OWCP-04 Uniform Billing Form

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Instructions for completing OWCP-04 Uniform Billing 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)
GENERALINFORMATION-FECAANDEEOICPACLAIMANTS: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 occupational illnesses defined under that Act. Benefits provided under these statutes include
Inpatient/outpatient hospital services, ambulatory surgical care, chemotherapy treatment services, and other non-professional medical services for covered injuries
or occupational illnesses. Services provided by skilled nursing facilities, nursing homes and hospices (including medications and other services such as oxygen and
respiratory services), as well as personal care services provided by a home health aide, licensed practical nurse or similarly trained individual, may also be
provided.
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 condition-specific fee schedule based on the Prospective
Payment System devised by the Centers for Medicare and Medicaid Services (CMS) 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), Revenue
Center codes and Diagnosis-Related Group (DRG) codes; therefore, use of correct codes and modifier(s) is required. Incorrect coding will result in inappropriate or
delayed 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.
ITEMIZEDBILLSANDTREATMENTPLANS: All forms submitted for inpatient hospital services must be accompanied by an itemized billing statement and an
admission/discharge summary. Forms submitted for hospice services or for personal care services provided in the home must be accompanied by a plan of care
and treatment.
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.
SIGNATUREOFPHYSICIANORSUPPLIER:Your submission of a bill with this form 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 not paid by OWCP for covered
services as the result of the application of its fee schedule or related tests for reasonableness (appeals are allowed). Your submission of a bill with this form 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,
BLBA or EEOICPA regulations. Finally, your submission of a bill with this form indicates that you understand that any false claims, statements or documents, or
concealment of a material fact, may be prosecuted under applicable Federal or State laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF INFORMATION
(PRIVACY ACT STATEMENT)
OWCP is authorized by 5 USC 8101 et seq., 30 USC 901 et seq., and 42 USC 7384d to collect information needed to administer the FECA, BLBA and EEOICPA.
The information collected is used to identify the eligibility of the claimant for benefits, and to determine coverage of services provided. There are no penalties for
failure to supply information; however, failure to furnish information regarding the medical service(s) received or the amount charged will prevent payment of the
claim. Failure to supply the claim number or required codes will delay payment or may result in rejection of the bill 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 as other wise
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 Department of Labor systems DOUGOVT -1, DOUE SA-5, DO L/ESA-6,
DOL/ESA-29, DOUESA-30, DOUESA-43, DOUESA-44, DOUESA-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
DFEC- FECA: Send all forms for FECA to OWCP/DFEC- FECA, PO Box 8300 London, KY 40742-8311-8300 unless otherwise instructed.
DEEOIC: Send all forms for DEEOIC to Energy Employees Occupational Illness Compensation Programs, PO Box 8304, London, KY 40742-8304, unless
otherwise instructed.
DCMWC: Send all forms for DCMWC to Federal Black Lung program, PO Box 8302, London, KY 40742-8302, unless otherwise instructed.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be
guilty of a criminal act punishable under law and may be subject to civil penalties.
I NSTRUCTIONS 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.
Block 1
Block 2
Block 3a
Block 3b
Block 4

Type or print complete provider name, street address, city, state and zip code. Also include area code and phone number.
Blank field.
Not required.
Not required.
Type of bill classification using appropriate three-digit code: 1st position indicates type of facility, 2nd position indicates type of care, 3rd position
indicates billing sequence.
Block 5 Type or print Federal tax I.D. assigned for tax reporting purposes.
Block 6 Type or print dates for the full ranges of services being invoiced (period from/through using MM/DD/YY).
Block 7 Type or print number of covered days.
Block 8 Type or print patient's name. Use a comma or space to separate the last and first names, do not use titles such as Mr. or Mrs., and do not leave a
space before a prefix to a last name. If last name is hyphenated, both names should be capitalized, and a space should separate a last name and
any suffix. For BLBA and EEOICPA, type or print name as it appears on the Medical Benefits Identification Card.
Block 9 Type or print complete mailing address of patient.
Block 10 Type or print month, year, and day of patient's birth (MM/DD/YY).
Block 11 Type or print sex of patient, using M or F only.
Block 12 Type or print month, day, and year {MM/DD/YY) of admission.
Block 13 Enter the code for admission hour.
Block 14 Required for Inpatient.
Block 15 Enter source of admission (Required for Inpatient).
Block 16 Type or print patient's two-digit status code on the last day of the billing period.
0MB No. 1240-0019
Expires: 05/31/2025

OWCP-04 PAGE 2 (Rev. 03-25)

Block 17
Block 18
Block 19
Block 20
Block 21
Block 22
Block 23
Block 24
Block 25
Block 26
Block 27
Block 28
Block 29
Block 30
Block 31
Block 32
Block 33
Block 34
Block 35
Block 36
Block 37
Block 38
Block 39
Block 40
Block 41
Block 42
Block 43
Block 44
Block 45
Block 46
Block 47
Block 48
Block 49
Block 50
Block 51
Block 52
Block 53
Block 54
Block 55
Block 56
Block 57
Block 58
Block 59
Block 60
Block
Block
Block
Block
Block

Enter status code.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Enter condition codes.
Not required.
Blank field.
Enter occurrence code and occurrence date.
Enter occurrence code and occurrence date.
Enter occurrence code and occurrence date.
Enter occurrence code and occurrence date.
Enter occurrence span code and occurrence span from date.
Enter occurrence span code and occurrence span from date.
Blank field.
Not required.
Enter value code 01-99 and A1-29, and value codes amount.
Enter value code 01-99 and A1-29, and value codes amount.
Enter value code 01-99 and A1-29, and value codes amount.
Type or print Revenue Center Code{s).
Type or print Revenue Center Code description{s). {If billing an unlisted J-Code with RCC 0636, a valid NDC Code must be specified in
this block and the drug quantity listed in Block 46.)
Type or print applicable private/semi-private room rate, and the CPT or HCPCS codes and modifiers based on bill type {inpatient or outpatient).
Enter service date for outpatient services not required for inpatient for each RCC.
Type or print units of service for inpatient. For outpatient, enter units of service for each RCC.
Type or print total charges by RCC and procedure code.
Not required.
Blank field.
Type or print program payer: U.S. DOL-OWCP-FECA, -BLBA or -EEOICPA, as appropriate, and Medicare number (51B) for inpatient services.
Medicare number 51B.
Not required.
Not required.
Type or print the amount of any prior payments made.
Not required.
Required. Enter Billing provider NPI.
Type or print other provider ID. OWCP provider number.
Type or print insured's last name, first name.
Not required.
For EEOICPA and BLBA: type or print patient's SSN. For FECA: type or print patient's claim/case number.

61
62
63
64
65

Not required.
Not required.
Not required.
Not required.
Not required.

Block 66 Type or print ICD diagnosis version.
Block 67a Type or print complete ICD-9-CM/ICD-10 diagnosis code for principal diagnosis. Enter the 4th and 5th digits if applicable. Each diagnosis must
be valid for the date of service.
Block 67b Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).

Block 67c Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67d Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67e Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67f Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67g Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67h Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67i Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis {if applicable).
Block 67j Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67k Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 671 Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67mType or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67n Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 670 Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67p Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 67q Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable).
Block 68 Blank field.
Block 69 Type or print complete ICD-9-CM/ICD-10 diagnosis code for admission diagnosis. Enter the 4th and 5th digit if applicable. Each diagnosis must be
valid for the date of service.
Block 70 Type or print patient's reason for visit code.
Block 71 Not required.
Block 72 Not required.
Block 73 Blank field.
Block 74 Type or print principal procedure using ICD-9-CM codes and date of occurrence (MM/DD/YY) during hospitalization. Inpatient claims and all surgical
procedures require ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74a Type or print any other procedure using ICD-9-CM codes and dates of occurrence {MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
OWCP-04 PAGE 3 (Rev. 03-25)

Block 74b Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74c Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74d Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 74e Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require
ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes.
Block 75 Blank field.
Block 76 Enter Attending provider NPI. When attending NPI is entered, attending taxonomy is required in Block 81CCB.
Block 77 Not required.
Block 78 Not required.
Block 79 Notrequired.
Block 80 Not required.
Block 81
81CCa: Required. Enter Taxonomy code for the billing provider. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.
81CCb: Required. Enter Taxonomy code for the attending provider. When attending taxonomy provider is entered attending NPI is required in Block 76.

Burden Disclosure Notice
Public reporting burden for this data collection is estimated to average six minutes per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This
collection of information is needed by OWCP and authorized by 5 USC 8101 et seq., 30 USC 901 et seq., and 42 USC 7384d to collect this information to
administer the FECA, BLBA and EEOICPA. The information collected is used to identify the eligibility of the claimant for benefits, and to determine coverage of
services provided. Please send comments regarding the burden estimate or any other aspect of this collection of information including suggestions for reducing
this burden, and reference OMB control number 1240-0019 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 (1240-0019), Washington, DC
20503. NOTE: Please do not send your completed form to this 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 your claims examiner to ask about this assistance.

OWCP-04 PAGE 4 (Rev. 03-25)