How To Submit OWCP 1500 Energy ICD10

How To Submit OWCP 1500 Energy ICD10.pdf

Health Insurance Claim Form

How To Submit OWCP 1500 Energy ICD10

OMB: 1240-0044

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HOW TO SUBMIT OWCP-1500 BILLS TO XEROX
OFFICE OF WORKERS’ COMPENSATION PROGRAMS
DIVISION OF ENERGY EMPLOYEES OCCUPATIONAL ILNESS COMPENSATION
The services performed by the following providers should be billed on the OWCP -1500 Form:
°Physicians (MD,

DO)

°X-Ray

°Independent

Laboratories

°Audiologists/Speech Pathologist

°Hearing

°Community Health

°DME

°Visual

°Chiropractors

°Home Health

°Prosthetics/Orthotics

°Ambulatory

°Home

°Rural Health Clinics

Departments

Surgical Centers

°Ambulance

Aid Specialists

Attendant Services

°Psychologist

°Therapists

Services

°Podiatrist

BILLS SHOULD BE SENT TO:
US Department of Labor
P O Box 8304
London, KY 40742-8304

ELECTRONIC REMITTANCE VOUCHER RETRIEVAL
Retrieving DOL remittance vouchers via electronic media offers the advantage of speed in
retrieval. All providers, including pharmacies, 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.

AUTHORIZATION REQUIREMENTS
The DEEOIC program pays for medical services rendered for employees of the Department of
Energy with radiation-related cancer and other illnesses related to radiation, Chronic Beryllium
Disease, and Chronic Silicosis. Some services require prior authorization. Listed below are
some of the services that require prior authorization:

◦Psychiatric Treatment

◦Acupuncture Treatments

°Chiropractic Services

°Home Health Services

°Durable Medical Equipment

°Organ Transplant (Including Stem Cell)

°Experimental Treatment

°Clinical Research

°Hospice Care

°Extended Care Facilities

°Vehicle/Housing Modifications

°Massage Therapy

Routine services such as office/clinic visits, plain x-ray films and laboratory services do
NOT require prior authorization.
Please call (866) 272-2682 or fax (800) 882-6147 to request an authorization.
To request an authorization via fax, use the appropriate template provided in this
packet.

BILLING REQUIREMENTS
1. All bills must contain the Division of Energy Employees Occupational Illness
Compensation Program (DEEOIC) 9 digit case identification number of your
patient or client and your 9-digit DEEOIC provider number.
2. All professional services will be paid using the Fee Schedule established by OWCP. This
Fee Schedule can be downloaded from
http://www.dol.gov/owcp/regs/feeschedule/fee.htm.
3. Anesthesia services must be billed with the appropriate anesthesia CPT code (00100 –
01999).
4. Drugs dispensed at the physician’s office, other than injections, require NDC.

5. 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.
6. When billing for services over a period of time, use the “From” and “Through” dates with
the appropriate units for each CPT code billed.
7. Please refer to the attached OWCP-1500 list and the required fields for additional
instructions.

CMS –1500
Claim Item

Title

Action

Required?

Medicare, Medicaid,
TRICARE CHAMPUS,
CHAMPVA, Group Health
Plan, FECA, Black Lung,
Other

No Entry Required.

Insured's ID Number

Mandatory Field. Enter the
claimant’s case number.

Patient’s Name

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.

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.

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.

9a-d

10a-c

N
N

CMS –1500
Claim Item

Title

10d

Claim Codes (Designated By
NUCC)

No Entry Required.

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.

11a

Insured’s Date of Birth

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.

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?

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 No Entry Required.
in Current Occupation

CMS –1500
Claim Item
17

17 a

17 b
18
19
20
21

22
23

24a

Title

Action

Name of Referring Provider
or Other Source

Required?

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

Additional Claim Information No Entry Required.
(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
or Injury
to 12 ICD-10-CM diagnosis codes.
Enter ‘9’ if using ICD9 codes. Enter ‘0’
ICD Ind
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

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.

CMS –1500
Claim Item

Title

Action

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

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.

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 unshaded 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

No Entry Required.
Enter total charges for the services
(i.e., total of all charges in 24f).

N
Y

CMS –1500
Claim Item

Title

Action

Required?

Amount Paid

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.

N
Y

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.

33 a

NPI#

33 b

Other ID#

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

Bill Date
32

Service Facility Location
Information

32 a

NPI#

32 b

Other ID#

Place of Service Codes (POS)
Code
3
4
5
6
7
8
11
12
15
20
21
22
23
24
25
26
31
32
33
34
41
42
50
51
52
53
54
55
56
60
61
62
65
71
72
81
99

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
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
Hospice
Ambulance-Land
Ambulance-Air or Water
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
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Rental Disease Treatment Facility
State or Local Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Place of Service

Authorization Request Form
Please fax with supporting medical documentation
800-882-6147
Effective January 3, 2005, all Prior Authorization requests must either be faxed on this template or be
submitted through the Medical Authorization Entry screen on the Web Bill Processing
Portal(http:\\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 # _______________
Claimant Name ____________________________________________
Claimant Date of Birth _______________
Provider Name _________________________________
ACS Provider Number _________________
Provider Tax ID ___________________________________
Date(s) of Service Requested ______________________________
ICD-9/ICD-10 Diagnosis code __________________
Procedure Code(s) and/or Modifier(s) (CPT, HCPCS, RCC) ________________________
________________________________________________________________________
Specific body part to be treated __________________________
Right___ , Left___ , Bilateral___ , N/A_____
Units/Days Requested _______________________
Is this a second surgery on the same body part? ________________________________
Comments ______________________________________________________________
_______________________________________________________________________

Please remember to send any supporting medical documentation with request.
Please put Case File # on every page faxed.
800-882-6147

Authorization Form-general medical

07/22/15

ICD-9/ICD-10 CODE(S):

ICD-9/ICD-10 CODES:

DEEOIC Home Health
Authorization Request
Please
fax
1-800-882-6147
Please ensure the prescription
signed
bytothe
physician and the Case/Subscriber
Number is included with this authorization request. Please submit fax to
1-800-882-6147.
Date Requested _____________

Requested by ___________________________

Case/Subscriber Number _______________
Claimant Name ____________________________________________
Claimant Date of Birth (optional) _______________
Provider Name _________________________________
ACS Provider Number _________________
Provider Tax ID ___________________________________
Date(s) of Service Requested ______________________________
ICD-9,&' __________________
Procedure Code(s) and/or Modifier(s) (CPT, HCPCS, RCC):
T1001