Sample Health Insurance Claim Form

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
FECA: Send all forms for FECA to the DFEC Central Mailroom, P.O. Box 8300, London, KY 40742-8300, unless otherwise instructed.
BLBA: Send all forms for BLBA to the Federal Black Lung Program, P.O. Box 8302, London, KY 40742-8302, unless otherwise instructed.
EEOICPA: Send all forms for EEOICPA to the Energy Employees Occupational Illness Compensation Program, P.O. Box 8304, London, KY
40742-8304, unless otherwise instructed.
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. Leave blank.
Item 1a. Enter the patient's claim number.
Item 2. Enter the patient's last name, first name, middle initial.
Item 3. Enter the patient's date of birth (MM/DD/YY) and check appropriate box for patient's sex.
Item 4. 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 OWCP-1500 PAGE 2 (Rev. 05-12)
Expires: 01/31/2016
Page 2/4
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Sample Health Insurance Claim Form PDF

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