Instructions for Required Data Elements for Pharmacy Bills (for 2012)

OMB No. 1240-0050
Expiration Date: XX/XX/XXXX
[INFORMATIONAL ONLY]
REQUIRED DATA ELEMENTS FOR ELECTRONIC AND PAPER PHARMACY BILLS
GENERAL INFORMATION: Claims for benefits filed under FECA (5 USC 8101 et seq.) are
for employment-related illness or injury. Claims under EEOICPA (42 USC 7384 et seq.) are
for occupational illnesses defined under that Act. Claims under BLBA (30 USC 901 et seq.)
are for Black Lung Disease as defined under that Act. Benefits provided under all three of
these statutes include medicinal drugs that are prescribed for the treatment of covered injuries
or occupational illnesses.
FEES: The Department of Labor’s Office of Workers’ Compensation Programs (OWCP) is the
responsible party for payment of bills submitted by pharmacies providing prescribed medicinal
drugs to claimants eligible under FECA, EEOICPA and BLBA. OWCP uses a drug-specific fee
schedule based on the average wholesale price plus a dispensing fee when it pays these bills.
Schedule limits are applied using an automated billing system based on the identification of
drugs using the National Drug Code (NDC) number; thus, use of correct codes is required.
Incorrect code usage will result in inappropriate or delayed payment. For specific information
about schedule limits, call the OWCP program office with jurisdiction over the claim.
SIGNATURE OF PROVIDER: Your signature indicates your agreement to accept the charge
determination for medicinal drugs you have dispensed as payment in full, and indicates your
agreement not to seek payment from the patient of any amounts not paid as the result of the
application of OWCP’s fee schedule (appeals are allowed). Your signature also indicates that
the drugs listed on your bill were provided, and that the billing information you have submitted
is complete and accurate. Finally, your signature indicates your understanding that any false
claims, statements or documents, or concealment of a material fact, may be prosecuted under
applicable Federal or State laws.
PAPER BILL SUBMISSION: Send paper pharmacy bills to the Central Mailroom, P.O. Box
8300, London, KY 40742, unless otherwise instructed.
REQUIRED DATA ELEMENTS FOR PAPER BILLS: A brief description of each required data
element for paper bills is listed below. For further information contact OWCP.
Data Element
Authorized Pharmacy
Representative Signature
Cardholder Name

Allowable Values
Comments
Valid signature or signature Y/N Signature indicator
substitute acceptable to
OWCP
Claimant name
For eligibility validation only

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Data Element
Cardholder’s ID Number

Days Supply Dispensed
Group Number
Metric Quantity
NDC – package number
NDC – product name
NDC – product number
New/Refill
Patient/Authorized Rep
Signature
Pharmacy Information – City,
State, ZIP Code
Pharmacy Information – Date
Prescription(s) filled
Pharmacy Information – Name
Pharmacy Information –
Pharmacy Number
Pharmacy Information – Street
Prescription Number
Total Price
Compound Drug Indicator

Allowable Values
FECA claim number, SSN
for BLBA and EEOICPA

Comments
If number is not on the eligibility
file, the bill will be returned with
a form letter stating that the bill
either lacks a claim number or
has an incorrect claim number
and requesting the pharmacy to
obtain the correct number and
resubmit the bill
EIN

N/R Indicator
May be signature on file

OWCP provider number

May be changed to the NABP
number in the future

Y/N Indicator
Privacy Act Statement

Collection of this information by OWCP is necessary for its administration of the Federal Employees’ Compensation Act, the Black
Lung Benefits Act and the Energy Employees Occupational Illness Compensation Program Act and is authorized under 20 CFR
10.801, 20 CFR 30.701, and 20 CFR 725.704 and 725.705. The information provided will be used to ensure accurate payment of
pharmacy bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the following systems of
records: DOL/GOVT-1, DOL/ESA-6 and DOL/ESA-49, published in the Federal Register, Vol. 67, page 16816, April 8, 2002, or
as updated and republished. This information will be furnished to OWCP and its data processing contractors, and may also be
disclosed to other federal and state agencies in connection with the administration of other programs, to the Department of Justice
for litigation purposes, and to medical and other provider review boards. Additional disclosures may be made through the routine
uses for information contained in the referenced systems of records.

Public Burden Statement
Under 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. Submission of the information requested by this collection
is voluntary; however, failure to provide the information (including EIN) will result in substantially delayed payment of pharmacy
bills. We estimate that the time required to respond to this information collection will average 5 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect to this
collection of information, including suggestions for reducing this burden, send them to the Director, Office of Workers’
Compensation Programs, U.S. Department of Labor, Room S-3524, 200 Constitution Avenue NW, Washington, D.C. 20210. DO
NOT SUBMIT PHARMACY BILLS TO THIS ADDRESS.

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