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 and Instruction	Modified	Repair queued
SS for 1240-0044 OWCP-1500 2015 Energy Rulemaking.docx	Supporting Statement A	Uploaded 2015-10-01	Available
20 CFR 725.405 BLBA Supporting Reg.doc	Supplementary Document	Uploaded 2012-10-23	Available
20 CFR 30.701 EEOICPA Supporting Reg.doc	Supplementary Document	Uploaded 2012-10-23	Available
20 CFR 10.801 FECA - Supporting Reg.doc	Supplementary Document	Uploaded 2012-10-23	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 1240-0044	ICR Reference No: 201506-1240-014
Status: Historical Inactive	Previous ICR Reference No: 201208-1240-002
Agency/Subagency: DOL/OWCP	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: Comment filed on proposed rule and continue	Conclusion Date: 01/19/2016
	Date Received in OIRA: 11/18/2015
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	05/31/2016
Responses	3,036,067	0	3,036,067
Time Burden (Hours)	322,838	0	322,838
Cost Burden (Dollars)	0	0	0

---

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. This information is required to pay health care providers for services rendered to injured employees covered under the Office of Workers' 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.

---

Authorizing Statute(s): US Code: 42 USC 7384 et seq. Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
   US Code: 30 USC 901 et seq. Name of Law: Black Lung Benefits Act
   US Code: 5 USC 8101 et seq. Name of Law: Federal Employees¿ Compensation Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA08	Proposed rulemaking	80 FR 72296	11/18/2015

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34459	06/16/2015
Did the Agency receive public comments on this ICR? No

---

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	Health Insurance Claim Form

---

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 the number of electronically submitted responses increase, the number of burden hours decreases. Electronically submitted responses require 1/10 of the burden hours than a manually submitted response. As a result, there is a net adjustment decrease of 41,982 hours (322,838 – 280,856 = 41,982).

---

Annual Cost to Federal Government: $9,813,394

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 11/18/2015

---