How To Submit OWCP-1500 FECA ICD10

How To Submit OWCP-1500 FECA ICD10.pdf

Health Insurance Claim Form

How To Submit OWCP-1500 FECA ICD10

OMB: 1240-0044

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1240-0044 can be found here:

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HOW TO SUBMIT OWCP - 1500 BILLS TO ACS
The services performed by the following providers should be billed on the OWCP-1500 Form:
°Physicians (MD,

°Radiologists

°Independent

°Audiologists/Speech Pathologist

°Hearing

°Therapists

°Community Health

°DME

°Visual

°Chiropractors

°Home Health

°Prosthetics/Orthotics

°Ambulatory

°Home

°Rural Health

DO)

Departments

Surgical Centers

°Ambulance

Aid Specialists

Attendant Services

°Psychologist

Laboratories

Services

Clinics

°Podiatrist

As a provider you have the option of sending your bills either electronically or by paper.

PAPER BILLS SHOULD BE SENT TO:
US Department of Labor
P O Box 8300
DFEC Central Mailroom
London, KY 40742-8300

ELECTRONIC BILL SUBMISSION
Submitting DOL bills via electronic media offers the advantage of speed in processing.
Providers may submit electronic bills or choose a billing agent that offers electronic bill
submission services. Billing agents must enroll as DOL providers.
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 electronic bill submission and report retrieval.
Process test transmissions.
Provide technical assistance on transmission difficulties.

AUTHORIZATION REQUIREMENTS
The FECA Program pays for medical services rendered for work-related injury or disease. Some
services require prior authorization. Listed below are some of the services that require prior
authorization:
°All

inpatient admissions

°All

surgical procedures

°Some

Injections

°Home

health services

°Some

durable medical equipment

°Anesthesia

CPT codes 01996

°Physical/Occupational

therapy services – Physical/Occupational therapy authorization
requests must be accompanied by a physician’s prescription and a treatment plan.
Authorization will be given for the number of modalities to be done per day and the
number of days requested.

Routine services such as office/clinic visits, diagnostic tests, and laboratory services do
NOT require prior authorization.
Please call (866) 335-5335, fax (800) 215-4901 using the attached authorization forms, or access
our website to request an authorization.

BILLING REQUIREMENTS
1. All bills must contain the Federal Employees' Compensation (FECA) 9-digit case
number of your patient or client, as well as, the 9 digit ACS Provider Number.
2. Anesthesia services must be billed with the appropriate anesthesia CPT code (00100 –
01999).
3. Drugs dispensed at the physician’s office, other than injections, require NDC along with
the quantity and strength.
4. Facility charges for ambulatory surgical center/outpatient surgery billing must be billed
using the surgical CPT code. Please use the SG modifier in addition to the surgical CPT
code.
5. When billing for services over a period of time, use the “From” and “Through” dates with
the appropriate units for each CPT code billed.
6. Please refer to the attached OWCP -1500 list and the required fields for additional
instructions.

HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITIEE

MEDICARE
(Medicare#}

MEDICAID
(Medicaid#}

TRICARE
(101/DoOI}

CHAMPVA
(Member/0#}

2 . PATIENT'S NAME (Last, First, Middle Initial)

GROUPHEALTH
PLAN(/01}

FECA BLK
LUNG I/O#}

3. PATIENT'S BIRTH DATE

SEX
OM

5. PATIENT'S ADDRESS (Street, City, State, Zip)

1a. INSURED I.D. NUMBER

OTHER
(101}

4. INSURED'S NAME (Last, First, Middle Initial)
OF

7. INSURED'S ADDRESS (Street, City, State, Zip)

6. PATIENT RELATIONSHIP TO INSURED

Self

D Spoose D

Child

8. RESERVED FOR NUCC USE

(For Program in Item 1)

Other

--TELEPHONE (Include Area Code):

TELEPHONE (Include Area Code):

0
f::

---

:::;
a::
0

u.
~

9. OTHER INSURED'S NAME (last, First, Middle lrnitial)

10. PATIENT'S CONDITION RELATED TO:

11. INSURED'S POLICY GROUP OR FECA NUMBER

a. OTHER INSURED POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED'S DATE OF BIRTH

aw
a::

::>
(/)

b. RESERVED FOR NUCC USE

ves

ONo

b. AUTO ACCIDENT?

Oves

PLACE (State)

~
0

SEX
M

f::

ONo

c. RESERVED FOR NUCC USE

c. OTHER ACCIDENT?

d. PATIENT'S PLAN OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

Oves

z<(
zfw

b. OTHER CLAIM ID (Designated by NUCC)

c. INSURANCE PLAN NAME OR PROGRAM NAME

ct.

ONo
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
If yes, complete items 9, 9a, and 9d.
ONo

Oves

READ BACK OF FORM BEFORE COMPLETIJiiG & SIGNING THIS FORM.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to
process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

13. 1NSURED'S OR AUTHORIZED PERSON'S SIGNATURE
I authorize payment of medical benefits to the undersigned physician
or supplier lor services described below..

SIGNED

S IGNED

DATE

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

15. OTHER DATE

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

QUAd

QUAL !

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

FROM:
TO:
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

-ij~~+NPi ~

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-Lto service line below (24e)

A
E.

From

PLACE OF
SERVICE

CPT/ HCP SCS

MODIFIER

Yes

ONo

22. RESUBMISSION CODE

ICD ind. o

D. PROCEDURES, SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)

EMG

$CHARGES

20. OUTSIDE LAB?
D

TO:

FROM:

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

24. A. DATE(S) OF SERVICE

...

ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

DIAGNOSIS

POINTER (A-l )

$CHARGES

G.
H.
I.
DAYS OR EPSOT
ID
Family QUAL
UNITS
Plan

J.
RENDERING
PROVIDER NPI #

------

NPI

------

NPI

f::

NPI

NPi___

------

NPI

NPi"-25. FEDERAL TAX I.D. NUMBER

26. PATIENT'S ACCOUNT NO.
SSN

D
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse

27. ACCEPT ASSIGNMENT?
(For govt. claims. see bacl<)

EIN

Oves

ONo

32. SERVICE FACILITY LOCATION INFORMATION

28. TOTAL CHARGE

29. AMOUNT PAID

30. Rsvd for NUCC Use

DATE

NUCC instruction Manual available at www.nucc.org

PLEASE PRINT OR TYPE

a::
w

::J
0..
0..

:>
(/)

a::

:'!;
~

:I:

33. BILLING PROVIDER INFO & PH#

apply to this bill and are made a part theroof.)

SIGNED

0
u.

(/)

1lb.
APPROVED OMB-0938-1197 FORM CMS-1500 (02-12)

0..

Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES'
COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS
COMPENSATION PROGRAM ACT of 2000 (EEOICPA)
G'ENERAL INFORMATION-FECA AND EEOICPA CLAIMANTS: Claims filed under FECA (5 USC 8101 et seq.) are for employment-related illness or
injury. Claims filed under EEOICPA (42 U SC 7384 et seq.) are for compensable illnesses defined under that Act. All services, appliances, and supplies
prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to give relief, reduce the degree or period of the disability
or illness, or aid in lessening the amount of the monthly compensation, may be furnished. "Physician" includes all Doctors of Medicine (M.D.), podiatrists,
dentists, clinical psychologists, optometrists, chiropractors, or osteopathic practitioners within the scope of tlheir practice as defined by State law. However,
the term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual manipulation of the
spine to correct a subluxation as demonstrated by x-ray to exist.
FEES: The Department of Labor's Office of Workers' Compensation Programs (OWCP) is responsible for payment of all reasonable charges stemming from
covered medical services provided to cla imants eligible under FECA and EEOICPA. OWCP uses a relative value scale fee schedule and other tests to
determine reasonableness. Schedule limitations are applied through an automated billing system that is based on the identification of procedures as defined
in the AMA's Current Procedural Termino logy (CPT); correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate payment. For
specific information about schedule limits, call the Dept. of Labor's Federal Employees' Compensation office or Energy Employees Occupational Illness
Compensation office that services your a rea.
REPORTS: A medical report that indicates the dates of treatment, diagnosis(es), findings, and type of treatment offered is required for services provided by a
physician (as defined above). For FECA claimants, the initial medical report should explain the relationship of the injury or illness to the employment. Test
results and x-ray findings should accompany billings.
G,ENERAL INFORMATION-BLBA CLAIMANTS: The BLBA (30 USC 901 et seq.) provides medical services to eligible beneficiaries for diagnostic and
therapeutic services for black lung disease as defined under the BLBA. For specific infor mation about reimbursable services, call the Department of Labor's
Bl ack Lung office that services your facility or call the National Office in Washington, D.C.
SIIGNATURE OF PHYSICIAN OR SUPPLIER: Your signature in Item 31 indicates your agreement to accept the charge determ ination of OWCP on covered
services as payment in full, and indicates your agreement not to seek reimbursement from the patient of any amounts not paid by OWCP for covered
services as the result of the application of its fee schedule or related tests for reasonableness (appeals are a llowed). Your signature in Item 31 also indicates
that the services shown on th is form were medically indicated and necessary for the hea lth of the patient and were personally furn ished by you or were
furnished incident to your professional services by your employee under your immediate personal supervision, except as otherwise expressly permitted by
FECA, Black Lung or EEOICPA regulations. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under
the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental, part of a covered physician's service, 3)
they must be of kinds commonly furnished in physician's offices, and 4) the services of non-physicians must be included on the bills. Finally, your signature
indicates that you understand that any false claims, statements or documents, or concealment of a material act, may be prosecuted under applicable Federal
or State laws.
NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION
(PRIVACY ACT STATEMENT)
We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to collect
information is in 5 USC 8101 et seq. ; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179. The information we
obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies
you received are covered by these programs and to insure that proper payment is made. Your response regJarding the medical service(s) received or the
amount charged is required to receive payment for the claim. See 20 CFR §§ 10.801 , 30.701, 725.406, 725.701 , and 725.704. Failure to supply the claim
number or CPT codes will delay payment or may result in rejection of the claim because of incomplete information. The information may also be given to
other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federal agencies, for the effective
administration of Federal provisions that require other third party payers to pay primary to Federal programs, and as otherwise necessary to administer these
programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made
through routine uses for information contained in systems of records. See Department of Labor systems DOUGOVT-1 , DOL/ESA-5, DOUESA-6, DOL!
ESA-29, DOL/ESA-30, DOUESA-43, DOU ESA-44, DOUESA-49 and DOUESA-50 published in the Federa'l Register, Vol. 67, page 16816, Mon. April 8,
2002, or as updated and republished .
You should be aware that P.L. 100- 503, the "Computer Matching and Privacy Protection Act of 1988," permits the government to verify information by way of
computer matches.
FORM SUBMISSION
FECA: Send all forms for FECA to the DFEC Central Mailroom, P_O_ Box 8300, London, KY 40742-8300, unless otherwise instructed_
BLBA: Send all forms for BLBA to the Federal Black Lung Program , P.O. Box 8302, London, KY 40742-8302, unless otherwise instructed.
EEOICPA: Send all forms for EEOICPA to the Energy Emp~oyees Occupational Illness Compensation Program, P.O. Box 8304, London, KY 40742-8304,
unless otherwise instwcted.
INSTRUCTIONS FOR COMPLETING THE FORM: A brief description of each data element and its applicability to requirements under FECA, BLBA and
EEOICPA are listed below. For further information contact OWCP.
Leave blank_
Enter the patient's claim number.
Enter the patient's last name, first name, middle initial.
Enter the patient's date of birth (MM/DDIYY) and check appropriate box for patient's sex.
For FECA: leave blank. For BLBA and EEOICPA: complete only if patient is deceased and this medical cost was paid by a survivor or estate_
Enter the name of the party to whom medical payment is due.
Enter the patient's address (street address, city, state, ZIP code; telephone number is optional).
ItemS.
ltem6.
Leave blank.
Item?. For FECA: leave blank. For BLBA and EEOICPA: complete if Item 4 was completed . Enter the address of the party to be paid.
ItemS. Leave blank.
ltem9. Leave blank.
Item 10. Leave blank.
Item 11. For FECA: enter patient's claim number. OMISSION WILL RESULT IN DELAYED BILL PROCESSING. For BLBA and EEOICPA: leave blank.
Item 1.
Item 1a.
ltem2.
ttem3.
ltem4.

OMB No. 1240-0044
Expires: 12/31/2015

OWCP-1500 PAGE 2 (Rev. 10-13)

ltem11a.
Item 11b.
Item 11c.
ltem11d.
Item 12.
Item 13.

Item 14.
Item 15.
Item 16.
Item 17.
Item 18.
Item 19.
ltem20.
Item 21 .

ltem22.
ltem23.
ltem24.

ltem25:
ltem26:
ltem27:
ltem28:
ltem29:
ltem30:
Item 31:
ltem32:
ltem33:

Ite m 33a.
Item 33b.

Leave blank.
Leave blank.
Leave blank.
Leave blank.
The siignature of the patient or authorized representative authorizes release of the medical information necessary to process the claim, and
requests payment. Signature is requ ired; mark (X) must be co-signed by w itness and relationship to patient indicated.
Signature indicates authorization for payment of benefits directly to the provider. Acceptance of this assignment is considered to be a
contractual arrangement. The "authorizing person" may be the beneficiary (patient) eligible under the program billed, a person with a power of
attorney, or a statement that the beneficiary's signature is on file with the billing provider.
Leave blank.
Leave blank.
Leave blank.
Leave blank.
Leave blank.
Leave blank.
Leave blank.
Enter the diagnosis(es) of the condition(s) being treated using current lCD codes. Enter codes in priority order (primary, secondary condition ).
Coding structure must follow the International Classification of Disease, 1Oth Edition, Clinical Modification or the latest revision published. A
brief narrative may also be entered but not substituted for the lCD code.
Leave blank.
Leave blank.
Column A: enter month, day and year (MM/DDIYY) for each service/consultation provided. If the "from" and "to" dates represent a series of
identical services, enter the number of services provided in Column G.
Column B: enter the correct CMS/OWCP standard "place of service" (POS) code (see below).
Column C: not required.
Column D : enter the proper five-digit CPT (current edition) code and modifier(s) , the HCPCS, or the OWCP generic procedure code.
Column E: enter the diagnostic reference letter (A, B, C, etc. in Item 21) to relate the date of service and the procedure(s) performed to the
appropriate lCD code, or enter the appropriate lCD code.
Column F: enter the total charge(s) for each listed service(s).
Column G : enter the num ber of services/units provided for period listed in Column A. Anesthesiologists enter time in total minutes, not units.
Column H: Leave blank.
Column 1: Leave blank.
Column J: Enter NPI. For FECA: required. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.
Enter the Federal tax I. D.
Provider may enter a patient account number that will appear on the remittance voucher.
Leave blank.
Enter the total charge for the listed services in Column F.
If any payment has been made, enter that amount here.
Enter the balance now due.
For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable.
Enter complete name of hospital, facility or physician's office were services were rendered. Item 32a. Enter NPI. Item 32b. Enter taxonomy
number.
Enter (1) the name and address to which payment is to be made, and (2) your DOL provider number after "PIN#" if you are an individual
provider, or after "GRP #"if you are a group provider. FAILURE TO ENTER THIS NUMBER WILL DELAY PAYMENT OR CAUSE A
REJECTION OF THE BILL FOR INCOMPLETE/INACCURATE INFORMATION.
Enter NPI.
Enter taxonomy number.

P lace of Service (POS) Codes for Item 24B

3
4

5
6

7
8
11

12
15
20
21

24
25
26
31
32

School
Homeless Shelter
Indian Health Service Free-Standing Facility
Indian Health Service Provider-Based Facility
Tribal 638 Free-Standing Facility
Tribal 638 P rovider-Based Facility
Office
Patient Home
Mobile Unit
Urgent Care
Inpatient Hospital
Outpatient Hospital
Emergency Room - Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility

OMB No. 1240-0044
Expires: 12131/2015

34
41
42
50
51
52
53
54

55
56
60
61
62

65
71

72
81
99

Hospice
Ambulance - Land
Ambulance - A ir or Water
Federally Qualified Health Center
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospita lization
Community Mental Health Center (CMHC)
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease Treatment Facility
State or Local Public Health C linic
Rural Health Clinic
Independent Laboratory
Other Place of Service

OWCP-1 500 PAGE 3 (Rev. 10-13)

Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it d isplays a valid OM B control number. The valid OMB control number for this information collection is 1240-0044. We estimate that it will
take an average of seven minutes to complete this collection of information, including time for reviewing instructions, abstracting information from the patient's
records and entering the data onto the form. This time is based on familiarity with standardized coding str uctures and prior use of this common form. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing th is burden, to the Office of
Workers' Compensatiion Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office on
Management and Budget, Paperwork Reduction Project (1240-0044), Washington, DC 20503. DO NOT SEND THE COMPLETED FORM TO EITHER OF
THESE OFFICES.

NOTICE
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in
the form of commun ication assistance, accommodation ancl modification to aid you in the claims process. For example, we will provide you with copies of
documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the
limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.

OMB No. 1240-0044
Expires: 12131/2015

OWCP-1500 PAGE 4 (Rev. 10-13)

OWCP–1500
Claim Item

Title

Action

Required?

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

Insured's ID Number

Mandatory Field. Enter the
claimant’s case number.

Patient’s Name

Enter the claimant’s last name, first
name, and middle initial.

Patient’s Birth Date

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

Sex
4

Insured’s Name

Patient’s Address

Telephone Number
Patient’s Relationship to
claimant

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

Insured’s Address,
Telephone Number

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

Reserved For NUCC Use

No Entry Required.

Other Insured’s Name

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

9a-d

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

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

Reserved For NUCC Use

No Entry Required.

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)

10a-c
10d

N
N
N

Insured’s Policy, Group, or
FECA Number

11a

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?

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.

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

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."

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."

Date of current illness, injury
or pregnancy

No Entry Required.

Other Date, Qualifier

No Entry Required.

Dates Patient Unable to Work
in Current Occupation

No Entry Required.

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
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.
Enter the NPI number of the referring,
ordering, or supervising provider.

17 a

Other ID#

17 b

NPI #

N
8

Hospitalization Dates Related No Entry Required.
to Current Services

Additional Claim
Information(Designated by
NUCC)
Outside Lab? $ Charges

20
21

22
23

24a

No Entry Required.

Complete this field when billing for
purchased services.
Diagnosis or Nature of Illness Enter the diagnosis/condition. List up
or Injury
to 12 ICD-10-CM diagnosis codes.
Enter ‘9’ if using ICD9 codes, Enter ‘0’ if
ICD Ind
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
Y

N
N

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.

24c

EMG

No Entry Required.

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.

24e

Diagnosis Pointer

Enter the diagnosis code reference
number (pointer) as shown in Item
Number 21 to relate the date of service
and the procedures performed to the
primary diagnosis.

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.

24g

Days or Units

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.

24h

EPSDT/Family Plan

No Entry Required.

24i

ID Qualifier

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

24j

Rendering Provider ID #

Federal Tax ID Number

Patient’s Account No.

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

27
28

Accept Assignment
Total Charge

N
Y

Amount Paid

No Entry Required.
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
Signature of Physician or
Supplier Including Degrees or
Credentials

No Entry Required
Enter the legal signature of the
practitioner or supplier, signature of
the 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, 2003) that the form was
signed.
Enter the name, address, city, state,
and zip code of the location where the
services were rendered.

Y
Y

Bill Date

Service Facility Location
Information

32 a

NPI#

Enter the NPI number of the service
facility location in 32a.

32 b

Other ID#

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.

NPI#

Enter the NPI number of the billing
provider.

33 a

33 b

Other ID#

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

Place of Service Codes (POS)
Code
3
4
5
6
7
8
09
11
12
13
14
15
16
17
18
20
21
22
23
24
25
26
31
32
33
34
41
42
49
50
51
52
53
54
55
56
57
60
61

Description
School
Homeless Shelter
Indian Health Service Free-Standing Facility
Indian Health Service Provider–Based Facility
Tribal 638 Free-Standing Facility
Tribal 638 Provider-Based Facility
Prison/Correctional Facility
Office
Patient Home
Assisted Living Facility
Group Home
Mobile Unit
Temporary Lodging
Walk-in Retail Healh Clinic
Place of Employment – Worksite
Urgent Care
Inpatient Hospital
Outpatient Hospital
Emergency Room-Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Ambulance-Land
Ambulance-Air or Water
Independent Clinic
Federally Qualified Health Center
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
Community Mental Health Center (CMHC)
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Non-residential Substance Abuse Treatment Facility
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
12

62
65
71
72
81
99

Comprehensive Outpatient Rehabilitation Facility
End Stage Rental Disease Treatment Facility
Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Place of Service

Transportation and Travel
Authorization Request
Please fax with supporting medical documentation
800-215-4901

Requested by

Date Requested
Case file# - - - - - - -

Claimant Name ____________________
Claimant Date of Birth----:-----Provider Name - - - - - - - - - - - - - - ACS Provider Number - - - - - - - Provider Tax ID - - - - - - - - - - - - - - Procedure Code Information:
Travel services for codes AO 100, AO 110, AO 120, AO 130, AO 140, and AO 170 are
authorized based on private transportation total charges. Travel services for claimant
. b ursement A0080 an d A0090 are authonze
. d base d on tota I roun d tnp
. m1"I es.
m1·1eage re1m
Travel
Code for Description of Travel Service Estimated Estimated
Travel
travel
Total
Miles (for
Date To
Date
Charge
claimant
From
'
travel only)
1:
2:
3:

A0100
A0110
A0120
A0130
A0140
A0170
A0080
A0090

5:
6:
7:
8:

Travel from:
Travel to:

0Hospital
0Hospital

Taxi
Bus, intra- or interstate carrier
Mini-Bus, mountain area
transports , and other transj)orts
Wheelchair Van
Air Travel
Transport Parking Fees/Tolls
Mileage
Mileage

00ffice/Ciinic
OOffice/Ciinic

0Lab
0Lab

NIA
NIA
N/A
NIA
NIA
N/A

NIA
NIA

0Home
0Home

Comments

Please remember to send any supporting medical documentation with request.
Please put Case File # on every page faxed.
800-215-4901

Authorization - Travel and Transportation
04-23·10

Physical Therapy/Occupational Therapy
Authorization Request
Please fax with supporting medical documentation. Fax# 1-800-215-4901

All Prior Authorization requests must either be faxed on this template or be submitted
through the Web Bill Processing Portal (owcp.dol.acs-inc.com). All fields are required
and must be complete. Incomplete requests and requests that are not properly coded
with CPT or HCPCS cannot be processed and will be returned.
Date Requested

Requested by

Case file#

Phone

Claimant's Name

Claimant Date of Birth

Date of injury

Provider Name
ACS Provider Number

Provider Tax ID

Are you in the process of enrolling?

r Yes

r No

Procedure Code Information: Enter up to Ten Procedure (CPT/HCPCS) codes.
For add"f
11onaI proced ures, please
I
compte
I t e an add"f
11onaI request .
Procedure
Date(s) of
#of Units Frequency Duration
Service
CP"f/HCPCS
per code

1
2

From

Code

Total# of
Units
Requested

Modifier

5
6
7

9
10

Treatment Plan Information :
Body part to be treated

Side of bod_y_

ICD-9 code

* Is the requested therapy related to post-operative treatment

Treatment

Freguenc~

D yes D no

Calculation

*To calculate Total Units/Days Requested, use the following formula for each procedure
code requested:
#of Units Requested per procedure codex Frequency Requested x Duration Requested
Comments:
Please remember to send prescription from attending physician and treatment plan with
requests for physical or occupational therapy. Please put Case File # on every page
faxed. Fax #800-215-4901
Authorization Request-PT OT
Effective 10-19-2009

General Medical and Surgical
Authorization Request
Please fax with supporting medical documentation
Fax# 1-SD0-215-4901

All Prior Authorization requests must either be faxed on this template or be submitted through
the Web Bill Processing Portal (owcp.dol.acs-inc.com). All fields are required and must be
complete. Incomplete requests and requests that are not properly coded with CPT or
HCPCS cannot be processed and will be returned.
Date Requested

Requested by

Case file#

Phone

Claimant's Name

Claimant Date of Birth
Provider Name
ACS Provider Number
Are you in the process of enrolling?

Provider Tax 10
r Yes

r Na

Procedure Code Information: *Up to Five Procedure (CPT/HCPCS/RCC) codes
may be entered
Note: For Units/Days Requested in the table below, please enter the number of visits
anticipated for each proced~re code. (For additional procedures, please complete an
add"ztwna
· l request )
Date of Service
Procedure
Unit/Days
CPT/HCPC/RCC
Requested
'
Td Date
From Date
Code
Modifier
Units or Days
1:

3:
4:
5:
Treatment Plan Information:
•

Specific body part to be treated _ _ _ _ _ __

•

Right_, Left._ _, Bilateral_, N/A._ _

•

ICD-9 Diagnosis Code(s) _ _ _ _ _ _ _ _ _ __

•

For Home health requests, frequency______ duration_ _ _ _ _ __

•

Is this a second surgery on the same body part?

•

Comments:

Please put Case File# on .every page faxed. Fax #800-215-4901

Authorization Request - General Medical and Surgical
Effective 10-19-2009

Durable Medical Equipment
Authorization Request
Please fax with supporting medical documentation
Fax# 1-800-215-4901
All Prior Authorization requests must either be faxed on this template or be submitted through the Web Bill Processing
Portal (owcp.dol.acs-inc.com). All fields are required and must be complete. Incomplete requests and requests that
are not properly coded with CPT or HCPCS cannot be processed and will be returned.
Date Requested

Requested by

Case f i l e # - - - - - - -

CUrumantName._________________________________________

Phone

Claimant Date of B i r t h - - - - - - - - - - - Claimant Date of Injury_____________________
Provider Name ______________________________________________________________
ACS Provider Number

--------------------

Provider Tax ID -------------------------

Are you in the process of enrolling? Yes
No
Procedure Code Information: *Up to Five Procedure (CfYI'/HCPCS) codes may be entered.
(For additional procedures, please complete an additional template)

Date of Service
From Date

To Date

Procedure

Rental (RR)
or Purchase
(NU)
Modifier

**Units/Days
Requested**

Code

RR or NU

Units or Days

Total Requested Price
Per Item

2:
3:
4:
5:

Treatment Plan Information:
• Specific body part(s) to be treated_ _ _ _ _ _ _ _ __
• Right
, Left
, Bilateral
, N/A _ __
• ICD-9 Diagnosis Code (s) - - - - - - - - - - - - - • Duration Requested, if rental ------------------------Is this an implant (YIN) _ _Total Cost of Implant _ _ _ _Total Units Requested._ _ _ __
**Please add units/days to each item per line**
Comments: ______________________________________________________________
Please remember to send prescription from attending physician and treatment plan with requests for DME. Please put
Case File # on every page faxed. Fax# 800-215-4901

Authorization Request-DME
Effective 01/1412013

File Type	application/pdf
Author	smarrero
File Modified	2015-07-14
File Created	2015-07-13