Health Insurance Claim Form

Forms and Documents

Document Name	Status
Form OWCP-1500 Health Insurance Claim Form Form and Instruction	Unchanged
OWCP-1500 Health Insurance Claim Form.pdf Supplementary Document	2020-02-20
Justifiction - OWCP1500 (HCFA).docx Justification for No Material/Nonsubstantive Change	2020-02-20
ICR SS 1240-0044 (OWCP-1500) DEEOIC RuleMaking.docx Supporting Statement A	2019-01-25
20 CFR 725.405 BLBA Supporting Reg.doc Supplementary Document	2012-10-23
20 CFR 30.701 EEOICPA Supporting Reg.doc Supplementary Document	2012-10-23
20 CFR 10.801 FECA - Supporting Reg.doc Supplementary Document	2012-10-23

IC Document Collections

IC ID	Document Title	Status
43805	Health Insurance Claim Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 1240-0044	ICR Reference No: 202002-1240-010
Status: Historical Active	Previous ICR Reference No: 201901-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Health Insurance Claim Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/27/2020
	Date Received in OIRA: 02/21/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	06/30/2021	06/30/2021
Responses	3,381,232	0	3,381,232
Time Burden (Hours)	321,455	0	321,455
Cost Burden (Dollars)	0	0	0

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Abstract: Requesting address change for Form OWCP-1500. 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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1240-AA08	Final or interim final rulemaking	84 FR 3026	02/08/2019

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 34459	06/16/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 9513	02/25/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,381,232	3,381,232	0	0	0	0
Annual Time Burden (Hours)	321,455	321,455	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $11,993,254

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/21/2020

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