Uniform Billing Form (OWCP-04)

OMB Control No: 1240-0019	ICR Reference No: 201208-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-019
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Uniform Billing Form (OWCP-04)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/08/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/27/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	229,997	0	21,924
Time Burden (Hours)	26,599	0	2,558
Cost Burden (Dollars)	0	0	0

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Abstract: OWCP requires institutional medical providers who provide services to beneficiaries covered under FECA, BLBA and EEOICPA to bill using a form based on the industry standard, the UB-04. Form OWCP-04 identifies the beneficiary, the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Federal Employee's Compensation Act (FECA)    US Code: 30 USC 901 Name of Law: Black Lung Benefits Act (BLBA)    US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 51830	08/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 70826	11/27/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Uniform Billing Form (OWCP-04) OWCP-04 Uniform Billing Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	229,997	21,924	0	0	208,073	0
Annual Time Burden (Hours)	26,599	2,558	0	0	24,041	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Federal Cost and the number of burden hours have increased due to the increase in the number of respondents. While not affecting the burden, OWCP added information regarding persons with disabilities on the form.

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Annual Cost to Federal Government: $2,108,689

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: James Paulik 202 693-0304 [email protected]

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Common Form ICR:  No

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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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 11/27/2012

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