EE-30 Transplant Authorization Request

Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms

EE-30 (Transplant Authorization Request)

OMB: 1240-0060

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Transplant Authorization Request


U.S. Department of Labor

Office of Workers’ Compensation Programs

Division of Energy Employees Occupational

Illness Compensation

Note: Please read the instructions carefully before completing this authorization request. Complete all applicable fields. All requests with supporting documentation must either be faxed to 1-800-882-6147 or be submitted through the Web Bill Processing Portal (https://owcpmed.dol.gov). Please include the Claimant Case ID on all pages. Incomplete requests cannot be processed and will be returned.

OMB Control No: 1240-0NEW

Expiration Date: XX/XX/20XX

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PART A: Requestor Information

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PART B: Claimant Information

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PART C: Provider Information

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PART D: Treating Physician Information

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PART

E:

Service Line Information




E1. Diagnosis Codes: A.


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B.


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C.


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D.

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Shape14 PART F: Transplant Information

F1. Transplant Facility: F2. Transplant Type:

F3. Transplant Facility Address:

F4: Transplant Facility Phone:

F5. Organ Transplant Coordinator Name: F6. Phone Number:



PART G: Supporting Documents

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All supporting documents must be attached to the request. Failure to include supporting documentation may result in a delay in processing or denial. Please include claimant’s case ID on each page. Required documentation:


Shape16 Letter of medical necessity from the treating physician describing the need for the transplant being requested. Initial and recent clinical evaluation (i.e., diagnostic studies and laboratory tests)

A copy of the treatment protocol


Instructions


Part A: Requestor Information





A1.

Type or print date on which this template is being completed

Required

A2.

Type or print name of the person requesting an authorization

Required

A3.

Type or print phone number of the person requesting an authorization




Part B: Claimant Information





B1.

Type or print claimant’s case ID

Required

B2.

Type or print claimant’s date of birth (mm/dd/yyyy)

Required

B3.

Type or print claimant’s first name

Required

B4.

Type or print claimant’s last name

Required

B5.

Type or print authorized representative’s name


B6.

Type or print authorized representative’s phone number



Part C: Provider Information





C1.

Type or print service rendering provider’s OWCP ID

Required

C2.

Type or print provider’s Tax ID (SSN or FEIN)

Required

C3.

Type or print provider’s name

Required

C4.

Type or print fax number. If entered, this fax number will be used for communication related to this authorization request. Leave it blank if fax number was provided during provider enrollment.




Part D: Treating Physician Information





D1.

Type or print referring physician’s name

Required

D2.

Type or print referring physician’s address

Required



Part E: Service Line Information





E1.

Type or print ICD-09 or ICD-10 diagnosis codes for which services are being rendered, up to 4 codes are allowed.

ICD-9 code is applicable if date of service is prior to 09/30/2015. Use ICD-10 code if date of service is after 10/01/2015.


E2.

Service lines



Type or print beginning date of the service

Required


Type or print end date of the service

Required


Select diagnosis code pointer from the diagnosis codes listed in Part D: A, B, C, D Select all applicable options.

Required


Select code type from following options:

  • CPT Procedure Code

  • HCPCS Procedure Code

Required


Type or print applicable procedure code

Required

E3.

Type or print additional notes or remarks, if any




Part F: Transplant Information




Required

F1.

Type or print transplant facility

Required

F2.

Type or print transplant type

Required

F3.

Type or print transplant facility address

Required

F4.

Type or print transplant facility phone

Required

F5.

Type or print name of person coordinating the organ transplant

Required

F6.

Type or print coordinator phone

Required



Part G: Supporting Documentation





G1.

Please check and attach the letter of medical necessity from the treating physician

Required

G2.

Please check and attach the initial and recent clinical evaluation

Required

G3.

Attach a copy of the treatment protocol

Required


PRIVACY ACT STATEMENT

The Privacy Act of 1974, as amended (5 U.S.C. 552a) authorizes OWCP to ask you for information needed in the administration of the EEOICPA program. Authority to collect information is in 42 USC 7384d, 20 CFR 30.1 et seq. and E.O. 13179. The information we obtain is used to decide if the services and supplies being billed for are covered by the program and to insure that proper payment is made. There are no penalties for failure to supply information; however, failure to furnish information regarding the medical service(s) at issue will prevent payment of the bill. Failure to supply the claim number or CPT codes will delay payment or may result in rejection of the authorization request because of incomplete information.


We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection Improvement Act of 1996, 31 U.S.C. 7701(c)(1), which mandates us to require persons who are doing business with a Federal agency to furnish a TIN or SSN. The SSN or TIN, and other information maintained by us may be used for identification, to support debt collection efforts carried on by the Federal government, and for other purposes required or authorized by law. Additional disclosures are made through routine uses for information contained in systems of records. See Department of Labor system DOL/OWCP-11 published in the Federal Register, Vol. 81, page 25868, April 29, 2016, or as updated and republished.


You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988,” permits the government to verify information by way of computer matches.


PUBLIC BURDEN STATEMENT

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 1240-0NEW.  There are no penalties for failure to supply information; however, failure to furnish information regarding the medical service(s) requested will prevent payment of the bill. We estimate that it will take an average of ten minutes to complete this collection of information, including time for reviewing instructions, abstracting information from the patient’s records and entering the data onto the form. This time is based on familiarity with standardized coding structures. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Department of Labor, Office of Workers’ Compensation Programs, Division of Energy Employees Occupational Illness Compensation, Room C3321, 200 Constitution Avenue NW, Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.



Page 5 Form EE-30 August 2020



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDEEOIC - Transplant
AuthorParikh, Tejal
File Modified0000-00-00
File Created2022-08-08

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