EEOICPA 20 CFR 30.701 Proposed

§ 30.700

20 CFR Ch. I (4–1–15 Edition)

Subpart H—Information for
Medical Providers
MEDICAL RECORDS AND BILLS

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§ 30.700 What kinds of medical records
must providers keep?
Federal Government medical officers,
private physicians and hospitals are required to keep records of all cases
treated by them under EEOICPA so
they can supply OWCP with a history
of the claimed occupational illness or
covered illness, a description of the nature and extent of the claimed occupational illness or covered illness, the results of any diagnostic studies performed, and the nature of the treatment rendered. This requirement terminates after a provider has supplied
OWCP with the above-noted information, and otherwise terminates ten
years after the record was created.
§ 30.701 How are medical bills to be
submitted?
(a) All charges for medical and surgical treatment, appliances or supplies
furnished to employees, except for
treatment and supplies provided by
nursing homes, shall be supported by
medical evidence as provided in § 30.700.
The physician or provider shall itemize
the charges on Form OWCP–1500 or
CMS–1500 (for professional charges),
Form OWCP–04 or UB–04 (for hospitals), an electronic or paper-based
bill that includes required data elements (for pharmacies), or other form
as warranted, and submit the form or
bill promptly for processing.
(b) The provider shall identify each
service performed using the Physician’s Current Procedural Terminology
(CPT) code, the Healthcare Common
Procedure Coding System (HCPCS)
code, the National Drug Code (NDC)
number, or the Revenue Center Code
(RCC), with a brief narrative description. Where no code is applicable, a detailed description of services performed
should be provided.
(c) For professional charges billed on
Form OWCP–1500 or CMS–1500, the provider shall also state each diagnosed
condition
and
furnish
the
corresponding diagnostic code using the
‘‘International Classification of Disease, 9th Edition, Clinical Modifica-

tion’’ (ICD–9–CM), or as revised. A separate bill shall be submitted when the
employee is discharged from treatment
or monthly, if treatment for the occupational illness is necessary for more
than 30 days.
(1)(i) Hospitals shall submit charges
for medical and surgical treatment or
supplies promptly on Form OWCP–04 or
UB–04. The provider shall identify each
outpatient radiology service, outpatient pathology service and physical
therapy
service
performed,
using
HCPCS/CPT codes with a brief narrative description. The charge for each
individual service, or the total charge
for all identical services, should also
appear on the form.
(ii) Other outpatient hospital services for which HCPCS/CPT codes exist
shall also be coded individually using
the coding scheme noted in this section. Services for which there are no
HCPCS/CPT codes available can be presented using the RCCs described in the
‘‘National Uniform Billing Data Elements Specifications,’’ current edition.
The provider shall also furnish the diagnostic code using the ICD–9–CM. If
the outpatient hospital services include surgical and/or invasive procedures, the provider shall code each procedure using the proper HCPCS/CPT
codes and furnishing the corresponding
diagnostic codes using the ICD–9–CM.
(2) Pharmacies shall itemize charges
for prescription medications, appliances, or supplies on electronic or
paper-based bills and submit them
promptly for processing. Bills for prescription medications must include all
required data elements, including the
NDC number assigned to the product,
the generic or trade name of the drug
provided, the prescription number, the
quantity provided, and the date the
prescription was filled.
(3) Nursing homes shall itemize
charges for appliances, supplies or services on the provider’s billhead stationery and submit them promptly for
processing.
(d) By submitting a bill and/or accepting payment, the provider signifies
that the service for which payment is
sought was performed as described and
was necessary. In addition, the provider thereby agrees to comply with all
regulations set forth in this subpart

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Office of Workers’ Compensation Programs, Labor
concerning the rendering of treatment
and/or the process for seeking payment
for medical services, including the limitation imposed on the amount to be
paid for such services.
(e) In summary, bills submitted by
providers must: Be itemized on Form
OWCP–1500 or CMS–1500 (for physicians), Form OWCP–04 or UB–04 (for
hospitals), or an electronic or paperbased bill that includes required data
elements (for pharmacies); contain the
signature or signature stamp of the
provider; and identify the procedures
using HCPCS/CPT codes, RCCs, or NDC
numbers. Otherwise, the bill may be returned to the provider for correction
and resubmission. The decision of
OWCP whether to pay a provider’s bill
is final when issued and is not subject
to the adjudicatory process described
in subpart D of this part.

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§ 30.702 How should an employee prepare and submit requests for reimbursement for medical expenses,
transportation costs, loss of wages,
and incidental expenses?
(a) If an employee has paid bills for
medical, surgical or other services,
supplies or appliances provided by a
professional due to an occupational illness or a covered illness, he or she
must submit a request for reimbursement on Form OWCP–915, together
with an itemized bill on Form OWCP–
1500 or CMS–1500 prepared by the provider and a medical report as provided
in § 30.700, for consideration.
(1) The provider of such service shall
state each diagnosed condition and furnish the applicable ICD–9–CM code and
identify each service performed using
the applicable HCPCS/CPT code, with a
brief narrative description of the service performed, or, where no code is applicable, a detailed description of that
service.
(2) The reimbursement request must
be accompanied by evidence that the
provider received payment for the service from the employee and a statement
of the amount paid. Acceptable evidence that payment was received includes, but is not limited to, a signed
statement by the provider, a mechanical stamp or other device showing receipt of payment, a copy of the employee’s canceled check (both front and

§ 30.702

back) or a copy of the employee’s credit card receipt.
(b) If a hospital, pharmacy or nursing
home provided services for which the
employee paid, the employee must also
use Form OWCP–915 to request reimbursement and should submit the request in accordance with the provisions
of § 30.701(a). Any such request for reimbursement must be accompanied by
evidence, as described in paragraph
(a)(2) of this section, that the provider
received payment for the service from
the employee and a statement of the
amount paid.
(c) The requirements of paragraphs
(a) and (b) of this section may be
waived if extensive delays in the filing
or the adjudication of a claim make it
unusually difficult for the employee to
obtain the required information.
(d) Copies of bills submitted for reimbursement will not be accepted unless
they bear the original signature of the
provider and evidence of payment. Payment for medical and surgical treatment, appliances or supplies shall in
general be no greater than the maximum allowable charge for such service
determined by OWCP, as set forth in
§ 30.705. The decision of OWCP whether
to reimburse an employee for out-ofpocket medical expenses, and the
amount of any reimbursement, is final
when issued and is not subject to the
adjudicatory process described in subpart D of this part.
(e) An employee will be only partially reimbursed for a medical expense
if the amount he or she paid to a provider for the service exceeds the maximum allowable charge set by OWCP’s
schedule. If this happens, the employee
will be advised of the maximum allowable charge for the service in question
and of his or her responsibility to ask
the provider to refund to the employee,
or credit to the employee’s account,
the amount he or she paid which exceeds the maximum allowable charge.
The provider that the employee paid,
but not the employee, may request reconsideration of the fee determination
as set forth in § 30.712.
(f) If the provider fails to make appropriate refund to the employee, or to
credit the employee’s account, within
60 days after the employee requests a
refund of any excess amount, or the

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