Form OWCP-1500 Health Insurance Claim Form

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HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE

1.

MEDICARE

D (Medicare#) D

MEDICAID
(Medicaid#)

□

TRICARE
(ID#/DoD#)

□

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CHAMPVA
(Member ID#)

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

□ GROUP HEALTH

PLAN(IO#J

□

FECABLK
LUNG(IO#J

□
SEX

3. PATIENT'S BIRTH DATE

□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

D

Spouse

□

Child

□

(For Program in Item 1)

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

z

0

8. RESERVED FOR NUCC USE

~

::;

a::

TELEPHONE (lndude Area Code):

0
u.

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

C

w

a::

::::,
Cf)

a. OTHER INSURED POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

□M

b. AUTO ACCIDENT?

PLACE (State)

c. OTHER ACCIDENT?

d. PATIENT'S PLAN OR PROGRAM NAME

10d. CLAIM CODES (Designated by NUCC)

□ Yes

c. INSURANCE PLAN NAME OR PROGRAM NAME

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

'

QUAL.i

FROM:

:;:: +NPII

FROM:

TO:

20. OUTSIDE LAB?
0Yes

I

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

B.

C.

D.

E.

F.

G.

H.

I.

J.

K.

L.

C.

TO:

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

EMG

.,.,

SIGNED
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

15. OTHER DATE

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

B.
PLACE OF
SERVICE

~

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
ff yes, complete items 9, 9a, and 9d.
DYes
□ No

DATE

To

z

□ No

SIGNED

From

z
<

f-

b. OTHER CLAIM ID (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 daim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

24. A. DATE(S) OF SERVICE

C

w

c. RESERVED FOR NUCC USE

QUAL.i

□F

□ No

0Yes

14. DATE OF CURRENT ILLNESS, INJU~Y, or PREGNANCY (LMP)

~

SEX

□ No

0Yes
b. RESERVED FOR NUCC USE

a. INSURED'S DATE OF BIRTH

ICDlnd. o

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

MODIFIER

$CHARGES

□ No

22. RESUBMISSION CODE

I

I

ORIGINAL REF. NO.

I

23. PRIOR AUTHORIZATION NUMBER

F.

E.
DIAGNOSIS
POINTER (A-L)

$CHARGES

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

J.
RENDERING
PROVIDER NPI #

------

NPI

------

z

NPI

0

------

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NPI

------

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~

NPI

a::

------

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NPI

w
a.
a.

::::,

------

NPI
25. FEDERAL TAX I.D. NUMBER

26. PATIENT'S ACCOUNT NO.
SSN

□

□

DATE

NUCC instruction Manual available at www.nucc.org

28. TOTAL CHARGE

29. AMOUNT PAID

0Yes

□ No

32. SERVICE FACILITY LOCATION INFORMATION

a.

Ib.
PLEASE PRINT OR TYPE

a::

0
30. Rsvd for NUCC Use

(For govt. claims, see back)

EIN

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.)

SIGNED

27. ACCEPT ASSIGNMENT?

Cf)

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$

$

33. BILLING PROVIDER INFO & PH#

a.

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

a.

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 EEO ICPA 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 DOUGOVT-1, DOUESA-5, DOL/ESA-6, DOU
ESA-29, DOL/ESA-30, DOL/ESA-43, DOL/ESA-44, DOUESA-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
EEO ICPA are listed below. For further information contact OWCP.
Item
Item
Item
Item
Item

1.
1a.
2.
3.
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.
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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
Item 13.
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.
Item 14.
Leave blank.
Item 15.
Leave blank.
Item 16.
Leave blank.
Item 17.
Leave blank.
Item 18.
Leave blank.
Item 19.
Item 20.
Leave blank.
Item 21.
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.
Item 22.
Leave blank.
Item 23.
Leave blank.
Item 24.
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 the Taxonomy code in the shaded area of the field. Enter the NPI number in the unshaded area of the field. When NPI is entered,
Taxonomy is required, and vice versa. Required: Enter the servicing NPI for group providers.
Enter the Federal tax I.D.
Item 25:
Provider may enter a patient account number that will appear on the remittance voucher.
Item 26:
Leave blank.
Item 27:
Enter the total charge for the listed services in Column F.
Item 28:
If any payment has been made, enter that amount here.
Item 29:
Enter the balance now due.
Item 30:
For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable.
Item 31:
Enter complete name of hospital, facility or physician's office were services were rendered. Item 32a. Enter NPI. Item 32b. Enter taxonomy
Item 32:
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
Item 33:
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.
Item 33a.
Enter billing provider NPI. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.
Item 33b.
Enter billing provider Taxonomy. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.
Place of Service (POS) Codes for Item 24B
Hospice
Telehealth
34
2
Ambulance - Land
School
41
3
4
Homeless Shelter
Ambulance - Air or Water
42
Independent Clinic
5
Indian Health Service Free-Standing Facility
49
Indian Health Service Provider-Based Facility
Federally Qualified Health Center
50
6
51
Inpatient Psychiatric Facility
7
Tribal 638 Free-Standing Facility
Psychiatric Facility Partial Hospitalization
Tribal 638 Provider-Based Facility
52
8
9
Prison
Community Mental Health Center (CMHC)
53
11
Intermediate Care Facility/Mentally Retarded
54
Office
55
Residential Substance Abuse Treatment Facility
12
Patient Home
Psychiatric Residential Treatment Center
Assisted Living
13
56
Non-Residential Substance Abuse Treatment Center
14
Group Home
57
Mass Immunization Center
15
Mobile Unit
60
Comprehensive Inpatient Rehabilitation Facility
17
Walk in Retail Health Clinic
61
Comprehensive Outpatient Rehabilitation Facility
Place of Employment/Worksite
18
62
End Stage Renal Disease Treatment Facility
19
65
Off Campus Outpatient Hospital
71
20
State or Local Public Health Clinic
Urgent Care
Rural Health Clinic
21
Inpatient Hospital
72
Independent Laboratory
Outpatient Hospital
22
81
99
Emergency Room - Hospital
Other Place of Service
23
Ambulatory Surgical Center
24
Birthing Center
25
Military Treatment Facility
26
31
Skilled Nursing Facility
Nursing Facility
32
Custodial Care Facility
33
Item 11a.
Item 11b.
Item 11c.
Item 11d.
Item 12.

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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 0MB control number. The valid 0MB 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.

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