CMS 1500 – BOX 11: INSURED’S POLICY GROUP OR FECA NUMBER
BOX 11a: INSURED’S DATE OF BIRTH AND SEX
If YES is checked in Box 11d, enter the month, day and year the policyholder was born. The format for a birth date must be MMDDYYYY.
Enter an X in the appropriate box for the policyholder’s sex. BOX 11b: EMPLOYER’S NAME OR SCHOOL NAME If YES is checked in Box 11d, enter the name of the policyholder’s employer or school.
BOX 11c: INSURANCE PLAN NAME OR PROGRAM NAME
If YES is checked in Box 11d, enter the name of the policyholder’s insurance plan or program. Do not enter Medicare or the name of any State program.
BOX 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?
If the member is covered by other primary insurance and he/she is not the policyholder, enter an X in the YES box and also complete Fields 9a-9c. If there is no other insurance, enter an X in the NO box.
Boxes 1a Insured’s ID Number & 11 Insured’s Policy Group or FECA NumberPaper claims are being rejected with edit 500401 SUBSCRIBER NAME OR ID. The primary reason this reject is happening is because claims are being submitted with the same information in Boxes 1a Insured’s ID Number and 11 Insured’s Policy Group or FECA Number. Most of the errors reviewed have been because the provider is submitting the Subscriber ID in both blocks. The provider should check the member’s ID card for both pieces of information and file them correctly.
GENERAL PROVISIONS OF THE FECA
Purpose and Scope
1. Purpose and Scope. This chapter is intended to serve as an introduction to the coverage and requirements of the Federal Employees’ Compensation Act (FECA) as amended. It summarizes the general provisions of the Act and describes the responsibilities of the Claims Examiner (CE) in administering the FECA. The reference materials listed at the end of the chapter should be available to CEs in each district office. 2-0200-2 General Provisions of the FECA
2. General Provisions of the FECA.
a. Definition of Injury. The term “injury” includes all diseases proximately caused by the employment as well as damage to or destruction of medical braces, artificial limbs and other prosthetic appliances. Aggravation of a pre-existing condition by the employment is also compensable.
b. Requirements for Eligibility. Each claim for compensation must be filed within three years of the date of injury, except where the official superior had actual knowledge of the injury within 30 days of its occurrence. The claimant must be a civil employee, and an injury must have resulted from the incident claimed. Finally, the injury or disease must have occurred in performance of the claimant’s duties, and it must be causally related to factors of employment. See FECA PM 2-800 through 2-806.
c. Medical Care. An injured employee who meets the statutory conditions of coverage is entitled to all medical care which is required to cure, give relief, or reduce the degree or period of disability. No dollar maximum or time limitation is placed on medical care, which will be provided as long as the evidence indicates it is needed for the effects of the job-related injury. See FECA PM 2-810 and FECA PM
Part 3.
d. Continuation of Pay. An employee who sustains a disabling job-related traumatic injury is entitled to continuation of regular pay (COP) for a period not to exceed 45 calendar days. To qualify for COP, the injured employee must file written notice of injury and claim for COP within 30 days of the injury. COP is not considered compensation and is subject to taxes and other payroll deductions. The employee must make separate claim for monetary compensation if the disability exceeds 45 days or results in any permanent disability. See FECA PM 2-807.
e. Compensation. Generally, for total disability an employee with no dependents is entitled to compensation equivalent to two-thirds of the weekly salary, while an employee with one or more dependents is entitled to three-fourths of the salary. Certain additional amounts, such as premium pay, night and Sunday differential, dirty work pay, and hazardous duty pay, may be included in salary. Overtime pay, however, cannot be included. A special formula is applied in cases where the employee is a part-time worker, an unpaid volunteer, a temporary employee, or a person working in a similar category. See FECA PM 2-900. Compensation payments are subject to garnishment for past due alimony and child support payments if the district office receives the proper documentation from a state agency or a court orderthat supports such action.
f. Vocational Rehabilitation. If the injured worker suffers a vocational handicap due to the injury and cannot resume usual employment, vocational rehabilitation services may be arranged to assist in training for work that the claimant can perform in the disabled condition. Rehabilitation services are usually provided by private rehabilitation counselors, who are supervised by the OWCP. Where rehabilitation is under way, the OWCP may provide a monthly maintenance allowance not to exceed $200, in addition to compensation for wage loss. See FECA PM 2-813 and OWCP PM Part 3.
g. Attendant Allowances. 20 C.F.R. 10.312 allows payment for services of an attendant where it is medically documented that the claimant requires assistance to care for personal needs such as bathing, dressing, eating, etc. Such services are paid as a medical expense under 5 U.S.C. 8103; are limited to $1500 per month under 5 U.S.C. 8111; and are paid directly to the provider of the services. See FECA PM 2-812.
h. Duration of Compensation. Compensation payments for total disability may continue as long as the medical evidence supports such payment. As with medical care, no cap is placed on the amount or the length of time for which compensation for total disability may be paid. See FECA PM 2-812.
i. Reemployment and Loss of Wage-Earning Capacity. When an injury results in partial disability, and the employee suffers a wage loss because of the disability, compensation may be paid for such loss of wage-earning capacity. See FECA PM 2-814.
j. Schedule Awards. The FECA also provides for payment of compensation for permanent loss or loss of use (either partial or total) of certain internal organs and members or functions of the body such as arms, legs, hands, feet, fingers, toes, eyes, and loss of hearing or loss of vision. Each extremity or function has been rated at a specific number of weeks of compensation which can be paid even though the employee returns to work at full salary. Where a serious disfigurement of the head, face, or neck results from a job-related injury, an award may also be made for such disfigurement, not to exceed $3,500. See FECA PM 2-808.
k. Survivor Benefits. In the event of death due to employment, the Act provides for funeral and burial expenses up to $800, and up to $200 for the administrative costs of terminating a decedent’s status as a Federal employee. The law provides compensation for widows or widowers with no eligible children at the rate of 50 percent of the deceased employee’s monthly salary, and for widows or widowers with eligible children at 45 percent. If a spouse survives, each child receives 15 percent, up to total of 30 percent. Where no spouse survives, the rate for the first child is 40 percent, plus 15 percent for each additional child, shared equally among all children. Monthly payments for all beneficiaries generally cannot exceed 75 percent of the employee’s monthly pay rate. Other persons who may also qualify for benefits are dependent parents, brothers, sisters, grandparents, and grandchildren. See FECA PM 2-700.
l. Cost-of-Living Adjustments. In general, if compensation has been paid in either a disability or death case for over a year, Consumer Price Index (CPI) adjustments are made to compensation. See FECA PM 2-900.
m. Third Party Liability. Where an employee’s compensable injury or death results from circumstances creating a legal liability on some party other than the United States, the cost of compensation and other benefits paid by the OWCP must be refunded from any settlement obtained. The OWCP will assist in obtaining the settlement; the law guarantees that a certain proportion of the settlement (after any attorney fees and costs are first deducted) may be retained even when the cost of compensation and other benefits exceeds the amount of the settlement. See FECA PM 2-1100.
n. Dual Benefits. The law provides that compensation may not be paid concurrently with certain benefits paid by other Federal agencies. In particular, compensation and a retirement annuity from OPM may not be paid for the same period except where OWCP is paying a schedule award, and veterans’ benefits may be subject to offset as well. See FECA PM 2-1000.
o. Review of OWCP Decisions. Under 5 U.S.C. 8116(c) the FECA is a beneficiary’s exclusive remedy for injury or death of a Federal civil employee in performance of duty. Although aggrieved parties on occasion do seek remedies outside the FECA through a Federal tort suit or other litigation, the existence of such litigation is not considered in adjudicating claims or taking other case actions. If an employee or the survivors disagree with a final determination of the OWCP, a hearing may be requested, where the claimant may present evidence in further support of the claim. Also, the claimant has the right to appeal to the Employees’ Compensation Appeals Board, a separate entity of the U. S. Department of Labor, and OWCP may review a case on its own initiative. See FECA PM 2-1600 through 2-1602.2-1602.
2-0200-3 Responsibilities of the Claims Examiner
3. Responsibilities of the Claims Examiner. The main tasks of the CE are to adjudicate claims; authorize benefits and set up compensation payments; manage individual cases, so that timely and proper actions are taken in each claim; and manage a case-load, so that all cases are handled promptly and effectively.
The CE is expected to exercise keen judgment, derived from experience, background, and acquired knowledge, tempered with compassion and common sense, in all claims processing. This exercise involves the ability to identify the issues, determine the additional evidence required, and make a decision once the evidence is assembled. Each case stands on its own merits and the decision in a given case must be based on the facts in evidence in the case file. The decision cannot be based on surmise, speculation, or unwarranted presumption.
The adjudication of a case on the evidence in the file does not preclude the use of precedents in arriving at a decision in a case. Precedents, as distinguished from questions of fact, are legal and medical principles, statements, or decisions rendered in other cases which may serve to define, explain, or justify the legal or medical determinations in like situations. When using precedent material in the adjudication of a case, the CE should place a memorandum in the case file citing the specific reference and principles relied upon, and the manner and extent to which such principle is applicable. Some of the most useful precedents for FECA cases are the case rulings of the Employees’ Compensation Appeals Board (ECAB), the highest appellate source for claims under the FECA. Opinions of the ECAB are first published separately on a case-by-case basis, then in book form. Other precedents are found in court decisions and in such publications as Arthur Larson’s Workmen’s Compensation Law..
2-0200-4 Reference Materials for the Claims Examiners
4. Reference Materials for Claims Examiners. Each district office should have a library which contains the following items for reference by CEs:
a. Federal Employees’ Compensation Act, 5 U.S.C. 8101 et seq., as amended.
b. 20 C.F.R. Part 10 (Title 20, Code of Federal Regulations, 1.1 et seq.); US GPO.
c. FECA Procedure Manual, Part 0, Overview; Part 1, Communications and Records; Part 2, Claims; Part 3, Medical; Part 4, Special Case Procedures; Part 5,
Benefit Payments; and Part 6, Debt Management.
d. FECA Program Memorandums, Bulletins, and Circulars.
e. Decisions of the Employees’ Compensation Appeals Board, with Index (issued annually), including floppy discs containing published ECAB decisions, volumes 39 and following.
f. Summaries of ECAB decisions issued periodically by the National Office.
g. Black’s Law Dictionary, West Publishing Co., St. Paul.
h. Workmen’s Compensation Law, Arthur Larson, Matthew Bender Publishing Co., Washington, with all updates.
i. Dorland’s Illustrated Medical Dictionary, W.B. Saunders Co., Philadelphia.
j. Current edition of the AMA Guides to the Evaluation of Permanent Impairment. A copy of prior editions should also be retained.
k. Current edition of The Merck Manual, Merck & Co., Rahway, N. J.
l. Current Directory of Medical Specialists, published by Marquis Who’s Who, Chicago (hard copy for reference, in addition to the version contained in the automated Physician Directory System).
m. Current directory of the American Medical Association for each state within the district office’s jurisdiction.
n. Current directory of the American Psychological Association.
o. Current directory of the American Chiropractic Association.
p. Current edition of the Dictionary of Occupational Titles, and supplements.
q. The most recent accountability review report.
r. Road maps or a road atlas covering the district office’s geographical jurisdiction.
s. Telephone directories for prominent areas in the district office’s jurisdiction.
BOX 11a: INSURED’S DATE OF BIRTH AND SEX
If YES is checked in Box 11d, enter the month, day and year the policyholder was born. The format for a birth date must be MMDDYYYY.
Enter an X in the appropriate box for the policyholder’s sex. BOX 11b: EMPLOYER’S NAME OR SCHOOL NAME If YES is checked in Box 11d, enter the name of the policyholder’s employer or school.
BOX 11c: INSURANCE PLAN NAME OR PROGRAM NAME
If YES is checked in Box 11d, enter the name of the policyholder’s insurance plan or program. Do not enter Medicare or the name of any State program.
BOX 11d: IS THERE ANOTHER HEALTH BENEFIT PLAN?
If the member is covered by other primary insurance and he/she is not the policyholder, enter an X in the YES box and also complete Fields 9a-9c. If there is no other insurance, enter an X in the NO box.
Boxes 1a Insured’s ID Number & 11 Insured’s Policy Group or FECA NumberPaper claims are being rejected with edit 500401 SUBSCRIBER NAME OR ID. The primary reason this reject is happening is because claims are being submitted with the same information in Boxes 1a Insured’s ID Number and 11 Insured’s Policy Group or FECA Number. Most of the errors reviewed have been because the provider is submitting the Subscriber ID in both blocks. The provider should check the member’s ID card for both pieces of information and file them correctly.
GENERAL PROVISIONS OF THE FECA
Purpose and Scope
1. Purpose and Scope. This chapter is intended to serve as an introduction to the coverage and requirements of the Federal Employees’ Compensation Act (FECA) as amended. It summarizes the general provisions of the Act and describes the responsibilities of the Claims Examiner (CE) in administering the FECA. The reference materials listed at the end of the chapter should be available to CEs in each district office. 2-0200-2 General Provisions of the FECA
2. General Provisions of the FECA.
a. Definition of Injury. The term “injury” includes all diseases proximately caused by the employment as well as damage to or destruction of medical braces, artificial limbs and other prosthetic appliances. Aggravation of a pre-existing condition by the employment is also compensable.
b. Requirements for Eligibility. Each claim for compensation must be filed within three years of the date of injury, except where the official superior had actual knowledge of the injury within 30 days of its occurrence. The claimant must be a civil employee, and an injury must have resulted from the incident claimed. Finally, the injury or disease must have occurred in performance of the claimant’s duties, and it must be causally related to factors of employment. See FECA PM 2-800 through 2-806.
c. Medical Care. An injured employee who meets the statutory conditions of coverage is entitled to all medical care which is required to cure, give relief, or reduce the degree or period of disability. No dollar maximum or time limitation is placed on medical care, which will be provided as long as the evidence indicates it is needed for the effects of the job-related injury. See FECA PM 2-810 and FECA PM
Part 3.
d. Continuation of Pay. An employee who sustains a disabling job-related traumatic injury is entitled to continuation of regular pay (COP) for a period not to exceed 45 calendar days. To qualify for COP, the injured employee must file written notice of injury and claim for COP within 30 days of the injury. COP is not considered compensation and is subject to taxes and other payroll deductions. The employee must make separate claim for monetary compensation if the disability exceeds 45 days or results in any permanent disability. See FECA PM 2-807.
e. Compensation. Generally, for total disability an employee with no dependents is entitled to compensation equivalent to two-thirds of the weekly salary, while an employee with one or more dependents is entitled to three-fourths of the salary. Certain additional amounts, such as premium pay, night and Sunday differential, dirty work pay, and hazardous duty pay, may be included in salary. Overtime pay, however, cannot be included. A special formula is applied in cases where the employee is a part-time worker, an unpaid volunteer, a temporary employee, or a person working in a similar category. See FECA PM 2-900. Compensation payments are subject to garnishment for past due alimony and child support payments if the district office receives the proper documentation from a state agency or a court orderthat supports such action.
f. Vocational Rehabilitation. If the injured worker suffers a vocational handicap due to the injury and cannot resume usual employment, vocational rehabilitation services may be arranged to assist in training for work that the claimant can perform in the disabled condition. Rehabilitation services are usually provided by private rehabilitation counselors, who are supervised by the OWCP. Where rehabilitation is under way, the OWCP may provide a monthly maintenance allowance not to exceed $200, in addition to compensation for wage loss. See FECA PM 2-813 and OWCP PM Part 3.
g. Attendant Allowances. 20 C.F.R. 10.312 allows payment for services of an attendant where it is medically documented that the claimant requires assistance to care for personal needs such as bathing, dressing, eating, etc. Such services are paid as a medical expense under 5 U.S.C. 8103; are limited to $1500 per month under 5 U.S.C. 8111; and are paid directly to the provider of the services. See FECA PM 2-812.
h. Duration of Compensation. Compensation payments for total disability may continue as long as the medical evidence supports such payment. As with medical care, no cap is placed on the amount or the length of time for which compensation for total disability may be paid. See FECA PM 2-812.
i. Reemployment and Loss of Wage-Earning Capacity. When an injury results in partial disability, and the employee suffers a wage loss because of the disability, compensation may be paid for such loss of wage-earning capacity. See FECA PM 2-814.
j. Schedule Awards. The FECA also provides for payment of compensation for permanent loss or loss of use (either partial or total) of certain internal organs and members or functions of the body such as arms, legs, hands, feet, fingers, toes, eyes, and loss of hearing or loss of vision. Each extremity or function has been rated at a specific number of weeks of compensation which can be paid even though the employee returns to work at full salary. Where a serious disfigurement of the head, face, or neck results from a job-related injury, an award may also be made for such disfigurement, not to exceed $3,500. See FECA PM 2-808.
k. Survivor Benefits. In the event of death due to employment, the Act provides for funeral and burial expenses up to $800, and up to $200 for the administrative costs of terminating a decedent’s status as a Federal employee. The law provides compensation for widows or widowers with no eligible children at the rate of 50 percent of the deceased employee’s monthly salary, and for widows or widowers with eligible children at 45 percent. If a spouse survives, each child receives 15 percent, up to total of 30 percent. Where no spouse survives, the rate for the first child is 40 percent, plus 15 percent for each additional child, shared equally among all children. Monthly payments for all beneficiaries generally cannot exceed 75 percent of the employee’s monthly pay rate. Other persons who may also qualify for benefits are dependent parents, brothers, sisters, grandparents, and grandchildren. See FECA PM 2-700.
l. Cost-of-Living Adjustments. In general, if compensation has been paid in either a disability or death case for over a year, Consumer Price Index (CPI) adjustments are made to compensation. See FECA PM 2-900.
m. Third Party Liability. Where an employee’s compensable injury or death results from circumstances creating a legal liability on some party other than the United States, the cost of compensation and other benefits paid by the OWCP must be refunded from any settlement obtained. The OWCP will assist in obtaining the settlement; the law guarantees that a certain proportion of the settlement (after any attorney fees and costs are first deducted) may be retained even when the cost of compensation and other benefits exceeds the amount of the settlement. See FECA PM 2-1100.
n. Dual Benefits. The law provides that compensation may not be paid concurrently with certain benefits paid by other Federal agencies. In particular, compensation and a retirement annuity from OPM may not be paid for the same period except where OWCP is paying a schedule award, and veterans’ benefits may be subject to offset as well. See FECA PM 2-1000.
o. Review of OWCP Decisions. Under 5 U.S.C. 8116(c) the FECA is a beneficiary’s exclusive remedy for injury or death of a Federal civil employee in performance of duty. Although aggrieved parties on occasion do seek remedies outside the FECA through a Federal tort suit or other litigation, the existence of such litigation is not considered in adjudicating claims or taking other case actions. If an employee or the survivors disagree with a final determination of the OWCP, a hearing may be requested, where the claimant may present evidence in further support of the claim. Also, the claimant has the right to appeal to the Employees’ Compensation Appeals Board, a separate entity of the U. S. Department of Labor, and OWCP may review a case on its own initiative. See FECA PM 2-1600 through 2-1602.2-1602.
2-0200-3 Responsibilities of the Claims Examiner
3. Responsibilities of the Claims Examiner. The main tasks of the CE are to adjudicate claims; authorize benefits and set up compensation payments; manage individual cases, so that timely and proper actions are taken in each claim; and manage a case-load, so that all cases are handled promptly and effectively.
The CE is expected to exercise keen judgment, derived from experience, background, and acquired knowledge, tempered with compassion and common sense, in all claims processing. This exercise involves the ability to identify the issues, determine the additional evidence required, and make a decision once the evidence is assembled. Each case stands on its own merits and the decision in a given case must be based on the facts in evidence in the case file. The decision cannot be based on surmise, speculation, or unwarranted presumption.
The adjudication of a case on the evidence in the file does not preclude the use of precedents in arriving at a decision in a case. Precedents, as distinguished from questions of fact, are legal and medical principles, statements, or decisions rendered in other cases which may serve to define, explain, or justify the legal or medical determinations in like situations. When using precedent material in the adjudication of a case, the CE should place a memorandum in the case file citing the specific reference and principles relied upon, and the manner and extent to which such principle is applicable. Some of the most useful precedents for FECA cases are the case rulings of the Employees’ Compensation Appeals Board (ECAB), the highest appellate source for claims under the FECA. Opinions of the ECAB are first published separately on a case-by-case basis, then in book form. Other precedents are found in court decisions and in such publications as Arthur Larson’s Workmen’s Compensation Law..
2-0200-4 Reference Materials for the Claims Examiners
4. Reference Materials for Claims Examiners. Each district office should have a library which contains the following items for reference by CEs:
a. Federal Employees’ Compensation Act, 5 U.S.C. 8101 et seq., as amended.
b. 20 C.F.R. Part 10 (Title 20, Code of Federal Regulations, 1.1 et seq.); US GPO.
c. FECA Procedure Manual, Part 0, Overview; Part 1, Communications and Records; Part 2, Claims; Part 3, Medical; Part 4, Special Case Procedures; Part 5,
Benefit Payments; and Part 6, Debt Management.
d. FECA Program Memorandums, Bulletins, and Circulars.
e. Decisions of the Employees’ Compensation Appeals Board, with Index (issued annually), including floppy discs containing published ECAB decisions, volumes 39 and following.
f. Summaries of ECAB decisions issued periodically by the National Office.
g. Black’s Law Dictionary, West Publishing Co., St. Paul.
h. Workmen’s Compensation Law, Arthur Larson, Matthew Bender Publishing Co., Washington, with all updates.
i. Dorland’s Illustrated Medical Dictionary, W.B. Saunders Co., Philadelphia.
j. Current edition of the AMA Guides to the Evaluation of Permanent Impairment. A copy of prior editions should also be retained.
k. Current edition of The Merck Manual, Merck & Co., Rahway, N. J.
l. Current Directory of Medical Specialists, published by Marquis Who’s Who, Chicago (hard copy for reference, in addition to the version contained in the automated Physician Directory System).
m. Current directory of the American Medical Association for each state within the district office’s jurisdiction.
n. Current directory of the American Psychological Association.
o. Current directory of the American Chiropractic Association.
p. Current edition of the Dictionary of Occupational Titles, and supplements.
q. The most recent accountability review report.
r. Road maps or a road atlas covering the district office’s geographical jurisdiction.
s. Telephone directories for prominent areas in the district office’s jurisdiction.