We have approved this paperwork package consisting of three uniform health insurance claim forms, the OWCP 1500, the Resubmission Turnaround Document, and the OWCP 82, for one year. We have given less than the full three-year clearance to this package so that any changes to the HCFA-1500, which is currently under OMB review, may be considered by ESA. This will serve to maintain the coordination and compatibility between the HCFA form and its OWCP counterpart. DOL shall continue to consider the use of the RTD in the Federal Employees' Compensation Program as the Department plans enhancements to this medical bill payment system.
Inventory as of this Action
Requested
Previously Approved
10/31/1991
10/31/1991
09/30/1990
877,000
0
1,680,000
174,266
0
257,066
0
0
0
HCFA 1500 IS A STANDARD CLAIM FORM USED BY ALL PROVIDERS EXCEPT HOSPITALS AND PHARMACIES TO REQUEST PAYMENT FOR FECA AND BL CLAIMANTS. UB 82 IS USED BY PROVIDERS TO BILL OWCP FOR PAYMENT FOR INPATIENT CARE PROVIDED TO CLAIMANTS. RTD COLLECTS MISSING INFORMATION FOR THE BL PORTION OF HCFA 1500 AND UB 82.
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT