OWCP/UB-92 Uniform Billing Form

1

FROM

8 N-C D.

7 COV D.

THROUGH

9 C-I D.

10 L-R D.

OCCURRENCE

CODE

35

36

OCCURRENCE

CODE

DATE

DATE

FROM

THROUGH

a
b
39

38

27

VALUE CODES

40

AMOUNT

46 SERV. UNITS

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48 NON-COVERED CHARGES

47 TOTAL CHARGES

53 ASG
BEN 54 PRIOR PAYMENTS

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8
9
10
11
12
13
14

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17
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19
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23

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6
7

56

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59 P. REL 60 CERT. - SSN - HIC. - ID NO.

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58 INSURED’S NAME

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DUE FROM PATIENT

57

5

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55 EST. AMOUNT DUE
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A
B
C

1
2
3
4

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52 REL
INFO

51 PROVIDER NO.

a
b
c
d

49

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19
20
21
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23

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17
18

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15
16

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13
14

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12

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10
11

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8
9

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6
7

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1
2
3
4
5

50 PAYER

AMOUNT

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45 SERV. DATE

VALUE CODES

CODE

AMOUNT

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44 HCPCS / RATES

30

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43 DESCRIPTION

29

41

VALUE CODES

CODE
○

a
b
c
d

31
28

A
B
C

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CODE

26

37
A
B
C

OCCURRENCE SPAN
CODE

25

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DATE

24

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34

OCCURRENCE

CONDITION CODES

20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO.

19 TYPE

○

CODE

18 HR

○

33

DATE

17 DATE

○

ADMISSION

15 SEX 16 MS

OCCURRENCE

42 REV. CD.

11

13 PATIENT ADDRESS

14 BIRTHDATE

CODE

6 STATEMENT COVERS PERIOD

5 FED. TAX NO.

12 PATIENT NAME

32

APPROVED OMB NO. 0938-0279
4 TYPE
OF BILL

3 PATIENT CONTROL NO.

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ST11843 1PLY UB-92

2

61 GROUP NAME

62 INSURANCE GROUP NO.

A
B
C

A
B
C
63 TREATMENT AUTHORIZATION CODES

64 ESC 65 EMPLOYER NAME

66 EMPLOYER LOCATION

A
B
C

A
B
C
67 PRIN. DIAG. CD.
79 P.C. 80

68 CODE

69 CODE

PRINCIPAL PROCEDURE

CODE

DATE

81

OTHER DIAG. CODES
71 CODE
72 CODE

70 CODE

OTHER PROCEDURE

CODE

DATE

A
OTHER PROCEDURE

CODE

C

DATE

DATE

D

DATE

75 CODE

76 ADM. DIAG. CD. 77 E-CODE

78

82 ATTENDING PHYS. ID

OTHER PROCEDURE

CODE

DATE

83 OTHER PHYS. ID

E
OTHER PHYS. ID

a 84 REMARKS
b
c
d
UB-92 HCFA-1450

OTHER PROCEDURE

CODE

74 CODE

B

OTHER PROCEDURE

CODE

73 CODE

85 PROVIDER REPRESENTATIVE

x
OCR/ORIGINAL

A
B

a
b
a
b
86 DATE

I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

UNIFORM BILL:

NOTICE: ANYONE WHO MISREPRESENTS OR FALSIFIES ESSENTIAL
INFORMATION REQUESTED BY THIS FORM MAY UPON CONVICTION BE
SUBJECT TO FINE AND IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW.

Certifications relevant to the Bill and Information Shown on the Face
Hereof: Signatures on the face hereof incorporate the following
certifications or verifications where pertinent to this Bill:
1. If third party benefits are indicated as being assigned or in participation
status, on the face thereof, appropriate assignments by the insured/
beneficiary and signature of patient or parent or legal guardian
covering authorization to release information are on file.
Determinations as to the release of medical and financial information
should be guided by the particular terms of the release forms that
were executed by the patient or the patient’s legal representative.
The hospital agrees to save harmless, indemnify and defend any
insurer who makes payment in reliance upon this certification, from
and against any claim to the insurance proceeds when in fact no
valid assignment of benefits to the hospital was made.
2. If patient occupied a private room or required private nursing for
medical necessity, any required certifications are on file.
3. Physician’s certifications and re-certifications, if required by contract
or Federal regulations, are on file.
4. For Christian Science Sanitoriums, verifications and if necessary reverifications of the patient’s need for sanitorium services are on file.
5. Signature of patient or his/her representative on certifications,
authorization to release information, and payment request, as required
be Federal law and regulations (42 USC 1935f, 42 CFR 424.36, 10
USC 1071 thru 1086, 32 CFR 199) and, any other applicable contract
regulations, is on file.
6. This claim, to the best of my knowledge, is correct and complete and
is in conformance with the Civil Rights Act of 1964 as amended.
Records adequately disclosing services will be maintained and
necessary information will be furnished to such governmental
agencies as required by applicable law.
7. For Medicare purposes:
If the patient has indicated that other health insurance or a state
medical assistance agency will pay part of his/her medical expenses
and he/she wants information about his/her claim released to them
upon their request, necessary authorization is on file. The patient’s
signature on the provider’s request to bill Medicare authorizes any
holder of medical and non-medical information, including employment
status, and whether the person has employer group health insurance,
liability, no-fault, workers’ compensation, or other insurance which is
responsible to pay for the services for which this Medicare claim is
made.
8. For Medicaid purposes:
This is to certify that the foregoing information is true, accurate, and
complete.
I understand that payment and satisfaction of this claim will be
from Federal and State funds, and that any false claims, statements,
or documents, or concealment of a material fact, may be prosecuted
under applicable Federal or State Laws.

ESTIMATED CONTRACT BENEFITS

9.For CHAMPUS purposes:
This is to certify that:
(a) the information submitted as part of this claim is true, accurate and
complete, and, the services shown on this form were medically
indicated and necessary for the health of the patient;
(b) the patient has represented that by a reported residential address
outside a military treatment center catchment area he or she does not
live within a catchment area of a U.S. military or U.S. Public Health
Service medical facility, or if the patient resides within a catchment
area of such a facility, a copy of a Non-Availability Statement (DD
Form 1251) is on file, or the physician has certified to a medical
emergency in any assistance where a copy of a Non-Availability
Statement is not on file;
(c) the patient or the patient’s parent or guardian has responded directly
to the provider’s request to identify all health insurance coverages,
and that all such coverages are identified on the face the claim except
those that are exclusively supplemental payments to CHAMPUSdetermined benefits;
(d) the amount billed to CHAMPUS has been billed after all such coverages
have been billed and paid, excluding Medicaid, and the amount billed
to CHAMPUS is that remaining claimed against CHAMPUS benefits;
(e) the beneficiary’s cost share has not been waived by consent or failure
to exercise generally accepted billing and collection efforts; and,
(f) any hospital-based physician under contract, the cost of whose
services are allocated in the charges included in this bill, is not an
employee or member of the Uniformed Services. For purposes of this
certification, an employee of the Uniformed Services is an employee,
appointed in civil service (refer to 5 USC 2105), including part-time or
intermittent but excluding contract surgeons or other personnel
employed by the Uniformed Services through personal service
contracts. Similarly, member of the Uniformed Services does not apply
to reserve members of the Uniformed Services not on active duty.
(g) based on the Consolidated Omnibus Budget Reconciliation Act of
1986, all providers participating in Medicare must also participate in
CHAMPUS for inpatient hospital services provided pursuant to
admissions to hospitals occurring on or after January 1, 1987.
(h) if CHAMPUS benefits are to be paid in a participating status, I agree
to submit this claim to the appropriate CHAMPUS claims processor
as a participating provider. I agree to accept the CHAMPUSdetermined reasonable charge as the total charge for the medical
services or supplies listed on the claim form. I will accept the
CHAMPUS-determined reasonable charge even if it is less than the
billed amount, and also agree to accept the amount paid by CHAMPUS,
combined with the cost-share amount and deductible amount, if any,
paid by or on behalf of the patient as full payment for the listed medical
services or supplies. I will make no attempt to collect from the patient
(or his or her parent or guardian) amounts over the CHAMPUSdetermined reasonable charge. CHAMPUS will make any benefits
payable directly to me, if I submit this claim as a participating provider.

Instructions for Completing OWCP-92 Uniform Billing 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 illnesses defined under that Act. Benefits provided under these statutes include inpatient/outpatient
hospital services, ambulatory surgical care, chemotherapy treatment services, and other non-professional medical services for covered injuries or illnesses.
Services provided by skilled nursing facilities, nursing homes and hospices (including medications and other services such as oxygen and respiratory services), as
well as personal care services provided by a home health aide, licensed practical nurse or similarly trained individual, may also be provided.
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 condition-specific fee schedule based on the Prospective
Payment System devised by the Centers for Medicare and Medicaid Services (CMS) 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),
Revenue Center codes and Diagnosis-Related Group (DRG) codes; therefore, use of correct codes and modifier(s) is required. Incorrect coding will result in
inappropriate or delayed 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.
ITEMIZED BILLS AND TREATMENT PLANS: All forms submitted for inpatient hospital services must be accompanied by an itemized billing statement and an
admission/discharge summary. Forms submitted for hospice services or for personal care services provided in the home must be accompanied by a plan of care
and treatment.
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.
NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION
(PRIVACY ACT STATEMENT)
OWCP is authorized by 5 USC 8101 et seq., 30 USC 901 et seq., and 42 USC 7384d to collect information needed to administer the FECA, BLBA and EEOICPA.
The information collected is used to identify the eligibility of the claimant for benefits, and to determine coverage of services provided. There are no penalties for
failure to supply information; however, failure to furnish information regarding the medical service(s) received or the amount charged will prevent payment of the
claim. Failure to supply the claim number or required codes will delay payment or may result in rejection of the bill 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 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.
SIGNATURE OF PROVIDER: Your signature in Block 85 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 Block 85 also indicates that the services shown on this
form were provided, and that the billing information submitted is both complete and accurate. Finally, your signature indicates that you understand that any false
claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.
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.
NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information
may be guilty of a criminal act punishable under law and may be subject to civil penalties.
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.
Block 1
Block 2
Block 3
Block 4
Block 5
Block 6
Block 7
Block 8
Block 9
Block 10
Block 11
Block 12

Block 13
Block 14
Block 15
Block 16
Block 17
Block 18
Block 19

Type or print complete provider name, street address, city, state and zip code. Also include area code and phone number.
Blank field.
Not required.
Type of bill classification using appropriate three-digit code: 1st position indicates type of facility, 2nd position indicates type of care, 3rd position
indicates billing sequence.
Type or print Federal tax I.D. assigned for tax reporting purposes.
Type or print dates for the full ranges of services being invoiced (period from/through using MM/DD/YY).
Type or print number of covered days.
Not required.
Not required.
Not required.
Blank field.
Type or print patient’s name. Use a comma or space to separate the last and first names, do not use titles such as Mr. or Mrs., and do not leave a
space before a prefix to a last name. If last name is hyphenated, both names should be capitalized, and a space should separate a last name and any
suffix. For EEOICPA, type or print name as it appears on the Medical Benefits Identification Card.
Type or print complete mailing address of patient.
Type or print month, year, and day of patient’s birth (MM/DD/YY).
Type or print sex of patient, using M or F only.
Not required.
Type or print month, day, and year (MM/DD/YY) of admission.
Enter the code for admission hour.
Not required.

OMB No. 1215-0176
Expires: 01/31/2010

OWCP-92
May 2006

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Block 80
Block 81
Block 82
Block 83
Block 84
Block 85
Block 86

Not required.
Not required.
Type or print patient’s two-digit status code on the last day of the billing period.
Not required.
Not required.
Not required.
Not required.
Not required.
Not required.
Not required.
Not required.
Blank field.
Not required.
Not required.
Not required.
Not required.
Not required.
Blank field.
Not required.
For BLBA: If billing for private room, the semi-private room rate is required.
Not required.
Not required.
Type or print Revenue Center Code(s).
Type or print Revenue Center Code description(s).
Type or print applicable private/semi-private room rate, and the CPT or HCPCS codes and modifiers based on bill type (inpatient or outpatient).
Not required.
Type or print units of service for inpatient. For outpatient, enter units of service for each RCC.
Type or print total charges by RCC and procedure code.
Not required.
Blank field.
Type or print program payer: U.S. DOL-OWCP-FECA, -BLBA or -EEOICPA, as appropriate, and Medicare number (on B) for inpatient services.
Type or print Provider I.D. Number provided by the program being billed, and Medicare number for inpatient services.
Not required.
Not required.
Type or print the amount of any prior payments made.
Not required.
Not required.
Blank field.
Type or print insured’s last name, first name.
Not required.
For EEOICPA and BLBA: type or print patient’s SSN. For FECA: type or print patient’s claim number.
Not required.
Not required.
Not required.
Not required.
Not required.
Not required.
Type or print complete ICD-9-CM diagnosis code for principal diagnosis. Enter the 4th and 5th digits if applicable. Each diagnosis must be valid for the
date of service.
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for other diagnosis (if applicable).
Type or print complete ICD-9-CM diagnosis code for admission diagnosis. Enter the 4th and 5th digits if applicable. Each diagnosis must be valid
for the date of service.
Not required.
Blank field.
Type or print indicator for type of code used in Blocks 80 and 81.
Type or print principal procedure using ICD-9-CM and date of occurrence (MM/DD/YY) during hospitalization. Inpatient claims and all surgical
procedures require ICD-9-CM codes. Outpatient claims require CPT/HCPCS codes.
Type or print any other procedure using ICD-9-CM and date of occurrence (MM/DD/YY) during hospitalization. Inpatient claims and all surgical
procedures require ICD-9-CM codes. Outpatient claims require CPT/HCPCS codes.
Not required.
Not required.
Not required.
Signature block for provider representative. Attests to conformance with certifications on the form.
Type or print date bill is submitted (MM/DD/YY).

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 1215-0176. 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 (1215-0176), Washington, DC 20503. DO NOT SEND THE COMPLETED FORM TO EITHER OF THESE OFFICES.