Details

The Owcp 1168 form is a document used to apply for Workers' Compensation benefits. The form can be completed online or through the mail, and it is important to ensure that all information is accurate and complete. In order to qualify for Workers' Compensation benefits, you must have suffered an injury or illness while on the job. Completed applications can be submitted online or by mail. For more information, visit our website today.

Here is some specifics that will help you determine the time it will require to finish the owcp 1168 form.

QuestionAnswer
Form NameOwcp 1168 Form
Form Length28 pages
Fillable?No
Fillable fields0
Avg. time to fill out7 min
Other names

Form Preview Example

Dear Provider:

Thank you for your interest in participating as a medical services provider for the four programs administered by the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP). The OWCP administers four major disability compensation programs which provide benefits to certain workers or their dependents who experience work­related injury or occupational disease. These programs include the Division of Federal Employees’ Compensation (DFEC), the Division of Energy Employees Occupational Illness Compensation (DEEOIC), the Division of Coal Mine Workers’ Compensation (DCMWC), and the Division of Longshore and Harbor Workers’ Compensation (DLHWC).

OWCP has contracted to provide medical bill processing services for these four programs. As part of their benefit structure, these programs reimburse medical and non­medical providers for services rendered for the care and treatment of a claimant’s compensable condition.

OWCP can only process bills from providers who have enrolled. To enroll, complete the enclosed provider enrollment form to be assigned a provider identification number. Instructions for completing the enrollment form and a list of provider types are enclosed. Any Provider Enrollment Form that is received with missing or incomplete information will be returned to the submitter for correction and/or completion.

The Debt Collection Improvement Act of 1996 requires that payments made by the Federal Government be sent by electronic funds transfer (EFT). EFT payments are mandatory because it simplifies the process, reduces the incidents of billing error, and allows for expedited handling. An enrollment form for EFT is enclosed. A remittance advice listing all bills paid on each EFT transaction will be sent to your mailing address. Please see notice on page 2.

You must submit current licensure information with your enrollment application. Moreover, each provider must maintain appropriate current licensure in order to receive payments under OWCP's programs.

Group practices are responsible for monitoring the licensure of each servicing provider in the practice. Where large group practices have providers in the group who are not providing medical services to our program on a regular basis, the group practice is responsible for monitoring the licensure of each provider who practices in the entire group.

Providers are required to enroll for each office location. Servicing providers under a group practice are not required to enroll separately.

You may register as a participant in any one or more of the following four OWCP compensation programs – DFEC, DEEOIC, DCMWC, and DLHWC. Please send the completed package(s)) at the address listed on the signature page (page 8) in the Form OWCP­1168.

To assist claimants seeking medical services, OWCP has an on­line listing of providers, by program that is searchable by: specialty, name, city, state, and zip code. Customers will be advised that a provider listing is not an endorsement, referral, or an agreement to reimburse for medical services rendered by the Department of Labor or OWCP. Nor does it guarantee that a medical provider will be reimbursed by OWCP for specific medical services or that a medical provider will agree to provide medical services to a particular claimant.

You will be notified by mail once your enrollment package has been processed. Once you have received your OWCP provider number, you may submit bills to the appropriate program at the following address(s):

U.S. Department of Labor OWCP/DFEC

P. O. Box 8300

London, KY 40742-8300

U.S. Department of Labor OWCP/DEEOIC

P. O. Box 8304

London, KY 40742-8304

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U.S. Department of Labor OWCP/DCMWC

P. O. Box 8302

London, KY 40742-8302

U.S. Department of Labor OWCP/DLHWC

P. O. Box 8313

London, KY 40742-8313

If you have any questions regarding this information, please contact us at:

1­844­493­1966

Our business hours are Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.

NOTICE: Please be aware that the information being requested on Department of Treasury SF 3881­ Payment Information Form ACH Vendor Payment System ­ is required as part of the Department of Treasury Regulation 31 C.F.R. Part 208. This federal regulation, in part, requires that all agencies issuing federal payment do so via Electronic Fund Transfer (EFT). This includes but is not limited to the requirement of requesting a bank signature. Failure to include this information at the time the provider enrollment and ACH Payment Information forms are submitted will result in the return of these documents to the provider.

NOTICE: Continued participation as a medical provider under the four DOL programs above can be contingent on your maintaining good standing as a medical provider under other federal health benefit programs such as Medicare. Exclusion as a medical provider in those circumstances operates as an automatic exclusion under the DFEC, DEEOIC and DLHWC Programs administered by OWCP. (See 20 C.F.R. §§ 10.815, 30.715, and 702.431. You may also be subject to the federal government’s suspension and debarment provisions. (See 48 C.F.R. Subpart 9.4 and 2 C.F.R. Part 180.

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Provider Enrollment Form

U.S. Department of Labor

 

Office of Workers’ Compensation Programs

OMB Number 1240­0021

Expires: 12/31/2023

1. Are you applying for a new enrollment or updating your record?

New Enrollment Re-Enrollment Re­Validation Update

1a. If Update, Re-Enrollment or Re-Validation,

Enter Provider ID or Federal Employer Identification Number (FEIN)

PART A: BASIC INFORMATION (Required)

2.Enrollment Type

Individual

Group Practice (Please see Page 9 for completion of group practice enrollment) Facility/Agency/Organization/Institution

3.Provider Type (For multi­specialty group provider, select primary provider type)

If you select “Other Provider” (96) or Non­Medical Vendor (53) 3a. Please explain

4. Program

 

 

 

DFEC

DCMWC

DEEOIC

DLHWC

5. Individual Information (If you enroll using SSN)

5a. Last Name

5b. First Name

5c. Middle Name

5d. SSN

6. Organization Information

6a. Organization Name

(Legal Business Name)

6b. Organization Business Name

(Doing Business As)

6c. FEIN

7.National Provider Identifier (NPI)

8.Entity Type 8a. If Other, please explain

9.Email Address

10. I do not wish to be included in an online searchable list of OWCP providers.

10a. Reason

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PART B: LOCATION (Required)

11. Location Contact Information

11a. Business Name

11b. Contact Last Name 11c. Contact First Name

11d. Phone Number 11e. Fax Number

11f. Email Address

12. Physical Address

12a. Address Line 1

Address Line 2

Address Line 3

12b. City/Town 12c.State/Province 12d. Zip Code

12e. County

 

 

 

 

12f. Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Mailing Address

 

Same as Physical Address

 

 

 

 

 

 

13a. Address Line 1

 

 

 

 

 

 

 

 

 

 

Address Line 2

 

 

 

 

 

 

 

 

 

 

Address Line 3

 

 

 

 

 

 

 

 

 

 

 

 

13b. City/Town 13c. State/Province 13d. Zip Code

13e. County 13f. Country

 

 

 

PART C: TAXONOMY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Taxonomy a.

 

b.

 

c.

 

d.

 

 

 

 

 

 

e.

 

 

Code(s)

 

 

 

 

 

 

 

 

 

 

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PART D: OWNERSHIP DETAILS

 

15.

Organization Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15a.

Organization Name

 

 

 

 

 

 

 

 

15b. FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Individual Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16a.

Last Name

 

 

 

 

16b. First Name

 

 

 

16c. SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17a. Address Line 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Line 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Line 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17b.

City/Town

 

 

 

 

 

 

17c. State/Province

SELECT

 

17d. Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17e.

County

 

 

 

 

 

17f. Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Ownership Information

 

 

 

 

 

 

 

 

 

 

 

 

18.

Organization Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18a.

Organization Name

 

 

 

 

 

 

 

18b. FEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Individual Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19a.

Last Name

 

 

19b. First Name

 

 

19c. SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20a. Address Line 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address Line 2 Address Line 3

20b. City/Town

20c. State/Province SELECT

20d. Zip Code

20e. County

20f. Country

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PART E: LICENSE AND CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21a.

License/Certification Category

 

 

 

21b. Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21c.

License/Certification Type

 

 

 

 

21d. License/Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21e. Initial Issue Date

 

 

 

21f. Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21g. Issued State

 

 

 

 

 

21h. Issuer Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21i.

Web Link

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21j.

 

 

License/Certification not required by State.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21k.

Please explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional License/Certification

 

 

 

 

 

 

 

 

 

 

 

 

22a.

License/Certification Category

 

 

 

22b. Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22c.

License/Certification Type

 

 

 

 

22d. License/Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22e. Initial Issue Date

 

 

22f. Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22g. Issued State

 

 

22h. Issuer Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22i.

Web Link

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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PART F: IDENTIFIERS

 

 

 

 

 

 

 

 

 

 

 

 

23.

Provider Identifier Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23a. Identifier Type

SELECT

 

 

23b. Identifier Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23c. Start Date

 

 

23d. End Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

Additional Provider identifier information

24a. Identifier Type SELECT

24b. Identifier Value

24c. Start Date

24d. End Date

PART G: EDI SUBMISSION METHOD

25. Mode of Submission. Check all applicable

 

 

 

 

 

Billing Agent/Clearinghouse

 

 

Web Interactive

 

FTP Secured Batch

 

 

 

 

 

 

 

 

 

 

 

 

 

Web Batch

 

 

None

 

 

 

 

 

 

 

 

 

 

PART H: EDI SUBMITTER DETAILS

26. Billing Agent/Clearinghouse/Submitter Information

26a. Billing Agent/Clearinghouse OWCP ID

26b. Start Date 26c. End Date

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PART I: EDI CONTACT DETAILS

27. EDI Contact Information

27a. Contact Title

27b. Last Name

27c. First Name

27d. Phone Number

27e. Fax Number

27f. Email Address

28. Address

28a. Address Line 1

Address Line 2

Address Line 3

 

 

 

 

 

 

 

 

 

 

28b.

City/Town

 

28c. State/Province

SELECT

28d. Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28e.

County

 

28f. Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29. Additional EDI Contact Information

29a. Contact Title

29b. Last Name 29c. First Name

29d. Phone Number 29e. Fax Number

29f. Email Address

30. Address

30a. Address Line 1

Address Line 2

Address Line 3

30b. City/Town

30c. State/Province SELECT

30d. Zip Code

30e. County

30f. Country

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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, the Longshore and Harbor Workers’ Compensation Act and the Energy Employees Occupational Illness Compensation Program Act, and is authorized under 20 CFR 10.800, 20 CFR 30.700, 20 CFR 702.145, 20 CFR 725.714 and 33 USC 918(b). The information provided will be used to ensure accurate payment of medical and vocational rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the following systems of records: DOL/GOVT­1, DOL/OWCP­4 DOL/OWCP­9 and DOL/OWCP­11, published in the Federal Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. Completion and submission of this form is voluntary; however, failure to provide the information (including SSN or FEIN) will result in substantially delayed payment of bills. 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., persons are not required to respond to a collection of information unless such collection displays a valid OMB control number. We estimate that it will take an average of 30 minutes to complete this information collection, including time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this collection including suggestions for reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THE ABOVE ADDRESS.

Notice

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you 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 the claims examiner to ask about this assistance.

Disclosure Statement

Within ten years of the date of this statement have you or any individual listed on this application had an action related to fraud or abuse in a government program taken against him or her resulting in (1) a felony or misdemeanor conviction; (2) a liability finding in civil proceedings; or (3) a settlement entered in lieu of conviction? Yes No

If Yes, provide details including type of action, Agency undertaking adverse action and date of action.

Required for DFEC providers

For Provider Type “Medical Supplies/Durable Medical Equipment (DME) / Prosthetics / Orthotics” (75) only: Are you an accredited DMEPOS supplier enrolled with Medicare? Yes No

If Yes, provide the phone number that you used in your Medicare DMEPOS enrollment.

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Confirm and Sign

I, the undersigned, certify to the following: I have read the contents of this application, and the information contained herein is true, correct, and complete. I authorize the OWCP to verify the information contained herein. I agree to notify the OWCP of any change in ownership, practice location and/or Final Adverse Action involving fraud or abuse within 30 days of the reportable event. In addition, I agree to notify the OWCP of any other changes to the information in this form within 90 days of the effective date of change.

I also certify that I am not currently sanctioned, suspended, debarred or excluded by any Federal or State Health Care Program, (e.g., Medicare, Medicaid, or any other Federal program), or otherwise prohibited from providing services to Medicare, Medicaid, or other Federal program beneficiaries nor are any owners, officers, or managing employees of the practice listed in this application.

I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to the Department of Labor, Office of Workers’ Compensation Program (OWCP), or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of OWCP billing privileges, civil damages, and/or imprisonment.

I agree to abide by the OWCP regulations and program instructions that apply to me or to the organization listed in Section 3A of this enrollment form. I understand that payment of a claim by OWCP is conditioned upon the claim and the underlying transaction complying with state and federal laws (including, but not limited to, the Federal anti­kickback statute) and OWCP regulations, and program instructions.

I have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT) form.

Print Name and Title

Signature Date

Print, sign and mail or fax form to the following address:

Provider Enrollment

Department of Labor ­ OWCP

P. O. Box 8312

London, KY 40742-8312

Fax: 888-444-5335

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Addendum 1: Individual Providers Information for Group Practice Enrollment (Part A)

Fill in this addendum to add, update or remove servicing providers for Group Practice as applicable.

Reviewer will validate NPI for all servicing providers.

Reviewer will also validate license and certificate for 9 or less servicing providers. For more than 9 providers, group is responsible for validating license and certificate.

1.

Add Update

Remove

2. Individual Information (Applicable if enrolling using SSN)

2a. Last Name

 

 

 

2c. Middle Name

 

 

 

 

 

 

 

 

2b. First Name

 

 

2d. SSN

 

 

 

 

 

 

 

 

 

3.Organization Information (Applicable if enrolling using FEIN)

3a.

Organization Name

 

 

 

 

 

 

3b.

Organization Business Name

 

3c. FEIN

 

 

 

 

 

4.Provider Type 5. NPI

6.Taxonomy a. b. c. d. e.

 

7. License/Certification Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License/

 

 

 

License/

Issued

Initial Issue

Expiration

 

Certification

 

 

License/Certification Type

Certification

State

Date

Date

 

Category

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

ense/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Addendum Information

1.2. Individual Information (Applicable if enrolling using SSN)

 

 

Add

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2a. Last Name

 

 

 

2c. Middle Name

 

 

 

 

 

 

 

Update

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Remove 2b. First Name

 

 

2d. SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.Organization Information (Applicable if enrolling using FEIN)

3a. Organization Name

3b. Organization Business Name 3c. FEIN

4. Provider Type 5. NPI

6.Taxonomy a. b. c. d. e.

7.License/Certification Information

License/

Certification

Category

License/Certification Type

License/

Certification

Number

Issued

State

Initial Issue

Date

Expiration

Date

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Addendum 2: Taxonomy Information (Part C)

Type or print additional Taxonomy information as applicable.

Use additional sheet(s) as required.

Taxonomy

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Addendum 3: License and Certification (Part E)

Type or print additional license and certification information as applicable.

Use additional sheet(s) as required

1. License/Certification Category 2. Name

3. License/Certification Type 4. License/Certification Number

5.Initial Issue Date 6. Expiration Date

7.Issued State 8. Issuer Agency

9.Web Link

1.License/Certification Category 2. Name

3. License/Certification Type

 

 

 

 

4. License/Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Initial Issue Date

 

 

6. Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

7.Issued State 8. Issuer Agency

9.Web Link

1.License/Certification Category 2. Name

3. License/Certification Type

 

 

 

4. License/Certification Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Initial Issue Date

 

 

6. Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.Issued State 8. Issuer Agency

9.Web Link

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Addendum 4: Billing Agent/Clearinghouse Provider ID (Part H)

Type or print additional Billing Agent/Clearinghouse Provider IDs as applicable.

Use additional sheet(s) as required.

Billing Agent/Clearinghouse ID

Start Date

End Date

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Instructions

 

A brief description of each data element is listed below. Be sure to sign and date the form when you submit it.

 

 

 

 

Part A: Basic Information

 

 

 

 

 

 

 

 

Indicate whether this form is being used for a New Enrollment, to Update an

 

1.

existing ACTIVE enrollment record, for a Re­Enrollment (previously enrolled

Required

provider was excluded, now has become re­eligible) or to Re­Validate currently

 

 

 

enrolled but EXPIRED enrollment record.

 

 

 

 

 

If the form is being submitted to Update, Re­Enrollment or Re­Validate your

 

 

record, enter your Provider Number or Federal Employer Identification Number.

Required if Update, Re­

 

For Re­Validation and Re­Enrollment, complete all applicable sections,

1a.

Enrollment or Re­Validate

 

sign and send the form.

option is selected in 1

 

For Update, complete ONLY changed sections, sign and send the form.

 

 

 

 

 

Select Enrollment Type:

 

 

Individual

 

 

Any provider who is eligible to receive a Type I National Provider

 

 

Identifier (NPI) through the National Plan and Provider Enumeration

 

 

System (NPPES). Providers eligible to receive an NPI are those who

 

 

deliver medical or health services, as defined under Section 1861(s) of

 

 

the Social Security Act, 42 U.S.C. 1395x(s).

 

 

Individuals providing only non­medical services, attendant care, or

 

 

personal care services, who do not need an NPI.

 

 

Group Practice

 

 

One or more health care practitioners who practice their profession at a

 

 

common location (whether or not they share common facilities, common

 

 

supporting staff, or common equipment) and have formed a partnership

 

 

or corporation or are employees of a person, partnership or corporation,

 

 

or other entity owning or operating the health care facilities at which they

 

 

practice. These entities have a Type II National Provider Identifier (NPI)

 

 

from the National Plan and Provider Enumeration System (NPPES).

Required

 

Fill out the appropriate parts in Addendum 1 of the form for each

2.

Refer to Appendix 2 for more

professional that will be providing services under the group Provider

 

 

information

 

Number (Name, Social Security number, Provider Type Code from list

 

 

 

below, NPI, DEA Number, Taxonomy, License or Certificate Type,

 

 

License Number, Issue Date, Issue State and Expiration Date of current

 

 

license). Continue additional sheet(s) as needed.

 

 

Facility/Agency/Organization/Institution

 

 

An Inpatient or Outpatient Hospital, a Skilled Nursing Facility, an

 

 

Intermediate Care Facility, a Clinic (RHC, FQHC, Hospital Based Clinic,

 

 

Urgent Care), a Psychiatric Facility, a Mental Institution, a Durable

 

 

Medical Equipment Supplier, a Free Standing Ambulatory Surgical

 

 

Center, a Long Term Care Facility, an Independent Clinical Laboratory, a

 

 

Free Standing Radiology, a Dialysis Center, a Pharmacy, a Partnership,

 

 

a Corporation, or any other entity that furnishes or arranges for the

 

 

furnishing of services for which payment is billed under the OWCP

 

 

programs. It does not include individual practitioners or groups of

 

 

practitioners. In addition, you must also be eligible to receive and

 

 

currently possess, a Type II National Provider Identifier, available

 

 

through the National Plan and Provider Enumeration System (NPPES).

 

 

Any entity other than individual who does not deliver medical care or

 

 

health services and is thus ineligible for a National Provider Identifier

 

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(NPI) available through the National Plan and Provider Enumeration

 

 

 

System (NPPES). This provider type can include Fiscal Intermediaries,

 

 

 

Non­Emergency Transportation, etc.

 

 

 

 

 

 

Type or print Provider Type

Required

3.

 

For Group Practice, type or print primary Provider Type.

Refer to Appendix 1 for more

 

 

information

 

 

 

 

 

 

 

3a.

Type or print explanation for Provider Type

Required if 53 or 96 is selected

in 3.

 

 

 

 

 

 

 

 

Check the Program(s) in which you want to enroll as a provider. If mailing, please

Required

 

 

4.

mail the application to P.O. Box as indicated on Page 8 of the application or fax a

Refer to Appendix 3 for more

 

separate document.

 

information

 

 

 

 

 

 

5.

Type or print Individual information

Required if enrolled using SSN

 

 

 

5a.

Type or print provider’s Last Name

Required

 

 

 

5b.

Type or print provider’s First Name

Required

 

 

 

5c.

Type or print provider’s Middle Name

 

 

 

 

5d.

Type or print SSN

Required

 

 

 

6.

Type or print Organization information

Required if enrolled using FEIN

 

 

 

6a.

Type or print Organization Name (i.e.) Legal Business Name

Required

 

 

 

6b.

Type or print Organization Business Name (i.e.) Doing Business As

Required

 

 

 

6c.

Type or print FEIN

Required

 

 

 

7.

Type or print NPI

Refer to Appendix 3 for

 

 

 

 

requirements

 

 

 

 

 

 

 

Type or print IRS W9 Entity Type. Select from following values:

 

 

C Corporation

 

 

S Corporation

 

 

Individual/Sole Proprietor or single­member LLC

 

 

LLC Filing as C Corporation

 

8.

LLC Filing as S Corporation

Required

 

 

 

LLC Filing as Partnership

 

 

LLC Filing as Sole Proprietor

 

 

Others

 

 

Partnership

 

 

 

 

8a.

Type or print Reason

Required if selected Others in 8

 

 

 

9.

Type or print Email Address

 

 

 

 

 

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Select this option if you do not wish to be included in the OWCP online

 

10.

searchable program. However, selecting this option will not exclude your

 

 

information in a FOIA (Freedom Of Information Act) request.

 

 

 

 

10a.

Type or print Explanation

Required if checkbox is selected

in 10

 

 

 

 

 

 

 

 

 

Part B: Location Information

 

 

 

 

 

Providers offering services at different location(s) are required to enroll

 

 

separately for each location. Servicing providers under a group practice are not

 

 

required to enroll separately.

 

 

 

 

11.

Location Contact information

Required

 

 

 

11a.

Type or print location Business Name

Required

 

 

 

11b.

Type or print contact Last Name

Required

 

 

 

11c.

Type or print contact First Name

Required

 

 

 

11d.

Type or print Phone number

Required

 

 

 

11e.

Type or print Fax number

 

 

 

 

11f.

Type or print Email Address

 

12.Type or print Physical Address

12a.

Type or print street Address Line 1

Required

 

 

 

 

Type or print street Address Line 2

 

 

 

 

 

Type or print street Address Line 3

 

 

 

 

12b.

Type or print City or Town

Required

 

 

 

12c.

Type or print State or Province

Required for domestic address

 

 

 

12d.

Type or print Zip (or postal) Code

Required

 

 

 

12e.

Type or print County

 

 

 

 

12f.

Type or print Country

Required for foreign address

 

 

 

13.

Select this option if the mailing address is same as the physical address.

 

Otherwise print or type Mailing Address

 

 

 

13a.

Type or print street Address Line 1

Type or print street Address Line 2

Type or print street Address Line 3

13b.

Type or print City or Town

13c.

Type or print State or Province

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13d.

Type or print Zip (or postal) Code

 

 

 

 

13e.

Type or print County

 

 

 

 

13f.

Type or print Country

 

 

 

 

 

 

 

 

Part C: Taxonomy

 

 

 

 

 

 

 

 

Type or print Taxonomy

 

14.

Use Addendum 1 for taxonomy for servicing providers

Refer to Appendix 3 for

 

Use Addendum 2 for additional taxonomy codes. Use additional sheet(s)

requirements

 

 

 

 

as required.

 

 

 

 

 

 

 

 

 

Part D is optional .

 

 

For DFEC and DEEOIC

 

 

providers, list any business

 

 

with more than a 5% interest

 

Part D: Ownership Details

in or where involvement is at

 

 

an officer, director or agent of

 

 

the company

15.

Type or print Organization Ownership information

If enrolling using FEIN

 

 

 

15a.

Type or print Organization Name

 

 

 

 

15b.

Type or print FEIN

 

 

 

 

16.

Type or print Individual Ownership information

If enrolling using SSN

 

 

 

16a.

Type or print individual Last Name

 

 

 

 

16b.

Type or print individual First Name

 

 

 

 

16c.

Type or print SSN

 

17.Type or print Ownership address

17a. Type or print street Address Line 1 Type or print street Address Line 2 Type or print street Address Line 3

17b. Type or print City or Town

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17c.

Type or print State or Province

For domestic address

 

 

 

 

17d.

Type or print Zip (or postal) Code

 

 

 

 

 

 

17e.

Type or print County

 

 

 

 

 

 

 

17f.

Type or print Country

For foreign address only

 

 

 

 

 

 

 

Section 18 to 20 are for additional ownership information, use additional

 

 

 

sheets as required

 

 

 

 

 

 

 

18.

Refer to instructions for Section 15

If additional sheets needed

 

 

 

 

 

 

 

19.

Refer to instructions for Section 16

If additional sheets needed

 

 

 

 

 

 

 

20.

Refer to instructions for Section 17

If additional sheets needed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part E: License and Certification

 

 

 

 

 

 

 

 

 

Please provide all license/certification required by your State to perform the

 

 

 

service under your Provider Type.

 

 

 

If a license or certification is not required by the State, attach letter/

 

 

 

 

evidence from the State authority.

 

 

 

OWCP will verify all your license/certification with your State's license

 

 

 

 

issuer agency before your enrollment can be approved.

 

 

 

After your enrollment is approved, you are responsible to keep your

 

 

 

 

license/certification information up to date.

 

 

 

Expired license/certification will cause the termination of the provider

 

 

 

 

status.

 

 

 

If you have a renewed license/certification under a different number, please

 

 

 

make sure to enter it using the exactly same License/Certification Type.

 

 

 

 

 

 

 

Use Addendum 1 for license and certification information of servicing

 

 

21.

 

providers for group practice enrollment.

 

Refer to Appendix 3 for

 

 

 

 

 

requirements

 

Refer to Addendum 3 to add additional license and certification information.

 

 

Use additional sheet(s), as required.

 

 

 

 

 

 

 

Type or print license or certification category from following options:

 

 

21a.

License

 

Required

 

certification

 

 

 

 

 

 

21b.

Type or print Name

 

Required

 

 

 

 

21c.

Type or print License or Certification Type

 

Required

 

 

 

 

21d.

Type or print License or Certification Number

 

Required

 

 

 

 

 

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21e.

Type or print License or Certification Initial Issue Date

 

Required

 

 

 

 

21f.

Type or print License or Certification Expiration Date

 

Required

 

 

 

 

21g.

Type or print License or Certification Issued State

 

Required

 

 

 

 

21h.

Type or print License or Certification Issuer Agency

 

Required

 

 

 

 

21i.

Type or print License or certification Web Link

 

Required

 

 

 

 

21j.

Select this option if License or Certification is not required by State

 

 

 

 

 

 

21k.

Type or print Explanation

 

Required if 25j. is selected

 

 

 

 

22.

Additional License and Certification information. Refer to instructions for section 21.

 

Use additional sheet(s) as required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part F: Identifiers

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare number is required for

23.

Identifier information

hospitals (Provider type: 01, 02,

 

 

 

03)

 

 

 

 

 

Type or print Identifier Value from below list of values:

 

 

 

DEA Number

 

 

 

NPI

 

 

23a.

Other Provider ID

Required

 

Previous Provider ID

 

 

 

Provider Medicare Number

 

 

 

United Mine Workers of America (UMWA) Number

 

 

 

 

 

23b.

Type or print Identifier Value

Required

 

 

 

23c.

Type or print Start Date

Required

 

 

 

 

23d.

Type or print End Date

 

 

 

 

 

 

24.

Additional Identifier information. Refer to instructions for section 23. Use

 

 

additional sheet(s) as required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part G: EDI Submission Method

 

 

25.

Select mode of Submission. Select all applicable options:

Billing

For providers who use a 3rd party to bill.

Agent/Clearinghouse

 

Web Interactive

For entering (keying) bills directly in the System.

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FTP Secured Batch:

For submitting files via an SFTP site.

Web Batch

For upload/download of files in the system.

None

For submissions through paper form ONLY.

"Web Batch" method is often used by providers who submit their own HIPAA batch transactions. It allows a maximum file size of 50 MB.

Your EDI submission method is "FTP Secured Batch" if you submit and retrieve batches at a secure web folder assigned to you by OWCP. This method was designed with clearinghouses and billing agents in mind. It allows a maximum file size of 100 MB.

Don't select “None” if other submission method is selected. You can always submit paper form in addition to EDI Submission.

 

Part H: EDI Submitter Details

 

 

 

 

 

 

 

 

Billing Agent/Clearinghouse information

 

 

Your Billing Agent/Clearinghouse must be enrolled with OWCP first.

 

 

Please obtain the Billing Agent/Clearinghouse’s OWCP ID to complete

 

 

this section.

Required if Billing

 

 

26.

If they are not yet enrolled, you can still complete your enrollment by

Agent/Clearinghouse selected in

 

temporarily choosing not to use Billing Agent/Clearinghouse.

Part G

 

 

 

You can add them later after they are enrolled with OWCP.

 

 

Refer to Addendum 4 for additional information. Use additional sheet(s) as

 

 

required.

 

 

 

 

26a.

Type or print Billing Agent/Clearinghouse OWCP ID

Required

 

 

 

26b.

Type or print Start Date

Required

 

 

 

26c.

Type or print End Date

 

 

 

 

 

 

 

 

Part I: EDI Contact Details

 

 

 

 

 

 

 

 

 

Required if FTP Secured Batch

27.

EDI Contact information

or Web Batch is selected in Part

 

 

G

 

 

 

27a.

Type or print Contact Title

Required

 

 

 

27b.

Type or print contact last name

Required

 

 

 

27c.

Type or print contact First Name

Required

 

 

 

27d.

Type or print contact Phone number

Required

 

 

 

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27e.

Type or print contact Fax number

 

 

 

 

27f.

Type or print contact Email Address

 

 

 

 

28.

Type or print Contact Address

 

 

 

 

28a.

Type or print street Address Line 1

Required

 

 

 

 

Type or print street Address Line 2

 

 

 

 

 

Type or print street Address Line 3

 

 

 

 

28b.

Type or print City or Town

Required

 

 

 

28c.

Type or print State or Province

Required for domestic address

 

 

 

28d.

Type or print Zip (or postal) Code

Required

 

 

 

28e.

Type or print County

 

 

 

 

28f.

Type or print Country

Required for foreign address

 

 

 

29.

Additional EDI Contact information. Refer to instructions for Section 27

 

 

 

 

30.

Additional EDI Contact address. Refer to instructions for Section 28

 

 

 

 

 

 

 

 

Addendum 1: Servicing Providers Information

Required for enrollment type

 

Group Practice

 

 

 

 

 

 

Select one option to add, update or remove a servicing provider:

 

 

For New Enrollment, only Add action can be selected.

 

1.

Type or print all the information for New and Update Action.

Required

 

 

Type or print SSN or FEIN for Remove Action.

 

 

Servicing providers can be enrolled using SSN (individual) or FEIN

 

 

(organization).

 

 

 

 

2.

Type or print Individual information

Required if enrolled using SSN

 

 

 

2a.

Type or print Last Name

Required

 

 

 

2b.

Type or print First Name

Required

 

 

 

2c.

Type or print Middle Name

 

 

 

 

2d.

Type or print SSN

Required

 

 

 

3.

Type or print Organization information

Required if enrolled using FEIN

 

 

 

3a.

Type or print Organization Name

Required

 

 

 

3b.

Type or print Organization Business Name

Required

 

 

 

3c.

Type or print FEIN

Required

 

 

 

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Required

4.

Type or print Provider Type

Refer to Appendix 1 for more

 

 

 

 

 

 

information

 

 

 

 

5.

Type or print NPI

Refer to Appendix 3 for

requirements

 

 

 

 

 

 

 

6.

Type or print Taxonomy

Refer to Appendix 3 for

requirements

 

 

 

 

 

 

 

7.

Type or print License/Certification information

Refer to Appendix 3 for

requirements

 

 

 

 

 

 

 

Type or print License or Certification Category from following options:

 

 

License

Required

 

certification

 

 

 

 

 

Type or print License or Certification Type

Required

 

 

 

 

Type or print License or Certification Number

Required

 

 

 

 

Type or print License or certification Issued State

Required

 

 

 

 

Type or print License or certification Initial Issue Date

Required

 

 

 

 

Type or print License or certification Expiration Date

Required

 

 

 

 

Addendum 2: Taxonomy

Refer to Part C instructions

Addendum 3: License and Certification

Refer to Part E instructions

Addendum 4: Billing Agent/Clearinghouse

Refer to Part H instructions

 

 

Required, please attach copy of

 

Supporting Documents

the applicable supporting

 

 

document(s)

 

 

 

 

 

 

1.

ACH Form

Required

 

 

 

 

Copy of License/Certification

Required if you provided

2.

License/Certification information

 

 

in Part E

 

 

 

3.

Other Supporting Document

 

 

 

 

4.

Provider Enrollment Form Signature Page

Required

 

 

 

5.

State Approval Letter

If you selected License not

required by state option in Part E

 

 

 

 

 

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Appendix 1: Provider/Hospital Type Codes

01

General Hospital

63

Optician

02

Special Hospital/ Rehabilitation Facility

65

Home Health Agency

03

Psychiatric Hospital

66

Rural Health Clinic

05

Community Mental Health Center

67

DMA Consult Contractor

20

Pharmacy

68

Federally Qualified Health Center

25

Physician (MD) & Physician (DO)

69

Birthing Center

27

Podiatrist

70

Health Maintenance Organization or

28

Chiropractor

 

Preferred Health Plan

29

Physician Assistant

71

Physical Therapist

30

Advanced Registered Nurse Practitioner

72

Occupational Therapist

 

(ARNP)

73

Pulmonary Rehabilitation

31

Certified Registered Nurse Anesthetist

74

Outpatient Renal Dialysis Facility

 

(CRNA)

75

Medical Supplies/Durable Medical

32

Psychologist

 

Equipment (DME) /Prosthetics/Orthotics

33

Contract Medical Consultant

76

Case Management Agency

34

Licensed Midwife

77

Social Worker

35

Dentist

78

Blood Bank

36

Registered Nurse (RN)

80

Pay­to­Intermediary

37

Licensed Practical Nurse (LPN)

88

Ambulatory Surgery Center

38

Nursing Attendant

89

Federal Facility (VA Hospital)

40

Ambulance

90

Skilled Nursing Facility (SNF)­Medicare

41

Contract Nurse

 

Certified & Non­Medicare Certified

42

Air/Water Ambulance Company

92

Intermediate Care Facility (ICF)

43

Taxi

93

Rural Hospital Swing Bed

44

Public Transportation & Private

94

Boarding House

 

Transportation

95

Insurance Company (Third party Carriers)

46

Hospice

96

Other Provider

47

FOH­DMA Providers

97

Billing Agent

50

Independent Laboratory

98

Lien Holder

51Portable X­Ray Company

52Alternative Medicine (e.g., Massage Therapist/Acupuncturist)

53Non­Medical Vendor

55Vocational Rehabilitation (Training, Tuition and Schools)

56Vocational Rehabilitation Counselor

57Rehabilitation Maintenance

58Assisted Re­employment

59Relocation Expenses

60Audiologist/Speech Pathologist

61Second Opinion Contractor

62Optometrist

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Appendix 2: Enrollment Type/Provider Type

Applicable provider types for each enrollment type are listed:

Enrollment Type

Provider Type

 

 

 

25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51,

Individual

52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74,

 

75, 76, 77, 78, 80, 88, 95, 96, 98

 

 

Group Practice

25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69,

70, 71, 72, 73, 74, 75, 76, 77, 96

 

 

 

Facility/Agency/Organization/Institution

01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69,

70, 73, 74, 75, 76, 78, 80, 88, 89, 90, 92, 93, 94, 95, 96, 98

 

 

 

Previous editions unusable

OWCP-1168

 

(Revised 04/20)

 

Page 23

 

 

Appendix 3: Provider Type Matrix

 

 

 

 

 

 

 

 

Provider

NPI required?

Taxonomy

License/Certification

Applicable Program(s)

Self­Enrollment

Type

required?

required?

allowed? **

 

 

01

All

 

 

 

 

 

 

02

All

 

 

 

 

 

 

03

All

 

 

 

 

 

 

05

All

 

 

 

 

 

 

20

All

 

 

 

 

 

 

25

All

 

 

 

 

 

 

27

All

 

 

 

 

 

 

28

All

 

 

 

 

 

 

29

All

 

 

 

 

 

 

30

All

 

 

 

 

 

 

31

All

 

 

 

 

 

 

32

All

 

 

 

 

 

 

33

 

 

DEEOIC

 

 

 

 

 

 

 

34

DFEC

 

 

 

 

 

 

35

All

 

 

 

 

 

 

36

All

 

 

 

 

 

 

37

All

 

 

 

 

 

 

38

All

 

 

 

 

 

 

40

All

 

 

 

 

 

 

41

 

DFEC

 

 

 

 

 

 

 

42

All

 

 

 

 

 

 

43

 

 

All

 

 

 

 

 

 

44

 

 

All

 

 

 

 

 

 

46

All

 

 

 

 

 

 

Previous editions unusable

OWCP-1168

 

(Revised 04/20)

 

Page 24

Provider

NPI required?

Taxonomy

License/Certification

Applicable Program(s)

Self­Enrollment

Type

required?

required?

allowed? **

 

 

47

DFEC

 

 

 

 

 

 

 

50

All

 

 

 

 

 

 

51

All

 

 

 

 

 

 

52

All

 

 

 

 

 

 

53

 

 

All

for DEEOIC

 

 

 

 

 

 

55

 

 

DFEC

 

 

 

 

 

 

 

56

 

 

DFEC

 

 

 

 

 

 

 

57

 

 

DFEC

 

 

 

 

 

 

 

58

 

 

DFEC

 

 

 

 

 

 

 

59

 

 

 

DFEC

 

 

 

 

 

 

 

60

All

 

 

 

 

 

 

61

All

 

 

 

 

 

 

 

62

All

 

 

 

 

 

 

63

All

 

 

 

 

 

 

65

All

 

 

 

 

 

 

66

All

 

 

 

 

 

 

67

DFEC

 

 

 

 

 

 

 

68

All

 

 

 

 

 

 

69

All

 

 

 

 

 

 

70

All

 

 

 

 

 

 

71

All

 

 

 

 

 

 

72

All

 

 

 

 

 

 

73

All

 

 

 

 

 

 

74

All

 

 

 

 

 

 

75

All

 

 

 

 

 

 

Previous editions unusable

OWCP-1168

 

(Revised 04/20)

 

Page 25

Provider

NPI required?

Taxonomy

License/Certification

Applicable Program(s)

Self­Enrollment

Type

required?

required?

allowed? **

 

 

76

All

 

 

 

 

 

 

77

All

 

 

 

 

 

 

78

All

 

 

 

 

 

 

80

All

 

 

 

 

 

 

88

All

 

 

 

 

 

 

89

All

 

 

 

 

 

 

90

All

 

 

 

 

 

 

92

All

 

 

 

 

 

 

93

All

 

 

 

 

 

 

94

All

 

 

 

 

 

 

95

 

 

All

 

 

 

 

 

 

96

All

 

 

 

 

 

 

97

 

 

 

All

 

 

 

 

 

 

98

 

 

 

All

 

 

 

 

 

 

 

** If Self­Enrollment is not allowed for a certain provider type, please contact 1­844­493­1966.

Previous editions unusable

OWCP-1168

 

(Revised 04/20)

 

Page 26