03-26885. Submission for OMB Review; Comment Request

October 16, 2003.

The Department of Labor (DOL) has submitted the following public information collection request (ICR) to the Office of Management and Budget (OMB) for review and approval in accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13, 44 U.S.C. chapter 35). A copy of this ICR, with applicable supporting documentation, may be obtained by calling the Department of Labor. To obtain documentation, contact Darrin King on 202-693-4129 (this is not a toll-free number) or E-Mail: [e-mail].

Comments should be sent to Office of Information and Regulatory Affairs, Attn: OMB Desk Officer the Employment Standards Administration (ESA), Office of Management and Budget, Room 10235, Washington, DC 20503 (202-395-7316/this is not a toll-free number), within 30 days from the date of this publication in the Federal Register.

The OMB is particularly interested in comments which:

• Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility;
• Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used:
• Enhance the quality, utility, and clarity of the information to be collected; and
• Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.

Agency: Employment Standards Administration.

Type of Review: Extension of a currently approved collection.

Title: Uniform Billing Form.

OMB Number: 1215-0176.

Affected Public: Business or other for-profit; Not-for-profit institutions; and Individuals or households.

Frequency: As needed.

Number of Respondents: 57,679.

Number of Annual Responses: 230,716.

Estimated Time Per Response: 7 minutes.

Total Burden Hours: 26,925.

Total Annualized Capital/Startup Costs: $0.

Total Annual Costs (operating/maintaining systems or purchasing services): $0.

Description: The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act (FECA) 5 U.S.C. 8101 et seq., the Black Lung Benefits Act (BLBA) 30 U.S.C. 901 et seq., and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq. These Acts provide, in addition to compensation for employment-related injury and/or disability, payments to provider institutions for certain non-professional medical treatment and services related to the injury or disability. The Uniform Billing Form (OWCP-92) consists of the industry standard billing form (UB-92), which has been approved by the American Hospital Association, the Centers for Medicare and Medicaid Services, and the Civilian Health and Medical Program of the Uniformed Services, by various other government health care programs, and the private sector, for the purpose of payment to institutional providers of medical services. The OWCP-92 also includes detailed instructions developed by OWCP that provide the information necessary to providers who file bills for services that may be payable under FECA, BLBA and the EEOICPA.

Ira L. Mills,

Departmental Clearance Officer.