Health Insurance Claim Form

ICR 202008-1240-069

OMB: 1240-0044

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Supplementary Document
2020-09-09
Supplementary Document
2020-08-27
Justification for No Material/Nonsubstantive Change
2020-08-27
Supplementary Document
2020-02-20
Justification for No Material/Nonsubstantive Change
2020-02-20
Supporting Statement A
2019-01-25
Supplementary Document
2012-10-23
Supplementary Document
2012-10-23
Supplementary Document
2012-10-23
IC Document Collections
IC ID
Document
Title
Status
43805 Modified
ICR Details
1240-0044 202008-1240-069
Active 202002-1240-010
DOL/OWCP
Health Insurance Claim Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 10/22/2020
Retrieve Notice of Action (NOA) 10/20/2020
  Inventory as of this Action Requested Previously Approved
06/30/2021 06/30/2021 06/30/2021
3,381,232 0 3,381,232
321,455 0 321,455
0 0 0
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.
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
  
None
1240-AA08 Final or interim final rulemaking 84 FR 3026 02/08/2019
  80 FR 34459 06/16/2015
81 FR 9513 02/25/2016
No
1
IC Title Form No. Form Name
Health Insurance Claim Form OWCP-1500 Health Insurance Claim Form
  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
No
No
$11,993,254
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/20/2020
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