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EN-11A Impairment Benefits Response Form

EN-11A Impairment Benefits Response Form 2025

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The document is a letter regarding a claim under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), informing the recipient of their eligibility for monetary benefits due to accepted illnesses. It outlines the process for obtaining an impairment rating, which is necessary for determining the amount of compensation based on the severity of the impairment. The letter includes instructions for completing a response form to pursue impairment benefits and emphasizes the importance of using qualified physicians for evaluations.

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What is an EE form?

Energy Workers Program. New Form EE-1A Required for Filing Claims for Consequential Conditions under the Energy Employees Occupational Illness Compensation Program Act.

What is the CPT code for impairment rating?

Texas Administrative Code. (11) V1, Level of MMI for Treating Doctor--This modifier shall be added to CPT Code 99455 when the office visit level of service is equal to a minimal level.

What is the procedure code for impairment rating?

Impairment ratings are billed with the CPT codes of 99455 or 99456. 99455 is utilized when the impairment evaluation is performed by the treating physician, while 99456 is utilized when the impairment evaluation is performed by someone other than the treating physician.

What is the CPT code for MMI?

Healthcare providers should use CPT 99455 when performing a work-related or medical disability evaluation. This might include: Initial Evaluation: Occurs when a patient presents with an injury or condition that might impact their ability to work.

What is the CPT code for disability evaluation?

At your appointment, the doctor will assess your impairment and/or disability and assign a percentage of whole-body disability or impairment, accounting for the work-related injury. If the rating remains above 35 percent, you will continue to receive full disability benefits.

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