMC determines that a condition/conditions is/are not at MMI (or if the condition(s) cannot be assigned a numerical percentage point), the condition(s) cannot be included in the impairment evaluation.

The DMCs have a handbook available to them that explains much of what they need to do for an impairment evaluation.




#33

Impairment Evaluations, continued The impairment evaluation should not apportion the

impairment rating between a covered illness and a non-covered illness, if the non-covered illness effects the same organ or for lifestyle choices (e.g., smoking)

If the report lacks clearly rationalized medical evidence, the CE should identify the deficient areas of the report and contact the physician to request additional clarification

33

Apportionment is discounting or lowering an impairment rating based on a non-covered illness within the same organ as a covered illness. This is not allowed; the physician must rate the whole organ.

For example, if we accepted asbestosis and denied COPD, the doctor must determine the impairment rating for the lungs without discounting any portion of impairment he may attribute to smoking and the resulting COPD.




#34

Cost of Impairment Evaluation The CE approves the bill for an impairment rating

only if it meets necessary criteria The CE also approves the cost of any medical

test/evaluations required for obtaining the impairment evaluation

Only one evaluation should be approved, unless, it is determined that additional testing is needed to make a determination for the impairment rating

34

Once the CE accepts the impairment evaluation as satisfactory, the CE should code EMCS-E with “MR-IMP”. The date of the “MR-IMP” should be the date that the report is received in the district office (punched date). If that date is not available, then the date stamped on the OWCP-1500 by the Medical Scheduler should be used.




#35

Incomplete RatingsIf the impairment rating report is unclear or lacks clearly rationalized medical evidence as support, additional clarification is required.

• The CE returns the impairment rating evaluation to the rating physician with a request for clarification, indicating what areas are in need of remedy.

• If the report was performed by the employee’s physician and no response is received or is returned without sufficient clarification, the CE notifies the physician of the need for additional justification. The CE should also advise the physician that if the requested information is not received within 30 days, his charges for the impairment evaluation will not be paid.

• If no response is received, the case is sent to a DMC for a new rating. If the incomplete report was submitted by a DMC, the CE must notify the DMC of the deficiency and request a more comprehensive report.

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#36

Processing Impairment Evaluation Payments Physician must submit the impairment evaluation

and OWCP-1500 form The CE reviews for accuracy and ensures that the

impairment meets the criteria If so, the CE approves the impairment rating in the

ECMS medical screen as a Prompt Pay Bill and then forwards for payment to the Medical Scheduler

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#37

ECMS - Medical Payment ScreenApproval of a Prompt Pay Bill Report indicator ‘N’ PA – Prior Approval ICD-9 – V70.9 Note – Impairment evaluation performed by Dr. ____ Condition Status – ‘A’ Accepted Status effective date and eligibility end date (OWCP-1500, Item 24A)

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#38

Rating Evaluation Calculation and AwardUpon completion of the impairment evaluation, the CE reviews the report to assure all the criteria is met, the award is then calculated:

• The calculation of an award is tabulated by multiplication of the percentage rating of whole-person impairment by $2,500.00 for each percentage point

• For example, if a claimant receives a 35% impairment rating. The claimants may receive $2,500 per percentage point ($2,500 x 35% = $87,500.00)

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In most instances, the physician will not apportion out for exposure because he cannot do so. The physician needs to explain that in his report.

The physician MUST provide the % of whole person based solely on the covered condition.

Trainee HANDOUT

Distribute the Impairment Case Study materials to the trainees.

Case Study The trainees are to review the materials for two cases and answer the series of questions for each case. After allowing sufficient time, review the case study outcomes eliciting information from the trainees.

Trainee HANDOUT

Distribute the Impairment Case Study Answer Sheet to the trainees upon completion of the case study activity.

#39

Pre-Recommended Decision Challenges The CE should not provide the employee with a copy of the

impairment evaluation unless a copy is requested in writing Employee may submit arguments making the challenge

and/or submit additional medical evidence of impairment If additional evaluation differs from one already in file, CE

must review the reports in detail to determine which has more probative value

If reports appear to be of equal value, CE may wish to refer file to DMC for additional consideration• If the DMC gives the opinion that both evaluations are of the

same probative value, the CE may obtain a referee medical examination

39




In weighing the medical evidence, the CE must use his/her judgment in the analysis of reports. If the reports appear to be of equal value, the CE may wish to refer the file to a DMC for additional consideration.

Keep in mind that probative means “believable” and the CE reviews each report to determine which one, on the whole, is more believable based upon the medical rationale provided and the evidence at hand overall (objective versus subjective).

#40

Issuing the Recommended Decision (RD) Determination of impairment must not delay issuance of

RD to accept on other issues (do not need an FD to accept in order to issue RD for impairment)

RD must have a thorough discussion of the impairment evidence submitted in the case.

Secondary CE designated (co-located) to FAB may develop for impairment while case is under review by FAB on other issues.

If more than one evaluation in file, CE provides detailed discussion of why one report was found to have more probative value than another.

40

The Recommended Decision must contain a thorough discussion of the impairment evidence submitted in the case.

Therefore, if there is more than one evaluation in the file, the CE must provide a detailed discussion of the reason why one report was found to have more probative value than another.

This is necessary because if the employee submits additional impairment evidence to the FAB, he/she will have the burden to prove that the additional impairment evidence has more probative value than the evaluation relied upon by the District Office.




#41

Development While at FAB Employee may submit new medical evidence to

challenge impairment determination in RD Employee bears burden of proving additional

impairment evidence has more probative value If FAB finds two impairment evaluations differ and

both evaluations are of virtually equal probative value, this alone is insufficient to enable the employee to meet his/her burden of proof.

41

The additional impairment evidence must meet the criteria addressed earlier in order for FAB to consider it.

If it does meet the criteria, and the FAB finds that the two impairment evaluations differ and that both evaluations are of virtually equal probative value, this alone is insufficient to enable the employee to meet his/her burden of proof; therefore FAB goes with the report used by the DO.




#42

FAB Review FAB reviews all relevant evidence of impairment in

file and bases determination on evidence it finds to be most probative

FD must contain detailed rationale/discussion for any determination concerning multiple impairment evaluations

Include evaluation of all relevant evidence and argument(s) in the file

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#43

Survivor Election of Benefits (EOB) If a covered Part E employee dies after submitting an impairment

claim but before compensation is paid and death is caused solely by a non-covered illness(es), the survivor may elect to receive the compensation that would have been payable to the employee.

The EOB is not available to survivors if the necessary diagnostic or medical evidence will not allow for a viable rating, and there is no way to collect new information following the death of the employee. The DMC in this situation would advise that given the available evidence, no rating is possible in accordance with the AMA’s Guides.

The specific deficiencies should be noted by the DMC, and this information should be furnished to the survivor in a letter from the CE.

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#44

Additional Filings Part E employee previously awarded impairment may

file for additional benefits• Based on increased rating for accepted covered illness

• Not earlier than two years from the date of award (date of Final Decision)

EE-10 is form used for additional filings

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A copy of the EE-10 is included in this session of the Participant Guide.

#45

Exceptions to the 2 Year Rule Impairment based upon condition not covered in

original award (Final Decision), i.e. – new accepted illness(es)

Employee received an impairment rating of 0%

45




A whole-body impairment evaluation is required; therefore, the CE must obtain recent medical evidence (within last 12 months) for all accepted conditions (including those conditions already awarded an impairment rating).

For previously rated 0%, must still be at MMI, provide appropriate medical documents, and be evaluated for a reopening of the claim.

#46

ECMS Coding Review IC – Impairment Claimed (status effective date = the

earliest date the claim is received) DO - Developing Other

• Reason code “IM (status effective date = the date a development letter for impairment is sent to the employee)

NIM (Not Claiming Impairment) entered after no or negative response

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#47

ECMS Coding Review, continued MS - Sent Medical Request for Impairment

Evaluation • Reason code “IM” + status effective date (=date the

Medical Scheduler mailed the DMC referral, i.e., date of cover letter)

MR – Received Impairment Evaluation • Reason code “IM” + status effective date (=date the report

is received by the DMC)

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#48

ECMS Coding Review, continued C-10 (Partial Closure Code) with corresponding reason code:

• “NM - not at MMI” is used with the status effective date of the letter advising the employee that he or she is not at MMI

• “ICW”-Impairment Claim Withdrawn

RD (Development Resumed) - status effective date = the date the medical evidence is received to establish the employee is at MMI • (Please note the RD code is only used to continue an impairment claim

following the C-10/NM code)

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#49

Questions

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#4#3#2#1Trainee HandoutsSession TitleInstructional Time Session DescriptionInstructional ObjectivesInstructor MaterialsParticipant GuideCase StudyInstructor NOTE#5#6#7General Process#9Participant Guide Pages#10#11#12#13#14#15#16#17#18#19Participant Guide Page#20#21#22#23Participant Guide Page#24Participant Guide Page#25Participant Guide Page#26#27#28#29#30#31#32#33#34#35#36#37#38Trainee HANDOUT Case StudyTrainee HANDOUT #39#40#41#42#43#44Participant Guide Page#45#46#47#48#49Session background informationimpairment benefits session instructional contentimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continuedimpairment benefits session instructional content, continued

Documents

PART E IMPAIRMENT BENEFITS SESSION - DOLInstructor Guide Page 1 . PART E IMPAIRMENT BENEFITS SESSION . Basic Claims Examiner Training Course Impairment Benefits Session Instructor