Health Insurance Claim Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OWCP-1500 Health Insurance Claim Form	Form	Modified	Available
83-I - Health Insurance Claim Form (1215-0055)(2009 clearance).doc	Supplementary Document	Uploaded 2009-07-06	Available
Supporting Stmt for 1215-0055 (7 17 2009) final.doc	Supporting Statement A	Uploaded 2009-07-17	Available
20 CFR 725.405 BLBA Supporting Reg.(2009 clearance).doc	Supplementary Document	Uploaded 2009-07-06	Available
20 CFR 30.701 EEOICPA Supporting Reg.(2009 clearance).doc	Supplementary Document	Uploaded 2009-07-06	Available
20 CFR 10.801 FECA - Supporting Reg.(2009 clearance).doc	Supplementary Document	Uploaded 2009-07-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43805	Health Insurance Claim Form	Form	Modified

ICR Details

OMB Control No: 1215-0055	ICR Reference No: 200907-1215-001
Status: Historical Active	Previous ICR Reference No: 200610-1215-006
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Health Insurance Claim Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/06/2009
	Date Received in OIRA: 08/24/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved	11/30/2009
Responses	2,996,416	0	2,940,000
Time Burden (Hours)	359,359	0	342,908
Cost Burden (Dollars)	0	0	0

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Abstract: Form OWCP-1500 is used by OWCP and contractor bill payment staff to process bills for medical services provided by medical professionals other than medical services provided by hospitals, pharmacies and certain other medical providers. OWCP is adding the data elements National Provider Identifier (NPI) and taxonomy number, which will be 32a and 33a on the revised OWCP-1500. This information is required to pay health care providers for services rendered to injured employees covered under the Office of Worker's Compensation Programs - administered programs. Appropriate payment cannot be made without documentation of the medical services that were provided by the health care provider that is billing OWCP. The information obtained to complete claims under these programs is used to identify the patient and determine their eligibility. It is also used to decide if the services and supplies received are covered by these programs and to assure that proper payment is made.

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Authorizing Statute(s): US Code: 42 USC 7384 et seq. Name of Law: EEOICPA
   US Code: 30 USC 901 et seq. Name of Law: BLBA
   US Code: 5 USC 8101 et seq. Name of Law: FECA
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 10778	03/12/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 42693	08/24/2009
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Health Insurance Claim Form	OWCP-1500, OWCP-1500	Health Insurance Claim Form ,   Health Insurance Claim Form

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ICR Summary of Burden

table that charts list 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	2,996,416	2,940,000	0	0	56,416	0
Annual Time Burden (Hours)	359,359	342,908	0	0	16,451	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: As use of the OWCP-1500 as the standard billing form for all three programs increases, the total number of bills submitted on the form also increases. Other factors also affect use of the OWCP-1500. For example, improved medical technology has resulted in an increase in outpatient services with a comparable decrease in inpatient services. This place of service change has resulted in an increase in the use of the OWCP-1500 because it is the most commonly used billing form for outpatient services. For these reasons, this collection shows a net adjustment increase of +16,451 hours.

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Annual Cost to Federal Government: $9,326,060

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)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 08/24/2009

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