Black Lung Medical Benefits: Questions and Answers about the Federal Black Lung Program
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Publication CM-6
March 2013
Black Lung Medical Benefits:
Questions and Answers about the Federal Black Lung Program
U.S. Department of Labor Office of Workers’ Compensation ProgramsBlack Lung Medical Benefits: Frequently Asked Questions about the Federal Black Lung Program U.S. Department of Labor Office of Workers’ Compensation Programs Division of Coal Mine Workers’ Compensation Revised March 2013 The following material gives you basic information about your medical benefits, but it is neither intended to cover every possible exception or special case, nor have the effect of law. Additionally, this information applies only if the Black Lung Disability Trust Fund is responsible for your medical benefits. If a private party, such as your employer or its insurance carrier, is responsible for your medical benefits, different procedures may apply. You may contact that private party directly or the District Office which handles your claim with questions about your medical benefits. STOP HEALTH CARE FRAUD. If you suspect any health care fraud, please call our toll-free number 1(800)347-2502.
Contents
Question Subject Page #
1-3 Black Lung Benefits Identification Card 1-2
4-5 State and Federal Black Lung Benefits 2
6 Social Security Black Lung Benefits 2
7 Covered Medical Services 3
8 Covered Prescription Drugs 3
9-10 Approval for Certain Services 4
11 Non-Covered Medical Services 4
12-16 Direct Billing by Medical Providers 5
17 Billing the Coal Company 6
18 Reimbursing You for Medical Services 6
19 Reimbursing You for Prescription Drugs 7
20 Reimbursing You for Travel 7
21-24 Processing Reimbursement Requests 8-9
25 Change of Address 9
26-27 Keeping Copies for Your Records 9
28 Payments and/or Reimbursements 9
Samples
# Subject Corresponds to Page #
1. Black Lung Benefits Identification Card (Q #1) 1
2. Medical Reimbursement Form, OWCP-915 (Doctor Visit) (Q #18) 10
3. Proof of Payment for Doctor Visit (Q #18) 11
4. Medical Reimbursement Form, OWCP-915 (Prescription (Q #19) 12
Drugs)
5. Pharmacy Bill Receipt (Q #19) 13
6. Proof of Payment: Computerized Printout Pharmacy (Q #19) 13
Receipt
7 Medical Travel Refund Request, OWCP-957 (Q #20) 14
8.a. Remittance Voucher (Front of Form) (Q #22) 15
8.b Remittance Voucher (Back of Form) (Q #22) 15
iIntroduction While this material gives you basic
information about your medical
Like all coal miners who qualify for the benefits, it is neither intended to cover
U.S. Department of Labor’s Federal every possible exception or special case,
Black Lung Program, you are entitled to nor have the effect of law. Additionally,
medical benefits to cover the reasonable this information applies only if your
cost of treatment, services or supplies medical benefits are being paid by the
for your pneumoconiosis and disability U.S. Department of Labor. If a private
(your black lung condition). Spouses, party, such as your employer or its
family members, and survivors of coal insurance carrier, is responsible for your
miners are not entitled to medical medical benefits, different procedures
benefits. You have the right to seek may apply. You may contact that
treatment from the medical provider private party directly or write or call
(physicians, pharmacies, hospitals, etc.) the U.S. Department of Labor, Division
of your choice. Most providers who of Coal Mine Workers’ Compensation
are enrolled in the Federal Black Lung (DCMWC) District Office with
Program will bill the Federal Black Lung which your claim is filed. For further
Program directly for you. But if the information about special circumstances
provider is not enrolled in the Federal or individual cases, please write or call
Black Lung Program (or chooses not to the District Office with which your claim
bill directly), it will be necessary for you is filed. If you are not sure which District
to pay for the services yourself then file Office handles your claim, you may find
with the Federal Black Lung Program on out by calling toll-free, Mon.-Fri., 8:00
your own for reimbursement of these a.m.- 8:00 p.m. (ET): 1-800-638-7072.
out-of-pocket payments.
The questions presented here are those
most often asked by Black Lung Program
beneficiaries about:
l The U.S. Department of Labor Black
Lung Benefits Identification Card
(medical treatment card);
l Medical benefits - covered and
non-covered services; and,
l Reimbursement for medical care and
associated travel.
iiWhat does the Black Lung Sample 1. Black Lung Benefits
1 Benefits Identification Card
look like?
Identification Card
The U.S. Department of Labor Black
Lung Benefits Identification Card is
white with a Department of Labor logo,
and is imprinted with your name, an
effective date, and possibly an expiration
date. The red-and-white cards previ-
ously issued are obsolete and should be
destroyed. When medical providers bill
the Federal Black Lung Program or when
you submit reimbursement requests,
your nine-digit Social Security number is 1. This card is the property of the U.S. Government and its counterfeiting, alteration
your identification number. For privacy or misuse is a violation of Section 499, Title 18, U.S. Code.
2. Carry this card with you at all times and show it to your doctor, clinic or hospital
reasons, your Social Security number when you are in need of medical services for your lung condition.
does not appear on your card. However, 3. The U.S. Department of Labor will pay for medical treatment that is authorized
under the Black Lung Act. Call 1-800-638-7072 for specific details.
you will need to give your Social Security 4. All bills should be submitted to the DOL Black Lung Program, P.O. Box 8302,
London, KY 40742-8302.
number to your medical treatment pro-
5. If found, drop in mailbox. Postmaster, postage guaranteed. Return to: DOL Black
viders so they can bill correctly. Lung Program, P.O. Box 8302, London KY 40742-8302.
6. When using the DOL OWCP bill payment website (http://owcp.dol.acs-inc.com/)
to request an authorization for medical services or to verify eligibility, your doctor
must use the following Card ID Number: 1234567830. Claimants can also use
this Card ID Number to access the DOL OWCP bill payment website.
MISUSE OF CARD IS PUNISHABLE BY LAW
Is my personal information
2 safe? What does my doctor
need to know?
Your Social Security number and address your eligibility for benefits and about
are not printed on the card, and this is bills they have filed. Your providers will
information only you will know and will probably want to photocopy both sides
need to give to your medical provid- of the card for their records, because
ers. There is a 10-digit number printed without the card ID number they will be
on the back of the card that is unique to unable to access the secure part of our
you. The purpose of this number is to web site.
allow the medical providers to access our
secure web site to get information about
1When do I use my U.S. Federal Black Lung Program. However,
3 Department of Labor Black
Lung Benefits Identification
bills or reimbursement requests must
first be submitted under the state pro-
Card? gram which awarded your benefits.
You should present your black lung If your medical providers’ bills or your
card whenever you seek treatment for own reimbursement requests are denied
your lung condition. Showing a medical under your state award, send the bill or
provider your card will identify you as a the reimbursement request and original
Federal Black Lung Program beneficiary, receipts (as discussed in Question 18),
and will help the medical provider deter- along with a copy of the denial letter, to:
mine the proper way to bill for services. FEDERAL BLACK LUNG PROGRAM
P.O. BOX 8302
I receive my black lung LONDON, KY 40742-8302
4 benefits through the U.S.
Department of Labor around If you have questions, please call the
the middle of each month, but DCMWC District Office that handles
I do not have a black lung card. What your Federal Black Lung Program claim.
should I do? If you do not have the address or phone
number of that office, you may get them
Write or call the DCMWC District Office by calling toll-free, Mon.- Fri., 8:00 a.m.-
with which your claim is filed. If you are 8:00 p.m. (ET): 1-800-638-7072.
not sure which office handles your claim,
call toll-free, Mon.-Fri., 8:00 a.m.- 8:00 I have been awarded black
p.m. (ET), and the operator can tell you
which District Office to contact:
6 lung benefits under both the
Federal Black Lung Program
1-800-638-7072. and a State Workers’ Compen-
sation Program. Should I have received
I was awarded black lung a black lung card?
5 benefits by the Federal Black
Lung Program. I also filed a If you have been awarded benefits for
claim with the state where your black lung condition under a State
I worked as a coal miner and was Workers’ Compensation Program, you
awarded benefits for black lung. Am I will NOT receive an identification card
still entitled to medical coverage under from the Federal Black Lung Program.
the Federal Black Lung Program? Expenses for the treatment of your black
lung condition that are not covered by
Expenses for the treatment of your black the state program may be covered by
lung condition that are not covered by the Federal Black Lung Program. (See
the state program may be covered by the Question 5.)
2What costs are covered The following items require special
7 under my Federal Black Lung
Program medical benefits?
approval:
l The purchase or rental of home
medical equipment such as oxygen
The cost of medical treatment services systems exceeding $300 (requires
and associated travel for the treatment Certificate of Medical Necessity—See
of your black lung condition is covered Question 10—completed by prescrib-
under the Federal Black Lung Benefits ing physician);
Act. Payment for medical treatment l Pulmonary rehabilitation (breathing
services is subject to a maximum allow- retraining) programs (requires Certif-
able fee. There is no deductible or co- icate of Medical Necessity completed
payment. Payment for travel is limited to by prescribing physician);
reasonable costs. l Home health care visits for skilled
nursing (requires Certificate of Medi-
The following is a list of services that cal Necessity completed by prescrib-
MAY be covered when they are per- ing physician); and,
formed for the treatment of your black l Overnight travel, related meals and
lung condition: lodging, and/or mileage that exceeds
l Doctor’s office calls, hospital visits, 200 miles round trip (requires special
and consultations; approval from your DCMWC District
l Inpatient and outpatient hospital Office).
charges, including emergency room
visits for ACUTE black lung related What prescription drugs are
conditions, diagnostic laboratory test-
ing and chest x-rays; 8 covered?
l Federal Black Lung Program
APPROVED prescription drugs, both Most drugs prescribed by your doc-
brand name and generic; tor for the treatment of your black lung
l Ambulance services limited to trans- condition will be covered (brand name
portation to the hospital for emer- or generic). However, there are some
gency ACUTE black lung related care; exceptions. In order to be sure a drug is
and, covered, you or your pharmacist may call
l Travel to the doctor, hospital, clinic, toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.
or other medical facility for round (ET): 1-800-638-7072. Your pharma-
trips of 200 miles or less. cist will also be able to learn at once if a
drug is covered if the bill is submitted by
Point-of-Sale technology.
3Do I need prior approval for What costs are NOT covered
9 certain services?
11 by my Federal Black Lung
Program medical benefits?
Yes. Whether you or a medical pro- The following are among the costs NOT
vider does the billing, your doctor must covered under the Federal Black Lung
complete the U.S. Department of Labor Program:
Certificate of Medical Necessity, CM-893
(CMN), for oxygen and other durable l Treatment of medical problems NOT
medical equipment, pulmonary rehabili- related to your black lung condition
tation, or skilled nursing care at home. —for example, arthritis, diabetes, and
most heart conditions;
The doctor should send the completed l Medical treatment for your spouse or
form, with the results of the required other family members;
medical tests attached, to the DCMWC l Dental or eye care, and X-rays other
District Office with which your claim is than chest X-rays;
filed. l Nurse’s aid (non-skilled nursing
care) services in the home;
CMNs for rental items must be re- l Home health aides
approved periodically (a prescription l Medicine that you can buy without a
for oxygen concentrator, for example). doctor’s prescription;
All CMNs must have the DOCTOR’S l Medicine for problems other than
ORIGINAL SIGNATURE. Your treat- your black lung condition;
ing physician’s original signature is the l Personal services in the hospital, such
ONLY signature acceptable on the CMN. as TV or telephone;
You, your physician, and the medical l Rental or purchase of an Intermittent
provider (if billing the Federal Black Positive Pressure Breathing (IPPB)
Lung Program for you) will be notified if machine for home use;
the CMN has been approved or denied. l Travel to and from your drugstore;
l Residence costs (room and board)
Where can my doctor get for nursing homes or skilled nursing
10 a Certificate of Medical
Necessity (CMN)?
facilities; and,
l Home medical equipment not autho-
rized for coverage under the Federal
Your doctor may call the Federal Black Black Lung Program.
Lung Program, toll-free, Mon.-Fri., 8:00
a.m.-8:00 p.m. (ET): 1-800-638-7072.
The form is also available for download-
ing and printing from our website, at
http://www.dol.gov/owcp/regs/compli-
ance/cm-893.pdf
4What is the best way to get my Does the medical provider
12 medical bills paid?
15 need special Department of
Labor billing forms?
WHENEVER POSSIBLE, have your doc- NO. The doctor, clinic, laboratory,
tor, hospital, pharmacy and other medi- ambulance and nursing service can bill
cal providers bill the Federal Black Lung using the standard OWCP-1500 form.
Program directly. If they are enrolled in
the Federal Black Lung Program as pro- The pharmacy can bill using the standard
viders, the Federal Black Lung Program OWCP-1500 form or the Universal Phar-
will pay them directly. ALWAYS show macy Billing Form. They may also bill
your Black Lung Benefits Identification directly at the Point-of-Sale for most drugs.
Card when seeking treatment.
The hospital can bill using the UB-04
How can a medical provider form for all inpatient charges and outpa-
13 get enrollment and billing
information from the Federal
tient charges for emergency room, che-
motherapy and ambulatory surgical care.
Black Lung Program? The OWCP-1500 form should be used
for other outpatient charges.
Medical providers not already participat-
ing in the Federal Black Lung Program What if the medical provider
may apply for enrollment at any time.
Those having questions about enrollment
16 wants to bill Medicare,
UMWA, or other insurance
or billing may call the Federal Black Lung carriers instead of the Black
Program, toll-free, Mon.-Fri., 8:00 a.m.- Lung Program?
8:00 p.m. (ET): 1-800-638-7072. They
may also apply online at http://owcp.dol. Other insurance carriers should NOT be
acs-inc.com/portal/providerEnrollment.do billed first for treatment of your black
lung condition, because Federal Black
Where should medical Lung Program medical benefits rep-
14 providers send Black Lung
related bills?
resent primary coverage for beneficia-
ries (unless there is a black lung award
under a state program. See Question
Answer: ALL Federal Black Lung 5). Medicare and many other insurance
Program medical treatment bills should carriers have a “workers’ compensation
be sent to the following address: exclusion clause.” This means that they
FEDERAL BLACK LUNG PROGRAM will not pay for treatment of occupa-
P.O. BOX 8302 tional disease, like black lung disease, if
LONDON, KY 40742-8302 a patient has medical coverage under a
workers’ compensation program or the
Federal Black Lung Program.
5The U.S. Department of Labor Send the completed Medical
17 has notified me that the coal
company has agreed to pay
Reimbursement Form with your item-
ized paid statements or detailed receipts,
for medical treatment for my securely attached, to:
black lung. How is this handled? FEDERAL BLACK LUNG PROGRAM
P.O. BOX 8302
You will need to ask the coal company LONDON, KY 40742-8302
or its insurance carrier how and where
both you and medical providers who Your detailed receipts or itemized state-
might bill for you should submit medical ments MUST include the following
claims. Usually, a medical benefit iden- information:
tification card is NOT issued by the coal l Your full name;
company. If you need help, you may l Name and address of the medical
write or telephone the DCMWC District provider;
Office that handles your claim. l Signature of the medical provider;
l Description of medical service per-
What if I have to pay the formed;
18 medical provider? How do I
get reimbursed by the Federal
l Date of service;
l Primary diagnosis or condition treated;
Black Lung Program? l Charge for each individual service;
and,
Present your Black Lung Benefits l Total amount you paid.
Identification Card to the medical pro-
vider whenever you seek treatment for Receipts and statements must be marked
your lung condition. A medical provider “patient paid” or “paid by patient” to
may bill directly, if already enrolled in show specifically who paid the charges.
the Federal Black Lung Program.
“Paid” or “paid in full” are NOT accept-
If you must pay for the medical ser- able.
vices out-of-pocket then you may
request reimbursement by completing A copy of the front and back of your
the U.S. Department of Labor Medical canceled check may serve as proof of
Reimbursement Form, OWCP-915, as payment ONLY when accompanied by
shown in Sample 2. Up to eight visits an itemized statement or copy of the
or services can be listed on this form. doctor’s ledger record. (See Sample 3.)
However, each line used MUST be filled
in COMPLETELY. Therefore, statements
such as “see attached” or “see attached
receipts” are NOT acceptable, when used
in any of the boxes on the form.
6How do I get reimbursed for l Charge actually paid for each drug
19 prescription drugs? less any discount (for example, senior
citizen, coupon, etc.); a
l A statement, marked “patient paid”
To obtain reimbursement, fill out a or “paid by patient,” showing specifi-
Medical Reimbursement Form, OWCP- cally who paid the charges. “Paid” or
915, as shown in Sample 4. Up to nine “paid in full” are NOT acceptable.
individual prescription drugs may be
listed on this form. However, each line (See Sample 5.)
used MUST be filled in COMPLETELY.
Therefore, statements such as “see NOTE: If you send an itemized comput-
attached” or “see attached receipts” are erized printout, it MUST include all of
NOT acceptable when used in any of the the information already listed, as well as
boxes on the form. the PHARMACIST’S ORIGINAL SIG-
NATURE.
Send the completed Medical
Reimbursement Form, along with the (See Sample 6.)
original pharmacy receipts, securely
attached, to: Your own itemized listing or cash regis-
FEDERAL BLACK LUNG PROGRAM ter receipt is NOT considered proof of
P.O. BOX 8302 payment.
LONDON, KY 40742-8302
A copy of the front and back of your
These are acceptable receipts: a pharmacy canceled check may serve as proof of
bag or sticker, a computerized printout, payment, ONLY when accompanied by
or an itemized listing on the pharmacy’s an itemized statement or pharmacist’s
letterhead. These receipts MUST include: ledger record.
l Your full name, address, and social
security number; If you need help getting or completing
l Name of the prescribing doctor; forms for the reimbursement of prescrip-
l Name and address of the pharmacy; tion drugs, please call toll-free, Mon.-
l Prescription number; Fri., 8:00 a.m.-8:00 p.m. (ET): 1-800-
l Amount prescribed - mg/ml or cc 638-7072.
and total ml or cc per bottle for liq-
uid medication, and/or mg per tablet Can I be reimbursed for the cost
and total number of tablets per pre-
scription;
20 of travel to get medical treatment
related to my black lung?
l Date purchased;
l Name of each drug; Mileage costs for most travel to obtain
l 11-digit National Drug Code (NDC) medical treatment for your lung con-
number for the prescribed medication; dition may be reimbursed. To get
7reimbursement, you must complete You will be notified by mail if your
a Medical Travel Refund Request, reimbursement requests will be paid
OWCP-957, as shown in Sample 7. You or denied, through a form called a
may submit up to three trips on each Remittance Voucher, as shown in
form. However, you MUST have the Samples 8.a. and 8.b. This statement will
MEDICAL PROVIDER, or an autho- contain the following information:
rized representative, complete and SIGN l The date of service;
block “H” for each visit. l The amount of your reimbursement
Mail the completed Medical Travel request;
Refund Request to: l The amount you will be paid;
FEDERAL BLACK LUNG PROGRAM l A Remittance Voucher number at
P.O. BOX 8302 the top of the form. (This number
LONDON, KY 40742-8302 will also appear on your check, if you
receive a payment, so you can match
NOTE: Overnight travel, related meals payments with your reimbursement
and lodging, and/or mileage that exceeds requests.); and,
200 miles round trip requires special l A “Message Code” which will explain
prior approval from the DCMWC why you were not paid for any por-
District Office. If you are not sure which tion of the reimbursement request.
office to contact, call the toll-free num- l You will NOT receive a Remittance
ber, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): Voucher if your medical provider
1-800-638-7072. bills the Federal Black Lung Program
Travel to a pharmacy to pick up pre- directly.
scriptions is NOT covered.
What will happen if I have not
Sample 7. Medical Travel Refund
Request, OWCP-957
23 submitted my reimbursement
request forms or receipts
correctly? Will I still receive a
How much time will my Remittance Voucher?
21 reimbursement requests take
to be processed? Any reimbursement request forms and
receipts that need correction or addi-
Reimbursement requests which are sub- tional information will be returned to
mitted correctly will be processed by the you along with a letter explaining what
Federal Black Lung Program within 30 is wrong or missing. It is very important
days. that you correct and mail back these
forms and receipts as soon as possible.
Will I be notified if the You cannot be paid by the Federal Black
22 reimbursement requests I
send in are going to be paid?
Lung Program until you submit all
forms and receipts properly. All correct-
ed reimbursement forms and receipts
8should be mailed to: operator will tell you whom to contact:
FEDERAL BLACK LUNG PROGRAM 1-800-638-7072.
P.O. BOX 8302
LONDON, KY 40742-8302 Should I keep copies of the
If you need help correcting reimburse-
26 bills that I send to the Federal
Black Lung Program?
ment requests which have been returned,
you may call toll-free, Mon.-Fri., 8:00 YES, if possible. Keeping a copy will
a.m.-8:00 p.m. (ET): 1-800-638-7072. give you a record of the reimbursement
requests and receipts you have submitted.
Will a check come with the
24 Remittance Voucher (RV)?
27
Can I look at my medical bills
on the internet?
No, the check is always mailed sepa-
rately. Checks are issued by the U.S. Yes. Black Lung has a secure website.
Treasury Department. The RV is sent Enter: http://owcp.dol.acs-inc.com in
from the Federal Black Lung Program your browser. Click “Claimant” by
office where your reimbursement DCMWC. You will need your SSN and
requests are processed. The RV will your ID number on the back of your
usually arrive shortly after your check. Member Benefits ID Card (MBIC).
Please remember to allow enough time
(10 to 14 days) for both the check and Payments and/or
the RV to arrive before making inquiries.
If you have questions about your RV, if
28 Reimbursements
you fail to receive either a check or an
RV, or if your payment is incorrect and The Treasury Department requires that
requires an adjustment, you may call all payments and/or reimbursements
toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. made to you must be electronic. You will
(ET): 1-800-638-7072. get your money faster, without the worry
about lost or stolen checks. You now
Whom should I notify if my have two options:
25 mailing address changes? 1. Have your payment sent directly to
your bank account or other financial
institution, or
Any changes in your mailing address 2. Elect to receive a Direct Express Card,
should be reported to the DCMWC which you can use to receive cash and
District Office with which your claim make purchases. All payments made to
is filed. If you are not sure which office you will be added to the amount avail-
handles your claim, call toll free, Mon.- able on your card.
Fri., 8:00 a.m.-8:00 p.m. (ET), and the
9Sample 2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)
10Sample 3. Proof of Payment for Doctor Visit
l Your full name
l Your address
l Your Social Security Number
l Name and address of medical provider
l Signature of medical provider
l Diagnosis or Condition Treated
l Date of Service
l Description of Service Performed
l Charges for each type of service
l Total amount you paid
l A statement showing specifically who paid the charges (PATIENT PAID or
l PAID BY PATIENT). “PAID” or “PAID IN FULL” are not acceptable.
If you need help getting or completing this form, please call toll-free, Mon.- Fri.,
8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.
11Sample 4. Medical Reimbursement Form, OWCP-915
(Prescription Drugs)
12Sample 5. Pharmacy Bill Receipt
Prescription Drugs l A statement showing specifically who
Receipts can be the pharmacy bag or paid the charges (PATIENT PAID
sticker, a computerized printout, or an or PAID BY PATIENT). “PAID” or
itemized listing on the pharmacy’s letter- “PAID IN FULL” are not acceptable.
head. These receipts must include:
l Your full name, address, and social
security number
l Name of the prescribing doctor
l Name and address of the pharmacy
l Prescription number
l Amount prescribed-mg/ml or cc and
total ml or cc per bottle for liquid
medication, and/or mg per tablet and
total number of tablets per prescription
l Date purchased
l Name of each drug
l 11-digit National Drug Code (NDC)
number for the prescribed medication
l Charge actually paid for each drug
less any discount (e.g., senior citizen
or coupon)
Sample 6. Proof of Payment:
Computerized
Printout
Pharmacy Receipt
13Sample 7. Medical Travel Refund Request, OWCP-957
14Sample 8.a. Remittance Voucher (Front of Form)
Sample 8.b. Remittance Advice (Back of Form)
15www.dol.gov U.S. Department of Labor Office of Workers’ Compensation Programs
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