Form OWCP-1500 Health Insurance Claim Form

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HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE

MEDICARE
(Medicare#)

MEDICAID
(Medicaid#)

TRICARE
(ID#/DoD#)

CHAMPVA
(Member ID#)

FECA BLK
LUNG (ID#)

GROUP HEALTH
PLAN (ID#)

SEX

3. PATIENT'S BIRTH DATE

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

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

1a. INSURED I.D. NUMBER

OTHER
(ID#)

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

6. PATIENT RELATIONSHIP TO INSURED
Self

Spouse

Child

(For Program in Item 1)

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

8. RESERVED FOR NUCC USE
TELEPHONE (Include Area Code):

TELEPHONE (Include Area Code):

9. OTHER INSURED'S NAME (Last, First, Middle Initial)

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

Yes
b. RESERVED FOR NUCC USE

b. AUTO ACCIDENT?

c. RESERVED FOR NUCC USE

c. OTHER ACCIDENT?

Yes

c. INSURANCE PLAN NAME OR PROGRAM NAME

No
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
If yes, complete items 9, 9a, and 9d.
Yes
No

10d. CLAIM CODES (Designated by NUCC)

READ BACK OF FORM BEFORE COMPLETING & 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.

QUAL.
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

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

DATE

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

SIGNED _______________________________________________

15. OTHER DATE

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
FROM:

QUAL.
17a.
17b.

TO:

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
NPI

FROM:
20. OUTSIDE LAB?

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

Yes
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24e)
A.
E.

B.
F.
J.

I.
24. A. DATE(S) OF SERVICE
From

B.

To

C.
EMG

D.
H.
L.

$ CHARGES
No
ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

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

TO:

22. RESUBMISSION CODE

ICD Ind.

C.
G.
K.
PLACE OF
SERVICE

F

b. OTHER CLAIM ID (Designated by NUCC)

PLACE (State)

No

Yes
d. PATIENT'S PLAN OR PROGRAM NAME

SEX
M

No

PATIENT AND INSURED INFORMATION

1.

OMB No. 1240-0044
Expires: 06/30/2021

MODIFIER

E.

F.

DIAGNOSIS
POINTER (A-L)

$ CHARGES

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

J.
RENDERING
PROVIDER NPI #

NPI
NPI
NPI
NPI
NPI
25. FEDERAL TAX I.D. NUMBER

26. PATIENT'S ACCOUNT NO.
SSN

27. ACCEPT ASSIGNMENT?
(For govt. claims, see back)

EIN

Yes
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)

32. SERVICE FACILITY LOCATION INFORMATION

SIGNED __________________ DATE

NUCC instruction Manual available at www.nucc.org

a.

b.

PLEASE PRINT OR TYPE

No

28. TOTAL CHARGE

29. AMOUNT PAID

30. Rsvd for NUCC Use

$

$

33. BILLING PROVIDER INFO & PH #

a.

b.

APPROVED OMB-093B-1197 FORM CMS-1500 (06-15)

PHYSICIAN OR SUPPLIER INFORMATION

NPI

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)
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 EEOICPA (42 USC 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 their 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 claimants 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 Terminology (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 area.
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.
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 signature in Item 31 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 signature in Item 31 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, 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 regarding 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 DOL/GOVT-1, DOL/ESA-5, DOL/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
DFELHWC-FECA: Send all forms for FECA to OWCP/DFELHWC-FECA, PO Box 8311, London, KY 40742-8311, (202) 513-6860
DEEOIC: Send all forms for DEEOIC to Energy Employees Occupational Illness Compensation Programs, PO Box 8304, London, KY 40742-8304
DCMWC: Send all forms for DCMWC to Federal Black Lung program, PO Box 8302, London, KY 40742-8302
DFELHWC-LHWC: Send all forms for LHWC to OWCP/DFELHWC - LHWC, PO Box 8313, London, KY 8313
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.
Item 1.
Item 1a.
Item 2.
Item 3.
Item 4.

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/DD/YY) 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.
Item 5. Enter the patient's address (street address, city, state, ZIP code; telephone number is optional).
Item 6. Leave blank.
Item 7. For FECA: leave blank. For BLBA and EEOICPA: complete if Item 4 was completed. Enter the address of the party to be paid.
Item 8. Leave blank.
Item 9. 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.
OMB No. 1240-0044
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OWCP-1500 PAGE 2 (Rev. 06-15)

Item 11a.
Item 11b.
Item 11c.
Item 11d.
Item 12.
Item 13.
Item 14.
Item 15.
Item 16.
Item 17.
Item 18.
Item 19.
Item 20.
Item 21.
Item 22.
Item 23.
Item 24.

Item 25:
Item 26:
Item 27:
Item 28:
Item 29:
Item 30:
Item 31:
Item 32:
Item 33:
Item 33a.
Item 33b.

Leave blank.
Leave blank.
Leave blank.
Leave blank.
The signature of the patient or authorized representative authorizes release of the medical information necessary to process the claim, and
requests payment. Signature is required; mark (X) must be co-signed by witness 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 ICD codes. Enter codes in priority order (primary, secondary condition).
Coding structure must follow the International Classification of Disease, 10th Edition, Clinical Modification or the latest revision published. A
brief narrative may also be entered but not substituted for the ICD code.
Leave blank.
Leave blank.
Column A: enter month, day and year (MM/DD/YY) 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 ICD code, or enter the appropriate ICD code.
Column F: enter the total charge(s) for each listed service(s).
Column G: enter the number of services/units provided for period listed in Column A. Anesthesiologists enter time in total minutes, not units.
Column H: Leave blank.
Column I: 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.

Place of Service (POS) Codes for Item 24B
2
Telehealth
3
School
4
Homeless Shelter
5
Indian Health Service Free-Standing Facility
6
Indian Health Service Provider-Based Facility
7
Tribal 638 Free-Standing Facility
8
Tribal 638 Provider-Based Facility
9
Prison
11
Office
12
Patient Home
13
Assisted Living
14
Group Home
15
Mobile Unit
17
Walk in Retail Health Clinic
18
Place of Employment/Worksite
19
Off Campus Outpatient Hospital
20
Urgent Care
21
Inpatient Hospital
22
Outpatient Hospital
23
Emergency Room - Hospital
24
Ambulatory Surgical Center
25
Birthing Center
26
Military Treatment Facility
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
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34
41
42
49
50
51
52
53
54
55
56
57
60
61
62
65
71
72
81
99

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 Center
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
End Stage Renal Disease Treatment Facility
State or Local Public Health Clinic
Rural Health Clinic
Independent Laboratory
Other Place of Service

OWCP-1500 PAGE 3 (Rev. 06-15)

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 displays a valid OMB 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 structures 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 this burden, to the Office of
Workers' 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 (1240-0044), 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 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.

OMB No. 1240-0044
Expires: 06/30/2021

OWCP-1500 PAGE 4 (Rev. 06-15)