[Code of Federal Regulations] [Title 20, Volume 1] [Revised as of April 1, 2005] From the U.S. Government Printing Office via GPO Access [CITE: 20CFR10.0] [Page 7-12] TITLE 20--EMPLOYEES' BENEFITS CHAPTER I--OFFICE OF WORKERS' COMPENSATION PROGRAMS, DEPARTMENT OF LABOR PART 10_CLAIMS FOR COMPENSATION UNDER THE FEDERAL EMPLOYEES' COMPENSATION ACT, AS AMENDED--Table of Contents Subpart A_General Provisions Sec. 10.0 What are the provisions of the FECA, in general? Subpart A_General Provisions Introduction Sec. 10.0 What are the provisions of the FECA, in general? 10.1 What rules govern the administration of the FECA and this chapter? 10.2 What do these regulations contain? 10.3 Have the collection of information requirements of this part been approved by the Office of Management and Budget (OMB)? Definitions and Forms 10.5 What definitions apply to these regulations? 10.6 What special statutory definitions apply to dependents and survivors? 10.7 What forms are needed to process claims under the FECA? Information in Program Records 10.10 Are all documents relating to claims filed under the FECA considered confidential? 10.11 Who maintains custody and control of FECA records? 10.12 How may a FECA claimant or beneficiary obtain copies of protected records? 10.13 What process is used by a person who wants to correct FECA-related documents? Rights and Penalties 10.15 May compensation rights be waived? 10.16 What criminal penalties may be imposed in connection with a claim under the FECA? 10.17 Is a beneficiary who defrauds the Government in connection with a claim for benefits still entitled to those benefits? 10.18 Can a beneficiary who is incarcerated based on a felony conviction still receive benefits? Subpart B_Filing Notices and Claims; Submitting Evidence Notices and Claims for Injury, Disease and Death--Employee or Survivor's Actions 10.100 How and when is a notice of traumatic injury filed? 10.101 How and when is a notice of occupational disease filed? 10.102 How and when is a claim for wage loss compensation filed? 10.103 How and when is a claim for permanent impairment filed? 10.104 How and when is a claim for recurrence filed? 10.105 How and when is a notice of death and claim for benefits filed? Notices and Claims for Injury, Disease and Death--Employer's Actions 10.110 What should the employer do when an employee files a notice of traumatic injury or occupational disease? 10.111 What should the employer do when an employee files an initial claim for compensation due to disability or permanent impairment? 10.112 What should the employer do when an employee files a claim for continuing compensation due to disability? 10.113 What should the employer do when an employee dies from a work- related injury or disease? Evidence and Burden of Proof 10.115 What evidence is needed to establish a claim? 10.116 What additional evidence is needed in cases based on occupational disease? 10.117 What happens if, in any claim, the employer contests any of the facts as stated by the claimant? 10.118 Does the employer participate in the claims process in any other way? 10.119 What action will OWCP take with respect to information submitted by the employer? 10.120 May a claimant submit additional evidence? 10.121 What happens if OWCP needs more evidence from the claimant? Decisions on Entitlement to Benefits 10.125 How does OWCP determine entitlement to benefits? 10.126 What does the decision contain? 10.127 To whom is the decision sent? [[Page 8]] Subpart C_Continuation of Pay 10.200 What is continuation of pay? Eligibility for COP 10.205 What conditions must be met to receive COP? 10.206 May an employee who uses leave after an injury later decide to use COP instead? 10.207 May an employee who returns to work, then stops work again due to the effects of the injury, receive COP? Responsibilities 10.210 What are the employee's responsibilities in COP cases? 10.211 What are the employer's responsibilities in COP cases? Calculation of COP 10.215 How does OWCP compute the number of days of COP used? 10.216 How is the pay rate for COP calculated? 10.217 Is COP charged if the employee continues to work, but in a different job that pays less? Controversion and Termination of COP 10.220 When is an employer not required to pay COP? 10.221 How is a claim for COP controverted? 10.222 When may an employer terminate COP which has already begun? 10.223 Are there other circumstances under which OWCP will not authorize payment of COP? 10.224 What happens if OWCP finds that the employee is not entitled to COP after it has been paid? Subpart D_Medical and Related Benefits Emergency Medical Care 10.300 What are the basic rules for authorizing emergency medical care? 10.301 May the physician designated on Form CA-16 refer the employee to another medical specialist or medical facility? 10.302 Should the employer authorize medical care if he or she doubts that the injury occurred, or that it is work-related? 10.303 Should the employer use a Form CA-16 to authorize medical testing when an employee is exposed to a workplace hazard just once? 10.304 Are there any exceptions to these procedures for obtaining emergency medical care? Medical Treatment and Related Issues 10.310 What are the basic rules for obtaining medical care? 10.311 What are the special rules for the services of chiropractors? 10.312 What are the special rules for the services of clinical psychologists? 10.313 Will OWCP pay for preventive treatment? 10.314 Will OWCP pay for the services of an attendant? 10.315 Will OWCP pay for transportation to obtain medical treatment? 10.316 After selecting a treating physician, may an employee choose to be treated by another physician instead? Directed Medical Examinations 10.320 Can OWCP require an employee to be examined by another physician? 10.321 What happens if the opinion of the physician selected by OWCP differs from the opinion of the physician selected by the employee? 10.322 Who pays for second opinion and referee examinations? 10.323 What are the penalties for failing to report for or obstructing a second opinion or referee examination? 10.324 May an employer require an employee to undergo a physical examination in connection with a work-related injury? Medical Reports 10.330 What are the requirements for medical reports? 10.331 How and when should the medical report be submitted? 10.332 What additional medical information will OWCP require to support continuing payment of benefits? 10.333 What additional medical information will OWCP require to support a claim for a schedule award? Medical Bills 10.335 How are medical bills submitted? 10.336 What are the time frames for submitting bills? 10.337 If OWCP reimburses an employee only partially for a medical expense, must the provider refund the balance of the amount paid to the employee? Subpart E_Compensation and Related Benefits Compensation for Disability and Impairment 10.400 What is total disability? 10.401 When and how is compensation for total disability paid? 10.402 What is partial disability? 10.403 When and how is compensation for partial disability paid? 10.404 When and how is compensation for a schedule impairment paid? [[Page 9]] 10.405 Who is considered a dependent in a claim based on disability or impairment? 10.406 What are the maximum and minimum rates of compensation in disability cases? Compensation for Death 10.410 Who is entitled to compensation in case of death, and what are the rates of compensation payable in death cases? 10.411 What are the maximum and minimum rates of compensation in death cases? 10.412 Will OWCP pay the costs of burial and transportation of the remains? 10.413 If a person dies while receiving a schedule award, to whom is the balance of the schedule award payable? 10.414 What reports of dependents are needed in death cases? 10.415 What must a beneficiary do if the number of beneficiaries decreases? 10.416 How does a change in the number of beneficiaries affect the amount of compensation paid to the other beneficiaries? 10.417 What reports are needed when compensation payments continue for children over age 18? Adjustments to Compensation 10.420 How are cost-of-living adjustments applied? 10.421 May a beneficiary receive other kinds of payments from the Federal Government concurrently with compensation? 10.422 May compensation payments be issued in a lump sum? 10.423 May compensation payments be assigned to, or attached by, creditors? 10.424 May someone other than the beneficiary be designated to receive compensation payments? 10.425 May compensation be claimed for periods of restorable leave? Overpayments 10.430 How does OWCP notify an individual of a payment made? 10.431 What does OWCP do when an overpayment is identified? 10.432 How can an individual present evidence to OWCP in response to a preliminary notice of an overpayment? 10.433 Under what circumstances can OWCP waive recovery of an overpayment? 10.434 If OWCP finds that the recipient of an overpayment was not at fault, what criteria are used to decide whether to waive recovery of it? 10.435 Is an individual responsible for an overpayment that resulted from an error made by OWCP or another Government agency? 10.436 Under what circumstances would recovery of an overpayment defeat the purpose of the FECA? 10.437 Under what circumstances would recovery of an overpayment be against equity and good conscience? 10.438 Can OWCP require the individual who received the overpayment to submit additional financial information? 10.439 What is addressed at a pre-recoupment hearing? 10.440 How does OWCP communicate its final decision concerning recovery of an overpayment, and what appeal right accompanies it? 10.441 How are overpayments collected? Subpart F_Continuing Benefits Rules and Evidence 10.500 What are the basic rules for continuing receipt of compensation benefits and return to work? 10.501 What medical evidence is necessary to support continuing receipt of compensation benefits? 10.502 How does OWCP evaluate evidence in support of continuing receipt of compensation benefits? 10.503 Under what circumstances may OWCP reduce or terminate compensation benefits? Return to Work--Employer's Responsibilities 10.505 What actions must the employer take? 10.506 May the employer monitor the employee's medical care? 10.507 How should the employer make an offer of suitable work? 10.508 May relocation expenses be paid for an employee who would need to move to accept an offer of reemployment? 10.509 If an employee's light-duty job is eliminated due to downsizing, what is the effect on compensation? Return to Work--Employee's Responsibilities 10.515 What actions must the employee take with respect to returning to work? 10.516 How will an employee know if OWCP considers a job to be suitable? 10.517 What are the penalties for refusing to accept a suitable job offer? 10.518 Does OWCP provide services to help employees return to work? 10.519 What action will OWCP take if an employee refuses to undergo vocational rehabilitation? 10.520 How does OWCP determine compensation after an employee completes a vocational rehabilitation program? Reports of Earnings From Employment and Self-Employment 10.525 What information must the employee report? [[Page 10]] 10.526 Must the employee report volunteer activities? 10.527 Does OWCP verify reports of earnings? 10.528 What action will OWCP take if the employee fails to file a report of activity indicating an ability to work? 10.529 What action will OWCP take if the employee files an incomplete report? Reports of Dependents 10.535 How are dependents defined, and what information must the employee report? 10.536 What is the penalty for failing to submit a report of dependents? 10.537 What reports are needed when compensation payments continue for children over age 18? Reduction and Termination of Compensation 10.540 When and how is compensation reduced or terminated? 10.541 What action will OWCP take after issuing written notice of its intention to reduce or terminate compensation? Subpart G_Appeals Process 10.600 How can final decisions of OWCP be reviewed? Reconsiderations and Reviews by the Director 10.605 What is reconsideration? 10.606 How does a claimant request reconsideration? 10.607 What is the time limit for requesting reconsideration? 10.608 How does OWCP decide whether to grant or deny the request for reconsideration? 10.609 How does OWCP decide whether new evidence requires modification of the prior decision? 10.610 What is a review by the Director? Hearings 10.615 What is a hearing? 10.616 How does a claimant obtain a hearing? 10.617 How is an oral hearing conducted? 10.618 How is a review of the written record conducted? 10.619 May subpoenas be issued for witnesses and documents? 10.62 Who pays the costs associated with subpoenas? 10.621 What is the employer's role when an oral hearing has been requested? 10.622 May a claimant withdraw a request for or postpone a hearing? Reviews by the Employees' Compensation Appeals Board (ECAB) 10.625 What kinds of decisions may be appealed? 10.626 Who has jurisdiction of cases on appeal to the ECAB? Subpart H_Special Provisions Representation 10.70 May a claimant designate a representative? 10.701 Who may serve as a representative? 10.702 How are fees for services paid? 10.703 How are fee applications approved? Third Party Liability 10.705 When must an employee or other FECA beneficiary take action against a third party? 10.706 How will a beneficiary know if OWCP or SOL has determined that action against a third party is required? 10.707 What must a FECA beneficiary who is required to take action against a third party do to satisfy the requirement that the claim be ``prosecuted''? 10.708 Can a FECA beneficiary who refuses to comply with a request to assign a claim to the United States or to prosecute the claim in his or her own name be penalized? 10.709 What happens if a beneficiary directed by OWCP or SOL to take action against a third party does not believe that a claim can be successfully prosecuted at a reasonable cost? 10.71 Under what circumstances must a recovery of money or other property in connection with an injury or death for which benefits are payable under the FECA be reported to OWCP or SOL? 10.711 How much of any settlement or judgment must be paid to the United States? 10.712 What amounts are included in the gross recovery? 10.713 How is a structured settlement (that is, a settlement providing for receipt of funds over a specified period of time) treated for purposes of reporting the gross recovery? 10.714 What amounts are included in the refundable disbursements? 10.715 Is a beneficiary required to pay interest on the amount of the refund due to the United States? 10.716 If the required refund is not paid within 30 days of the request for repayment, can it be collected from payments due under the FECA? 10.717 Is a settlement or judgment received as a result of allegations of medical malpractice in treating an injury covered by the FECA a gross recovery that must be reported to OWCP or SOL? [[Page 11]] 10.718 Are payments to a beneficiary as a result of an insurance policy which the beneficiary has purchased a gross recovery that must be reported to OWCP or SOL? 10.719 If a settlement or judgment is received for more than one wound or medical condition, can the refundable disbursements paid on a single FECA claim be attributed to different conditions for purposes of calculating the refund or credit owed to the United States? Federal Grand and Petit Jurors 10.725 When is a Federal grand or petit juror covered under the FECA? 10.726 When does a juror's entitlement to disability compensation begin? 10.727 What is the pay rate of jurors for compensation purposes? Peace Corps Volunteers 10.73 What are the conditions of coverage for Peace Corps volunteers and volunteer leaders injured while serving outside the United States? 10.731 What is the pay rate of Peace Corps volunteers and volunteer leaders for compensation purposes? Non-Federal Law Enforcement Officers 10.735 When is a non-Federal law enforcement officer (LEO) covered under the FECA? 10.736 What are the time limits for filing a LEO claim? 10.737 How is a LEO claim filed, and who can file a LEO claim? 10.738 Under what circumstances are benefits payable in LEO claims? 10.739 What kind of objective evidence of a potential Federal crime must exist for coverage to be extended? 10.740 In what situations will OWCP automatically presume that a law enforcement officer is covered by the FECA? 10.741 How are benefits calculated in LEO claims? Subpart I_Information for Medical Providers Medical Records and Bills 10.800 What kind of medical records must providers keep? 10.801 How are medical bills to be submitted? 10.802 How should an employee prepare and submit requests for reimbursement for medical expenses, transportation costs, loss of wages, and incidental expenses? 10.803 What are the time limitations on OWCP's payment of bills? Medical Fee Schedule 10.805 What services are covered by the OWCP fee schedule? 10.806 How are the maximum fees defined? 10.807 How are payments for particular services calculated? 10.808 Does the fee schedule apply to every kind of procedure? 10.809 How are payments for medicinal drugs determined? 10.810 How are payments for inpatient medical services determined? 10.811 When and how are fees reduced? 10.812 If OWCP reduces a fee, may a provider request reconsideration of the reduction? 10.813 If OWCP reduces a fee, may a provider bill the claimant for the balance? Exclusion of Providers 10.815 What are the grounds for excluding a provider from payment under the FECA? 10.816 What will cause OWCP to automatically exclude a physician or other provider of medical services and supplies? 10.817 When are OWCP's exclusion procedures initiated? 10.818 How is a provider notified of OWCP's intent to exclude him or her? 10.819 What requirements must the provider's reply and OWCP's decision meet? 10.820 How can an excluded provider request a hearing? 10.821 How are hearings assigned and scheduled? 10.822 How are subpoenas or advisory opinions obtained? 10.823 How will the administrative law judge conduct the hearing and issue the recommended decision? 10.824 How can a party request review by the Director of the administrative law judge's recommended decision? 10.825 What are the effects of exclusion? 10.826 How can an excluded provider be reinstated? Authority: 5 U.S.C. 301, 8103, 8145 and 8149; 31 U.S.C. 3716 and 3717; Reorganization Plan No. 6 of 1950, 15 FR 3174, 64 Stat. 1263; Secretary's Order 5-96, 62 FR 107. Source: 63 FR 65306, Nov. 25, 1998, unless otherwise noted. Introduction The Federal Employees' Compensation Act (FECA) as amended (5 U.S.C. 8101 et seq.) provides for the payment of workers' compensation benefits to civilian officers and employees of all [[Page 12]] branches of the Government of the United States. The regulations in this part describe the rules for filing, processing, and paying claims for benefits under the FECA. Proceedings under the FECA are non-adversarial in nature. (a) The FECA has been amended and extended a number of times to provide workers' compensation benefits to volunteers in the Civil Air Patrol (5 U.S.C. 8141), members of the Reserve Officers' Training Corps (5 U.S.C. 8140), Peace Corps Volunteers (5 U.S.C. 8142), Job Corps enrollees and Volunteers in Service to America (5 U.S.C. 8143), members of the National Teachers Corps (5 U.S.C. 8143a), certain student employees (5 U.S.C. 5351 and 8144), certain law enforcement officers not employed by the United States (5 U.S.C. 8191-8193), and various other classes of persons who provide or have provided services to the Government of the United States. (b) The FECA provides for payment of several types of benefits, including compensation for wage loss, schedule awards, medical and related benefits, and vocational rehabilitation services for conditions resulting from injuries sustained in performance of duty while in service to the United States. (c) The FECA also provides for payment of monetary compensation to specified survivors of an employee whose death resulted from a work- related injury and for payment of certain burial expenses subject to the provisions of 5 U.S.C. 8134. (d) All types of benefits and conditions of eligibility listed in this section are subject to the provisions of the FECA and of this part. This section shall not be construed to modify or enlarge upon the provisions of the FECA.