Official Federal Forms > US Dept Of Labor
Health Insurance Claim Form OWCP-1500 - Official Federal Forms
| Health Insurance Claim Form Form. This is a national form and can be used in US Dept Of Labor . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA PICA MEDICAID TRICARE CHAMPUS CHAMPVA GROUP (Medicare #) (Medicaid #) (Sponsor's SSN) 5. PATIENT'S ADDRESS (No., Street) 1. MEDICARE (Medicaid #) HEALTH PLAN (SSN or ID) MM DD YY 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE (SSN) M BLK LUNG FECA (ID) F OTHER 1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) SEX 4. INSURED'S NAME (Last Name, First Name, Middle Initial) 6. PATIENT RELATIONSHIP TO INSURED Self Spouse Child Married 7. INSURED'S ADDRESS (No., Street) Other Single ZIP CODE TELEPHONE (Include Area Code) Other ZIP CODE TELEPHONE (Include Area Code) ( ) Employed Full-Time Student Part-Time Student 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER a. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (CURRENT OR PREVIOUS) YES YES a. INSURED'S DATE OF BIRTH MM DD YY NO M SEX F b. OTHER INSURED'S DATE OF BIRTH MM DD YY M SEX b. AUTO ACCIDENT? F YES NO PLACE (State) b. EMPLOYER'S NAME OR SCHOOL NAME c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME NO d. IS THERE ANOTHER HEALTH BENEFIT PLAN? d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE YES NO If yes, return to and complete item 9 a-d. 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 necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. DATE YY SIGNED 14. DATE OF CURRENT: MM DD ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY(LMP) 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY MM DD MM DD YY GIVE FIRST DATE FROM TO 17a. 17 b. NPI 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD FROM TO YY 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE YY 19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? YES NO $ CHARGES 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 1. 2. 24. A. 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 3. 4. DATE(S) OF SERVICE From DD YY MM To DD YY PROCEDURES, SERVICES, OR SUPPLIES E. (Explain Unusual Circumstances) DIAGNOSIS MODIFIER POINTER 23. PRIOR AUTHORIZATION NUMBER MM CPT/HCPCS $ CHARGES RENDERING PROVIDER ID. # 1 2 3 4 5 6 25. FEDERAL TAX I.D. NUMBER SSN EIN NPI NPI NPI NPI NPI 26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? YES NO (For govt. claims, see back) 28. TOTAL CHARGE $ NPI 29. AMOUNT PAID 30. BALANCE DUE $ $ 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH # ( ) SIGNED DATE a. b. a. b. OMB No. 1240-0044 Expires: 12/31/2015 NUCC Instruction Manual available at: www.nucc.org American LegalNet, Inc. www.FormsWorkFlow.com PHYSICIAN OR SUPPLIER INFORMATION B. C. Place of Service EMG D. F. G. H. I. DAYS EPSDT OR Family ID UNITS Plan QUAL.. J. PATIENT AND INSURED INFORMATION CITY STATE 8. PATIENT STATUS CITY STATE CARRIER 1500 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 the identification 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 paymen
|
|||||||
