NASA Procedures and Guidelines
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NPR 1800.1D Eff. Date: October 06, 2009 Cancellation Date: September 19, 2019	NASA Occupational Health Program Procedures
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Appendix H: Federal Workers' Compensation: Form CA-16 Fact Sheet

J.1 Useful information for Form CA-16 follows.

1. Form CA-16 is 2 pages in length, with 2.5 pages of accompanying instructions. The latest version is dated May 2011 and expires on 10-31-14.

2. CA-16 provides medical providers authorization from NASA for employee examination and/or treatment and guarantees payment for these services, regardless of whether the claim made by the employee is accepted or denied by the Department of Labor (DOL) Office of Workers Compensation Program (OWCP). The authorization constitutes a contractual obligation by NASA to pay the cost of necessary medical treatment. Therefore, per NASA's Legal Office, contractor personnel cannot sign the CA-16 as an authorizing official.

3. There is no monetary limit associated with what can be charged using the CA-16 as an authorization for payment. Some mistakenly have thought there is a limit of $1,500; however this is incorrect.

4. Historically, the CA-16 was used more frequently because it was so time-consuming (days/weeks) to obtain a case number from DOL for an employee, especially in emergency situations when the employee had to go to an acute care facility for immediate surgery or care.

5. When medical providers have an employee's case number, they are able to go through the normal process of billing DOL for services via DOL's online ACS registration (https://owcp.dol.acs-inc.com/portal/pef/CreateNewApplication.do) or electronically via EDI (http://www.acs-gcro.com/gcro/). Now that we have ECOMP and can submit a claim electronically and within 4 hours or less obtain a claim number, we can communicate to the medical provider what the employee's claim number is. This does not preclude us from issuing the CA-16 if the employee requests us to do so, since we cannot impede their obtaining medical treatment/assistance for what is by default deemed to be a workplace injury until it is otherwise determined by the DOL.

6. Per the DOL Claims Examiner Procedure Manual, a CA-16 cannot be issued unless a notice of injury or occupational disease has been or is about to be filed (that is, a notice of injury has been completed and is in possession of the employing agency). NASA cannot issue a CA-16 until it is confirmed that the employee plans to file a workers' compensation claim and the process has been initiated.

7. Claimants always have the opportunity to submit reimbursement requests for out of pocket costs they have incurred:

• Reimbursement for pharmacy expenses/medications, medical appliances and supplies, and medical, surgical, and dental services can be claimed using Form OWCP-915 "Claimant Medical Reimbursement Form". This form is available on the OWCP Web Bill Processing Portal. Click on the "Forms and Links" link. Put each date of service on a separate line. If you are requesting reimbursement for a co-pay, write "Co-Pay" in the "Description of Charge" field. Use a separate form for each provider you paid. Don't mix prescriptions and office visits on the same form.
• A reimbursement claim for medical services, surgical services, medical appliances, or medical supplies must be accompanied by a copy of the OWCP-1500/HCFA-1500 "Health Insurance Claim Form" showing individual charges and signed by the medical Provider.
• A reimbursement claim for pharmacy expenses/medications must be accompanied by a copy of the Universal Claim Form or other pharmacy statement showing the name of the drug, NDC code, quantity provided, cost, prescribing physician, and date the prescription was filled.
• All reimbursement requests must be accompanied by proof of payment • a cash receipt, cancelled check, or credit card receipt.
• Mail the completed OWCP-915 and related documentation to:
• U.S. Department of Labor, DFEC Central Mailroom, PO Box 8300
• London, KY 40742-8300
• Be sure to include your claim number on EVERY page you send.

(a) When an employee sustains a work-related traumatic injury that requires medical examination, medical treatment, or both, the employer will authorize such examination and/or treatment by issuing a Form CA-16. This form may be used for occupational disease or illness only if the employer has obtained prior permission from OWCP.

(b) The Form CA-16 should be issued within four hours of the claimed injury. If the employer gives verbal authorization for such care, he or she should issue a Form CA-16 within 48 hours. The employer is not required to issue a Form CA-16 more than one week after the occurrence of the claimed injury. The employer may not authorize examination or medical or other treatment in any case that OWCP has disallowed.

(c) Form CA-16 must contain the full name and address of the qualified physician or qualified medical facility authorized to provide service. The authorizing official must sign and date the form and must state his or her title. Form CA-16 authorizes treatment for 60 days from the date of injury, unless OWCP terminates the authorization sooner.

(d) The employer should advise the employee of the right to his or her initial choice of physician. The employer shall allow the employee to select a qualified physician, after advising him or her of those physicians excluded under subpart I of this part. The physician may be in private practice, including a health maintenance organization (HMO), or employed by a Federal agency such as the Department of the Army, Navy, Air Force, or Veterans Affairs.

Any qualified physician may provide initial treatment of a work-related injury in an emergency. Per 20 CFR •10.825(b):

(b) Notwithstanding any exclusion of a physician, hospital, or provider of medical services or supplies under this subpart, OWCP shall not refuse an employee reimbursement for any otherwise reimbursable medical treatment, service or supply if:

(1) Such treatment, service or supply was rendered in an emergency by an excluded physician; or

(2) The employee could not reasonably have been expected to have known of such exclusion.

(c) An employee who is notified that his or her attending physician has been excluded shall have a new right to select a qualified physician.

9. The NASA authorizing official cannot sign the CA-16 unless the form is properly completed, including the name and address of the physician/hospital where the employee is going is entered on the form. This part of the form cannot be left blank.

10. Per DOL, Form CA-16 may be used to authorize treatment in cases of a doubtful nature, and in emergencies or unusual circumstances. However, if NASA's authorizing official has doubts that the employee's condition is caused by an occupational injury, the box B.2 on Line #6 must be checked. 20 CFR •10.302 states: If the employer doubts that the injury occurred, or that it is work-related, he or she should authorize medical care by completing Form CA-16 and checking block 6B of the form. If the medical and factual evidence sent to OWCP shows that the condition treated is not work-related, OWCP will notify the employee, the employer, and the physician or hospital that OWCP will not authorize payment for any further treatment.

11. A CA-16 can only be used for payment of services for 60 days from the date of injury. Typically, NASA knows from DOL whether the claim has been accepted or denied, significantly before 60 days pass.

12. A CA-16 authorizes payment and treatment and services for the following:

• Office visits and consultations
• Lab work
• Hospital services (inpatient included)
• X-rays
• MRIs
• CT scans
• Physical therapy
• Emergency services (including surgery)
• Chiropractic services (limited to charges for exams and x-rays to diagnose subluxation of spine and manual manipulation of the spine to correct subluxation found by x-ray)

13. CA-16 does not authorize payment for elective and non-emergency surgery

14. Line 8 on CA-16 requires NASA to provide a signature of an authorizing official. Per Title 20: Employees' Benefits, Part 10 Claims for Compensation Under the Federal Employees' Compensation Act, As Amended, Subpart A General Provisions: Employer or Agency means any civil agency or instrumentality of the United States Government, or any other organization, group or institution employing an individual defined as an "employee" by this section. These terms also refer to officers and employees of an employer having responsibility for the supervision, direction or control of employees of that employer as an "immediate superior," and to other employees designated by the employer to carry out the functions vested in the employer under the FECA and this part, including officers or employees delegated responsibility by an employer for authorizing medical treatment for injured employees.•Title 20 does not state that the authorizing official must be an injured employee's supervisor.

15. Per the DOL Claims Examiner Procedure Manual: OWCP may approve payment for medical expenses incurred even if Form CA-16 has not been issued and the claim is subsequently denied. Payment in situations meeting these criteria must be determined on a case-by-case basis (see Val D. Wynn, Docket No. 88-1813, issued March 10, 1989). D.P., Docket No. 11-50 (issued October 26, 2011) (ECAB held that although there was insufficient rationalized medical evidence to establish appellant's claim of injury, OWCP failed to consider whether emergency or otherwise unusual circumstances were present such that reimbursement of medical expenses would be appropriate even though a CA-16 had not been issued in this case.) For example, if an employee sustains an injury due to a car accident while on travel and a CA-16 is not issued, OWCP should consider whether payment of expenses is appropriate.

16. Per CA-10 (What a Federal Employee Should Do When Injured At Work): Before you obtain medical treatment, ask your supervisor to authorize medical treatment by use of form CA-16. You may initially select the physician to provide necessary treatment. This may be a private physician or, if available, a local Federal medical officer/hospital. Emergency medical treatment may be obtained without prior authorization. Take the form CA-16 and form OWCP-1500/HCFA-1500 to the provider you select. The form OWCP-1500/HCFA 1500 is the billing form physicians must use to submit bills to OWCP. Hospitals and pharmacies may use their own billing forms. On occupational disease claims form CA-16 may not be issued without prior approval from OWCP.

17. Per CA-11 (When Injured at Work Information Guide for Federal Employees): For traumatic injuries, ask your employer to authorize medical treatment on Form CA-16 BEFORE you go to the doctor. Take Form CA-16 when you go to the doctor, along with Form OWCP-1500, which the doctor must use to submit bills to OWCP. Your employer may authorize medical treatment for occupational disease ONLY if OWCP gives prior approval.

18. Per DOL's Web site (Federal Employees' Compensation Act • Frequently Asked Questions)

• The CA-16 is not available on our Web site because it guarantees payment of medical expenses. We limit access to the form as it is to be issued by the employing agency and may only be used in certain circumstances.
• If you are the injured worker, your agency will provide this form if it is appropriate.
• If you are the supervisor of an injured worker, please contact your Workers' Compensation Unit for this form.
• If you are with the Workers' Compensation unit, your Headquarters should have a supply of these forms. Even if a supply is unavailable, they should be able to provide you with one CA-16 that you can copy as needed. Federal agencies can purchase the revised CA-16 (revised 2/05) through the Government Printing Office.
• Authorized employing agency users of the Agency Query System (AQS) may access an electronic version of the CA-16 for download through the AQS Web site.

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