TABLE OF CONTENTS
Chapter E-1100 Decisions and Hearings
Table of Contents. . . . . . . . i 03/06 06/02
1
Purpose and Scope. . . . . . . . 1 03/06
06/02
2 Authority.
. . . . . . . . . . . 1 03/06
06/02
3 Issuing
Decisions in General . . 1 03/06
06/02
4 Recommended
Decisions. . . . . . 3 03/06
06/02
5 Objections
and Waivers. . . . . 9 03/06 06/02
6 FAB
Decisions. . . . . . . . . . 11 03/06
06/02
7 FAB
Hearing Process. . . . . . . 16 03/06
06/02
8 Secondary CEs Designated
to the FAB.
. . . . . . . . . . 20 03/06
06/02
9 Alternative
Filing. . . . . . . 24 03/06
06/02
10 ECMS
Coding. . . . . . . . . . . 24 03/06
06/02
Exhibit
1. Cover Letter for Partial Accept/Partial Deny RD
2. Partial Accept/Partial Deny Waiver
3.
Cover
Letter for Non-eligible Survivor Denials
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.
(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 60th
day after the RD issuance date. (The date of the RD is not included in the 60
calendar days). If the 60th 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 –
(2) CLF –
(3) JAF –
(4) DEF –
(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
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.
(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.
(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.
(c) WAG – ‘Wage Loss.’ (E only). This is used when the claim for wage loss is
being denied.
(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
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.
(c) WAG – ‘Wage Loss.’ (E only). This is used when the claim for wage loss is
being denied.
(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.
(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.
(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.
(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 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.
(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% 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.
(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%)’ 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.
(c) WAG – ‘Wage Loss.’
This is used when claimed wage loss is the only portion being denied.
(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.