Form Owcp 1500 Details

When it comes to our health, we want to be sure that we are doing everything possible to protect ourselves. This includes making sure that any claims we make about our health are accurate and substantiated. The form health claim is a document that can help us do just that. By filling out this form, you can provide information about any health-related statements you may have made. This will help ensure that your statements are factually correct and not misleading in any way. Filling out this form is an important step in protecting both yourself and others from inaccurate information about health.

In the table, there's some good information concerning the form health claim. It may be helpful to know its length, the typical time needed to prepare the form, the blanks you should fill in, and so on.

QuestionAnswer
Form NameForm Health Claim
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesform owcp 1500, fillable health insurance claim form, form health claim pdf, form insurance claim print

Form Preview Example

HEALTH INSURANCE CLAIM FORM

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE

OMB No. 1240-0044 Expires: 06/30/2021

1.

MEDICARE

MEDICAID

TRICARE

 

 

 

 

CHAMPVA

GROUP HEALTH

FECA BLK

 

 

OTHER

 

 

 

1a. INSURED I.D. NUMBER

 

 

 

 

(For Program in Item 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Medicare#)

(Medicaid#)

(ID#/DoD#)

 

 

 

 

(Member ID#)

PLAN (ID#)

LUNG (ID#)

 

 

(ID#)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. PATIENT'S NAME (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

3. PATIENT'S BIRTH DATE

 

 

 

 

 

 

SEX

 

 

 

 

 

4. INSURED'S NAME (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. PATIENT'S ADDRESS (Street, City, State, Zip)

 

 

 

 

 

 

 

 

6. PATIENT RELATIONSHIP TO INSURED

 

 

 

 

 

 

 

 

7. INSURED'S ADDRESS (Street, City, State, Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

 

 

 

Spouse

Child

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. RESERVED FOR NUCC USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE (Include Area Code):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE (Include Area Code):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. OTHER INSURED'S NAME (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

10. PATIENT'S CONDITION RELATED TO:

 

 

 

 

 

 

 

 

11. INSURED'S POLICY GROUP OR FECA NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. EMPLOYMENT? (Current or Previous)

 

 

 

 

 

 

 

 

a. INSURED'S DATE OF BIRTH

 

 

 

 

 

 

 

SEX

a. OTHER INSURED POLICY OR GROUP NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. RESERVED FOR NUCC USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. AUTO ACCIDENT?

 

PLACE (State)

 

 

 

 

 

b. OTHER CLAIM ID (Designated by NUCC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. RESERVED FOR NUCC USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. OTHER ACCIDENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. PATIENT'S PLAN OR PROGRAM NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10d. CLAIM CODES (Designated by NUCC)

 

 

 

 

 

 

 

 

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

If yes, complete items 9, 9a, and 9d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE

 

 

 

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessaryto

I authorize payment of medical benefits to the undersigned physician

process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

 

 

 

 

 

or supplier for services described below..

 

 

 

 

 

 

 

 

SIGNED _________________________________________________

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED _______________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

 

15. OTHER DATE

 

 

 

 

 

 

 

 

 

 

16.

DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUAL.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM:

 

 

 

 

 

 

 

 

 

TO:

 

 

 

 

 

 

 

 

 

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

 

 

 

 

17a.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17b.

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM:

 

 

 

 

 

 

 

 

 

 

TO:

 

 

 

 

 

 

 

 

 

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. OUTSIDE LAB?

 

 

 

 

 

 

$ CHARGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24e)

 

 

ICD Ind.

 

 

 

 

22. RESUBMISSION CODE

 

 

 

 

 

ORIGINAL REF. NO.

A.

 

 

 

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

 

 

 

 

 

 

 

 

 

 

 

 

 

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E.

 

 

 

F.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G.

 

 

 

 

 

 

 

 

 

 

 

 

 

H.

 

 

 

 

 

 

 

 

 

 

 

23. PRIOR AUTHORIZATION NUMBER

 

 

 

 

 

 

 

 

I.

 

 

 

J.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K.

 

 

 

 

 

 

 

 

 

 

 

 

 

L.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. A. DATE(S) OF SERVICE

 

 

 

 

 

 

 

 

B.

 

C.

D. PROCEDURES, SERVICES, OR SUPPLIES

 

 

E.

 

 

 

 

 

 

F.

 

 

G.

 

H.

 

I.

 

 

 

 

J.

 

 

 

 

 

 

 

 

 

 

 

PLACE OF

 

 

 

 

 

 

 

(Explain Unusual Circumstances)

 

 

 

 

 

DIAGNOSIS

 

 

 

 

 

 

 

 

 

DAYS OR

EPSOT

 

ID

 

 

RENDERING

 

From

 

 

To

 

SERVICE

EMG

 

 

CPT/HCPSCS

 

 

 

 

MODIFIER

 

 

 

 

 

POINTER (A-L)

 

 

$ CHARGES

UNITS

Family

QUAL.

 

PROVIDER NPI #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

25. FEDERAL TAX I.D. NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26. PATIENT'S ACCOUNT NO.

 

 

 

 

27. ACCEPT ASSIGNMENT?

28. TOTAL CHARGE

29. AMOUNT PAID

30. Rsvd for NUCC Use

 

 

 

 

 

 

 

 

 

 

SSN EIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(For govt. claims, see back)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

 

 

32. SERVICE FACILITY LOCATION

 

 

 

 

 

33. BILLING PROVIDER INFO & PH #

 

 

 

 

 

 

 

 

 

INCLUDING DEGREES OR CREDENTIALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(I certify that the statements on the reverse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

apply to this bill and are made a part thereof.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED __________________

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

 

 

 

 

 

b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT AND INSURED INFORMATION

PHYSICIAN OR SUPPLIER INFORMATION

NUCC instruction Manual available at www.nucc.org

PLEASE PRINT OR TYPE

APPROVED OMB-093B-1197 FORM CMS-1500 (06-15)

Instructions for Completing OWCP-1500 Health Insurance Claim 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 compensable illnesses defined under that Act. All services, appliances, and supplies prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to give relief, reduce the degree or period of the disability or illness, or aid in lessening the amount of the monthly compensation, may be furnished. "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.

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 relative value scale fee schedule and other tests to determine reasonableness. Schedule limitations are applied through an automated billing system that is based on theidentification of procedures as defined in the AMA's Current Procedural Terminology (CPT); correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate 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.

REPORTS: 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 (as defined above). 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.

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.

SIGNATURE OF PHYSICIAN OR SUPPLIER: 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 notpaid 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 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. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental, part of a covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of non-physicians must be included on the bills. Finally, your signature indicates that you understand that any false claims, statements or documents, or concealment of a material act, may beprosecuted under applicable Federal or State laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION

(PRIVACY ACT STATEMENT)

We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to collect information is in 5 USC 8101 et seq.; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179.The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are covered by these programs and to insure that proper payment is made. Your response regarding the medical service(s) received or the amount charged is required to receive payment for the claim. See 20 CFR §§ 10.801, 30.701, 725.406, 725.701, and 725.704. Failure to supply the claim number or CPT codes will delay payment or may result in rejection of the claim 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 asotherwise 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 systems of records. See 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.

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 otherwiseinstructed.

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.

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.

Item 1. Leave blank.

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 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 5. Enter the patient's address (street address, city, state, ZIP code; telephone number is optional). Item 6. Leave blank.

Item 7. For FECA: leave blank. For BLBA and EEOICPA: complete if Item 4 was completed. Enter the address of the party to bepaid. Item 8. Leave blank.

Item 9. Leave blank. Item 10. Leave blank.

Item 11. For FECA: enter patient's claim number. OMISSION WILL RESULT IN DELAYED BILL PROCESSING. For BLBA and EEOICPA: leave blank.

OMB No. 1240-0044

OWCP-1500 PAGE 2 (Rev. 06-15)

Expires: 05/31/2019

 

Item 11a.

Leave blank.

 

Item 11b.

Leave blank.

 

Item 11c.

Leave blank.

 

Item 11d.

Leave blank.

 

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 13.

Signature indicates authorization for payment of benefits directly to the provider. Acceptance of this assignment is considered to be a

 

 

contractual arrangement. The "authorizing person" may be the beneficiary (patient) eligible under the program billed, a person with a power of

 

attorney, or a statement that the beneficiary's signature is on file with the billing provider.

 

Item 14.

Leave blank.

 

Item 15.

Leave blank.

 

Item 16.

Leave blank.

 

Item 17.

Leave blank.

 

Item 18.

Leave blank.

 

Item 19.

Leave blank.

 

Item 20.

Leave blank.

 

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.

 

Item 22.

Leave blank.

 

Item 23.

Leave blank.

 

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 (see below).

 

 

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 NPI. For FECA: required. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.

 

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 27:

Leave blank.

 

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.

 

Item 31:

For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable.

 

Item 32:

Enter complete name of hospital, facility or physician's office were services were rendered. Item 32a. EnterNPI. 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 youare 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 NPI.

 

Item 33b.

Enter taxonomy number.

 

Place of Service (POS) Codes for Item 24B

 

 

 

 

2

Telehealth

34

Hospice

 

 

3

School

41

Ambulance - Land

 

4

Homeless Shelter

42

Ambulance - Air or Water

5

Indian Health Service Free-Standing Facility

49

Independent Clinic

 

6

Indian Health Service Provider-Based Facility

50

Federally Qualified Health Center

7

Tribal 638 Free-Standing Facility

51

Inpatient Psychiatric Facility

8

Tribal 638 Provider-Based Facility

52

Psychiatric Facility Partial Hospitalization

9

Prison

53

Community Mental

Health Center (CMHC)

11

Office

54

Intermediate

Care

Facility/Mentally Retarded

12

Patient Home

55

Residential Substance Abuse Treatment Facility

13

Assisted Living

56

Psychiatric Residential Treatment Center

14

Group Home

57

Non-Residential Substance Abuse Treatment Center

15

Mobile Unit

60

Mass Immunization Center

17

Walk in Retail Health Clinic

61

Comprehensive Inpatient Rehabilitation Facility

18

Place of Employment/Worksite

62

Comprehensive Outpatient Rehabilitation Facility

19

Off Campus Outpatient Hospital

65

End Stage Renal Disease Treatment Facility

20

Urgent Care

71

State or Local Public Health Clinic

21

Inpatient Hospital

72

Rural Health

Clinic

 

22

Outpatient Hospital

81

Independent

Laboratory

23

Emergency Room - Hospital

99

Other Place

of Service

24Ambulatory Surgical Center

25Birthing Center

26Military Treatment Facility

31Skilled Nursing Facility

32Nursing Facility

33Custodial Care Facility

OMB No. 1240-0044

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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 1240-0044. 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 andprior 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 (1240-0044), Washington, DC 20503. DO NOT SEND THE COMPLETED FORM TO EITHER OF THESE OFFICES.

NOTICE

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law givesyou the right to receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.

OMB No. 1240-0044

OWCP-1500 PAGE 4 (Rev. 06-15)

Expires: 05/31/2019

 

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