Uniform Billing Form (UB-92)

Forms and Documents

Document	Type	Status	Availability
Form OWCP-92 Uniform Billing Form (UB-92)	Form and Instruction	Modified	Repair queued
DOL ESA-49.pdf	Supplementary Document	Uploaded 2006-09-20	Available
DOL ESA-6.pdf	Supplementary Document	Uploaded 2006-09-20	Available
DOL GOVT-1.pdf	Supplementary Document	Uploaded 2006-09-20	Available
Supporting regulations.doc	Supplementary Document	Uploaded 2006-09-20	Available
Supporting Stmt 1215-0176 May 26, 2006 clearance.doc	Supporting Statement A	Uploaded 2006-09-20	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
38466	Uniform Billing Form (UB-92)	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0176	ICR Reference No: 200609-1215-002
Status: Historical Active	Previous ICR Reference No: 200506-1215-012
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Uniform Billing Form (UB-92)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/05/2007
	Date Received in OIRA: 10/23/2006
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	36 Months From Approved	01/31/2007
Responses	30,372	0	231,224
Time Burden (Hours)	3,544	0	26,984
Cost Burden (Dollars)	0	0	0

---

Abstract: OWCP requires institutional medical providers who provide services to beneficiaries covered under FECA, BLBA and EEOICPA to bill using a form based on the industry standard, the UB-92. Form OWCP-92 identifies the beneficiary , the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.

---

Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Federal Employee's Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illiness Compensation Program Act of 2000 (EEOICPA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 35451	06/20/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 62122	10/23/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Uniform Billing Form (UB-92)	UB-92, OWCP-92	Uniform Billing Form ,   Uniform Billing Form

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	30,372	231,224	0	0	-200,852	0
Annual Time Burden (Hours)	3,544	26,984	0	0	-23,440	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Many of the data fields on the Form OWCP-92 are generated in electronic billing systems already used by hospitals and other institutional medical providers for patient billing, inventories, and bookkeeping. As a result, this reduces the burden hours for any one use of the form. In addition, institutional providers are reducing their use of the form for billing purposes and are moving to other billing formats. For these reasons, OMB Form 83-I shows a net adjustment decrease of -23,440 hours.

---

Annual Cost to Federal Government: $906,273

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/23/2006

---