EE-22 General Medical Authorization Request

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

EE-22 (General Medical Authorization Request)

OMB: 1240-0060

Document [docx]
Download: docx | pdf

Shape1 Shape2

General Medical 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

Shape3

PART A: Requestor Information

Shape4


Shape5

PART B: Claimant Information

Shape6


Shape7

PART C: Provider Information

Shape8


Shape10 Shape9
C6. If Yes, please provide relationship to the claimant:


Shape11

PART D: Service Line Information

Shape12


Shape13 D2. Is this an implant?: D3. Cost of implant:


D4. Place of Service (Select one)





D5.

Shape17

From Date

To Date

Diagnosis Pointer

A B C D

Code Type

Revenue Code/NDC

Procedure Code

Modifier

Units/Days Requested



























































Ambulatory Surgery Center (ASC)

Shape18 Home Office Outpatient

PART E: Supporting Documents

Shape19

All supporting documents must be attached to this request. Failure to include supporting documentation may result in a delay in processing or denial. See instructions for required documents. Please include claimant’s case ID on each page.


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


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.


C5.

Select an option if providing care for a family member

  • Yes

  • No

Required

C6.

Type or print relationship to the claimant

Required if “Yes” is selected in field C5


Part D: Service Line Information


D1.

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.

Required

D2.

Select an appropriate option if this is an implant

  • Yes

  • No

Required

D3.

Type or print cost of implant

Required, if Yes is selected in field D2

D4.

Select place of surgery from the following options:

  • ASC

  • Home

  • Office

  • Outpatient

Required

D5.

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 Selects all applicable options.

Required


Select code type from following options:

  • CPT Procedure Code

  • HCPCS Procedure Code

  • Revenue Code

Required



Note: Select Revenue Code type for Outpatient Facility services



Type or print Revenue Code when Code Type is Revenue Code. Type or print

NDC when code type is HCPCS and Procedure Code is one of the unlisted J- Codes - J3490, J3590, J7999, J8499, J8999, J9999

Required


Type or print applicable procedure code (including unlisted J-Code) if code type is CPT or HCPCS code. If code type is Revenue Code and procedure code is required for the outpatient revenue code, type or print applicable procedure code here

Required, if code type is CPT or HCPCS. OR the

outpatient Revenue Code requires procedure code


Type or print procedure code modifier



Type or print number of units or days requested

Required

D6.

Type or print additional notes or remarks, if any



Part E: Supporting Documentation



Documents for supporting the need for the service as it relates to the accepted condition(s), such as letter of medical necessity, medical records, treatment plan, etc.

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 1 Form EE-22 August 2020

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy