View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
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
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.
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
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
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
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
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.
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 paulik.james@dol.gov
Common Form ICR:
No
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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