Form OWCP-04 Uniform Billing Form

__

__

4

3a PAT.
CNTL #
b. MED.
REC. #

2

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1

__

6

5 FED. TAX NO.

8 PATIENT NAME

9 PATIENT ADDRESS

a

10 BIRTHDATE

11 SEX

31
OCCURRENCE
CODE
DATE

12

DATE

a
c

ADMISSION
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT

32
OCCURRENCE
CODE
DATE

33
OCCURRENCE
DATE
CODE

18

7

STATEMENT COVERS PERIOD
FROM
THROUGH

b

b

TYPE
OF BILL

19

20

34
OCCURRENCE
CODE
DATE

CONDITION CODES
24
22
23

21

35
CODE

25

26

27

36
CODE

OCCURRENCE SPAN
FROM
THROUGH

d
28

e

29 ACDT 30
STATE

37

OCCURRENCE SPAN
FROM
THROUGH

a

a

b

b

38

39
CODE

40
CODE

VALUE CODES
AMOUNT

41
CODE

VALUE CODES
AMOUNT

VALUE CODES
AMOUNT

a
b
c
d
42 REV. CD.

44 HCPCS / RATE / HIPPS CODE

43 DESCRIPTION

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

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PAGE

23

OF

TOTALS

CREATION DATE

50 PAYER NAME

52 REL.
INFO

51 HEALTH PLAN ID

53 ASG.
BEN.

23

55 EST. AMOUNT DUE

54 PRIOR PAYMENTS

A

56 NPI
57

A

B

OTHER

B

C

PRV ID

C

58 INSURED’S NAME

59 P. REL 60 INSURED’S UNIQUE ID

62 INSURANCE GROUP NO.

61 GROUP NAME

A

A

B

B

C

C

65 EMPLOYER NAME

64 DOCUMENT CONTROL NUMBER

63 TREATMENT AUTHORIZATION CODES
A

A

B

B

C

C

66
DX

67
I

A
J

69 ADMIT
70 PATIENT
DX
REASON DX
PRINCIPAL PROCEDURE
a.
74
CODE
DATE

B
K
a

b

OTHER PROCEDURE
CODE
DATE

C
L
b.

c

D
M

71 PPS
CODE
OTHER PROCEDURE
CODE
DATE

E
N
75

72
ECI

F
O
a
76 ATTENDING

G
P
b
NPI

LAST
c.

OTHER PROCEDURE
CODE
DATE

d.

OTHER PROCEDURE
DATE
CODE

e.

OTHER PROCEDURE
CODE
DATE

77 OPERATING

81CC
a

UB-04 CMS-1450

APPROVED OMB NO.

78 OTHER

b

LAST

c

79 OTHER

d

LAST

NUBC

™

National Uniform
Billing Committee

73

QUAL
FIRST

NPI

LAST
80 REMARKS

H
Q
c

68

QUAL
FIRST

NPI

QUAL
FIRST

NPI

QUAL
FIRST

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.
LIC9213257

Instructions for Completing OWCP-04 Uniform Billing 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)
GENERAL INFORMATION—FECA AND EEOICPA CLAIMANTS: Claims filed under FECA (5 USC 8101 et seq.) are for employment-related illness or injury.
Claims filed under EEO ICPA (42 USC 7384 et seq.) are for occupational illnesses defined under that Act. Benefits provided under these statutes include
Inpatient/outpatient hospital services, ambulatory surgical care, chemotherapy treatment services, and other non-professional medical services for covered injuries
or occupational illnesses. Services provided by skilled nursing facilities, nursing homes and hospices (including medications and other services such as oxygen
and respiratory services), as well as personal care services provided by a h ome health aide, licensed practical nurse or similarly trained individual, may also be
provided.
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 claimants eligible under FECA and EEOICPA. OWCP uses a condition-specific fee schedule based on the Prospective
Payment System devised by the Centers for Medicare and Medicaid Services (CMS) and other tests to determine reasonableness. Schedule limitations are
applied through an atotomated billing system that is based on the identification of procedures as defined in the AMA’s Current Procedural Terminology (CPT),
Revenue Center codes and Diagnosis-Related Group (DRG) codes; therefore, use of correct codes and modifier(s) is required. Incorrect coding will result in
inappropriate or delayed 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 area.
ITEMIZED BILLS AND TREATMENT PLANS: All forms submitted for inpatient hospi tal services must be accompanied by an itemized billing statement and an
admission/discharge summary. Forms submitted for hospice services or for persona l care services provided in the home must be a ccompanied by a plan of care
and treatment.
GENERAL 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 information about reimbursable services, call the Department of Labor’s Black
Lung office that services your facility or call the National Office in Washington, D.C.
SIGNATURE OF PHYSICIAN OR SUPPLIER: Your submission of a bill with this form indicates your agreement to accept the charge determination 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 allowed). Your submission of a bill with this form also
indicates that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished 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,
BLBA or EEOICPA regulations. Finally, your submission of a bill with this form indicates that you understand that any false claims, statements or documents, or
concealment of a material fact, may be prosecuted under applicable Federal or State laws.
NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF INFORMATION
(PRIVACY ACT STATEMENT)
OWCP is authorized by 5 USC 8101 et seq., 30 USC 901 et seq., and 42 USC 7384d to collect information needed to administer the FECA, BLBA and EEOICPA.
The information collected is used to identify the eligibility of the claimant for benefits, and to determine coverage of s ervices provided. There are no penalties for
failure to supply information; however, failure to furnish information regarding the medical service(s) received or the amount charged will prevent payment of the
claim. Failure to supply the claim number or required codes will delay payment or may result in rejection of the bill 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 other wise
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 Department of Labor systems DOL/GOVT -1, DOL/E SA-5, DO L/ESA-6,
DOL/ESA-29, DOL/ESA-30, DOL/ESA-43, DOL/ESA-44, DOL/ESA-49 and DOL/ ESA-50 published in the Federal 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 Employees Occupational Illness Compensation Program, P. O. Box 8304, London, KY 40742-8304, unless
otherwise instructed.
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information
may be guilty of a criminal act punishable under law and may be subject to civil penalties.
A brief description of each data element and its applicability to requirements under FECA, BLBA and
INSTRUCTIONS FOR COMPLETING THE FORM:
EEOICPA are listed below. For further information contact OWCP.
Block 1
Block 2
Block 3a
Block 3b
Block 4
Block 5
Block 6
Block 7
Block 8
Block 9
Block 10
Block 11
Block 12
Block 13
Block 14
Block 15
Block 16

Type or print complete provider name, street address, city, state and zip code. Also include area code and phone number.
Blank field.
Not required.
Not required.
Type of bill classification using appropriate three-digit code: 1st position indicates type of facility, 2nd position indicates type of care, 3rd position
indicates billing sequence.
Type or print Federal tax I.D. assigned for tax reporting purposes.
Type or print dates for the full ranges of services being invoiced (period from/through using MM/DD/YY).
Type or print number of covered days.
Type or print patient’s name. Use a comma or space to separate the last and first names, do not use titles such as Mr. or Mrs., and do not leave a
space before a prefix to a last name. If last name is hyphenated, both names should be capitalized, and a space should separate a last name and
any suffix. For BLBA and EEOICPA, type or print name as it appears on the Medical Benefits Identification Card.
Type or print complete mailing address of patient.
Type or print month, year, and day of patient’s birth (MM/DD/YY).
Type or print sex of patient, using M or F only.
Type or print month, day, and year (MM/DD/YY) of admission.
Enter the code for admission hour.
Required for Inpatient.
Enter source of admission (Required for Inpatient).
Type or print patient’s two-digit status code on the last day of the billing period.

OMB No. 1240-0019
Expires: 05/31/2019

OWCP-04 PAGE 2 (Rev. 06-12)

Block 17 Enter status code.
Block 18 Enter condition codes.
Block 19 Enter condition codes.
Block 20 Enter condition codes.
Block 21 Enter condition codes.
Block 22 Enter condition codes.
Block 23 Enter condition codes.
Block 24 Enter condition codes.
Block 25 Enter condition codes.
Block 26 Enter condition codes.
Block 27 Enter condition codes.
Block 28 Enter condition codes.
Block 29 Not required.
Block 30 Blank field.
Block 31 Enter occurrence code and occurrence date.
Block 32 Enter occurrence code and occurrence date.
Block 33 Enter occurrence code and occurrence date.
Block 34 Enter occurrence code and occurrence date.
Block 35 Enter occurrence span code and occurrence span from date.
Block 36 Enter occurrence span code and occurrence span from date.
Block 37 Blank field.
Block 38 Not required.
Block 39 Enter value code 01-99 and A1-29, and value codes amount.
Block 40 Enter value code 01-99 and A1-29, and value codes amount.
Block 41 Enter value code 01-99 and A1-29, and value codes amount.
Block 42 Type or print Revenue Center Code(s).
Block 43 Type or print Revenue Center Code description(s).
Block 44 Type or print applicable private/semi-private room rate, and the CPT or HCPCS codes and modifiers based on bill type (inpatient or outpatient).
Block 45 Enter service date for outpatient services not required for inpatient for each RCC.
Block 46 Type or print units of service for inpatient. For outpatient, enter units of service for each RCC.
Block 47 Type or print total charges by RCC and procedure code.
Block 48 Not required.
Block 49 Blank field.
Block 50 Type or print program payer: U.S. DOL-OWCP-FECA, -BLBA or -EEOICPA, as appropriate, and Medicare number (51B) for inpatient services.
Block 51 Medicare number 51B.
Block 52 Not required.
Block 53 Not required.
Block 54 Type or print the amount of any prior payments made.
Block 55 Not required.
Block 56 Type or print the NPI number of the facility.
Block 57 Type or print other provider ID. OWCP provider number.
Block 58 Type or print insured’s last name, first name.
Block 59 Not required.
Block 60 For EEOICPA and BLBA: type or print patient’s SSN. For FECA: type or print patient’s claim/case number.
Block 61 Not required.
Block 62 Not required.
Block 63 Not required.
Block 64 Not required.
Block 65 Not required.
Block 66 Type or print ICD diagnosis version.
Block 67a Type or print complete ICD-9-CM/ICD-10 diagnosis code for principal diagnosis. Enter the 4th and 5th digits if applicable. Each diagnosis must
be valid for the date of service.
Block 67b Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67c Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67d Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67e Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67f Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67g Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67h Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67i Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67j Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67k Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67l Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67mType or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67n Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67o Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67p Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67q Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 68 Blank field.
Block 69 Type or print complete ICD-9-CM/ICD-10 diagnosis code for admission diagnosis. Enter the 4th and 5th digit if applicable. Ea ch diagnosis must be
valid for the date of service.
Block 70 Type or print patient’s reason for visit code.
Block 71 Not required.
Block 72 Not required.
Block 73 Blank field.
Block 74 Type or print principal procedure using ICD-9-CM codes and date of occurrence (MM/DD/YY) during hospitalization. Inpatient claims and all surgical
procedures require ICD -9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74a Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
OWCP-04 PAGE 3 (Rev. 06-12)

Block 74b Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74c Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74d Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74e Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 75 Blank field.
Block 76 Not required.
Block 77 Not required.
Block 78 Not required.
Block 79 Not required.
Block 80 Not required.
Block 81 Not required.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agenc y may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1240-0019. 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 structures and prior use of this common form. Send comments regarding this
burden estimate or any other as pect of this collection of infomation, including suggestions for reducing this burden, to the Office of Workes’ Compensation
Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office of Management and Budget, Paperwork
Reduction Project (1240-0019), 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 communication assistance, accommodation and 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.

OWCP-04 PAGE 4 (Rev. 06-12)