Form OWCP-1500 at a glance
What it is: Form OWCP-1500 is the health insurance claim form for medical services under FECA, BLBA and EEOICPA (Act of 2000); FECA (5 USC 8101 et seq.) claims are for employment-related illness or injury.
Who signs: 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).
What to bring and attach to Form OWCP-1500
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.
A filled-in Form OWCP-1500 example: a clinic bills one office visit
How to fill out Form OWCP-1500, box by box
Claim number, patient name, birth date and address
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 5: Enter the patient's address (street address, city, state, ZIP code; telephone number is optional).
Items 4, 7 and 11
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 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 11: For FECA: enter patient's claim number. Omission will result in delayed bill processing. For BLBA and EEOICPA: leave blank.
Item 12: the signature of the patient or authorized representative
Item 12: The signature of the patient or authorized representative authorizes release of the medical information necessary to process the claim, and requests payment. Signature is required; mark (X) must be co-signed by witness and relationship to patient indicated.
Item 21: diagnosis codes
Item 21: Enter the diagnosis(es) of the condition(s) being treated using current ICD codes. Enter codes in priority order (primary, secondary condition).
Coding structure must follow the International Classification of Disease, 10th Edition, Clinical Modification or the latest revision published. A brief narrative may also be entered but not substituted for the ICD code.
Date(s) of service, procedures and charges
Item 24: Column A: enter month, day and year (MM/DD/YY) for each service/consultation provided.
If the "from" and "to" dates represent a series of identical services, enter the number of services provided in Column G.
Column B: enter the correct CMS/OWCP standard "place of service" (POS) code.
Column C: not required.
Column D: enter the proper five-digit CPT (current edition) code and modifier(s), the HCPCS, or the OWCP generic procedure code.
Column E: enter the diagnostic reference letter (A, B, C, etc. in Item 21) to relate the date of service and the procedure(s) performed to the appropriate ICD code, or enter the appropriate ICD code.
Column F: enter the total charge(s) for each listed service(s).
Column G: enter the number of services/units provided for period listed in Column A. Anesthesiologists enter time in total minutes, not units.
Column H: Leave blank. Column I: Leave blank.
Column J: enter the Taxonomy code in the shaded area of the field. Enter the NPI number in the unshaded area of the field. When NPI is entered, Taxonomy is required, and vice versa. Required: Enter the servicing NPI for group providers.
Correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate payment.
Failure to supply the claim number or CPT codes will delay payment or may result in rejection of the claim because of incomplete information.
Federal tax I.D. number, account number and charges
Item 25: Enter the Federal tax I.D.
Item 26: Provider may enter a patient account number that will appear on the remittance voucher.
Item 28: Enter the total charge for the listed services in Column F.
Item 29: If any payment has been made, enter that amount here.
Item 30: Enter the balance now due.
Signature date, service facility and billing provider
Item 31: For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable.
31. Signature of physician or supplier including degrees or credentials: the signer certifies that the statements apply to this bill and are made a part thereof.
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.
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.
Item 32: Enter complete name of hospital, facility or physician's office where services were rendered.
Item 32a: Enter NPI. Item 32b: Enter taxonomy number.
Item 33: Enter (1) the name and address to which payment is to be made, and (2) your DOL provider number after "PIN #" if you are an individual provider, or after "GRP #" if you are a group provider. Failure to enter this number will delay payment or cause a rejection of the bill for incomplete/inaccurate information.
Item 33a: Enter billing provider NPI. Item 33b: Enter billing provider Taxonomy. Omission of either will result in delayed bill processing.
More rules for Form OWCP-1500
Item 13: Signature indicates authorization for payment of benefits directly to the provider.
Claims, physicians, reports and items to leave blank
Claims under each Act
Claims filed under EEOICPA (42 USC 7384 et seq.) are for compensable illnesses defined under that Act.
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.
Physician, as defined by State law
"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.
Medical report and test results
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.
OWCP payment of reasonable charges
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.
Items to leave blank
Items 1, 6, 8, 9 and 10: Leave blank.
Items 11a, 11b, 11c, 11d, 14, 15, 16, 17, 18, 19, 20, 22, 23 and 27: Leave blank.
Common questions about Form OWCP-1500
Where do I file it?
Send all forms for FECA to OWCP/DFEC-FECA, PO Box 8300, London, KY 40742-8300, (202) 513-6860; for DEEOIC to Energy Employees Occupational Illness Compensation Programs, PO Box 8304, London, KY 40742-8304; for DCMWC to Federal Black Lung program, PO Box 8302, London, KY 40742-8302.
Sources
[1] Form OWCP-1500 (03-25), Health Insurance Claim Form, U.S. Department of Labor (the Official source link on this page).
