20 Cfr 725.707

Office of Workers’ Compensation Programs, Labor
(c) If adequate treatment cannot be
obtained in the area of the claimant’s
residence, OWCP may authorize the use
of physicians or medical facilities outside such area as well as reimbursement for travel expenses and overnight
accommodations.

rmajette on DSKBCKNHB2PROD with CFR

§ 725.704 How are arrangements for
medical care made?
(a) Operator liability. If an operator
has been determined liable for the payment of benefits to a miner, OWCP will
notify the operator or its insurance
carrier of the names, addresses, and
telephone numbers of the authorized
providers of medical benefits chosen by
an entitled miner, and require the operator or carrier to:
(1) Notify the miner and the providers chosen that the operator or carrier will be responsible for the cost of
medical services provided to the miner
on account of the miner’s total disability due to pneumoconiosis;
(2) Designate a person or persons
with decision-making authority with
whom OWCP, the miner and authorized
providers may communicate on matters involving medical benefits provided under this subpart and notify
OWCP, the miner and providers of this
designation;
(3) Make arrangements for the direct
reimbursement of providers for their
services.
(b) Fund liability. If there is no operator found liable for the payment of
benefits, OWCP will make necessary
arrangements to provide medical care
to the miner, notify the miner and providers selected of the liability of the
fund, designate a person or persons
with whom the miner or provider may
communicate on matters relating to
medical care, and make arrangements
for the direct reimbursement of the
medical provider.
§ 725.705 Is prior authorization for
medical services required?
(a) Except as provided in paragraph
(b) of this section, medical services
from an authorized provider which are
payable under § 725.701 do not require
prior approval of OWCP or the responsible operator.
(b) Except where emergency treatment is required, prior approval of

§ 725.707

OWCP or the responsible operator must
be obtained before any hospitalization
or surgery, or before ordering medical
equipment where the purchase price exceeds $300. A request for approval of
non-emergency hospitalization or surgery must be acted upon expeditiously,
and approval or disapproval will be
given by telephone if a written response cannot be given within 7 days
following the request. No employee of
the Department of Labor, other than a
district director or the Chief, Medical
Audit and Operations Section, DCMWC,
is authorized to approve a request for
hospitalization or surgery by telephone.
§ 725.706 What reports must a medical
provider give to OWCP?
(a) Within 30 days following the first
medical or surgical treatment provided
under § 725.701, the provider must furnish to OWCP and the responsible operator or its insurance carrier, if any, a
report of such treatment.
(b) In order to permit continuing supervision of the medical care provided
to the miner with respect to the necessity, character and sufficiency of any
medical care furnished or to be furnished, the provider, operator or carrier must submit such reports in addition to those required by paragraph (a)
of this section as OWCP may from time
to time require. Within the discretion
of OWCP, payment may be refused to
any medical provider who fails to submit any report required by this section.
§ 725.707 At what rate will fees for
medical services and treatments be
paid?
(a) All fees charged by providers for
any medical service, treatment, drug
or equipment authorized under this
subpart will be paid at no more than
the rate prevailing for the service,
treatment, drug or equipment in the
community in which the provider is located.
(b) When medical benefits are paid by
the fund at OWCP’s direction, either on
an interim basis or because there is no
liable operator, the prevailing community rate for various types of service
will be determined as provided in
§§ 725.708–725.711.

587

VerDate Sep<11>2014

14:52 Jul 14, 2020

Jkt 250069

PO 00000

Frm 00597

Fmt 8010

Sfmt 8010

Y:\SGML\250069.XXX

250069

§ 725.708

20 CFR Ch. VI (4–1–20 Edition)

(c) The provisions of §§ 725.708–725.711
do not apply to charges for medical
services or treatments furnished by
medical facilities of the U.S. Public
Health Service or the Departments of
the Army, Navy, Air Force and Veterans Affairs.
(d) If the provisions of §§ 725.708–
725.711 cannot be used to determine the
prevailing community rate for a particular service or treatment or for a
particular provider, OWCP may determine the prevailing community rate by
reliance on other federal or state payment formulas or on other evidence, as
appropriate.
(e) OWCP must review the payment
formulas described in §§ 725.708–725.711
at least once a year, and may adjust,
revise or replace any payment formula
or its components when necessary or
appropriate to ensure miners’ access to
care or for other reasons.
(f) Except as otherwise provided in
this
subpart,
the
provisions
of
§§ 725.707–725.711 apply to all medical
services and treatments rendered after
August 31, 2018.

rmajette on DSKBCKNHB2PROD with CFR

§ 725.708 How are payments for professional medical services and medical
equipment determined?
(a)(1) OWCP pays for professional
medical services based on a fee schedule derived from the schedule maintained by the Centers for Medicare &
Medicaid Services (CMS) for the payment of such services under the Medicare program (42 CFR part 414). The
schedule OWCP utilizes consists of: An
assignment of Relative Value Units
(RVU) to procedures identified by
Healthcare Common Procedure Coding
System/Current
Procedural
Terminology (HCPCS/CPT) code, which represents the work (relative time and intensity of the service), the practice expense and the malpractice expense, as
compared to other procedures of the
same general class; an assignment of
Geographic Practice Cost Index (GPCI)
values, which represent the relative
work, practice expense and malpractice
expense relative to other localities
throughout the country; and a monetary value assignment (conversion factor) for one unit of value for each coded
service.

(2) The maximum payment for professional medical services identified by
a HCPCS/CPT code is calculated by
multiplying the RVU values for the
service by the GPCI values for such
service in that area and multiplying
the sum of these values by the conversion factor to arrive at a dollar amount
assigned to one unit in that category of
service.
(3) OWCP utilizes the RVUs published, and updated or revised from
time to time, by CMS for all services
for which CMS has made assignments.
Where there are no RVUs assigned,
OWCP may develop and assign any
RVUs that OWCP considers appropriate. OWCP utilizes the GPCI for the
locality as defined by CMS and as updated or revised by CMS from time to
time. OWCP will devise conversion factors for professional medical services
using OWCP’s processing experience
and internal data.
(b) Where a professional medical
service is not covered by the fee schedule described in paragraph (a) of this
section, OWCP may pay for the service
based on other fee schedules or pricing
formulas utilized by OWCP for professional medical services.
(c) Paragraphs (a) and (b) of this section apply to professional medical services rendered after April 26, 2020.
(d) OWCP pays for medical equipment identified by a HCPCS/CPT code
based on fee schedules or other pricing
formulas utilized by OWCP for such
equipment.
[83 FR 27695, June 14, 2018, as amended at 84
FR 64198, Nov. 21, 2019]

§ 725.709 How are payments for prescription drugs determined?
(a)(1) OWCP pays for drugs prescribed
by physicians by multiplying a percentage of the average wholesale price,
or other baseline price as specified by
OWCP, of the medication by the quantity or amount provided, plus a dispensing fee.
(2) All prescription medications identified by National Drug Code are assigned an average wholesale price representing the product’s nationally recognized wholesale price as determined
by surveys of manufacturers and
wholesalers, or another baseline price
designated by OWCP.

588

VerDate Sep<11>2014

14:52 Jul 14, 2020

Jkt 250069

PO 00000

Frm 00598

Fmt 8010

Sfmt 8010

Y:\SGML\250069.XXX

250069