U.S. Office of Personnel Management Office of Merit Systems Oversight and Effectiveness Classification Appeals and FLSA Programs Chicago Oversight Division 230 S. Dearborn Street, DPN-30-6 Chicago, IL 60604-1687 Classification Appeal Decision Under section 5112 of title 5, United States Code Appellants: [appellant 1] [appellant 2] Agency classification: Claims Assistant (OA) GS-998-5 Organization: Health Information Management Section Patient Administrative Service VA Medical Center Department of Veterans Affairs [city and state] OPM decision: Claims Assistant (OA) GS-998-5 OPM decision number: C-0998-05-02 _____________________________ Manuela Martinez Classification Appeals Officer October 30, 2002 ______________________________ Date As provided in section 511.612 of title 5, Code of Federal Regulations, this decision constitutes a certificate that is mandatory and binding on all administrative, certifying, payroll, disbursing, and accounting officials of the government. The agency is responsible for reviewing its classification decisions for identical, similar, or related positions to ensure consistency with this decision. There is no right of further appeal. This decision is subject to discretionary review only under conditions and time limits specified in the Introduction to the Position Classification Standards, appendix 4, section G (address provided in appendix 4, section H). Decision sent to: [appellant 1] Patient Administrative Service VA Medical Center [address] [city and state] [appellant 2] Patient Administrative Service VA Medical Center [address] [city and state] [representative] AFGE Local 2280 VA Medical Center [address] [city and state] Mr. Wayne H. Davis HRM Division VA Medical Center 6000 West National Avenue Mail Stop HR-05 Milwaukee, Wisconsin 53295 Ms. Ventris C. Gibson Deputy Assistant Secretary for Human Resources Management (05) Department of Veterans Affairs 810 Vermont Avenue, NW., Room 206 Washington, DC 20420 Introduction On May 8, 2002, the Chicago Oversight Division of the U.S. Office of Personnel Management (OPM) accepted a classification appeal from [appellants 1 & 2]. On May 31, 2002, the Division received the agency's administrative report concerning the appeal. The appellants’ position is currently classified as Claims Assistant (OA), GS-998-5. The appellants believe the classification of their position should be Claims Assistant (OA), GS-998-6. They work in the Health Information Management Section, Patient Administrative Service, Veterans Affairs (VA) Medical Center, Department of Veterans Affairs, [city and state]. We have accepted and decided this appeal under section 5112 of title 5, United States Code (U.S.C.). This decision is based on a thorough review of all information provided by the appellants and their agency. In addition, we conducted separate telephone interviews with the appellants and their current supervisor, the Chief of the Patient Administrative Service. Both the appellants and their supervisor have certified the accuracy of the appellants’ official position description (PD), number 585-1563A. Position information The appellants work in the Health Information Management Section, along with four GS-7 Medical Records Technicians, a GS-6 Program Support Assistant (OA), a GS-5 Medical Records Technician, and two GS-5 Medical Clerks. The appellants’ major duties include establishing administrative entitlement to outpatient fee basis benefits, determining legal eligibility for dental benefits and the Community Nursing Home/State Home, determining administrative eligibility for unauthorized claims and for payment under the Millennium Health Care and Benefits Act, and obligating and managing five fund control points. The primary purpose of their position is to process a wide variety of transactions for all areas of fee basis. The duties of the position require a thorough knowledge of laws, executive orders, regulations, policies, standards, procedures, decisions and precedents of not only the VA, but also the OPM, General Accounting Office and Office of Management and Budget. They use veterans’ records and other means to determine eligibility for non-VA outpatient medical care, and enter documentation into the Veterans’ Health Information Systems and Technology Architecture (VISTA) package. They also process unauthorized claims (including non-emergencies that fall under the Veterans Millennium Health Care and Benefits Act), claims for dental care, and claims for Community Nursing Home care. The appellants are responsible for accurately entering and approving 25-35 patient fund deposits and withdrawals into the VISTA package each month. Series, title, and standard determination The agency determined that the appellants’ position is properly classified as Claims Assistant (OA), GS-998, and is classified by application of the Job Family Position Classification Standard for Assistance Work in the Legal and Kindred Group, GS-900. The parenthetical addition of (OA) to the title is appropriate, as the position requires knowledge of office automation and full typing qualifications. The appellant did not disagree with these determinations, and we agree. Therefore, the appealed position is allocated properly as Claims Assistant (OA), GS-998. Grade determination The Claims Assistant classification standard uses the Factor Evaluation System (FES) format. Under the FES, positions are evaluated on the basis of their duties, responsibilities, and the qualifications required in terms of nine factors common to non- supervisory General Schedule positions. A point value is assigned to each factor based on a comparison of the position’s duties with the factor-level descriptions in the standard. For a position factor to warrant a given point value, it must be fully equivalent to the overall intent of the selected factor-level description. If the position fails in any significant aspect to meet a particular factor level description in the standard, the point value for the next lower factor level must be assigned, unless the deficiency is balanced by an equally important aspect which meets a higher level. The appellant disagrees with factors 1, 3, 4, 5, 6 and 7. We have reviewed factors 2, 8, and 9 and agree with the agency determinations. Therefore, our decision will discuss only those factors contested by the appellant. Factor1, Knowledge required by the position This factor measures the nature and extent of information or facts that a worker must understand to do acceptable work, such as the steps, procedures, practices, rules, policies, theories, principles, and concepts; and the nature and extent of the skills needed to apply this knowledge. At Level 1-3, the employee has knowledge of basic math and standardized rules, processes, and procedures concerning claims processing, along with the skill to apply them in reviewing claims. The employee determines allowable items, appropriate provisions under which claims should be submitted, and the nature and amount of supporting evidence required. The employee assists claimants in preparing supporting evidence, examines files, and calculates correct amounts. At Level 1-4, the employee has knowledge of an extensive body of rules and procedures concerning claims. In addition, the employee has the skill to apply that knowledge to perform interrelated and nonstandard support work. The work involves examining documents where the facts are straightforward, readily verifiable, and need little development. This type of work requires limited searches of references, files, or historical material. He or she plans, coordinates, and/or resolves problems in support activities; uses a wide range of software applications to prepare complex documents containing tables or graphs; and uses online resources to obtain information accessible over the Internet. At this level, the employee also analyzes issues and makes determinations on cases, explains current criteria for benefits or obligations, reviews guidelines and regulations to determine the specific provisions that are applicable, and determines the status of an individual’s claim. Level 1-3 is met. The appellants indicate that they do not normally take the time to look up information; that they need to know the material in order to be responsive to their contacts. They also indicate that they spend a substantial amount of time explaining to veterans what can be done and what cannot be done regarding the veterans’ requests. The appellants must be knowledgeable of the Fee Medical Process, and determine appropriate provisions to use. This is consistent with Level 1- 3, in that the appellants apply standardized rules, processes, and procedures in reviewing and processing claims, and have the knowledge to know what to look for when examining files, determining the nature of the claim, and identifying the appropriate provisions to be used by the claimant for submitting the claim. Level 1-4 is not met. The position is limited to examining claims where the information is straightforward, readily verifiable, and needs little development. The work does not require in-depth analysis of issues. The appellants do not use a wide range of software applications to prepare complex documents containing tables or graphs as described at Level 1-4. The appellants do not apply an extensive body of rules and procedures, and they do not perform interrelated and nonstandard support work as is characteristic at Level 1-4. We evaluate this factor at Level 1-3 and credit 350 points. Factor 3, Guidelines This factor covers the nature of guidelines and the judgment needed to apply them. At level 3-2, the employee uses readily available guidelines in the form of agency policies and procedures that are clearly applicable to most transactions. Guidelines may include legal regulations, computer manuals, office manuals, office policies and procedures, directives, general decisions and agency guides. The employee determines the most appropriate guidelines or procedures to follow, adapts guidelines, makes minor deviations, and refers issues that do not readily fit instructions or are outside existing guidelines to a supervisor for resolution. At Level 3-3, the highest level described in the standard, the employee uses guidelines that have gaps in specificity and are not applicable to all work situations. The employee may have to rely on experienced judgment rather than guides to fill in gaps, identify sources of information, and make working assumptions about what transpired. The employee may reconstruct incomplete files, devise more efficient methods for processing, gather and organize information for inquires, and solve problems referred by others. In some situations, the employee may be required to make adaptations to cover new and unusual work situations to which guidelines do not directly apply. Level 3-3 is met. The appellants use readily available hard copy and online versions of guidelines that are applicable to most situations, such as the Fee Basis Users Manual and pertinent parts of the Code of Federal Regulations. As at Level 3-2, the appellants determine the most appropriate guidelines or procedures to follow and; if necessary, make minor adaptations in applying them. Level 3-3 is not met. The guidelines used by the appellants do not have gaps in specificity which are characteristic of Level 3- 3. They are not regularly confronted with new and unusual circumstances which require them to significantly alter their approach, and inapplicable guidelines as described at Level 3-3. We evaluate this factor at Level 3-2 and credit 125 points. Factor 4, Complexity This factor covers the nature, number, variety, and intricacy of tasks, steps, processes, or methods in the work performed; the difficulty in identifying what needs to be done; and the difficulty and originality involved in performing the work. At Level 4-2, the work consists of related steps, processes and standard explanations of methods or programs in the function. The employee processes claim forms, checking for accuracy, appropriateness, and consistency of information provided on the claim, obtaining supporting documentation when required, and requesting additional information when needed. The employee recognizes different procedures for evaluating sources of information and determines whether furnished documentation and information is adequate. At Level 4-3, the highest level described in the standard, the work consists of different and unrelated processes, methods, and sequences of tasks. The employee analyzes facts and identifies issues, defines problems, determines courses of action from many alternatives, determines the interrelationships among pieces of available information, assesses a variety of situations, selects and applies appropriate resources, and develops recommendations for problem resolution. The employee determines what needs to be done, including choosing the order of research necessary, the sequence of steps, and the manner in which findings are presented. Verification or development of information from external sources is frequently required. The organization and presentation of information can vary substantially. Level 4-2 is met. Although the work requires making determinations regarding veterans’ eligibility, the appellants’ work involves related steps and processes. The steps to be followed are routine and clearly laid out in writing. Eligibility is determined through interpretation and application of the appropriate VA regulations and manuals. As at Level 4-2, the appellants check claim forms for accuracy, appropriateness, and consistency of information. Level 4-3 is not met. Although each case has unique features, there are common procedures to follow, and the appellants are not required to determine courses of action from many alternatives. The appellants’ work involves various tasks related to determining eligibility and making payments for claims. The appellants do not perform work that consists of different and unrelated processes, methods, and sequences of tasks, as at Level 4-3. They also do not perform comparable in-depth analysis. The acceptance or denial of a claim is determined through the application of clearly defined standard criteria. We evaluate this factor at Level 4-2 and credit 75 points. Factor 5, Scope and effect This factor covers the relationship between the nature of the work, as measured by the purpose, breadth, and depth of the assignment, and the effect of work products or services both within and outside the organization. At Level 5-2, the work involves specific rules, regulations or procedures. Conditions are well-defined. Tasks include reviewing documents for missing information, searching records and files, verifying and maintaining records, and answering routine procedural questions. Work provides the basis for subsequent actions taken by the office to provide services to the public. At Level 5-3, the highest level described in the standard, the purpose of the work is to examine legal instruments and supporting documents to determine whether requested actions meet governing provisions. The work is accomplished in accordance with established criteria and may involve subjective considerations, such as looking for misrepresentations, fraud, or other illegal activity. The work directly affects the ability of individuals, partnerships, corporations, and others to obtain licenses, permits, rights, or privileges; to conduct various financial or contractual matters; to ascertain that persons have ownership or interest in property or securities; or to carry out other transactions that affect personal livelihoods. Level 5-2 is met. The work of the appellants involves planning, developing, and carrying out all aspects of the fee basis program to ensure accuracy, timely responses, and proper and timely payment of medical services for veterans. They search for and retrieve hard-copy and computerized information related to claims, and use software to prepare correspondence and spreadsheets. Level 5-3 is not met. While the appellants do review guidelines and regulations to determine the type of an incoming claim, their work does not affect the ability of individuals or organizations to negotiate settlements or compromise their rights or privileges to conduct various financial or contractual matters as described at factor 5-3. We evaluate this factor at Level 5-2 and credit 75 points. Factor 6, Personal contacts, and Factor 7, Purpose of contacts The GS-900 standard treats Factors 6 and 7 together. Contacts credited under Factor 6 must be the same contacts considered under Factor 7. Factor 6 (Levels 1 to 2) includes face-to face contacts and telephone dialogue with persons not in the supervisory chain. Levels of this factor are based on what is required to make the initial contact, the difficulty of communicating with those contacted, and the setting in which the contact takes place (e.g., the degree to which the employee and those contacted recognize their relative roles and authorities). Factor 7 (Levels a to b) addresses the purpose of personal contacts, which may range from factual exchange of information to situations involving significant or controversial issues and differing viewpoints or objectives. Personal contacts At Level 2, the highest level described in the standard, contacts are with various members of the general public, such as individuals and representatives of businesses or corporations, including attorneys; representatives of public, private, or nonprofit organizations; other personnel at different levels in the employee's agency; and employees in other Federal, state, or local entities. The contacts generally occur on a routine basis in the course of normal office activities. Level 2 is met. The appellants’ work with veterans, officials in their agency, employees of other medical facilities, and representatives of a variety of other organizations and businesses. We evaluate this factor at level 2. This factor covers the purpose of personal contacts, which may range from factual exchange of information to situations involving significant or controversial issues and differing viewpoints or objectives. Purpose of contacts At Level a, the purpose of contacts is to obtain, verify or exchange information or facts in order to complete assignments. At Level b, the highest level described in the standard, the purpose of contacts is to plan or arrange work efforts, to coordinate and schedule activities, and to resolve problems relating to documents or procedures. It also includes contacts to provide explanations of why approval was not given, discuss measures that might be taken to obtain approval in the future, and explain alternative options that may be available. The purpose of the appellants’ contacts compares to Level a. They make contacts to secure or provide information to process claims. They also answer questions from Veterans regarding eligibility. Unusual problems are referred to the appellants’ supervisor. The appellants do not plan or arrange work efforts, nor do they coordinate and schedule activities, as described at Level b. They do not provide comparable explanations of claim actions or discuss measures that might be taken to obtain approval in the future. These factors are credited at Level 2a for 45 points. Summary In summary, we have evaluated the appellant’s position as follows: Factor Level Points 1. Knowledge required by the position 1-3 350 2. Supervisory controls 2-3 275 3. Guidelines 3-2 125 4. Complexity 4-2 75 5. Scope and effect 5-2 75 6. Personal contacts and 7. Purpose of contacts 2a 45 8. Physical demands 8-1 5 9. Work environment 9-1 5 Total Points: 955 A total of 955 points falls into the GS-5 grade level point range of 855-1100 points on the Grade Conversion Table. Decision The appellant’s position is properly classified as Claims Assistant (OA), GS-998-05.