Chapter E-1100 Decisions and Hearings

1. Purpose and Scope. This chapter describes the process by which the Division of Energy Employees Occupational Illness Compensation (DEEOIC) issues Recommended Decisions (RD) and Final Adjudication Branch (FAB) decisions on claims arising out of Part B and Part E of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). This chapter further outlines the FAB review and hearing process. Please refer to EEOICPA PM 2-1100 Recommended Decisions and 2-1300 FAB Review Process for further guidance.

2. Authority. 20 C.F.R. § 30.300 grants the District Office (DO) authority to make determinations with regard to compensability and issue RDs with respect to EEOICPA claims. The DO is authorized to recommend the acceptance or denial of a claim for benefits under the EEOICPA. 20 C.F.R. § 30.310 allows a claimant to object to all or part of the RD within 60 calendar days from the date the decision is issued. The FAB is required to consider all timely filed objections to the RD, conduct hearings, and review the written record as requested. The FAB reviews all RDs, all argument and evidence of record, and issues a FD pursuant to 20 C.F.R. § 30.316, or a remand order pursuant to 20 C.F.R. § 30.317. FAB also reviews claimant requests for reconsideration under 20 C.F.R. § 30.319.

3. Issuing Decisions in General. While claims filed under the EEOICPA are claims filed under one Act, it is important that a claimant can read a recommended or final decision and know whether his/her award or denial of benefits was made under Part B and/or Part E of the Act. If a decision awards or denies benefits under only one Part of the Act, the decision must clearly state which Part of the Act (B or E) that award/denial is being made, and state, if appropriate, that adjudication of the claim(s) under the other Part of the Act is deferred or under development. All decisions must clearly state which Part(s) of the Act are being adjudicated in that decision. In all instances, the recommended and final decision must also reference the proper statutory and regulatory citations when delineating benefits awarded or denied under either Part of the Act. Discussing benefits in a clear and concise way provides transparency to the claimant(s) regarding the program and avoids confusion as to which benefits are being awarded, denied, or held in abeyance for further development, and under which Part(s) of the Act these decisions are being made.

a. Example for Part E condition only. If a claim for asbestosis is filed and medical evidence establishing asbestosis entered into the record, the CE issues the RD accepting for asbestosis and any other associated benefits. The decision outlines that benefits are being awarded under Part E of the Act and provides the proper citation. There is no need to issue a denial for benefits under Part B in this instance, because asbestosis is solely a Part E condition and employment at a DOE facility is claimed.

Note: If a claim for asbestosis was filed with DOL prior to the October 2004 Part E Amendment, or if the claimant indicates in writing that they are claiming benefits under Part B, a decision for both Part B and Part E benefits must be issued.

b. Example for Part B and Part E conditions. If a claim is filed for beryllium illness, cancer, or chronic silicosis (Part B conditions) the claim is developed for benefits under both Parts of the Act, because there are no “non-covered” illnesses under Part E. The CE reviews the employment evidence to determine whether or not claimed employment qualifies as covered Part E employment (DOE contractor/subcontractor or a covered RECA employee). If Part E employment is claimed, the CE develops the claim under both Parts of the statute and issues the RD based upon the findings of the evidence as a whole. If the claim is for chronic beryllium disease (CBD) and the $150,000 lump sum benefit is awarded under Part B and wage loss and impairment are awarded under Part E, the decision clearly distinguishes between the two distinct Parts of the Act, outlining the specific benefits awarded with the corresponding statutory citation supporting the award.

(1) No denial unless benefits are sought or claimed. In the situation above, if CBD is claimed but the employment is with a beryllium vendor (not covered Part E employment) and no benefits are claimed under Part E, the decision is issued awarding benefits for Part B, but no denial under Part E is necessary, because no benefits were sought or claimed.

c. Old Part D Claims. In instances where an old Part D claim is being adjudicated, the RD and FAB decision clarifies the benefits being awarded and explain the Part D claim within the body of the decision. A narrative of the claim history in the Statement of the Case outlines the Part D claim history and indicates that the claim file is now being adjudicated under Part E with the repeal of Part D.

4. Recommended Decisions. Once the CE has conducted the requisite development and is in the position to accept a claim for an employee’s illness, death, wage loss, or impairment, a RD is issued. There is no need to wait until all aspects of a claim are adjudicated before issuing the RD accepting benefits. RDs denying benefits are issued as set out below. The format for writing a RD conforms to instructions provided in EEOICPA PM 2-1100. Due to the many different possible claim scenarios and the necessity to accept claims once developed, the requirement for one RD per case file is no longer applicable. There is the potential for multiple RDs on case files and no limitation exists as to how many RDs may be issued on one file. The RD clearly states which benefits are being accepted or denied under which specific Part of the statute and provides the proper statutory language upon which the decision is based. The decision also delineates which benefits, if any, are being held in abeyance pending further development. Please see the ECMS section to this chapter for coding actions associated with Part E RD issuance. Part B coding can be found in EEOICP PM 2-1500.

a. Recommended Acceptances. Various different claim elements can be in alternating states of development and adjudication due to the wide variety of possible benefits available under Part B and Part E. In order to expedite acceptances, the CE issues a RD to accept as many claim elements (i.e. medical benefits or a lump sum payment) as possible once all development is complete and the claim element is in posture for acceptance. If other claim elements (i.e. wage loss, impairment or another claimed illness) are unresolved and require further development, those elements are held in abeyance until fully developed and adjudication is possible.

(1) Full Recommended Acceptance. In instances where development is completed and the entire case file can be accepted and no outstanding claim elements remain (i.e. wage loss, impairment, or a cancer claim pending dose reconstruction at the National Institute for Occupational Safety and Health [NIOSH]) for further development and future adjudication, the CE issues a RD to accept in full.

(a) Wage Loss and Impairment. With respect to wage loss and impairment, the CE may issue an RD to accept without waiting for a FD accepting the covered illness that is attributed to the wage loss and/or impairment. The CE develops for wage loss and impairment as set out under the Wage Loss Determinations and Impairment Ratings chapters where such claims are identified. Once development is completed, the RD is issued.

(2) Partial Accept/Develop. When a claim element is fully developed and ready for acceptance, but other elements remain for further development (i.e. wage loss, impairment, another claimed illness, or a cancer pending dose reconstruction at NIOSH) the CE issues the RD accepting the covered illness and outlines all associated benefits awarded under both Parts of the Act, as applicable. The CE indicates clearly in the RD what portion or portions of the claim are held in abeyance until further development is complete.

(a) Development Required for Additional Illness or Illnesses. If another claimed illness requires further development, the CE continues such development and issues another RD as soon as all development steps are exhausted and a benefit determination can be reached. This situation will especially arise in instances where a cancer claim is pending NIOSH dose reconstruction.

(b) Wage Loss and Impairment. In some instances not enough evidence will exist to make a determination and claimed wage loss and impairment adjudication will require deferral until additional development is conducted. Only wage loss/impairment that is actually claimed is deferred in a decision. Wage loss/impairment under development that is not actually claimed is not deferred; it is developed by the CE to determine whether or not an RD should be issued. The RD/FD details the elements being accepted and explains that claimed wage loss/impairment is being deferred for additional development and that a decision regarding benefits will be issued independently.

(3) Partial Accept/Deny/Develop. The CE addresses as many claim elements as possible when issuing a RD. If a portion of the claim is in posture for acceptance and another portion of the claim is in posture for denial while yet another portion requires additional development, the CE issues a RD addressing all claim elements in one comprehensive RD. As with all RDs issued in instances where a certain claim element is partially accepted and other elements are either denied or held for additional development, the RD clearly outlines the status of each particular element that is not accepted in the decision. The claimant is provided with rights of action to contest the portion of the RD denying benefits. (See Exhibit 1, “Cover Letter for Partial Accept/Partial Deny RD,” and Exhibit 2, “Partial Accept/Partial Deny Waiver.”) See the Objections and Waivers section below for a full discussion.

(4) Partial Accept/Partial Deny. If a RD can be issued on all the elements of a claim without any further development required, the CE issues a RD that clearly delineates the covered illness accepted and benefits awarded and the covered illness and benefits denied. The claimant is provided with rights of action to contest the portion of the RD denying benefits. (See Exhibit 1, “Cover Letter for Partial Accept/Partial Deny RD,” and Exhibit 2, “Partial Accept/Partial Deny Waiver.”) See the Objections and Waivers section below for a full discussion.

b. Recommended Denials. Whenever possible, the CE issues a RD recommending denial on a claim as a whole once all required development steps are exhausted. As noted above, there are instances where a portion of the claim is accepted and a portion denied or held for further development. Additionally, instances will arise where a denial is issued and a portion of the claim is held in abeyance for further development. Such decisions are partial denial/partial develop and are necessary when a denial must be issued and other portions of the claim require further development.

(1) Issuing Recommended Denials. The CE must remain cognizant of the various adjudicatory issues regarding the claim file as a whole when issuing a RD denial. When issuing the RD denial, the CE denies as many claim elements as possible in one decision.

(a) RDs are issued to reduce the chance of multiple hearings whenever possible. In instances where a hearing is scheduled and the Secondary CE (CE2) designated to the FAB is conducting additional development, the CE issues a RD denying benefits if it is possible to address all claimed elements at the one hearing. A RD denying benefits during the FAB hearing review process should only be issued if all possible benefits being claimed can be denied under the RD. The CE coordinates the issuance of the RD denial with the FAB HR so that the HR is aware of the potential for additional objections to arise at the hearing. The purpose of this procedure is to try and entertain all possible claimed/denied benefits at one hearing, thus eliminating the need for multiple hearings. As such, the CE only issues the RD denial if the decision addresses all claimed benefits. If the need for additional development or a potential future denial situation exists, the CE continues with development and does not issue the RD until all development is exhausted, because the issuance of the RD will not eliminate the possible necessity of another hearing.

(b) Non Contested. Where no objection is pending at FAB, the CE develops all possible claim elements in posture for denial and whenever possible issues one comprehensive decision denying all possible claims for benefits under the Act as a whole. Other portions may require further development and a partial denial/partial develop may also be necessary.

c. Survivor claims with multiple claimed conditions. In some situations, a survivor will claim multiple conditions, only one of which caused or contributed to the death. If it is determined that the condition that caused or contributed to the death is compensable, the CE accepts the case based on this condition. The RD does not need to accept or deny the other claimed conditions. The RD acknowledges the other conditions and advises the claimant that no decision is being made on these conditions since no additional benefits would result. However, a decision must be made if the employee originally filed a claim for these conditions prior to his or her death and payment of additional medical treatment is an issue. Unless the maximum amount of $175,000 has been paid, the claimant should be advised of the right to request benefits for wage loss if the evidence suggests that the employee may have had such prior to attaining “normal SSA retirement age.” (See 20 C.F.R. § 30.801). If the claimant does so, and the request shows wage loss was caused by the non-accepted conditions, the CE will develop the case further to determine if radiation or toxic exposure caused, aggravated, or contributed to these conditions.

d. Claims with Multiple Survivors. A decision is sent to all survivors who filed a claim, even if a survivor only filed a claim under Part B and the decision pertains to Part D/E. But if a situation arises where not all Part B claimants file under Part E (no old Part D filings), only the claimants who filed a new Part E claim are issued a Part E decision.

(1) In certain instances multiple survivors will have filed and adjudication is not possible for all survivors at one time. In such cases, the CE issues the RD on as many claimants as possible and defers a decision on the claims that cannot be adjudicated at that time. All claimants receive a copy of the RD, but a decision on certain claimants is deferred until a later date.

(a) Example: Five surviving children file claims and it is clear that four do not meet the “survivor” criteria under Part E. The fifth child has claimed that she is incapable of self support but has not provided sufficient evidence to support that contention. A decision denying the four clearly ineligible children can be issued while holding the claim for the final child open until eligibility is fully developed and a decision can be rendered.

(2) In instances where there are multiple Part B claimants and at least one Part D claimant, all of the claimants are assumed to have filed for benefits under both Parts of the statute and receive a decision accordingly. All Part B claimants are presumed to have filed under Part D and the earliest discernable Part D filing date is used for all claimants when adjudicating the Part D/E claim.

5. Objections and Waivers. A claimant is given the right to either object to a RD or waive his or her right to object. Given that there are many instances where the DO accepts one part of the claim and denies another part of the claim within one RD, it is possible that a waiver and an objection could be received regarding the same RD. This subsection describes the nature of objections and waivers in general. FAB CEs/HRs must be vigilant in tracking objections and waivers, as their receipt in the FAB drives the FAB review and decision process.

a. Objections. A claimant has 60 calendar days from the date the RD is issued in which to file an objection in writing. The claimant does not need to specify the basis for the objection in order for it to be considered; merely that he or she disagrees with the determinations made in the RD. The claimant also has the right to request an oral hearing. Objections are considered timely if the envelope containing them is postmarked no later than the 60^th day after the RD issuance date. (The date of the RD is not included in the 60 calendar days). If the 60^th day falls on a non-business day, the envelope must be postmarked on the next business day for the objection to be considered timely filed.

b. Waiver. The claimant may waive his or her right to object by submitting a signed waiver form to the DO or the FAB within 60 calendar days of the RD issuance date. The submission of a waiver denotes the claimant’s willingness to accept the conclusions of law reached by the DO in the RD. The FAB may issue a FD at any point after receiving a waiver. In the case of acceptances, the FAB should issue a FD upon receipt of the waiver and review of the case file so that benefits may be paid to the claimant as soon as possible. To expedite the FAB review process, the DO must immediately forward all waivers to FAB upon receipt. Given that the possibility exists for multiple decisions to be issued on one case, the CE must date the waiver accompanying the RD. The date on the waiver is the date of the RD issuance.

(1)Partial Accept/Deny Waiver. A special waiver has been drafted for use when a decision accepts one or more elements of a claim and denies one or more elements. Exhibit 2 is the waiver that is sent with RDs that are partial acceptances/partial denials. This new waiver provides the claimant with two options if he or she chooses to waive the right to object. Option 1 allows the claimant to waive the right to object to the benefits awarded but reserve the right to object to the recommended denial of benefits. Option 2 allows the claimant to waive the rights to object to all findings and conclusions. This waiver is only supposed to be used in situations where an element is accepted and another is denied.

(2) All other decisions where elements are denied in full, accepted in full, or accepted/denied and in need of further development use the standard waiver. The CE sends the standard waiver in all decisions that do not accept in part/deny in part. The standard waiver is located in EEOICPA PM 2-1100, Exhibit 4.

c. Implied Waiver. The claimant’s right to object is considered waived if after 60 calendar days from the RD he or she has not submitted a written objection or waiver. Unless the decision contains an error or other technical deficiency, the HR makes specific findings of fact and conclusions of law and issues a FD. Again, the FAB should issue any FD accepting the claim for benefits as soon as possible.

6. FAB Decisions. Absent guidance to the contrary set out in this chapter, FAB decisions are issued in accordance with the procedures set out under EEOICPA PM 2-1300. The FAB reviews the case record, all evidence of file and makes findings of facts and conclusions of law upon which the FAB decision is based. The FAB reviewer does not simply accept the findings of the RD and incorporate them into the decision, but issues an independent decision to stand as the final agency decision. Please see the ECMS coding section to this chapter when issuing FAB decisions under Part E. ECMS coding for Part B decisions is outlined in EEOICPA PM 2-1500.

As with RDs, multiple FAB decisions are possible on one case. The FAB decision is written to clearly identify under which specific Part of the Act benefits are being awarded or denied. FAB decisions are written to be as transparent to the claimant as possible and are designed to avoid confusion on the part of the recipient. FAB decisions must always employ the proper statutory/regulatory language when outlining the benefits being awarded or denied.

a. Acceptances. When FAB receives a RD accepting benefits, even if other portions of the claim are denied, the FAB makes findings of facts and conclusions of law and issues the FD, provided no technical or procedural errors exist that require a remand to the DO.

(1) Full Acceptance/Non-Contested. The RD accepts the claim in full and no portions of the claim are denied or remain at the DO for development. FAB issues the FD awarding benefits in full. In such instances FAB issues the FD upon receipt of the waiver, or upon expiration of the 60 day post-RD objection period.

(2) Partial Acceptances. As noted above, when necessary the DO issues a RD accepting one or more claim element(s), while denying and/or holding other portions in abeyance for further development. In such instances, the FAB issues the FD as soon as possible to expedite the claimant’s receipt of benefits. FAB does not wait to issue the FD until the elements under development at the DO are adjudicated, as in most cases those elements will require their own RD and FD once all necessary development steps are completed.

(a) Waiver. Upon receipt of a waiver and review of the case file FAB issues the FD accepting benefits. As noted above, the waiver in Exhibit 2 is issued with RDs that are partial acceptances/partial denials. If the claimant selects Option 1, FAB can issue a FD accepting the approved portion(s) and can hold the remainder of the claim in abeyance until the claimant either objects or the period in which to file an objection expires. If the claimant selects Option 2, FAB can issue a FD accepting the approved portion(s) and denying the denied portion(s). If the claimant mistakenly selects both options, or provides an ambiguous response to the standard waiver (See EEOICPA PM 2-1100, Exhibit 4), a FAB representative contacts the claimant and requests clarification in writing. If it is determined in writing that the claimant did not wish to waive his/her right to object, the waiver code is removed from ECMS by a FAB manager.

(i) Multiple Claimants. In cases where there are multiple claimants, FAB must wait until all waivers are received before issuing the FD.

(b) Without Waiver. FAB issues the FD once the 60-day post-RD objection period expires.

(c) Objection. If a claimant files a timely written objection as set out above, FAB cannot issue a FD until the objection is duly considered either through the hearing process or a review of the written record. Contested decisions and the review and hearing processes are addressed below.

(i) Exception. The exception is the case discussed above where a claimant waives his or her right to object to the accepted portion of the claim but does object to the denied portion. In that instance, FAB issues the FD accepting the approved portion and considers the objection as outlined below.

b. Denials. When FAB receives a RD denying the claim in full or in part, FAB prepares a final decision to be issued when the 60-day post-RD objection period expires, a hearing is held, or a waiver of objection is received. The FAB reviews the decision for technical or procedural errors that might warrant a remand and considers the RD and the evidence as a whole in preparation for the final decision. The Secondary CE designated to work cases at the FAB develops portions that are not part of the recommended decision being reviewed by the FAB.

(1) Non-Contested Denials. Absent any technical or procedural error, the FAB issues a FD accepting the RD findings and denying the claim for benefits in cases where no timely objection is filed or a waiver is received. Where no waiver is received, the FD is issued as soon as possible after the 60-day post-RD objection period expires.

(2) Contested Denials. The FAB must consider the timely filed written objection by either conducting a hearing or a review of the written record before a FD is issued.

c. Contested Decisions in General. Once FAB has duly considered a timely filed written objection by conducting a hearing or reviewing the written record, FAB issues a decision based upon its independent findings. The FAB can issue a FD, a remand order returning the case file to the DO for further development or some other action, or a FD reversing a RD denying benefits based upon the finding of additional evidence or some finding or error that warrants overturning the RD and accepting the claim outright (see reversal below). Remand orders and FD reversals are discussed below and can be issued on both contested and non-contested claims.

(1) Review of the Written Record. Once the FAB has fully examined all of the evidence of record, the CE/HR issues a decision based upon the review of the written record outlining the facts of the case, the objection(s) raised to the RD and the findings of the FAB.

(2) Decisions Following a Hearing. Once the FAB conducts the hearing and satisfies all of the requirements of the hearing process set out in EEOICPA PM 2-1300, a decision is issued. While the hearing itself may entertain objections raised due to the findings of several RDs, one FAB decision will be issued and address each contested RD following the resolution of the entire hearing process. Each FAB decision outlines the facts of the case, the objection(s) raised regarding the RD(s) in question, an overview of the hearing process, and the findings of the FAB. Although a remand order should conform to other guidance regarding the format of remand orders, they should also discuss the objections raised and provide an overview of the hearing process.

d. Remand Orders. The FAB is granted regulatory authority to review RDs and return them to the DO when necessary. Should the FAB find a technical, procedural, or some other error requiring a remand order, the FAB returns the case file to the DO with instructions as to how to further proceed. Remand orders are largely issued in instances where further development is required at the DO level. FAB does not issue a remand order in instances where FAB personnel can conduct minor development to resolve the issue at hand. When FAB is conducting such minor development, it is conducted by FAB staff, not the CE2. In instances where a case is at FAB for review of any kind on one issue and a remand order is issued on another issue, the Secondary CE assigned to handle FAB issues at the DO addresses the remand order. In all other instances, the case file is returned to the DO that issued the RD. The FAB may also issue remand orders in part, returning one portion of the claim to the DO for further action and issue a FD on other portions of the claim.

e. Reversal. A reversal is a FD issued by FAB when such evidence of file is available to show that either the RD denied benefits in error or new and compelling evidence has come to light to warrant overturning a RD denial and accept a claim for benefits. In such cases, the FAB issues the reversal order pursuant to the guidance set out under EEOICPA PM 2-1300, reversing the RD to accept the claim for benefits. A reversal can be issued when a case is denied in full or in part. In partial denials, the FAB may reverse to accept if the portion of the claim denied by the RD is found to be in posture for acceptance and DO error is identified. A FAB decision reversing the RD is used rarely, and only in cases where a denial is reversed to accept benefits. The rationale for reversals must be clearly stated in the body of the decision and forwarded along with the case file itself to the FAB Chief for review and approval. A reversal can not be issued without such approval.

f. Reconsiderations. Reconsiderations are conducted pursuant to the guidance set out under EEOICPA PM 2-1300.However, since case files now contain various different claim elements at various different stages of development and adjudication, it is important that case files are maintained at one location wherever possible. These procedures alter EEOICPA PM 2-1300 in one important aspect. NO FAB and all DO FABs possess the authority to review requests for reconsideration and issue decisions accordingly.

7. FAB Hearing Process. The FAB hearing process is conducted under the guidance set out in EEOICPA PM 2-1300. Prior to the hearing, the FAB HR must review the adjudicatory history of the case file as a whole to determine the proper handling of additional evidence and/or objections that might be received at the hearing. This is particularly important in situations in which more than one RD is pending (see discussion below). If more than one RD is pending, the FAB HR contacts each objecting claimant and advises that all objections may be discussed during the hearing, not simply those pertaining to the recommended decision under which the hearing was requested.

The claimant(s) will be encouraged to bring evidence, even if it is regarding a RD that was not timely objected to. All telephonic contact prior to the hearing is entered into ECMS. Any evidence or testimony a claimant wishes to enter into the record is entered, even if it pertains to a RD that was previously issued and the 60 day post-decision timeframe to object has expired. The HR will accept all testimony and evidence presented at the hearing. However, only timely filed objections will be considered and given weight in the post-hearing FAB decision.

a. More than one RD. Since it is possible that more than one RD denying benefits can be issued prior to a hearing, generating additional objections and hearing requests, measures are required to streamline the hearing process.

(1) Hearing Requests made on multiple pending RDs. When additional hearing requests are submitted arising out of other RD denials prior to the hearing date on a case file, the FAB HR contacts the requesting party to advise that all objections will be considered at the hearing so that one hearing may serve to accept evidence and testimony on several different RDs. This process is designed to eliminate multiple hearings where possible. The FAB HR memorializes the conversation with the claimant in ECMS confirming that the claimant was made aware that all outstanding objections will be considered at the hearing. Separate hearing request acknowledgments and hearing notices are not required. The HR must be prepared to entertain objections from all RDs issued up until the date of the hearing and will take testimony and evidence on all outstanding objections at the hearing. Each RD in question is considered in a single FAB decision once the FAB hearing process is concluded.

(2) Hearing Request made on one RD, request for RWR made on another. If a claimant has requested a hearing on one outstanding recommended decision and has requested a review of the written record on the other, the FAB HR allows the claimant to present evidence regarding the objections at the hearing, as long as FAB has not issued a final decision on the RWR request (if a final decision has been issued on the request for RWR, see (4) below). The objection and evidence are considered at the hearing and treated with all other objections and evidence in the post-hearing FAB decision. No review of the written record decision is issued. Coding in ECMS should be changed to reflect a Request for a Hearing, rather than a Request for a Review of the Written Record.

(a) Multiple Claimants. In cases with multiple claimants where one claimant requests a review of the written record and another requests a hearing, no decision is issued to either claimant until the hearing process is complete. All claimants, whether they request a hearing or not, are served with notice of the hearing and are afforded the opportunity to present at the hearing and participate.

(3) Hearing Request made on one RD, no objection filed on another. The FAB HR should be prepared to take testimony and evidence on any RD that has been issued up until the hearing date. As noted above, even if testimony or evidence is presented regarding an RD and the 60 day post-decision objection period has expired without an objection having been filed for that particular decision, all testimony and evidence will be entered into the record and the timeliness of such objections will be addressed when the post-hearing FAB decision is issued.

(4) Hearing Request made on one RD, FD issued on another. A claimant may request reconsideration of a FD within 30 days of the FD’s issuance. If a FD has been issued and the hearing is held within the 30 day post-decision reconsideration period, any new evidence related to the FD is reviewed by FAB as a request for reconsideration of the FD. In the case of a remand, the evidence is forwarded to the appropriate DO for consideration. If a FD has already been issued and the claimant presents evidence or argument at the hearing and the hearing date is outside of the 30 day post-decision reconsideration period, the FAB HR reviews the evidence as a possible reopening and handles it according to the guidance set out under EEOICPA PM 2-1400.

b. Process Following the Hearing. After the hearing, the case file remains at FAB until the issuance of the FAB decision(s) regarding the contested RD(s) considered at the hearing. Once the FAB decision is issued, the case file is returned to the DO with jurisdiction over the case.

(1) Cases Remaining at FAB. If additional FAB review is required after a hearing decision has been issued, the case file remains at FAB until such pending action is resolved.

(a) Reconsiderations. If FAB is reviewing a FD for reconsideration, the case file remains at FAB until such review is completed. In such instances, if a remand order is issued based upon any of the RDs considered at the hearing, the Secondary CE designated to work FAB issues receives the remand order and addresses all issues contained therein. Once the request for reconsideration is reviewed and a decision issued, the case file is returned to the proper adjudicatory DO so long as no other outstanding issues remain.

(b) Remand Orders. As noted above, if the case file remains at FAB for additional action, the Secondary CE designated to work FAB issues addresses the remand order after the hearing. If no additional FAB action is required, the case file is immediately returned to the DO that issued the RD in question and the adjudicatory DO addresses the remand order and issues a new RD.

(c) Decisions in General. Once the FAB issues a decision on each RD considered at the hearing, the case file is returned to the DO with jurisdiction over the case file. In cases where both a FD and a remand order are issued, the case file is returned to the DO with jurisdiction over the case file to address the remand order.

(2) Cases Returned to the DO. Where there are no outstanding issues as outlined above, the case file is returned to the DO with jurisdiction considered at the hearing pursuant to procedures currently in place.

8. Secondary CEs Designated to the FAB. FAB offices are geographically located as set out under EEOICPA PM 2-1300. However, given that DO adjudicatory functions are sometimes required while a case is at FAB for review, each district office assigns certain DO CEs to handle district office development and adjudication while the case is pending review at FAB. These CEs report to the DO or National Office (NO) Branch of Policy, Regulations and Procedures (BPRP) if at NO FAB and adjudicate only issues that are outside the scope of the issue being addressed by FAB. This group of designated CEs is referred to as the secondary CE in the co-located DO. The individuals within the co-located DO are referred to as secondary CEs because the FAB HR or CE is considered the primary CE while the case is in FAB’s jurisdiction. This process eases the burden of file sharing and allows for case files to be maintained in one central location (the FAB) while FDs are pending review or FAB is addressing objections by conducting hearings or reviews of the written record and further DO-level development is required. The secondary CE should remain cognizant of hearing dates and issue denials whenever possible prior to the hearing so that objections to all outstanding RDs can be entertained, thus avoiding multiple hearings whenever possible.

a. Co-located DO Identifiers. Each co-located DO possesses a ‘DO2’ field identifying the location of the office. The ‘DO2’ field is populated when the ECMS “Co-located Development” (discussed below) section is populated. The respective codes are as follows:

(1) SEF – Seattle co-located FAB.

(2) CLF – Cleveland co-located FAB.

(3) JAF – Jacksonville co-located FAB.

(4) DEF – Denver co-located FAB.

(5) NAF – National Office co-located FAB.

b. Assign/Unassign Secondary CE (CE2) Role. In order to enable or disable the CE2 role, the DD, or DD designee, emails the Branch Chief of BPRP with a copy to Energy Technical Support requesting the role change. The email contains the name of the CE and the reason for the request. The FAB manager of the FAB to which the CE2 is co-located is also copied on the email so that FAB is kept abreast of personnel changes that affect FAB workflow.

c. The DO issues a Recommended Decision. When a DO CE prepares a RD, he/she must be aware of any outstanding claim issues that that have not been addressed in that RD and are in need of further development. If additional development is needed concurrent to the FAB’s review of the case, the CE prepares a memorandum on a gold piece of paper addressed to the FAB manager from the Senior CE, Supervisor, or District Director (DD) who is the final reviewer of the RD. The subject line reads “Co-located DO development for (case #).” The body of the memorandum addresses any outstanding claims issues that require development while the case is being reviewed by the FAB. The memorandum must also designate a secondary CE. When the recommended decision is reviewed and signed, the memorandum is also reviewed and signed. Once approved and signed, the original memorandum is spindled on top of the case file documents. A copy of the memorandum is forwarded to the secondary CE when the case file is transferred to FAB.

d. Receipt of Case by the FAB and Secondary CE Assignment. The FAB CE/HR reviews the co-located FAB development memorandum and notes any district office development needed on any portion of the case. In addition, the FAB CE/HR may also become aware of issues during their review process. If DO-level development is needed, the FAB CE, HR or Manager must complete the additional CE/location area titled "Co-located Development" located on the case screen in ECMS. The fields that require completion in this section are the “CE2” and “CE2 Assign Dt” fields. “CE2” field represents the name of the Secondary CE designated in the co-located FAB development memorandum, whose identifier should be selected from the drop down menu. The FAB CE/HR tabs over to the CE assign date, which automatically populates with the current date and time.

While only the FAB assigns the CE2 in ECMS, actual workload assignments are cleared through the appropriate DD. If DO development is required where no co-located FAB memorandum exists in the case file, the FAB notifies the DD to make assignment. The FAB CE/HR must not assign any development actions regarding matters before the FAB for review to the CE2. The FAB CE/HR conducts whatever necessary development that is needed regarding matters that are before the FAB for review.

e. Secondary CE and FAB Coordination. Both the FAB CE/HR and the CE2 can make entries into ECMS without having to transfer the case file in the system. The FAB CE/HR and the secondary CE coordinate their work to ensure that the file is where it is needed and the appropriate work can be completed on the case. If both the FAB CE/HR and the secondary CE need the actual file, the FAB CE/HR’s need takes precedence. Every secondary CE in the Co-located FAB will have a three character location identifier of DO1-DO9. (More location codes will be added if necessary.) As always, the case location code and case file jacket must be annotated to reflect any change in the file’s physical location.

f. Development by Secondary CE. The CE2 conducts all necessary development on all outstanding claim elements not related to the decision currently in front of the FAB CE/HR and codes ECMS appropriately to reflect those actions for the duration of the FAB review process. If possible, the CE2 issues RDs whenever development is concluded. If the CE2 issues a RD, the SrCE in the DO (or DD designee) reviews and signs off on the decision before issuance. The case file is transferred to the DO for immediate review and transferred back to the FAB once complete. Once the decision is reviewed and approved by the appropriate individual at the DO, the CE2 enters the ECMS RD code that reflects the posture of the decision.

g. FAB Issues a Decision. At the time the FAB completes their review process, the CE2 determines whether the evidence of file is sufficient to issue a RD on an outstanding claim element.

(1) Issuing a RD. Should the record contain enough evidence of file to support a RD on any of the outstanding claim elements, the secondary CE issues the RD before the case file is returned to the DO. It is particularly important to issue a RD in cases such as this if the claim element is in posture for acceptance. If additional portions of the claim require further development, the secondary CE prepares a memorandum to the DO as outlined below.

(2) Further Development Required. If the district office development issues can not be completed with a recommended decision, the secondary CE ceases development. The secondary CE prepares a memorandum on gold paper to the DD explaining what development actions have been taken and what future actions are required to address any outstanding issues. The memorandum is spindled on the top of the case file materials. If additional FAB review is pending, the secondary CE continues development and issues RDs as the requisite evidence is received and evaluated.

h. Transferring Case Back to DO. When the case file is ready to be returned to the DO, the FAB representative transferring the case file out of the office will click on the “Unassign CE2” button in the Co-located Development portion of the case screen. This will deactivate the co-located development.

9. Alternative filing under Part E. If a claimant is denied as an ineligible survivor under Part E, he or she has the right to apply for alternative filing. In this situation, the FAB should advise the claimant of this right in the cover letter of the FD (see Exhibit 3, “Cover Letter for Non-eligible Survivor Denials”). The claimant requests such a review by submitting a written request to the district office. An alternative filing review provides survivors with an assessment of a facility where alleged employment and exposure took place and a determination as to potential causation. Such a determination does not change the survivor’s eligibility for benefits or establish causation under the Act, and it is not subject to further agency or judicial review. Please see Chapter E-600.11 for further guidance regarding the handling of alternative filings for survivors.

10. ECMS Coding. When issuing RDs and FAB decisions please refer to the following guidance for the proper ECMS coding associated with each respective action. In keeping with current procedures, it is the responsibility of the FAB CE/HR to ensure that all coding throughout the claim file is correct when a FAB decision is issued. For example, the FAB CE/HR must change/update the appropriate status code/reason code combinations – based on procedural rules contained herein – to accurately and comprehensively record in ECMS B and E precisely what the recommended decision stated. When making a change to the status code record, the FAB CE/HR must be careful to select from the drop down box the district office that issued the recommended decision and ensure that the status effective date is equal to the date of the recommended decision.

Decisions issued pursuant to this guidance clearly delineate which benefits are awarded/denied/held in abeyance under which specific Part of the Act (B or E or both). Currently there are two systems for ECMS separately tracking Part B and Part E activity. The recommended and final decision coding is entered with a decision code/reason code combination that relates to the ‘Part B’ portion in ECMS B, and a decision code/reason code combination that relates to the ‘Part E’ portion in ECMS E. This is necessary to ensure accurate statistics about what decisions were made in relation to the ‘Part B’ and ‘Part E’ portions of the case.

It is also important to note the following rules for ECMS coding of combination or ‘partial’ decisions, that is, any decision that describes two or more of the following outcomes: acceptance, denial, and development (i.e., deferring or holding in abeyance).

For context and clarity throughout the remainder of this section, a ‘Primary’ decision status code is defined as one that is used to record and define a recommended or final decision to accept or deny a claim for benefits. Primary decision status codes are listed and described below in sections 10.a, RD Codes and 10.b, FAB Codes. A ‘Secondary’ decision status code must only be used in ECMS E and must only be used in tandem with a ‘Primary’ decision status code entered with the same status effective date. Secondary decision status codes are listed and described below in section 10.c, Secondary Decision Status Codes.

To reiterate: the facts that distinguish a primary decision status code from a secondary decision status code are that the primary decision status code can be used in ECMS E and/or ECMS B and it may be entered without a tandem entry of a secondary decision status code. The secondary decision status code must only be used in ECMS E and it must never be entered without tandem entry (i.e., same status effective date) of a primary decision status code in ECMS E and/or ECMS B.

It may be procedurally correct to enter one primary decision status code in ECMS E and another in ECMS B at the same time, with the same status effective date, but it is never correct to enter more than one primary decision status code in ECMS E with the same status effective date or more than one primary decision status code in ECMS B with the same status effective date.

The ‘PD’ [Partial Deny] secondary decision status code must never be used without tandem entry in ECMS E of a primary decision status code describing a partial E acceptance or denial. That is, ‘PD’ must never be entered without first entering – with the same status effective date – one of the following ‘primary’ decision status codes in ECMS E: A2/G2, A8/F8, or D7/F9.

The ‘DV’ [Partial Develop] secondary decision status code is used exclusively in ECMS E to record findings in a decision that describe 1) partial development under Part E (deferring or holding an E claim in abeyance) along with 2) either an acceptance and/or denial under Part E and/or Part B.

The basic rule for using the ‘DV’ status code and ‘PD’ status code diverge on the following main point: the ‘PD’ status code may only be used in ECMS E in tandem with a primary decision status code – also in ECMS E; the ‘DV’ status code may be used without tandem entry in ECMS E of a primary decision status code, but only if tandem entry of a primary decision status code is made in ECMS B. Such a coding circumstance is procedurally correct only to record a decision that makes a finding to hold any/all Part E portions of the claim in abeyance (for further development), while denying and/or accepting at least one Part B claimed condition.

To reiterate, for decisions describing ‘partial’ outcomes for B-only claimed conditions, coding options in ECMS B are limited to one of the following ‘primary’ decision status codes: A1/G1, A2/G2, or A8/F8 – without associated entry in ECMS B of either ‘DV’ or ‘PD’.

To determine proper coding in ECMS B and ECMS E for ‘partial’ decisions you must identify and separate the outcomes (accept/deny/defer) described in the decision as either Part B or Part E, and then code the outcomes separately in ECMS B and ECMS E. For example, a decision that accepts a claimed condition under E and denies a second claimed condition under B is not considered a ‘partial’ decision outcome for coding purposes. Instead use the ‘A0’ acceptance status code in ECMS E and the appropriate ‘D_’ denial status code in ECMS B. It is incorrect to consider the ECMS E outcome as ‘A8’ [Partial Accept/Partial Deny] because the partial deny outcome does not apply to Part E. The following examples attempt to further articulate these rules.

Example 1: If there is a recommended decision that is denying cancer for POC under Part B, and there is an E case that is yet to be developed and therefore the Part E decision is deferred, the coding would be: ’D5’ [Recommended Deny - Cancer not work related/POC<50%], with Reason Code ‘B’ [Part B] in ECMS B, and ‘DV’ [Partial Develop] with no primary recommended decision status code in ECMS E. The final decision code, if upheld by FAB, would be: ‘F5’ [Final Deny - Cancer not work related/POC<50%] in ECMS B, with Reason Code ‘B’ [Part B] and ‘DV’ [Partial Develop] with no primary final decision status code in ECMS E (assuming the E claim is still under development).

Example 2: If there is a recommended decision to accept CBD for both Part B and E, but the claims for wage loss and impairment are being deferred under Part E, the coding would be: ‘A0’ [Recommended Accept] in ECMS B, with Reason Code ‘B’ [Part B] (since all of the medical conditions are accepted and completed in Part B), and ‘A1’ [Recommended Partial Accept/Partial Develop] in ECMS E, with Reason Code ‘CAU’, since the CBD is being partially accepted (for causation). To record in ECMS E that the claims for wage loss and impairment are being deferred (the case is only deferred if there is an actual claim for wage loss/impairment in the case file) enter status code ‘DV’ [Partial Develop], with Reason Code ‘IMW’ [Impairment and Wage Loss]. The final decision coding, if upheld by FAB, would be: ‘F0’ [Final Accept] in ECMS B, with Reason Code ‘B’[Part B] and ‘G1’ [Final Partial Accept/Partial Develop] in ECMS E, with Reason Code ‘CAU.’ To record in ECMS E that the claims for wage loss and impairment are being deferred enter status code ‘DV’ [Partial Develop], with Reason Code ‘IMW’ [Impairment and Wage Loss].

Example 3: If there is a recommended decision to accept Asbestosis in Part E, and defer wage loss and impairment, and also deny cancer in both Part B and E (because the claimant did not prove he had cancer), the coding would be: ‘D7’ [Recommended Deny - medical information insufficient to support claim], with Reason Code ‘B’ [Part B] in ECMS B (since the cancer was denied for insufficient medical evidence), and ‘A2’ [Recommended Partial Accept/Partial Deny/Partial Develop] in ECMS E, with Reason Code ‘CAU’ (for accepting Asbestosis for causation). To record in ECMS E that the claims for wage loss and impairment related to Asbestosis are being deferred enter status code ‘DV’ [Partial Develop], with Reason Code ‘IMW’ [Impairment and Wage Loss]. To record in ECMS E that the claim for cancer is being denied enter status code ‘PD’ [Partial Deny], with Reason Code ‘IN’ [Insufficient Medical to establish claimed illness]. The final decision coding, if upheld by FAB, would be nearly identical to the RD coding: Status Code ‘F9’ [Final Deny - medical information insufficient to support claim] with Reason Code ‘B’ in ECMS B and ‘G2’ [Final Partial Accept/Partial Deny/Partial Develop] with Reason Code ‘CAU’ in ECMS E, along with status codes ‘DV’, with Reason Code ‘IMW’; and ‘PD’, with Reason Code ‘IN’.

a. RD Codes. Input the appropriate RD code listed below when issuing a RD. The status effective date of the code equals the RD issuance date. Bear in mind that for coding purposes under Part E accepted “causation” for employee claimants means that a causal link was found between the claimed covered illness and exposure to a toxic substance at a covered facility or site. Accepted “causation” for a survivor claimant means exposure to a toxic substance at a covered facility or site was a significant factor in aggravating, contributing to, or causing the death of the employee.

(1) A0 - ‘Recommended Accept – Sent to FAB.’ When the CE renders a RD on a claim for approval for benefits under EEOICPA, where there are no other pending elements on the claim (including additional medical conditions, wage loss, impairment), the DO enters the ‘A0’ code in ECMS. The status effective date is equal to the date of the RD. Upon entering the ‘A0’ code into ECMS, the CE must select a specific reason code from the “reason cd” field. This field is a drop-down box corresponding to the ‘A0’ claim status code. To record any Part B accepted component of the decision, the CE must always select reason code ‘B’[Part B] for entry in ECMS B. To record any accepted Part E component of the decision in ECMS E, the CE must select one of the following reason codes from the drop down menu to record all of the claimed elements (i.e. wage loss or impairment) being accepted in the current decision. These drop down codes are required exclusively for Part E ECMS.

(a) CAU – ‘Causation.’ This is used when causation is established under Part E, which results in medical benefits for an employee or death benefit for an eligible survivor.

(b) CAW – ‘Causation and Wage Loss.’ This is used when causation and wage loss are all that are claimed under Part E and both are being accepted simultaneously.

(c) CAI – ‘Causation and Impairment.’ This is used when causation and impairment are all that are claimed under Part E and both are being accepted simultaneously.

(d) IMP – ‘Impairment.’ This is used when causation was established on a previous decision and impairment is all that is being claimed and accepted in this decision under Part E.

(e) WAG – ‘Wage Loss.’ This is used when causation was established on a previous decision and wage loss is all that is being claimed and accepted in this decision under Part E.

(f) IMW – ‘Impairment and Wage Loss.’ This is used when causation was established in a previous decision and the current decision is accepting for wage loss and impairment.

CIW – ‘Causation, Impairment, and Wage Loss.’ This is used when causation, impairment, and wage loss were all claimed and the recommended decision to accept all three is being rendered on the current decision.

(2) A1 - ‘Recommended Partial Accept/Partial Develop.’ When the CE renders a RD where part of the claim is approved for benefits under EEOICPA, while another part of the claim needs further development (including additional medical conditions, wage loss, impairment), the DO enters the ‘A1’ code in ECMS. The status effective date is equal to the date of the RD. This code allows benefit disbursement, if FAB upholds the decision, while other development continues. Use status code ‘A1’ with reason code ‘B’ [Part B] in ECMS B for recommended decisions that describe a partial acceptance for one claimed condition under Part B and partial development for one or more other conditions under B. For Part E cases only, it is required that the CE selects the appropriate reason code from the drop down menu for input into ECMS E. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being held in abeyance for additional development are identified by the secondary decision status code ‘DV’ [Partial Develop] and corresponding reason code set out in section c below.

(a) CAU – ‘Causation.’ This is used when causation for a claimed condition is accepted for benefits and additional development of another claimed element is required.

(b) CAW – ‘Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and additional development of another claimed element is required.

(c) CAI – ‘Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and additional development of another claimed element is required.

(d) IMP – ‘Impairment.’ This is used when causation has been previously accepted and claimed impairment alone is being accepted and the additional development of another claimed element is required.

(e) WAG – ‘Wage Loss.’ This is used when causation has been previously accepted and claimed wage loss alone is being accepted and the additional development of another claimed element is required.

(f) IMW – ‘Impairment and Wage Loss.’ This is used when causation has been previously accepted and impairment and wage loss are both claimed and a decision is being issued that accepts both claimed elements for benefits and the additional development of another claimed element is required (i.e. a cancer that is undergoing dose reconstruction at NIOSH).

(g) CIW – ‘Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and the additional development of another claimed element is required (i.e. a cancer that is undergoing dose reconstruction at NIOSH).

(3) A2 - ‘Recommended Partial Accept/Partial Deny/Partial Develop.’ When the CE renders a RD where part of the claim is approved for benefits under EEOICPA, while another part of the claim is denied, and yet another part of the claim needs further development (including additional medical conditions, wage loss, impairment), the DO enters the ‘A2’ code in ECMS. The status effective date is equal to the date of the RD. This code allows for benefits to be administered, if FAB upholds the decision, while other development continues. Use status code ‘A2’ with reason code ‘B’ [Part B] in ECMS B for recommended decisions that describe a partial acceptance for one claimed condition under Part B and partial denial and partial development for one or more other conditions under B. For Part E cases only, the CE is required to select the appropriate reason code from the drop down menu in ECMS E. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being held in abeyance for additional development/denied are identified by the secondary decision status codes ‘PD’ [Partial Denial] and ‘DV’ [Partial Develop] and corresponding reason codes set out in section c below.

(a) CAU – ‘Causation.’ This is used when causation for a claimed condition is accepted for benefits and a portion of the claim is being denied and a portion of the claim requires additional development.

(b) CAW – ‘Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(c) CAI – ‘Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(d) IMP – ‘Impairment.’ This is used when causation has been previously accepted and claimed impairment alone is being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(e) WAG – ‘Wage Loss.’ This is used when causation has been previously accepted and claimed wage loss alone is being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(f) IMW – ‘Impairment and Wage Loss.’ This is used when causation has been previously accepted and impairment and wage loss are both claimed and a decision is being issued that accepts both claimed elements for benefits and a portion of the claim is being denied and a portion of the claim requires additional development.

(g) CIW – ‘Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and a portion of the claim is being denied and a portion of the claim requires additional development (i.e. a cancer is undergoing dose reconstruction at NIOSH).

(4) A8 - ‘Recommended Partial Accept/Partial Deny.’ When the CE renders a RD where part of the claim is going to be approved for benefits under EEOICPA, while another part of the claim is going to be denied, the DO enters the ‘A8’ code in ECMS. The status effective date is equal to the date of the RD. This code allows for benefit administration, if FAB upholds the decision, while development continues. Use status code ‘A8’ with reason code ‘B’[Part B] in ECMS B for recommended decisions that describe a partial acceptance for one claimed condition under Part B and partial denial for one or more other conditions under B. For Part E cases only, the CE is required to select the appropriate reason code from the drop down menu. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being denied is identified by the secondary decision status code ‘PD’ [Partial Deny] and corresponding reason code set out in section c below.

(a) CAU – ‘Causation.’ This is used when causation for a claimed condition is accepted for benefits and a portion of the claim is being denied.

(b) CAW – ‘Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and a portion of the claim is being denied.

(c) CAI – ‘Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and a portion of the claim is being denied.

(d) IMP – ‘Impairment.’ This is used when causation has been previously accepted and claimed impairment alone is being accepted and a portion of the claim is being denied.

(e) WAG – ‘Wage Loss.’ This is used when causation has been previously accepted and claimed wage loss alone is being accepted and a portion of the claim is being denied.

(g) CIW – ‘Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and a portion of the claim is being denied.

(5) D1 - ‘Recommended Deny – non-covered employment.’ When the CE renders a RD to deny benefits under EEOICPA due to employment that is not covered, the DO enters the ‘D1’ code in ECMS. The status effective date is equal to the date of the RD.

(6) D3 - ‘Recommended Deny - survivor not eligible.’ When the CE renders a RD to deny benefits under EEOICPA due to the fact the claimed survivor is not eligible, the DO enters the ‘D3’ code in ECMS. The status effective date is equal to the date of the RD.

(7) D5 - ‘Recommended Deny - Cancer not work related (POC).’ When the CE renders a RD to deny benefits under EEOICPA due to the fact that the Probability of Causation (POC) result from NIOSH is less than 50%, the DO enters the ‘D5’ code in ECMS. The status effective date is equal to the date of the RD. Please see EEOICPA PM 2-600 for a full discussion of NIOSH procedures. This is the only decision status code approved for use when denying a radiogenic cancer claim based upon the POC being less than 50% under BOTH B and E.

Upon entry in ECMS of the ‘D5’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘D5’ claim status code. The reason codes available for the ‘D5’ claim status code are listed below.

The only reason code allowable for ECMS B is ‘B’ [Part B].

Note 1: The ‘D5’ code is also used when coding decisions that partially deny benefits and deny other benefits while holding other benefits in abeyance for further development. One of the following ‘D5’ reason codes is entered to denote what is being denied in the decision. In tandem with the ‘D5’ entry, the CE enters the ‘DV’ status code and appropriate associated reason code listed in section c below to identify which benefits are being held for further development. This coding is done exclusively in ECMS Part E and only when the ‘D5’ decision code is the primary reason for denial based upon a POC that is less that 50%. Whenever a decision contains a denial based upon the POC, the ‘D5’ must be used as the primary denial code.

Note 2: If there is a secondary finding in the decision to deny one or more claimed conditions in addition to the one(s) specifically included in the NIOSH probability of causation determination (described by using the ‘D5’ code), it is appropriate to enter in tandem with the ‘D5’ entry status code ‘PD’ [Partial Deny] with applicable reason code to describe/record the secondary denial.

(a) B – ‘Part B’ (B only).

(b) CAU – ‘Causation’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established.

(d) CAW – ‘Causation and Wage Loss.’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established and claimed wage loss must also be denied.

(e) IM0 – ‘Impairment – 0%’ (E only). This is used when the claim for impairment is being denied because the impairment rating is 0%.

(f) IMN – ‘Impairment – Not Ratable’(E only). This is used when the claim for impairment is being denied because the claimed impairment is non-ratable, such as certain psychiatric conditions.

(g) IMR – ‘Impairment – Resolved’ (E only). This is used when the claim for impairment is being denied because the claimed impairment was resolved prior to the issuance of the decision.

(h) I0W – ‘Impairment (0%) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because it has a 0% rating.

(i) INW – ‘Impairment (not ratable) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because the condition being claimed is not ratable for impairment, such as certain psychiatric conditions.

(j) IRW – ‘Impairment (resolved) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is being denied because the impairment was resolved prior to the issuance of the decision.

(k) C0W – Causation, Impairment (0%) and Wage Loss (E only). This is used when a claim for causation, impairment, and wage loss are denied simultaneously. The impairment is denied because the impairment rating is 0%.

(l) CNW – ‘Causation, Impairment (Not Ratable), and Wage Loss, &’ (E only). This is used when a claim is made based on causation, wage loss, and impairment, all of which are being denied in the decision. The impairment is being denied because it is for a non-ratable condition.

(m) CRW – ‘Causation, Impairment (Resolved), and Wage Loss’ (E only). This is used when a claim for causation, impairment and wage loss are being denied simultaneously. The impairment claim is being denied because the impairment was resolved prior to the issuance of the decision.

(n) CA0 – ‘Causation and Impairment (0%)’ (E only). This is used when causation and 0% impairment are being denied simultaneously.

(o) CAN – ‘Causation and Impairment (not ratable)’ (E only). This is used when causation and an impairment that is not ratable are being denied simultaneously.

(p) CAR – ‘Causation and Impairment (Resolved)’ (E only). This is used when causation and impairment that is resolved prior to the issuance of the decision are being denied simultaneously.

(8) D7 - ‘Recommended Deny – medical information insufficient to support claim.’ When the CE renders a RD to deny benefits under EEOICPA due to the fact that after developing the claimed covered condition(s), there is insufficient medical evidence to support an acceptance, the DO enters the ‘D7’ code in ECMS. The status effective date is equal to the date of the RD. Upon entry in ECMS of the ‘D7’ code, the CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘D7’ claim status code. The reason codes available for the ‘D7’ claim status code are listed below. The only reason code allowable for ECMS B is ‘B’ [Part B]. The system will show all possible codes, and it is the CE’s responsibility to make certain that the following reason codes are input in Part E ECMS only.

Note 1: The ‘D7’ code is also used when issuing a Part E decision that partially denies benefits while holding other benefits in abeyance for further development. One of the following ‘D7’ decision reason codes are entered to denote what is being denied in the decision. In tandem with the ‘D7’ entry, the CE enters the ‘DV’ status code and appropriate associated reason code listed in section c below to identify which benefits are being held for further development.

Note 2: If the decision contains findings to deny multiple claimed conditions, and one denial is for insufficient medical evidence to establish claimed illness and another denial is for inability to establish causation, impairment or wage loss, follow this procedure: enter ‘D7’ with the reason code describing the causation/impairment/wage loss denial; in tandem with the ‘D7’ entry, enter ‘PD’ [Partial Deny] with reason code ‘IN’ to record the denial for insufficient medical to establish illness.

(a) B – ‘Part B’(B only).

(b) IN – ‘Insufficient medical to establish claimed illness’(E only). This is used when a covered illness is claimed under E but medical evidence is insufficient to establish the illness.

(c) CAU – ‘Causation’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established.

(d) WAG – ‘Wage Loss.’ (E only). This is used when the claim for wage loss is being denied due to lack of medical evidence to support work-related disability.

(e) CAW – ‘Causation and Wage Loss.’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established and claimed wage loss must also be denied.

(f) IM0 – ‘Impairment – 0%’ (E only). This is used when the claim for impairment is being denied because the impairment rating is 0% under the Guides.

(g) IMN – ‘Impairment – Not Ratable’(E only). This is used when the claim for impairment is being denied because the claimed impairment is non-ratable, such as certain psychiatric conditions.

(h) IMR – ‘Impairment – Resolved’ (E only). This is used when the claim for impairment is being denied because the claimed impairment was resolved prior to the issuance of the decision.

(i) I0W – ‘Impairment (0%) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because it has a 0% rating.

(j) INW – ‘Impairment (not ratable) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because the condition being claimed is not ratable for impairment, such as certain psychiatric conditions.

(k) IRW – ‘Impairment (resolved) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is being denied because the impairment was resolved prior to the issuance of the decision.

(l) C0W – Causation, Impairment (0%) and Wage Loss (E only). This is used when a claim for causation, impairment, and wage loss are denied simultaneously. The impairment is denied because the impairment rating is 0%.

(m) CNW – ‘Causation, Impairment (Not Ratable), and Wage Loss, &’ (E only). This is used when a claim is made based on causation, wage loss, and impairment, all of which are being denied in the decision. The impairment is being denied because it is for a non-ratable condition.

(n) CRW – ‘Causation, Impairment (Resolved), and Wage Loss’ (E only). This is used when a claim for causation, impairment and wage loss are being denied simultaneously. The impairment claim is being denied because the impairment was resolved prior to the issuance of the decision.

(o) CA0 – ‘Causation and Impairment (0%)’ (E only). This is used when causation and 0% impairment are being denied simultaneously.

(p) CAN – ‘Causation and Impairment (not ratable)’ (E only). This is used when causation and an impairment that is not ratable are being denied simultaneously.

(q) CAR – ‘Causation and Impairment (Resolved)’ (E only). This is used when causation and impairment that is resolved prior to the issuance of the decision are being denied simultaneously.

b. FAB Decision Codes. When issuing FAB decisions under this Part, the following codes are input into ECMS. Input the appropriate Final Decision code, listed below, when issuing a FD. The status effective date of the code will be equal to the date the FINAL DECISION was issued. Bear in mind that under Part E “causation” for employee claimants means that the claimed covered illness was caused by exposure to a toxic substance at a covered Part E facility or site. “Causation” for a survivor claimant means exposure to a toxic substance at a covered Part E facility or site was a significant factor in aggravating, contributing to, or causing the death of the employee.

(1) F0 - ‘Final Accept.’ When the CE/HR renders a final decision on an approved claim for benefits under EEOICPA, where there are no other pending elements on the claim (including additional medical conditions, wage loss, impairment), the FAB CE/HR enters the ‘F0’ code in ECMS. The status effective date is equal to the date of the final decision. Upon entering the ‘F0’ code into ECMS, the CE/HR must select a specific reason code from the “reason cd” field. This field is a drop-down box corresponding to the ‘F0’ claim status code. To record any Part B accepted component of the decision, the CE/HR must always select reason code ‘B’ [Part B] for entry in ECMS B. To record any accepted Part E component of the decision in ECMS E, the CE must select one of the following reason codes from the drop down menu to record all of the claimed elements being accepted in the current decision. These reason codes are to be entered exclusively in Part E ECMS.

(a) CAU – ‘Causation Accepted.’ This is used when causation is established under Part E, which results in medical benefits for an employee or death benefit for an eligible survivor.

(b) CAW – ‘Causation and Wage Loss Accepted.’ This is used when causation and wage loss are all that are claimed under Part E and both are being accepted simultaneously.

(c) CAI – ‘Causation and Impairment Accepted.’ This is used when causation and impairment are all that are claimed under Part E and both are being accepted simultaneously.

10. ECMS Coding. (Continued)

(d) IMP – ‘Impairment Only Accepted (Causation Previously Accepted).’ This is used when causation was established on a previous decision and impairment is all that is being claimed and accepted in this decision under Part E.

(e) WAG – ‘Wage Loss Only Accepted.’ This is used when causation was established on a previous decision and wage loss is all that is being claimed and accepted in this decision under Part E.

(f) IMW – ‘Impairment and Wage Loss Accepted.’ This is used when causation was established in a previous decision and the current decision is accepting for wage loss and impairment.

(g) CIW – ‘Causation, Impairment, and Wage Loss Accepted.’ This is used when causation, impairment, and wage loss were all claimed and the decision to accept all three is being rendered on the current decision.

(2) G1 - ‘Final Partial Accept/Partial Develop.’ When the CE/HR renders a final decision where part of the claim is going to be approved for benefits under EEOICPA, while another part of the claim needs further development (including additional medical conditions, wage loss, impairment), the FAB CE/HR enters the ‘G1’ code in ECMS. The status effective date is equal to the date of the final decision. This code allows for benefits to be administered while development continues. Use status code ‘G1’ with reason code ‘B’ [Part B] in ECMS B for final decisions that describe a partial acceptance for one claimed condition under Part B and partial development for one or more other conditions under B. For Part E cases only, it is required that the CE/HR select the appropriate reason code from the drop down menu for input into ECMS E. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being held in abeyance for additional development are identified by the secondary decision status code ‘DV’ [Partial Develop] and corresponding reason code set out in section c below.

(a) CAU – ‘Accept Causation.’ This is used when causation for a claimed condition is accepted for benefits and additional development of another claimed element is required.

(b) CAW – ‘Accept Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and additional development of another claimed element is required.

(c) CAI – ‘Accept Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and additional development of another claimed element is required.

(d) IMP – ‘Accept Impairment.’ This is used when causation has previously been accepted and claimed impairment alone is being accepted and the additional development of another claimed element is required.

(e) WAG – ‘Accept Wage Loss.’ This is used when causation has previously been accepted and claimed wage loss alone is being accepted and the additional development of another claimed element is required.

(f) IMW – ‘Accept Impairment and Wage Loss.’ This is used when causation was previously accepted and impairment and wage loss are both claimed and a decision is being issued that accepts both claimed elements for benefits and the additional development of another claimed element is required.

(g) CIW – ‘Accept Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and the additional development of another claimed element is required (i.e. a cancer claim is pending dose reconstruction at NIOSH).

(3) F1 - ‘Final Deny - employee not covered.’ When the CE/HR renders a final decision to deny benefits under EEOICPA due to employment that is not covered, the FAB CE/HR enters the ‘F1’ code in ECMS. The status effective date is equal to the date the final decision was issued.

(4) G2 - ‘Final Partial Accept/Partial Deny/Partial Develop.’ When the CE/HR renders a final decision where part of the claim is going to be approved for benefits under EEOICPA, while another part of the claim is going to be denied, and yet another part of the claim requires further development, the FAB CE/HR enters the ‘G2’ code in ECMS. The status effective date is equal to the date of the Final Decision document. This code allows for benefits to be administered while development continues. Use status code ‘G2’ with reason code ‘B’ [Part B] in ECMS B for final decisions that describe a partial acceptance for one claimed condition under Part B and partial denial and partial development for one or more other conditions under B. For Part E cases, the CE/HR is required to select the appropriate reason code from the drop down menu. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being held in abeyance for additional development/denied are identified by the secondary decision status codes ‘PD’ [Partial Denial] and ‘DV’ [Partial Develop] and corresponding reason codes set out in section c below. These reason codes are entered exclusively in Part E ECMS.

(a) CAU – ‘Accept Causation.’ This is used when causation for a claimed condition is accepted for benefits and a portion of the claim is being denied and a portion of the claim requires additional development.

(b) CAW – ‘Accept Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(c) CAI – ‘Accept Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(d) IMP – ‘Accept Impairment.’ This is used when causation has been previously accepted and claimed impairment alone is being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(e) WAG – ‘Accept Wage Loss.’ This is used when causation has been previously accepted and claimed wage loss alone is being accepted and a portion of the claim is being denied and a portion of the claim requires additional development.

(f) IMW – ‘Accept Impairment and Wage Loss.’ This is used when causation has been previously accepted and impairment and wage loss are both claimed and a decision is being issued that accepts both claimed elements for benefits and a portion of the claim is being denied and a portion of the claim requires additional development.

(g) CIW – ‘Accept Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and a portion of the claim is being denied and a portion of the claim requires additional development (i.e. a cancer claim is undergoing dose reconstruction at NIOSH).

(5) F3 - ‘Final Deny - survivor not eligible.’ When the CE/HR renders a final decision to deny benefits under EEOICPA due to the fact the claimed survivor is not eligible, the FAB CE/HR enters the ‘F3’ code in ECMS. The status effective date is equal to the date of the Final Decision.

(6) F5 - ‘Final Deny - Cancer not work related (POC).’ When the CE/Hearing Rep renders a final decision to deny benefits under EEOICPA due to the fact that the Probability of Causation (POC) result from NIOSH is less than 50%, the FAB CE/Hearing Rep enters the ‘F5’ code in ECMS. This code is also to be used in cases of CLL-cancer only, wherein the POC is presumed to be zero. The status effective date is equal to the date of the Final Decision. This code is used for BOTH Part B and Part E cancer denials based upon the POC being less than 50%.

Upon entry in ECMS of the ‘D5’ code, the HR/CE selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘D5’ claim status code. The reason codes available for the ‘D5’ claim status code are listed below.

The only reason code allowable for ECMS B is ‘B’ [Part B].

Note 1: The ‘F5’ code is also used when coding decisions that partially deny benefits and deny other benefits while holding other benefits in abeyance for further development. One of the following ‘F5’ reason codes is entered to denote what is being denied in the decision. In tandem with the ‘F5’ entry, the HR/CE enters the ‘DV’ status code and appropriate associated reason code listed in section c below to identify which benefits are being held for further development. This coding is done exclusively in ECMS Part E and only when the ‘F5’ decision code is the primary reason for denial based upon a POC that is less that 50%. Whenever a decision contains a denial based upon the POC, the ‘F5’ must be used as the primary denial code.

Note 2: If there is a secondary finding in the decision to deny one or more claimed conditions in addition to the one(s) specifically included in the NIOSH probability of causation determination (described by using the ‘F5’ code), it is appropriate to enter in tandem with the ‘F5’ entry status code ‘PD’ [Partial Deny] with applicable reason code to describe/record the secondary denial.

(a) B – ‘Part B’ (B only).

(b) CAU – ‘Causation’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established.

(d) CAW – ‘Causation and Wage Loss.’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established and claimed wage loss must also be denied.

(e) IM0 – ‘Impairment – 0%’ (E only). This is used when the claim for impairment is being denied because the impairment rating is 0% based upon the Guides.

(f) IMN – ‘Impairment – Not Ratable’(E only). This is used when the claim for impairment is being denied because the claimed impairment is non-ratable, such as certain psychiatric conditions.

(g) IMR – ‘Impairment – Resolved’ (E only). This is used when the claim for impairment is being denied because the claimed impairment was resolved prior to the issuance of the decision.

(h) I0W – ‘Impairment (0%) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because it has a 0% rating.

(n) CA0 – ‘Causation and Impairment (0%)’ (E only). This is used when causation and 0% impairment are being denied simultaneously.

(o) CAN – ‘Causation and Impairment (not ratable)’ (E only). This is used when causation and an impairment that is not ratable are being denied simultaneously.

(p) CAR – ‘Causation and Impairment (Resolved)’ (E only). This is used when causation and impairment that is resolved prior to the issuance of the decision are being denied simultaneously.

(7) F6 - ‘Final Accept – Reversal from Denial.’ When the CE/HR renders a final decision to approve benefits despite the recommended decision to deny, the CE/HR enters the ‘F6’ code in ECMS. The status effective date is equal to the date of the Final Decision document.

(8) F7 – ‘FAB Remanded’. This code is input when FAB remands a decision of the DO. The full list of FAB remand codes is available in EEOICPA PM 2-1500. When issuing partial decisions that include a remand order, please input the ECMS coding in this order:

(a) Partial Accept/Partial Remand: F0 + reason code, followed by F7 + reason code.

(b) Partial Deny/Partial Remand: PD + reason code, followed by F7 + reason code.

The status effective date for both codes is equal to the date of the Final Decision.

(9) F8 - ‘Final Partial Accept/Partial Deny.’ When the CE/HR renders a final decision where part of the claim is approved for benefits under EEOICPA, while another part of the claim is denied, the FAB CE/HR enters the ‘F8’ code in ECMS. The status effective date is equal to the date of the Final Decision. The status effective date is equal to the date of the final decision. Use status code ‘F8’ with reason code ‘B’ [Part B] in ECMS B for final decisions that describe a partial acceptance for one claimed condition under Part B and partial denial for one or more other conditions under B. For Part E cases, the CE/HR is required to select the appropriate reason code from the drop down menu and enter it into Part E ECMS. The reason code for the decision explains only what is being accepted in the current decision. The portion(s) of the claim being denied in the decision is identified by the secondary decision status code ‘PD’ [Partial Deny] and corresponding reason code set out in section c below.

(a) CAU – ‘Accept Causation.’ This is used when causation for a claimed condition is accepted for benefits and a portion of the claim is being denied.

(b) CAW – ‘Accept Causation and Wage Loss.’ This is used when causation and claimed wage loss are being accepted and a portion of the claim is being denied.

(c) CAI – ‘Accept Causation and Impairment.’ This is used when causation and claimed impairment are being accepted and a portion of the claim is being denied.

(d) IMP – ‘Accept Impairment.’ This is used when causation was previously accepted and claimed impairment alone is being accepted and a portion of the claim is being denied.

(e) WAG – ‘Accept Wage Loss.’ This is used when causation was previously accepted and claimed wage loss alone is being accepted and a portion of the claim is being denied.

(g) CIW – ‘Accept Causation, Impairment, and Wage Loss.’ This is used when causation is accepted along with both claimed impairment and wage loss and a portion of the claim is being denied (i.e. a cancer claim is pending dose reconstruction at NIOSH).

(10) F9 - ‘Final Deny - medical information insufficient to support claim.’ When the CE/HR renders a final decision to deny benefits under EEOICPA due to the fact that after developing the claimed covered condition(s), the medical evidence is insufficient to prove that the condition can be covered, the FAB CE/HR enters the ‘F9’ code in ECMS. The status effective date is equal to the date of the Final Decision document. Upon entry in ECMS of the ‘F9’ code, the CE/HR selects a specific reason code from the "reason cd" field. This field is a drop-down box that corresponds with the ‘F9’ claim status code. The reason codes available for the ‘F9’ claim status code are listed below. The only reason code allowable for ECMS B is ‘B’ [Part B].

Note 1: The ‘F9’ code is also used when issuing a Part E decision that partially denies benefits while holding other benefits in abeyance for further development. One of the following ‘F9’ decision reason codes are entered to denote what is being denied in the decision. In tandem with the ‘F9’ entry, the CE/HR enters the ‘DV’ [Partial Develop] status code and appropriate associated reason code listed in section c below to identify which benefits are being held for further development.

Note 2: If the decision contains findings to deny multiple claimed conditions, and one denial is for insufficient medical evidence to establish claimed illness and another denial is for inability to establish causation, impairment or wage loss, follow this procedure: enter ‘F9’ with the reason code describing the causation/impairment/wage loss denial; in tandem with the ‘F9’ entry, enter ‘PD’ [Partial Deny] with reason code ‘IN’ to record the denial for insufficient medical to establish illness.

(a) B – ‘Part B’(B only).

(b) IN – ‘Insufficient medical to establish claimed illness’(Used for B and E). This is used when a covered illness is claimed under E or an occupational illness is claimed under B, but medical evidence is insufficient to establish the illness.

(c) CAU – ‘Lack of Causation’ (E only). This is used when a covered illness is claimed under E, but causation cannot be established.

(d) WAG – ‘Wage Loss.’ (E only). This is used when the claim for wage loss is being denied.

(e) IM0 – ‘Impairment – 0%’ (E only). This is used when the claim for impairment is being denied because the impairment rating is 0% based upon the Guides.

(f) IMN – ‘Impairment – Not Ratable’(E only). This is used when the claim for impairment is being denied because the claimed impairment is non-ratable, such as certain psychiatric conditions.

(g) IMR – ‘Impairment – Resolved’ (E only). This is used when the claim for impairment is being denied because the claimed impairment was resolved prior to the issuance of the decision.

(h) I0W – ‘Impairment (0%) and Wage Loss (E only). This is used when wage loss and impairment are both being denied. The claim for impairment is denied because it has a 0% rating based upon the Guides.

(l) CNW – ‘Deny Causation, Wage Loss, & Impairment (Not Ratable)’ (E only). This is used when a claim is made based on causation, wage loss, and impairment, all of which are being denied in the decision. The impairment is being denied because it is for a non-ratable condition.

(n) CA0 – ‘Causation and Impairment (0%)’ for E only. This is used when causation and 0% impairment based upon the Guides are being denied simultaneously.

(o) CAN – ‘Causation and Impairment (not ratable)’ for E only. This is used when causation and an impairment that is not ratable are being denied simultaneously.

(p) CAR – ‘Causation and Impairment (Resolved)’ for E only. This is used when causation and impairment that is resolved prior to the issuance of the decision are being denied simultaneously.

c. Secondary Decision Status Codes for use when a portion of the claim requires further development or is being denied or both.

(1) Partial Development. The following codes are used as secondary decision codes for recommended decisions and final decisions that hold a claimed element in abeyance for further development. This code is only to be used in ECMS E. The CE/HR inputs the claim status code ‘DV’ to denote development. The ‘DV’ status code is entered in tandem with a primary decision status code using the same status effective date (the date the decision is issued). Once the ‘DV’ status code is entered, the CE selects the reason code from the drop down menu that corresponds with the element(s) being held in abeyance for further development. This code is used by both the DO and the FAB when issuing decisions that require partial development codes.

(a) CAU – ‘Causation’. Causation for another claimed condition requires further development.

(b) CAW – ‘Causation and Wage Loss.’ Causation for another claimed condition and wage loss require further development.

(c) CAI – ‘Causation and Impairment.’ Causation for another claimed condition and impairment require further development.

(d) IMP – ‘Impairment.’ Claimed impairment requires further development.

(e) WAG – ‘Wage Loss.’ Claimed wage loss requires further development.

(f) IMW – Impairment and Wage Loss.’ Claimed impairment and claimed wage loss require further development.

(g) CIW – Causation, Impairment, and Wage Loss.’ Causation for another claimed condition, claimed impairment and claimed wage loss require further development.

(2) Partial Denial. The following codes are used as secondary decision codes for recommended decisions and final decisions that deny a portion of a claim. This code is only to be used in ECMS E. The CE/HR inputs the claim status code ‘PD’ to denote partial denial. The ‘PD’ status code is entered in tandem with the primary decision status code using the same status effective date (the date the decision is issued). Once the ‘PD’ status code is entered, the CE selects the reason code from the drop down menu that corresponds with the element(s) being denied in part. This code is used by both the DO and FAB when issuing decisions that require partial denial coding.

(a) IN – ‘Insufficient medical to establish claimed illness’. This is used when a covered illness is claimed under E but medical evidence is insufficient to establish the illness.

(b) CAU – ‘Causation.’ This is used when a covered illness is claimed under E, but causation cannot be established.

(d) CAW – ‘Causation and Wage Loss.’ This is used when a covered illness is claimed under E, but causation cannot be established and claimed wage loss must also be denied.

(e) IM0 – ‘Impairment – 0%.’ This is used when the claim for impairment is the only portion of the claim being denied because the impairment rating is 0% based upon the Guides.

(f) IMN – ‘Impairment – Not Ratable.’ This is used when the claim for impairment is the only portion being denied because the claimed impairment is non-ratable, such as certain psychiatric conditions.

(g) IMR – ‘Impairment – Resolved.’ This is used when the claim for impairment is the only portion being denied because the claimed impairment was resolved prior to the issuance of the decision.

(h) I0W – ‘Impairment (0%) and Wage Loss.’ This is used when wage loss and impairment are both the only portions being denied. The claim for impairment is denied because it has a 0% rating based upon the Guides.

(i) INW – ‘Impairment (not ratable) and Wage Loss.’ This is used when wage loss and impairment are both the only portions being denied. The claim for impairment is denied because the condition being claimed is not ratable for impairment, such as certain psychiatric conditions.

(j) IRW – ‘Impairment (resolved) and Wage Loss.’ This is used when wage loss and impairment are both the only portions being denied. The claim for impairment is being denied because the impairment was resolved prior to the issuance of the decision.

(k) C0W – Causation, Impairment (0%) and Wage Loss.’ This is used when a claim for causation, impairment, and wage loss are the portions being denied simultaneously. The impairment is denied because the impairment rating is 0% based upon the Guides.

(l) CNW – ‘Deny Causation, Wage Loss, & Impairment (Not Ratable).’ This is used when a claim is made based on causation, wage loss, and impairment, all of which are being denied in the decision. The impairment is being denied because it is for a non-ratable condition.

(m) CRW – ‘Causation, Impairment (Resolved), and Wage Loss.’ This is used when a claim for causation, impairment and wage loss are being denied simultaneously as portions of the claim as a whole. The impairment claim is being denied because the impairment was resolved prior to the issuance of the decision.

(n) CA0 – ‘Causation and Impairment (0%).’ This is used when causation and 0% impairment based upon the Guides are the only portions being denied simultaneously.

(o) CAN – ‘Causation and Impairment (not ratable).’ This is used when causation and an impairment that is not ratable are the only portions being denied simultaneously.

(p) CAR – ‘Causation and Impairment (Resolved).’ This is used when causation and impairment that is resolved prior to the issuance of the decision are the only portions being denied simultaneously.

d. Alternative Filing Codes When a claimant requests an alternative filing under Part E, use the ECMS codes below.

(1) XR – ‘Alternative Filing Review Requested’: When a claimant requests an alternative filing, the CE enters the ‘XR’ code in ECMS. The status effective date is equal to the postmark date or date stamp the letter is received in the office, whichever is earlier.

(2) XC – ‘Alternative Filing Review Completed’: When the CE sends out a final response to the alternative filing request, he/she enters the ‘XC’ code in ECMS. The status effective date is the date of the written response. Depending upon the determination reached in the review, two findings are possible: positive and negative. Depending upon the finding, the CE selects the appropriate reason code from the drop down menu to indicate the whether or not a causal link was found to have existed.

(a) If the finding of the causal review is positive, the CE selects “Positive” from the reason code drop down menu to show that a causal link was found to exist.

(b) If the finding of the causal review is negative, the CE selects “Negative” from the reason code drop down menu to show that no causal link was found to exist.

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