10112023 - (06) Insufficient Records - Benefits Determination Letter - CLEAN

Health Systems Bureau

5600 Fishers Lane

Rockville, MD 20857

[Current Date]

[Requester name]

[Requester home address]

[Requester City, State, Zip code]

Case Number: CICP [Case number]

Dear [Requester name]:

This letter is to inform you that there is insufficient documentation for the Countermeasures Injury Compensation Program (CICP or the Program) to make a determination concerning the total amount of your request for CICP benefits. See 42 C.F.R. § 110.71. In a letter dated [Compensation letter date], the CICP notified you that [Injured Countermeasure Recipient’s name] is eligible for compensation for certain expenses stemming from the serious injury ([list injury]) [Injured Countermeasure Recipient’s name] experienced as a direct result of the administration of the [list countermeasure]. In a subsequent letter, also dated [Compensation letter date], the CICP explained the documentation that you would need to submit to obtain compensation.

You submitted documentation concerning unreimbursed medical expenses (UME) for which you are seeking compensation. However, as described below, the Program requires additional supporting documentation to complete your benefits determination. You must submit the necessary documentation, identified below, to the CICP within 60 calendar days from the date of this letter. If insufficient documentation is submitted in response to this letter, the CICP may disapprove the portion of the Request for Benefits for which insufficient documentation was submitted based on the failure to submit sufficient documentation. 42 C.F.R. § 110.71.

Additional Documentation Required

The CICP has received documents from [beginning date of treatment], to [ending date of treatment] pertaining to your claim for UME. The Program’s regulation allows payments or reimbursements for medical services and items that the Program determines are reasonable and necessary to diagnose or treat a covered injury, or to diagnose, treat, or prevent the health complication(s) of a covered injury. 42 C.F.R. § 110.31(a). The CICP is the payer of last resort, which means that it may only reimburse or pay for medical services or items for which third-party payers, such as health insurance, do not have an obligation to pay. 42 C.F.R. § 110.3(ee).

Listed below are [list documentation of insurance claims, etc.] claims that were included in the documentation submitted to the CICP as part of your request for UME for which the CICP cannot determine the correct dollar amount for your reimbursement, whether the associated items and services were related to [Injured Countermeasure Recipient’s name] [list countermeasure] injury and/or its health complications, or were associated with an unrelated injury or condition. To assist the CICP in making a determination as to whether such items or services were reasonable and necessary to diagnose or treat [Injured Countermeasure Recipient’s name and injury], or to diagnose, treat, or prevent its health complications, and the correct dollar amounts, please submit the additional documentation described in the table below:

CLAIM # AND DATE(S) OF SERVICE	SERVICE PROVIDED	REQUIRED DOCUMENTATION

The CICP prefers that medical records are sent directly to the Program by your health care provider(s). Within 60 calendar days from the date of this letter, you must submit additional documentation to the CICP. If insufficient documentation is submitted in response to this letter, the CICP may disapprove the Request for Benefits. 42 C.F.R. § 110.71. The indicated required documentation/explanation should be sent to the CICP online at injurycompensation.hrsa.gov (preferred). If unable to submit electronically, please send them to the following address:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

If you are unable to provide the required additional documentation, you may provide, within 60 calendar days from the date of this letter, a written explanation of the reason(s) that the requested documentation is unavailable and the efforts you have made to obtain the documentation. 42 C.F.R. §§110.50(c); 110.71. The CICP may accept such a statement in place of the required documentation or disapprove the portion of the Request for Benefits for which insufficient documentation was submitted.

If you have questions, please call 1-855-266-2427, email CICPBenefits@HRSA.gov, or mail them to the address above.

Sincerely,

_________________________________ ______________________

CDR George Reed Grimes, MD, MPH Date

Director, Division of Injury Compensation Programs

Health Resources and Services Administration

www.hrsa.gov