OWCP 1500 Health Insurance Claim Form

What Is the OWCP 1500 Form?

The Office of Workers Compensation Programs (OWCP) uses the Standard Form 1500, also known as the Health Insurance Claim Form, to process medical claims for workers who receive benefits under the Federal Employees Compensation Act (FECA). The form is the primary vehicle for submitting charges for medical services, supplies, and ancillary items to the United States Department of Labor.

When Should You Use the Form?

Use the OWCP 1500 whenever a healthcare provider or a claimant submits a bill for services rendered to an employee covered under FECA. Typical scenarios include:

• Hospital inpatient or outpatient treatment
• Physician office visits
• Physical therapy, occupational therapy, and speech therapy
• Diagnostic imaging (Xray, MRI, CT scan)
• Prescription drugs and medical supplies
• Durable medical equipment (e.g., braces, wheelchairs)

Key Parts of the Form

The OWCP 1500 is divided into three main sections: the Patient/Insured, the Provider, and the Claim Details. Below is a brief overview of each field.

1. Patient/Insured Information (Topleft)

• Claimants Name Full legal name of the employee.
• Social Security Number Ninedigit SSN; required for identification.
• Claim Number Assigned by OWCP when the claim is opened.
• Date of Injury/Illness When the workrelated event occurred.

2. Provider Information (Topright)

• Provider Name & Address Hospital, clinic, or practitioner details.
• National Provider Identifier (NPI) Mandatory for most providers.
• Tax Identification Number (TIN) Required for billing purposes.
• Phone Number For followup questions.

3. Claim Details (Center and Bottom)

• Dates of Service Start and end dates for each line item.
• Procedure Code (CPT/HCPCS) Standardized codes for services.
• Diagnosis Code (ICD10CM) Reason for the service.
• Charges Amount billed for each service.
• Place of Service Code Indicates where the service was rendered.
• Signature & Date Providers certification that the information is accurate.

For providers who bill electronically, the same data elements are submitted via the Electronic Data Interchange (EDI) 837P format.

Filling Out the Form StepbyStep

1. Gather Required Information Patient details, claim number, provider NPI, and all relevant CPT and ICD10 codes.
2. Enter Patient Data Write the claimants name, SSN, claim number, and injury date in the topleft block.
3. Complete Provider Block Include name, address, NPI, and TIN. If the provider is a group practice, list the groups NPI.
4. List Each Service For every date of service, add a separate line with the appropriate CPT code, diagnosis, and charge amount. Use the Units column when applicable (e.g., for therapy minutes).
5. Calculate Totals Sum the charges for all lines and write the total in the bottomright box.
6. Sign and Date The authorized provider or billing representative signs, confirming the claims accuracy.
7. Submit Mail the completed form to the address listed on the OWCP website or submit electronically through the OWCP portal.

Common Errors to Avoid

• Missing or Incorrect Claim Number The claim will be rejected or delayed.
• Incorrect CPT/HCPCS Codes Leads to denied charges or additional queries.
• Unclear Dates of Service Ensure each line reflects the exact date(s) the service was provided.
• Improper Signature Only an authorized provider may sign; a missing signature results in a return for signature.
• Using an Outdated Form Always download the most recent version from the OWCP website.

What Happens After Submission?

Once OWCP receives the claim, the following steps occur:

1. Initial Review The system checks for completeness and validates the claim number.
2. Medical Review A medical examiner determines if the services are reasonable and necessary for the workrelated injury.
3. Payment Processing Approved charges are paid directly to the provider; any remainder is sent to the claimant.
4. Notification The provider and claimant receive a notice indicating approval, partial payment, or denial with reasons.

Denials can be appealed. The notice includes instructions for filing an appeal within 30 days of receipt.

Resources & Helpful Links

• OWCP Forms and Instructions Download the latest 1500 form and accompanying guidelines.
• Form 15002 (Attachments) Use for additional documentation such as operative reports.
• Claims Processing Overview Stepbystep description of the OWCP claims cycle.
• CPT & HCPCS Codes Search tool for professional coding.
• ICD10CM Codes Find accurate diagnosis codes.

Quick Checklist for Providers

• Verify claim number before starting.
• Use current NPI and TIN.
• Enter accurate CPT and ICD10 codes.
• Include dates of service for each line.
• Total charges correctly.
• Sign and date the form.
• Submit within 30 days of service to avoid delays.