Health Insurance Claim Form

ICR 200907-1215-001

OMB: 1215-0055

Federal Form Document

IC Document Collections
IC ID
Document
Title
Status
43805 Modified
ICR Details
1215-0055 200907-1215-001
Historical Active 200610-1215-006
DOL/ESA
Health Insurance Claim Form
Revision of a currently approved collection   No
Regular
Approved without change 11/06/2009
Retrieve Notice of Action (NOA) 08/24/2009
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved 11/30/2009
2,996,416 0 2,940,000
359,359 0 342,908
0 0 0

Form OWCP-1500 is used by OWCP and contractor bill payment staff to process bills for medical services provided by medical professionals other than medical services provided by hospitals, pharmacies and certain other medical providers. OWCP is adding the data elements National Provider Identifier (NPI) and taxonomy number, which will be 32a and 33a on the revised OWCP-1500. This information is required to pay health care providers for services rendered to injured employees covered under the Office of Worker's Compensation Programs - administered programs. Appropriate payment cannot be made without documentation of the medical services that were provided by the health care provider that is billing OWCP. The information obtained to complete claims under these programs is used to identify the patient and determine their eligibility. It is also used to decide if the services and supplies received are covered by these programs and to assure that proper payment is made.

US Code: 42 USC 7384 et seq. Name of Law: EEOICPA
   US Code: 30 USC 901 et seq. Name of Law: BLBA
   US Code: 5 USC 8101 et seq. Name of Law: FECA
  
None

Not associated with rulemaking

  74 FR 10778 03/12/2009
74 FR 42693 08/24/2009
No

1
IC Title Form No. Form Name
Health Insurance Claim Form OWCP-1500, OWCP-1500 Health Insurance Claim Form ,   Health Insurance Claim Form

  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 2,996,416 2,940,000 0 0 56,416 0
Annual Time Burden (Hours) 359,359 342,908 0 0 16,451 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
As use of the OWCP-1500 as the standard billing form for all three programs increases, the total number of bills submitted on the form also increases. Other factors also affect use of the OWCP-1500. For example, improved medical technology has resulted in an increase in outpatient services with a comparable decrease in inpatient services. This place of service change has resulted in an increase in the use of the OWCP-1500 because it is the most commonly used billing form for outpatient services. For these reasons, this collection shows a net adjustment increase of +16,451 hours.

$9,326,060
No
No
Uncollected
Uncollected
No
Uncollected
Sheldon Turley 202-693-5337 Turley.Sheldon@dol.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/24/2009


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