Uniform Billing Form (OWCP-04)

Forms and Documents

Document Name	Status
Form OWcp-04 Uniform Billing Form (OWCP-04) Form and Instruction	Modified
NOTE TO REVIEWER 1215-0176.doc Supplementary Document	2009-06-09
1215-0176 Supporting Statement 9-24-2009 final[2].doc Supporting Statement A	2009-09-24

IC Document Collections

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

ICR Details

OMB Control No: 1215-0176	ICR Reference No: 200905-1215-001
Status: Historical Active	Previous ICR Reference No: 200701-1215-007
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Uniform Billing Form (OWCP-04)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/06/2009
	Date Received in OIRA: 10/06/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved	01/31/2010
Responses	21,924	0	30,372
Time Burden (Hours)	2,558	0	3,544
Cost Burden (Dollars)	0	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-92. Form OWCP-92 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. On January 5, 2007, Form OWCP-92, which incorporates the first page of the paper UB-92, was renewed for three years in OMB Control NO. 1215-0176. However, the National Uniform billing Committee (a non-governmental body) has recently made minor changes to the UB-92 to accommodate reporting of the National Provider Identifier (NPI), and has renamed the form as the UB-04. Since the OWCP-92 incorporates the first page of this collection instrument, this 83-C is being submitted to accommodate the incorporation of the new UB-04 into the OWCP-92, which has been renamed as the OWCP-04. No change is sought in the expiration date of January 31, 2010.

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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: The Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illiness 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	74 FR 29721	06/23/2009

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 29721	06/23/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 51173	10/05/2009
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 Approved	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	21,924	30,372	0	0	-8,448	0
Annual Time Burden (Hours)	2,558	3,544	0	0	-986	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: Many of the data fields on the OWCP-04 are generated in electronic systems already used by hospitals and other institutional medical providers for patient billing, inventories, and bookkeeping. As a result, this reduces the burden hours for any one use of the form. Actual use of Form-04 in the EEOICPA program has been less than was originally estimated in 2001. For these reasons, There is a net adjustment decrease of -986 hours.

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Annual Cost to Federal Government: $502,183

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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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: 10/06/2009

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