Health Insurance Claim Form

ICR 201506-1240-014

OMB: 1240-0044

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2015-10-01
Supplementary Document
2012-10-23
Supplementary Document
2012-10-23
Supplementary Document
2012-10-23
IC Document Collections
IC ID
Document
Title
Status
43805 Modified
ICR Details
1240-0044 201506-1240-014
Historical Inactive 201208-1240-002
DOL/OWCP
Health Insurance Claim Form
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 01/19/2016
Retrieve Notice of Action (NOA) 11/18/2015
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.
  Inventory as of this Action Requested Previously Approved
12/31/2015 36 Months From Approved 05/31/2016
3,036,067 0 3,036,067
322,838 0 322,838
0 0 0

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.

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
  
None

1240-AA08 Proposed rulemaking 80 FR 72296 11/18/2015

  80 FR 34459 06/16/2015
No

1
IC Title Form No. Form Name
Health Insurance Claim Form OWCP-1500 Health Insurance Claim Form

No
No
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).

$9,813,394
No
No
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/18/2015


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