Chapter E-200 Case Creation

1. Purpose and Scope. This chapter describes the procedures for determining whether a claim filed is designated as a claim filed under Part B, Part E, or both. It also discusses how to create electronic records in ECMS (B), (E), or both.

2. Resource Center Role. Resource Centers (RC) provide assistance to claimants. RCs receive new EE-1/2 forms. Department of Energy (DOE) claim forms are no longer accepted. In addition to accepting claim forms, RCs conduct initial employment verification on all new non-RECA claims filed at the RC. The RC has 7 days upon receipt of the claim in which to conduct initial employment verification (See Chapter E-400). In addition to employment verification, the RCs also conduct occupational history development on most claims filed under Part E. The RC attempts to complete all tasks within the initial 7 day period and sends all claim forms and associated documents to the District Office (DO) for case create with a memorandum providing a chronological outline of their actions.

3. Receipt of New Claim. New claims are generally received in the DO after the RC conducts the initial development steps outlined above. Sometimes new claims are received directly in the DO. Claims received in the DO are immediately created and employment verification is conducted at the DO. The DO reviews the claim before creation by the case create clerk (CCC) in ECMS to determine whether it should be entered in ECMS as a Part B claim, a Part E claim, or both.

a. New claim forms received directly in the DO are date stamped per current procedure (see EEOICPA PM 1-200). The date stamp or post mark (whichever is the earliest discernable date) is the claim filing date.

b. New claim forms received directly in the RC are date stamped at the RC. The post mark or RC date stamp date (whichever is earliest) is the claim filing date. The DO also date stamps the forms upon receipt.

c. When a new claim is received directly in the DO or after RC development, it is immediately given to a DEEOIC employee with experience in claims processing. The employee, as designated by the District Director (DD), reviews the claim to determine whether to enter the claimed medical condition(s) in ECMS (B), ECMS (E), or both.

4. Case Create Review. The designated DO case create employee reviews the claim forms (EE-1/2, EE-3, and EE-4 where applicable). On claims initially filed at the RC, in some instances the RC verifies employment through the Oak Ridge Institute for Science and Education (ORISE) or clarifies the nature of the claimed employment. Any attached employment verification documents and/or medical evidence is reviewed in conjunction with the claim forms (claimed condition and employment) to make the case create determination as to whether or not the claim belongs in ECMS B, E, or both.

5. Case Create Worksheet. The Case Create Worksheet (Exhibit 1) is used to identify the ECMS system required for case creation, and the medical conditions entered in either or both systems. If a claim identifies Part B medical conditions and other medical conditions, the Part B medical conditions are specified for entry in both ECMS B and E, while the other conditions are specified for entry in ECMS E only (Box 1b). All other medical conditions that are not Part B medical conditions are identified for data entry in ECMS E only (Box 2). However, the reviewer only enters a condition in ECMS E if employment is covered Part E employment. The reviewer completes the case create worksheet specifying which ECMS system(s) and medical condition(s) to enter in ECMS. Upon completion, the reviewer signs and dates the worksheet, attaches it to the claim form, and forwards all documents to the CCC for case creation.

a. Example 1: If any of the Part B medical condition types are claimed on the EE-1/2 form (Chronic Beryllium Disease, Beryllium Sensitivity, Chronic Silicosis or Cancer), those medical conditions are to be indicated for data entry into both ECMS B and E on the Case Create Worksheet (Box 1a). If the claim indicates employment at an Atomic Weapons Employer (AWE) or Beryllium Vendor, the claim is only created in ECMS B, regardless of the condition claimed.

Some AWE/BE Vendors are also designated as DOE facilities for remediation during certain portions of the covered time period. Additional development by the CE may be required to ascertain if the employee can be considered a covered DOE contractor/subcontractor employee if employment falls during the DOE designated period. If it is determined that this employee is a DOE contractor/subcontractor, then the claim could also be entered into ECMS E.

(1) The CE usually makes this determination after case creation. If the CE decides the case is to be created in ECMS E, the CE sends the case back to the CCC.

b. Example 2: The employee worked at a DOE facility. The claimed condition of prostate cancer is applicable under both Part B and Part E but the claimed condition of asbestosis is only applicable under Part E.

c. Example 3: If chronic silicosis is indicated on the form, the claim is entered in ECMS B only if the employee worked in underground tunnels in Nevada or Amchitka Island, Alaska. If the employment indicates a location other than those locations, the claim is only to be entered in ECMS E.

d. Example 4: For all new RECA 5 claims, the medical conditions are entered in both ECMS B and E. Also, a survivor claim accepted under Part B may need development to establish survivorship under Part E. RECA 4 claims are filed strictly under Part E.

e. For the covered occupational illnesses under Part B of the EEOICPA, refer to Chapters 2-0600, 2-0700, and 2-0800 for the Eligibility Criteria for Cancer, Beryllium Illness, and Silicosis, respectively. For the covered illnesses under Part E of the EEOICPA, refer to the Chapter on Evidentiary Requirements for Causation (Part E-500).

6. Case Creation. Case Create procedures are primarily the same as outlined in EEOICPA PM 1-300 (Case Creation) and 2-1500 (ECMS). After completion of the case create worksheet and upon receipt, the CCC creates the claim as outlined above. The CCC must enter the appropriate filing date when the case is created. (Please see Exhibit 5 for filing date chart).

a. General Rules for Establishing the Claim Filing Date: When the claim is returned from the designated employee, the CCC enters the file date of the EE-1/2 directly in ECMS. The file date is determined based on the following guidelines:

(1) Part B/E joint or separate filing, the claim filling date is the postmark date on the envelope or date stamp in the RC or DO (earliest determinable date), whichever is earliest. [Not earlier than July 31, 2001 for Part B and not earlier than October 30, 2000 for Part E.]

(2) Part B filing only, the claim filing date is the date of the postmark on the envelope or date stamp in the RC or DO (earliest determinable date), no earlier than July 31, 2001.

(3) Part D filing only, the claim filing date is the date of the postmark on the envelope or date stamp in the RC or DO (earliest determinable date), no earlier than October 30, 2000.

(4) Part E filing only, the claim filing date is the date of the postmark on the envelope or date stamp in the RC or DO (earliest determinable date), no earlier than October 28, 2004.

(5) If multiple Part B claimants already exist and at least one but not all filed a claim under Part D, all Part B claimants must be created in Part E. The earliest Part D claimant filing date (no earlier than October 30, 2000) is used for all other Part B claimants when determining their Part E filing date. Once it is determined that such claims require creation, the CE prepares a memorandum to the CCC requesting that the uncreated Part D claims be created as Part E claims. The date of the memorandum requesting this action is the receipt date for each claim.

(6) Old Part B acceptances with no corresponding Part D/E claim where Part B claimants are eligible under Part E, the CE prepares a memorandum to file stating that creation of the Part E claim is based upon the Part B acceptance. The date of the CE’s memorandum to file is the Part E filing date.

(a) These claims are to be created immediately to coincide as closely as possible with the date of the RD. If a claim is created after the date of the RD, the claim create date in ECMS E will post-date the of the RD.

(b) Part B claimants who do not meet the Part E survivorship definition are ineligible for Part E benefits. No memorandum is prepared and no Part E claim is created based upon the Part B acceptance.

(7) New Part B acceptance not based upon a NIOSH Probability of Causation (POC) of 50% or greater with no corresponding Part D/E claim where Part B claimants are eligible under Part E, the Part E claim filing date is the date of the recommended decision accepting Part B benefits. The received date is the same as the filing date.

(8) Part B acceptances based upon a NIOSH Probability of Causation (POC) of 50% or greater with no corresponding Part D/E claim where Part B claimants are eligible under Part E, the Part E claim filing date is the date stamp upon which the dose reconstruction was received from NIOSH in the DO. The received date is the same as the filing date.

b. When a New Claim Form is required. In certain instances the CE must determine whether a new claim form is required before a Part E claim can be created.

(1) A new claim form is required when:

(a) A Part B denial has been issued and a claimant wishes to file for Part E benefits and no Part D filing was ever made.

(b) A Part B claim filed prior to February of 2005 is pending adjudication and a claimant wishes to file for Part E benefits (and no Part D filing was ever made).

(2) A new claim form is not required when:

(a) Benefits are accepted under Part B.

(b) Part B claim filed after February of 2005 is pending adjudication. No claim form is required in this instance because it is assumed that the claim has already been reviewed for benefits under both Parts of the Act.

(3) If a new claim form is required, the CE contacts the appropriate individual in writing and provides claim forms and filing instructions. The new claim solicitation package to the claimant includes a cover letter, the EE-1/2 and EE-3 forms, as applicable. This action may occur concurrently with development of the claim.

c. Procedures for entry of claims into ECMS.

(1) As outlined on the Case Create Worksheet, box 1, 2, or 3 determines which ECMS to use: ECMS B and E, ECMS B only, or ECMS E only.

(a) Box 1: Indicates that the claim is created in both ECMS B and E.

(b) Box 1a: Indicates that all claimed medical conditions are entered in both ECMS B and E.

(c) Box 1b: Indicates that a certain medical condition(s) is to be entered in ECMS B or E. Specifies under “B-Medical Conditions” any medical conditions entered in ECMS B only, and under “E-Medical Conditions” any medical conditions entered in ECMS E only.

(d) Box 2: Indicates that the claim is created in ECMS B only. Any medical condition listed on the claim form is entered in ECMS B.

(e) Box 3: Indicates that the claim is created in ECMS E only. Any medical condition listed on the claim form is entered in ECMS E.

(2) For the most part, ECMS B and ECMS E function the same and allow for independent data entry into either system. To limit the number of key strokes and ensure cases are keyed to the same location and transferred at the same time, all of the information on the first screen (case screen), except for the claim(s) section at the bottom of the screen, is shared between ECMS B and ECMS E. Case information that automatically transfers between the two systems includes the following fields/sections:

· CE

· CE Assign Dt

· Dist Office

· Location

· Location Assign Dt

· Employee Name and Address

· Employee Census Information

· Employee Dependents

· Work Sites

Note: Phone messages and call-ups are also shared between both systems.

(3) The CCC first queries ECMS. If the employee SSN already exists in one system, a new claim is added to the other system through the “Open Case” menu in the system that the claim has not been created in yet, as opposed to the “Add Case” option. If the employee SSN does not yet exist in one of the systems, then the usual case create procedures are applicable.

(4) For all cases that are both B and E, all claimant information entered during the case create process needs to be entered directly into both ECMS B and E. As discussed above, the case information only needs to be entered once because it is shared between both systems.

d. Once the case is created in ECMS, the Case Create

Worksheet is signed and dated by the CCC. Current procedures are followed for creating physical files, sending a letter of acknowledgement (Exhibit 2), and distributing cases to the Claims Examiner.

e. If there is an existing claim for benefits (EE-1/EE-2),

the new claim form(s) is spindled directly after the existing claim form(s).

f. The Case Create Worksheet is attached to the top of the case jacket for Claims Examiner review.

7. Claims Examiner Review. Upon receipt of a new case and prior to beginning case adjudication, the responsible CE must review the claim form(s), any attached employment or medical evidence assembled at the RC, the Case Create Worksheet, and ECMS to ensure the claim was entered correctly in ECMS.

a. The CE ensures that the claim is entered in the correct ECMS system. If a claim is created in the wrong system, certain steps must be followed in order to delete the incorrect entry (Item #8). If a claim is not created in one of the required ECMS systems, the CE returns the claim to the CCC for case creation.

b. The CE ensures that the medical condition(s) is entered in the correct ECMS system. If a medical condition is incorrectly entered, or not entered at all, the CE corrects the medical information in the appropriate version of ECMS, as outlined in EEOICPA PM 02-1500 (ECMS).

c. After the CE review is completed, the Case Create Worksheet is attached to the inside cover on the left side of the case file, and all associated claim file documents are placed in the file in chronological order.

8. Deleting a Claim from ECMS. If the CE determines that a claim was created in the wrong ECMS system or needs to be added to a system, the claim must be returned to case create. The CE must write a memo (Exhibit 3) to the Case Create Manager informing him/her of which ECMS system to delete or add a claim. The memo must be maintained in chronological order within the case file.

a. Example: If a claim is E only (such as by condition - asbestosis), but was entered in ECMS B and E, the B claim needs to be deleted. The CCC deletes the claim information, not case information, in the incorrect version of ECMS. (Exhibit 4). Once the claim is deleted, only the District Director or Chief of Operations can change the part type. The CCC forwards the case file to the Chief of Operations/District Director to complete the case deletion.

(1) Part D claims may not be deleted under any circumstances. Each Part D claimant must receive a decision regarding his/her claim. A Part E claim may be deleted from the system if it was created in error (facility or employment not covered) and no Part D claim exists.