Uniform Billing Form

Forms and Documents

Document Name	Status
Form OWCP-04 Uniform Billing Form (OWCP-04) Form and Instruction	Modified
ICR 1240-0019 - Supporting Statement A 2.25.22.docx Supporting Statement A	2022-02-25
20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 30.701 EEOICPA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 10.801 FECA - Supporting Reg.pdf Supplementary Document	2012-11-05

IC Document Collections

IC ID	Document Title	Status
38466	Uniform Billing Form (OWCP-04) Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0019	ICR Reference No: 202112-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202008-1240-072
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Uniform Billing Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/01/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2022
Responses	246,305	259,865
Time Burden (Hours)	24,684	29,466
Cost Burden (Dollars)	0	0

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Abstract: OWCP requires institutional medical providers who provide services to beneficiaries covered under FECA, BLBA, and EEOICPA to bill using a form based on the industry standard, the UB-04. Form OWCP-04 identifies the beneficiary, the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Federal Employee's Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 64529	11/18/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11483	03/01/2022
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
Uniform Billing Form (OWCP-04)	OWCP-04	Uniform Billing Form

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ICR Summary of Burden

	Total Request	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	246,305	259,865	0	0	-13,560	0
Annual Time Burden (Hours)	24,684	29,466	0	0	-4,782	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: The Federal Cost and Burden hours have increased due to the increase in the number of forms submitted. In addition, the final BLBA rule continues the current information collection requirements but would change where the regulatory authorities are codified. This ICR updates the regulatory citation for the BLBA program’s authority to collect the information. The instruction for UB-04 Block 43 have been updated to include the following: “If billing an unlisted J-Code with RCC 0636, a valid NDC Code must be specified in this block and the drug quantity listed in Block 46."

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Annual Cost to Federal Government: $4,426,132

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? No

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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: 03/01/2022

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