How to Submit OWCP 1500 Black Lung ICD10

HOW TO SUBMIT OWCP - 1500 BILLS TO
THE FEDERAL BLACK LUNG PROGRAM
OFFICE OF WORKERS’ COMPENSATION PROGRAMS
DIVISION OF COAL MINE WORKERS’ COMPENSATION
The services performed by the following providers should be billed on the OWCP -1500 Form:
° Physicians
°

(MD, DO)

Ambulatory Surgical Centers

° Pulmonary

Rehabilitation

°

DME Suppliers

°Independent

°

Home Nursing Agencies

° Ambulance

°

Pharmacies (Optional)

Laboratories

° Nursing Homes

(Limited)

BILLS SHOULD BE SENT TO:
US Department of Labor
P O Box 8302
London, KY 40742-8302

HOW WE WILL PROCESS YOUR BILL:
Bills will be processed by Affiliated Computer Services (ASC)/ XEROX, the Fiscal Agent for
the Office of Worker’s Compensation Programs, which includes the Federal Black Lung
Program. The ACS/Xerox facility in London, Kentucky will receive and scan your bill. If the
bill must be returned without processing, you will be notified with a Return to Provider (RTP)
letter giving the reason. The bill should be resubmitted with the necessary corrections to the
London, Kentucky address noted above.
After the bill is scanned and entered into the processing system, it will be reviewed to determine
if it is payable under the Federal Black Lung Program. You will then be issued a Remittance
Voucher (RV), approximately 1 week from date of payment, describing, if applicable, the
payment made, a reason for denial, and a reason why full payment was not approved. The RV
will be mailed to you from London, Kentucky. At approximately the same time, an electronic
funds transfer of the approved amount will be made to your financial institution.

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ELECTRONIC SERVICES
ACS is pleased to offer enhanced services on its web portal (http://owcp.dol.acsinc.com/portal/main.do). To take advantage of these services, and others that may be added in
the future, you will need to know the patient’s information, including the claim number and the
Black Lung Benefits Identification Card number, which is a 10-digit number on the reverse side
of the card that every eligible beneficiary receives. The claim number is the patient’s Social
Security number, which does not appear on the card for security reasons.

REMITTANCE VOUCHER RETRIEVAL
Retrieving DOL remittance vouchers via electronic media offers the advantage of speed in
retrieval. Providers may access reports online as well as receive paper copies of the remittance
vouchers.
The Electronic Data Interchange (EDI) Support Unit assists providers who have questions about
electronic bill submission. ACS’s EDI Support Unit is available to all providers Monday
through Friday from 8:00 a.m. to 8:00 p.m. Eastern Standard Time at 800-987-6717.
EDI Support will:
•
•
•

Provide information on available services.
Assist in enrolling users for report retrieval.
Provide technical assistance on retrieval difficulties.

CLAIMANT ELIGIBILITY INQUIRY
Because the Federal Black Lung Program is limited to coverage of treatment for the patient’s
pneumoconiosis and related illnesses, the web portal also allows you to help determine if a
procedure or diagnosis is covered, or if the patient was covered on a specific date of service.

USING THE OWCP -1500
Physician services rendered in the treatment of a miner’s pulmonary disease are reimbursable
under the following categories: office visits, hospital visits, procedures at an outpatient clinic,
home visits, pulmonary consultations, immunizations for flu and pneumonia, radiology for the
diagnosis and/or treatment of a pulmonary disease, pulmonary therapy, and prescriptions for and
administration of drugs on the lists of drugs and laboratory tests covered by the Department of
Labor program. When care is rendered for an acute condition causing hospitalization,
emergency room, or ambulatory care services, the acute condition must be indicated on the
billing form before reimbursement can be considered.

AUTHORIZATION REQUIREMENTS
The Federal Black Lung Program pays for medical services rendered to coal miners disabled
from pneumoconiosis (black lung disease). Some services, specifically home nursing services,
durable medical equipment, require prior authorization in the form of a Certificate of Medical
Necessity (CM-893.) Because the Federal Black Lung Program has unique requirements and
standards for authorization, the CM-893 is required. To request a Certificate of Medical
Necessity, you may contact the claimant’s district office or download and print the CMN at.
www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm. See Attachment 1 or go to
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http://www.dol.gov/owcp/dcmwc/blcontac.htm for the appropriate DCMWC District Office
address and telephone number.
Nursing homes that provide services requiring pre-approval must also follow these procedures,
and bill using the OWCP -1500. The Federal Black Lung Program does not cover room and
board for nursing homes, but will pay for covered physicians’ services and prescriptions in
addition to pre-approved services.

BILLING REQUIREMENTS
1. All bills must contain the 9-digit Social Security number of your patient and your 9digit DCMWC provider number. Your patient’s SSN is not shown on the Black
Lung Benefits Identification Card for privacy reasons.
2. Anesthesia services must be billed with the appropriate anesthesia CPT code (00100 –
01999).
The following modifiers must be used for services requiring anesthesia:
Anesthesia

AA

3. For surgical procedures, no modifier is necessary. If an assistant surgeon is needed,
services must be coded with modifier 80:
Assistant Surgeon

80

4. Drugs dispensed/administered at the physician’s office:
Using procedure codes J3490, J8499, J8999 and J9999 will require a National Drug Code.
5. When billing for services over a period of time, use the “From” and “Through” dates to
represent the date range, with the appropriate units for each CPT/HCPCS code billed per the
service code description.
The following modifiers must be used for procedures billed as professional or technical
components if a full fee is not billed:
Professional

26

Technical

TC

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The following modifiers must be used for durable medical equipment billed as purchase or
rental:
Purchase

NU

Rental

RR

6. For additional instructions, please refer to Attachment 2, a detailed OWCP -1500 listing
with the required fields.

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Attachment 1 - Black Lung District Office List
JOHNSTOWN, PENNSYLVANIA
U.S. Department of Labor
ESA/OWCP/DCMWC
319 Washington Street, Second Floor
Johnstown, Pennsylvania 15901
Commercial: (814) 533-4323
Toll-Free: (800) 347-3754

Virginia

GREENSBURG, PENNSYLVANIA

Maryland

U.S. Department of Labor
ESA/OWCP/DCMWC
1225 South Main Street, Suite 405
Greensburg, Pennsylvania 15601
Commercial: (724) 836-7230
Toll-Free: (800) 347-3753

Thirty-seven counties in Pennsylvania: Adams, Bedford,
Berks, Blair, Bucks, Cambria, Cameron, Centre, Chester,
Clearfield, Clinton, Cumberland, Dauphin, Delaware, Elk,
Franklin, Fulton, Huntingdon, Indiana, Jefferson, Juniata,
Lancaster, Lebanon, Lycoming, McKean, Mifflin,
Montgomery, Montour, Northumberland, Perry, Philadelphia,
Potter, Somerset, Snyder, Tioga, Union, and York.

Sixteen counties in Pennsylvania: Allegheny, Armstrong,
Beaver, Butler, Clarion, Crawford, Erie, Fayette, Forest,
Greene, Lawrence, Mercer, Venango, Warren, Washington,
and Westmoreland
Connecticut, Delaware, District of Columbia, Maine,
Massachusetts, New Hampshire, New Jersey, New York,
Puerto Rico, Rhode Island, Vermont
The following fourteen counties in Pennsylvania: Bradford,
Carbon, Columbia, Lackawanna, Lehigh, Luzerne, Monroe,
Northampton, Pike, Schuylkill, Sullivan, Susquehanna,
Wayne, and Wyoming

CHARLESTON, WEST VIRGINIA
U.S. Department of Labor
ESA/OWCP/DCMWC
Charleston Federal Center - Suite 110
500 Quarrier Street
Charleston, West Virginia 25301
Commercial: (304) 347-7100
Toll-Free (800) 347-3749

Fifteen counties in West Virginia including Boone, Cabell,
Fayette, Kanawha, Lincoln, Logan, McDowell, Mercer,
Mingo, Monroe, Putnam, Raleigh, Summers, Wayne and
Wyoming.

PARKERSBURG, WEST VIRGINIA
U.S. Department of Labor
ESA/OWCP/DCMWC, Suite 3116
425 Juliana Street
Parkersburg, West Virginia 26101
Commercial: (304) 420-6385
Toll-Free: (800) 347-3751

All counties in West Virginia not under the jurisdiction of the
Charleston Office.

Continued on following page

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PIKEVILLE, KENTUCKY
U.S. Department of Labor
ESA/OWCP/DCMWC
164 Main Street, Suite 508
Pikeville, Kentucky 41501
Commercial: (606) 432-0116
Toll-Free: (800) 366-4599
MOUNT STERLING, KENTUCKY
U.S. Department of Labor
ESA/OWCP/DCMWC
402 Campbell Way
Mount Sterling, Kentucky 40353
Commercial: (859) 498-9700
Toll-Free: (800) 366-4628
COLUMBUS, OHIO
U.S. Department of Labor
ESA/OWCP/DCMWC
1160 Dublin Road Suite 300
Columbus, Ohio 43215
Commercial: (614) 469-5227
Toll-Free: (800) 347-3771
DENVER, COLORADO
U.S. Department of Labor-Black Lung
ESA/OWCP/DCMWC
1999 Broadway, Suite 690
P.O. Box 46550
Denver, Colorado 80201-6550
Commercial: (720) 264-3100
Toll-Free: (800) 366-4612

All claims from Kentucky. This office is part of the
Jacksonville Region

Alabama, Florida, Georgia, Mississippi, North Carolina,
South Carolina, and Tennessee. This office is part of the
Jacksonville Region.

Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin.

Alaska, American Samoa, Arizona, Arkansas, California,
Colorado, Guam, Hawaii, Idaho, Iowa, Kansas, Louisiana,
Missouri, Montana, Nebraska, Nevada, New Mexico, North
Dakota, the North Mariana Islands, Oklahoma, Oregon, South
Dakota, Texas, Utah, Washington, and Wyoming.

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Attachment 2 – Detailed Instructions for Completion of OWCP-1500
OWCP –1500
Claim Item

Title

Action

Required?

1

Medicare, Medicaid, TRICARE No Entry Required.
CHAMPUS, CHAMPVA, Group
Health Plan, FECA, Black
Lung, Other

N

1a

Insured's ID Number

Mandatory Field. Enter the claimant’s
case number.

Y

2

Patient’s Name

Y

3

Patient’s Birth Date

Enter the claimant’s last name, first
name, and middle initial.
Enter the claimant’s 8-digit birth date
(MM | DD | CCYY).
Use an “X” to mark the appropriate box
for patient sex.
Enter the claimant’s last name, first
name, and middle initial.
Enter the claimant’s address

Y

Sex

Y

4

Insured’s Name

5

Patient’s Address

6

Telephone Number
Patient’s Relationship to
claimant

Enter the claimant’s telephone number.
No Entry Required.

7

Insured’s Address,
Telephone Number

No Entry required unless the claimant is
covered by other insurance.

N

8

Reserved for NUCC Use

No Entry Required.

N

Other Insured’s Name

If Item Number 11d is marked, complete
fields 9 and 9a-d, otherwise leave blank.

N

Enter the policy or group number of the
claimant.
No Entry Required

N

9b

Other Insured’s Policy or
Group Number
Reserved For NUCC Use

9c

Reserved For NUCC Use

No Entry Required

N

9d

Insurance Plan Name or
Enter the claimant’s insurance plan or
Program Name
program name.
Is Patient’s Condition Related When appropriate, enter an X in the
to:
correct box.
Claim Codes (Designated By No Entry Required.
NUCC)

9a-d
9a

10a-c
10d
11

Insured’s Policy, Group, or
FECA Number

Enter the claimant’s policy or group
number as it appears on the claimant’s
health care identification card. If Item
Number 4 is completed, then this field
should be completed.

Y

N

N

N
N
N
N



OWCP –1500
Claim Item
11a

Title
Insured’s Date of Birth
Sex

11b
11c
11d

Insured’s Employer’s Name
or School Name
Insurance Plan Name or
Program Name
Is there another Health
Benefit Plan?

Action

Required?

Enter the 8-digit date of birth (MM | DD |
CCYY) of the claimant.
Enter an X to indicate the sex of the
claimant.
Enter the name of the claimant’s
employer or school.
Enter the insurance plan or program
name of the claimant.
When appropriate, enter an X in the
correct box. If marked "YES", complete
9 and 9a–d.

N

N
N
N

12

Patient’s or Authorized
Person’s Signature

Enter "Signature on File," "SOF," or
legal signature. When legal signature,
enter date signed in 6 digit format
(MMDDYY) or 8-digit format
(MMDDCCYY). If there is no signature
on file, leave blank or enter "No
Signature on File."

Y

13

Insured’s or Authorized
Person’s Signature

Enter "Signature on File," "SOF," or
legal signature. If there is no signature
on file, leave blank or enter "No
Signature on File."

Y

14

Date of current illness, injury No Entry Required.
or pregnancy

N

15

Other Date, Qualifier

No Entry Required.

N

16

Dates Patient Unable to Work No Entry Required.
in Current Occupation

N

17

Name of Referring Provider
or Other Source

Enter the name (First Name, Middle
Initial, Last Name) and credentials of
the professional who referred, ordered,
or supervised the service(s) or supply(s)
on the claim. If multiple providers are
involved, enter one provider using the
following priority order:
1. Referring Provider
2. Ordering Provider
3. Supervising Provider

N

17 a

Other ID#

The Other ID number of the referring,
ordering, or supervising provider is
reported in 17a in the shaded area. The
qualifier indicating what the number
represents is reported in the qualifier
field to the immediate right of 17a.

N

17 b

NPI #

18
19

Enter the NPI number of the referring,
ordering, or supervising provider.
Hospitalization Dates Related No Entry Required.
to Current Services

N

Additional Claim

N

No Entry Required.

N

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OWCP –1500
Claim Item

20
21

Title

Action

Information(Designated by
NUCC)
Outside Lab? $Charges

Complete this field when billing for
purchased services.
Diagnosis or Nature of Illness Enter the diagnosis/condition. List up to
or Injury
12 ICD-10-CM diagnosis codes.

Required?

N
Y

ICD Ind
22
23

24a

Enter ‘9’ if using ICD9 codes. Enter ‘0’
if using ICD10 codes.
Resubmission Code, Original No Entry Required.
Ref No
Prior Authorization Number Enter any of the following: prior
authorization number, referral number,
mammography pre-certification number,
or Clinical Laboratory Improvement
Amendments (CLIA) number, as
assigned by the payer for the current
service. (Optional)
Date(s) of Service
Mandatory Field. Enter the beginning
date of service in month, day, year
format.

N
N

Y

Services rendered in one calendar
month may be billed on one line with a
“From Date” and a “To Date.”
24b

Place of Service

Mandatory Field. Enter the two-digit
place of service (POS) code for each
procedure performed.

Y

24c

EMG

No Entry Required.

N

24d

Procedures, Services, or
Supplies

Enter the CPT or HCPCS code(s) and
modifier(s) (if applicable) from the
appropriate code set in effect on the
date of service.

Y

24e

Diagnosis Pointer

Enter the diagnosis code pointer
reference letter as shown in Item
Number 21 (A,B,C, etc.) to relate the
date of service and the procedures
performed to the primary diagnosis.

Y

24f

$ Charges

Enter number right justified in the dollar
area of the field. Do not use commas.
Dollar signs should not be entered.
Enter 00 in the cents area if the amount
is a whole number.

Y

24g

Days or Units

Y

24h

EPSDT/Family Plan

Enter the number of days or units. This
field is most commonly used for multiple
visits, units of supplies, anesthesia units
or minutes, or oxygen volume. If only
one service is performed, the numeral 1
must be entered.
No Entry Required.

N
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OWCP –1500
Claim Item

Title

Action

Required?

24i

ID Qualifier

Enter in the shaded area of 24i the
qualifier identifying if the number is a
non-NPI.

N

24j

Rendering Provider ID #

Enter the non-NPI ID number in the
shaded area of the field. Enter the NPI
number in the un-shaded area of the
field.

Y

25

Federal Tax ID Number

Enter the provider of service or supplier
federal tax ID (employer identification
number) or Social Security number.
Enter an X in the appropriate box to
indicate which number is being
reported.

Y

26

Patient’s Account No.

Enter the patient’s account number
assigned by the provider of services or
supplier’s accounting system.

N

27

Accept Assignment

No Entry Required.

N

28

Total Charge

Y

29

Amount Paid

Enter total charges for the services (i.e.,
total of all charges in 24f).
Enter total amount the patient or other
payers paid on the covered services
only. Enter number right justified in the
dollar area of the field. Do not use
commas when reporting dollar amounts.
Negative dollar amounts are not
allowed. Dollar signs should not be
entered. Enter 00 in the cents area if the
amount is a whole number.

30
31

Rsvd For NUCC Use
No Entry Required.
Signature of Physician or
Enter the legal signature of the
Supplier Including Degrees or practitioner or supplier, signature of the
Credentials
practitioner or supplier representative,
“Signature on File,” or “SOF.”
Enter either the 6-digit or 8 digit date, or
alphanumeric date (e.g., January 1,
Bill Date
2003) that the form was signed.

N
Y

32

Service Facility Location
Information

Enter the name, address, city, state,
and zip code of the location where the
services were rendered.

Y

32 a

NPI#

N

32 b

Other ID#

Enter the NPI number of the service
facility location in 32a.
Enter the two digit qualifier identifying
the non-NPI number followed by the ID
number.

Billing Provider Info & Ph #

Enter the provider’s or supplier’s billing
name, address, zip code, and phone
number.

Y

NPI#

Enter the NPI number of the billing
provider.

N

33

33 a

N

N

14

OWCP –1500
Claim Item
33 b

Title
Other ID#

Action

Required?

ACS Provider Number is required
You may also use a two digit qualifier
identifying the non-NPI number followed
by the ID number.

Y

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Attachment 3 – Place of Service Codes
Place of Service Codes (POS)
Code
11
12
15
20
21
22
23
24
26
31
32
33
34
41
42
50
60
71
72
81
99

Description
Office
Patient Home
Mobile Unit
Urgent Care
Inpatient Hospital
Outpatient Hospital
Emergency Room-Hospital
Ambulatory Surgical Center
Military Treatment Facility
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Ambulance-Land
Ambulance-Air or Water
Federally Qualified Health Center
Mass Immunization Center
State or Local Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Place of Service

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