| FECA BULLETIN NO. 14-02 Issue Date: January 29, 2014 |
Subject: Reimbursement of Travel Expenses for Claimants and Providers Providing Transportation Services
References:
5 U.S.C. §8103 of the Federal Employees' Compensation Act (FECA) provides that an injured employee is entitled to receive medical services, appliances or supplies which a qualified physician prescribes or recommends and which OWCP considers necessary to treat the work-related injury. This section further provides that an employee may be furnished necessary and reasonable transportation and expenses incident to the securing of such services, appliances and supplies when authorized. See 5 U.S.C. 8103. This circular briefly describes the circumstances and limitations on authorizing and paying for transportation services.
Effective August 29, 2011, 20 CFR §10.315, provides in pertinent part as follows with regard to payment for transportation to obtain medical treatment:
(a) The employee is entitled to reimbursement of
reasonable and necessary expenses, including transportation needed to
obtain authorized medical services, appliances or supplies. To
determine what is a reasonable distance to travel, OWCP will consider
the availability of services, the employee's condition, and the means of
transportation. Generally, a roundtrip distance of up to 100 miles is
considered a reasonable distance to travel. Travel should be undertaken
by the shortest route, and if practical, by public conveyance. If the
medical evidence shows that the employee is unable to use these means of
transportation, OWCP may authorize travel by taxi or special
conveyance.
(b) For non-emergency medical treatment, if
roundtrip travel of more than 100 miles is contemplated, or air
transportation or overnight accommodations will be needed, the employee
must submit a written request to OWCP for prior authorization with
information describing the circumstances and necessity for such travel
expenses. OWCP will approve the request if it determines that the
travel expenses are reasonable and necessary, and are incident to
obtaining authorized medical services, appliances or supplies. Requests
for travel expenses that are often approved include those resulting
from referrals to a specialist for further medical treatment, and those
involving air transportation of an employee who lives in a remote
geographical area with limited local medical services.
Background: The change to requiring
suspension of the reimbursement request and referring the request for
claims examiner review whenever the request involves more than 100 miles
per day of mileage reimbursement (Section A below) was effective
January 17, 2013. The additional procedures outlined in this Bulletin
were effective July 17, 2013.Purpose: The purpose of this Bulletin is to address the manner in which travel procedure codes will be processed and paid by the Central Bill Processing (CBP) system when submitted for authorized examinations/treatments.
Applicability: Appropriate National Office and District Office personnel and FECA medical billing contractor.
Action:
A. Mileage Reimbursement for Examinations/Treatment. Periodically and in certain situations, travel to authorized examinations and/or treatment could exceed the allowable 100 mile distance outlined in 20 CFR 10.315(a) as noted above. When a claimant submits a reimbursement request (on Form OWCP-957, Medical Travel Refund Request) in excess of 100 miles for a single date of service, the bill will be automatically suspended and the CBP provider will send notification to the claims examiner seeking authorization. The notification sent by CBP will include the applicable date(s) of service, as well as the miles being claimed.
1. If the request is for a single trip and the
mileage claimed is allowable, such as for a scheduled Second Opinion
(SECOP) or Independent Medical Examination (IME), the Claims Examiner
(CE) will simply authorize the reimbursement.
2. In limited circumstances it may be necessary for
a claimant to travel more than 100 miles on a regular basis, such as to
be seen by his/her treating physician or therapist if the claimant
lives in a remote area. Upon receipt of notification from CBP in these
instances, the CE should provide a range for this ongoing authorization,
including both total miles and period that the authorization covers.
This range should be calibrated to the claimant's treatment location and
can extend up to 900 miles and up to six (6) months in length, using
Procedure Code A0080.
3. Should the claimant exceed the miles authorized
within this period, the CE will again be notified by CBP. If such
travel is medically necessary for the work-related conditions, the CE
has the authority to authorize an extension of the mileage, but can only
do so after writing a memo to the case file to justify the increased
number of miles allowable.
4. If the need for increased mileage continues past
the initial six month authorization period, another authorization and
memo to the file is also required for an additional 6 month period.
Such authorization and documentation is required every 6 months.
5. If the proper authorization is on file, or the
requested mileage does not exceed 100 miles for a single date of
service, the bill will simply be processed by CBP. There will be no
need for a notification to be sent to the CE.
B. Incidental Charges. Periodically, a claimant could incur incidental charges that may exceed $75.00 while travelling to authorized examinations.
1. If the claimant requests reimbursement for any
of the following procedure codes (including those that require prior
authorization), and the charge exceeds $75.00, the system will post Edit
501 (Service exceeds Allowable amount, Original Receipt/Invoice of the
charge is required).
A0110 – Taxi
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
A0180 – Lodging
A0190 – Meals
A0200 – Lodging Escort
A0210 – Meals Escort
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
A0180 – Lodging
A0190 – Meals
A0200 – Lodging Escort
A0210 – Meals Escort
2. If the receipt/invoice is present, a notification will be sent to the CE to obtain authorization for the amount. However if the receipt/invoice is not
present, the service will be denied for Edit 501. CBP will not send a
notification to the CE if there are no receipts attached; it will simply
deny the charge.
3. If the claimant submits a request for
reimbursement of "TRANS," and there is no description present for using
this code or the description is equal to "GAS," the system will post
Edit 520 (A description of the service is required. Please provide the
description and resubmit. Gas is not covered.) and deny the charge
since charges for gasoline are not permitted in addition to mileage
reimbursement.
Note: Where a claimant has been denied
authorization for treatment or reimbursement for expenses related to
transportation, a formal decision with appeal rights will be issued upon
claimant request. Amounts paid (including amounts paid under
the OWCP fee schedule) for medical services are not appealable to ECAB.
See 20 C.F.R. § 10.625.]
C. Payment to Transportation Providers. The OWCP-1500 Form is to be used by those providing authorized transportation to claimants for medical treatment/appointments.
1. If the charge for these services exceeds $75.00,
prior authorization is required and the bill must be accompanied with
an invoice justifying the charge.
2. A provider must have prior authorization for any
of the following transportation procedure codes if the charge billed
exceeds $75.00:
A0100 - Taxi
A0110 – Bus
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
A0110 – Bus
A0120 – Mini Bus
A0130 – Wheel Chair Van
A0140 – Air Travel
A0170 – Tolls/Parking
If there is not an authorization on file or the
provider fails to submit an invoice, the system will post Edit 501 and
deny the bill. In those instances where the amount being billed exceeds
the amount authorized, CBP will send a notification to the CE
requesting direction to extend the dollar amount of the authorization,
to pay only the authorized amount, or deny the service.
3. If the billed charge is less than $75.00, no
edit will post and the bill will be processed through the system, even
without a receipt or invoice.
4. Providers who bill using mileage codes A0080
and/or A0090 will be paid based on the current GSA mileage rate, and
prior authorization is required if the miles/units billed is for more
than 100 miles/units for a single date of service. If an authorization is not on file, the CBP will deny the bill.
D. Mileage Reimbursement for Pharmacy Pick up
A claimant may claim mileage for pharmacy pick up
to his or her local pharmacy; reimbursement is generally limited to the
closest pharmacy by the shortest route.
Disposition: This bulletin is to be retained until the FECA PM has been updated.DOUGLAS C. FITZGERALD
Director, Federal Employees' Compensation
