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| FECA BULLETIN NO.
99-04 Issue Date: November 20, 1998 _________________________________________________________________ Expiration Date: November 19, 1999 _________________________________________________________________ Subject: Bill Payment/BPS--Medications Which Do Not "Match" Accepted Conditions Background: The new procedures for processing pharmacy bills have prompted queries about handling "mismatches" between accepted conditions and medications billed. Such "mismatches" may come to OWCP's attention either because the Bill Processing System (BPS) flags the medication as questionable in the case at hand or because a bill has been denied and the claimant or the pharmacy has returned the explanation of benefits (EOB) to OWCP. In either instance, OWCP must take further action. While some medications may prove to be payable, others will continue to be ineligible for payment or reimbursement. This bulletin describes the actions which bill resolvers and claims staff will need to take in processing bills for medications which do not "match" the accepted condition(s) in the case. Reference: FECA Bulletin 98-11 Purpose: To describe the actions to be taken when a particular medication does not "match" the accepted condition Applicability: Claims Examiners, Senior Claims Examiners, Supervisors, Bill Processing Staff, Rehabilitation Specialists, Staff Nurses, and Technical Assistants Actions: 1. Where OWCP has already denied a bill for a "mismatch", the edit code is likely to be one of the following: 734 (therapeutic class is not payable for the accepted condition(s); 738 (the relationship between the therapeutic class and the accepted condition(s) requires manual review); and 746 (the accepted condition is missing from the relationship table). Edit 734 results in an automatic denial, while edits 738 and 746 result in suspension. The suspension can be overridden if the bill is payable, or set to deny if the bill is not payable. 2. When an EOB letter is returned, and the reason for denial was code 734, an NDC query should be performed. The relationship file has recently been updated, and additional changes will continue to be made periodically. As a result of these changes, a medication that was previously denied may now be payable. Also, if the accepted conditions have been updated, the medication may now be payable. 3. If the bill is now payable, it should be rekeyed. If the bill was originally denied with EOB 738 or 746, and it should have been paid, it should be rekeyed, and the edit suspension overridden. Entry of a note to indicate that the medication is payable should prevent erroneous denials in the future. 4. If the bill is not payable, but experience has shown that the medication is often used to treat the condition in question, the District Medical Advisor (DMA) should be consulted. If the DMA agrees that the medication is properly used to treat the condition, the issue should be referred to Dr. Virginia Miller, OWCP Medical Director, so that modification of the relationship table may be considered. 5. If the bill remains unpayable after these steps have been taken, the Claims Examiner (CE) will need to review the medical evidence in file and/or obtain additional medical evidence to determine whether the medication is correctly used in the case at hand. The Physicians' Desk Reference (PDR) may be consulted to determine the proper use of various medications. As always, the CE will need to exercise judgment in deciding if a particular medication should be (or continue to be) authorized. The CE should ensure that the accepted conditions accurately reflect the scope and severity of the claimant's injury and update the ICD-9 codes if warranted. 6. If the medical evidence supports payment but is not conclusive, the CE may obtain the advice of a District Medical Adviser. It is not anticipated that second opinion or impartial referrals will be needed to adjudicate such questions. 7. In long-term cases, OWCP may have paid for a questionable medication for many months or years. (By one estimate, over a third of periodic roll cases involve at least one medication where the relevance to the accepted condition(s) is questionable.) In such instances the CE should add "P99" as a temporarily accepted condition to allow for payment during development of the issue. (This code should also be used to indicate an adjunct condition, and instead of any "placeholder" acceptance codes.) A note showing that the medication is payable should be placed on the system, as edit 746 will suspend the bill if it is not otherwise payable. 8. If payment is denied, the responsible CE may release a letter decision to that effect. A sample is shown as Attachment 1. It is being added to the Letter Generator system. 9. A claimant who objects to this decision, either in writing or by telephone, should be issued a formal decision with full appeal rights. However, receipt of additional bills for the medication in question will not, by itself, be considered an "objection" to the letter decision. The claimant must actually express disagreement with the letter decision. Any formal decision must be based on the medical evidence of record, not the outcome of relationship editing by the BPS. 10. At present, there is no vehicle for advising injured workers with new claims that pharmacies may bill OWCP directly using the Universal Claim Form, or that injured workers should use Form CA-915 if they are seeking reimbursement of pharmacy expenses. Form CA-1008 is being revised with this information (a copy of the revised form is shown as Attachment 2.) The information will be added to Forms CA-14 and CA-1009 as soon as the forms are revised in conjunction with the program's new regulations. Disposition: Retain until the indicated expiration date. THOMAS M. MARKEY Director for Federal Employees' Compensation Distribution:List No. 2--Folioviews Groups A and D (Claims Examiners, All Supervisors, Systems Managers, District Medical Advisors, Technical Advisors, Rehabilitation Specialists, and Fiscal and Bill Pay Personnel) Attachment 1: Form CA-1008 (999) 999-9999 File Number: 11-1111111 Date of Injury: 02/02/1900 Employee: CLAIMANT M. NAME CLAIMANT M. NAME 0000000000000000000000000000000 0000000000000000000000000000000 0000000000000000000000000000000 0000000000000000000000000000000 Dear CLAIMANT M. NAME: I am writing in reference to your claim for injury on 02/02/1900, which you sustained while employed by the agency identified below. Your claim is accepted for: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX If your injury results in disability for work or the need for medical treatment, you may be eligible to receive continuation of pay (COP) until you recover or return to light duty, up to a maximum of 45 calendar days. If wage loss continues after the expiration of COP, you are eligible to claim disability compensation on Form CA-7. Bills for medical expenses related to the accepted condition(s) noted above will be processed for payment by this office following proper submission of charges. This includes medications which are prescribed for the accepted condition(s) noted above. Pharmacies may bill this office directly using the Universal Claim Form. The pharmacy should include the following information: the case file number, the nine-digit tax ID number, the NDC number, the prescription number, the quantity of medication prescribed, the name of the prescribing physician, and the date of purchase. If you request reimbursement, please complete Form CA-915, which is used in addition to the Universal Claim Form. You may obtain Form CA-915 from your employing agency or from this office. The enclosure, which is entitled "Now That Your Claim Has Been Accepted...", provides information about payment of bills, claims for compensation, and other matters pertinent to your claim. Sincerely, NAME OF SIGNER TITLE CA1008-1098 Page 1 Attachment 2: Sample Letter--Prescription Bill Denied Dear NAME OF CLAIMANT: I am writing in reference to prescription bills submitted in your claim for injury on 02/02/1900, which has been accepted for: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX All claims for prescription payments must contain a National Drug Council (NDC) code for each drug billed. Each NDC code is an 11-digit number which represents a specific medication, made by a specific manufacturer, of a certain strength. The NDC coding system is used by pharmacies all over the United States. On receipt of a bill for prescription expenses, the Office of Workers' Compensation Programs (OWCP) compares the NDC code to the medical condition(s) which OWCP has accepted as work-related. Sometimes, this comparison shows that the medication is not one which is properly used to treat the accepted condition. In your case, OWCP received a bill from NAME OF PHARMACY on DATE OF RECEIPT for NAME OF MEDICATION. The NDC code for this medication, which is 99999999999, does not correspond to your accepted condition of ACCEPTED CONDITION. This means that the medical community does not generally recognize NAME OF MEDICATION as effective or safe to use in treating ACCEPTED CONDITION. For this reason, payment for NAME OF MEDICATION is denied. This does not mean that your physician has prescribed NAME OF MEDICATION in error, or that you should not take this medication. Of course, NAME OF MEDICATION may be needed to treat some other, condition which is not related to your work, and you should consult your physician before changing the kind or amount of any medication you are taking. You may wish to submit bills for NAME OF MEDICATION to your health insurance carrier for consideration of payment. If you have any questions, please do not hesitate to contact this office. Sincerely, NAME OF SIGNER TITLE
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