The following material gives you basic information about your medical benefits, but it is neither intended to cover everypossible exception or special case, nor have the effect of law. Additionally, this information applies only if the Black LungDisability 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 directlyor 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.

Black Lung Medical Benefits:Frequently Asked Questions about the Federal Black Lung Program

U.S. Department of Labor Employment Standards AdministrationOffice of Workers' Compensation ProgramsDivision of Coal Mine Workers' CompensationDecember 2004

Contents

Question Subject Page #

1-3 Black Lung Benefits Identification Card

4-5 State and Federal Black Lung Benefits

6 Social Security Black Lung Benefits

7 Covered Medical Services

8 Covered Prescription Drugs

9-10 Approval for Certain Services

11 Non-Covered Medical Services

12-16 Direct Billing by Medical Providers

17 Billing the Coal Company

18 Reimbursing You for Medical Services

19 Reimbursing You for Prescription Drugs

20 Reimbursing You for Travel

21-24 Processing Reimbursement Requests

25 Change of Address

26-27 Keeping Copies for Your Records

28 Information Service

Samples

# Subject Corresponds to Page #

1. Black Lung Benefits Identification Card

2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)

3. Proof of Payment for Doctor Visit

4. Medical Reimbursement Form, OWCP-915 (Prescription Drugs)

5. Pharmacy Bill Receipt

6. Proof of Payment: Computerized Printout Pharmacy Receipt

7. Medical Travel Refund Request, OWCP-957

8. a. Remittance Voucher (Front of Form)

8. b. Remittance Voucher (Back of Form)

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(Q #1)

(Q #18)

(Q #18)

(Q #19)

(Q #19)

(Q #19)

(Q #20)

(Q #22)

(Q #22)

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Introduction

Like all coal miners who qualify for theU.S. Department of Labor's FederalBlack Lung Program, you are entitled tomedical benefits to cover the reasonablecost of treatment, services or supplies foryour pneumoconiosis and disability(your black lung condition). Spouses,family members, and survivors of coalminers are not entitled to medical bene-fits. You have the right to seek treatmentfrom the medical provider (physicians,pharmacies, hospitals, etc.) of yourchoice. Most providers who are enrolledin the Federal Black Lung Program willbill the Federal Black Lung Programdirectly for you. But if the provider isnot enrolled in the Federal Black LungProgram (or chooses not to bill directly),it will be necessary for you to pay for theservices yourself then file with theFederal Black Lung Program on yourown for reimbursement of these out-of-pocket payments.

The questions presented here are thosemost often asked by Black Lung Programbeneficiaries about:� The U.S. Department of Labor Black

Lung Benefits Identification Card(medical treatment card);

� Medical benefits - covered and non-covered services; and,

� Reimbursement for medical care andassociated travel.

While this material gives you basic infor-mation about your medical benefits, it isneither intended to cover every possibleexception or special case, nor have theeffect of law. Additionally, this informa-tion applies only if your medical benefitsare being paid by the U.S. Department ofLabor. If a private party, such as youremployer or its insurance carrier, isresponsible for your medical benefits,different procedures may apply. You maycontact that private party directly orwrite or call the U.S. Department ofLabor, Division of Coal Mine Workers'Compensation (DCMWC) DistrictOffice with which your claim is filed. Forfurther information about special cir-cumstances or individual cases, pleasewrite or call the District Office withwhich your claim is filed. If you are notsure which District Office handles yourclaim, you may find out by calling toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):1-800-638-7072.

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What does the Black LungBenefits Identification Cardlook like?

The U.S. Department of Labor BlackLung Benefits Identification Card iswhite with a Department of Labor logo,and is imprinted with your name, aneffective date, and possibly an expirationdate. The red-and-white cards previ-ously issued are obsolete and should bedestroyed. When medical providers billthe Federal Black Lung Program or whenyou submit reimbursement requests,your nine-digit Social Security number isyour identification number. For privacyreasons, your Social Security numberdoes not appear on your card. However,you will need to give your Social Securitynumber to your medical treatmentproviders so they can bill correctly.

Sample 1. Black Lung Benefits Identification Card

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1. This card is the property of the U.S. Government and its counterfeiting, alterationor 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 hospitalwhen you are in need of medical services for your lung condition.

3. The U.S. Department of Labor will pay for medical treatment that is authorizedunder the Black Lung Act. Call 1-800-638-7072 for specific details.

4. All bills should be submitted to the DOL Black Lung Program, P.O. Box 8302,London, KY 40742-8302.

5. If found, drop in mailbox. Postmaster, postage guaranteed. Return to: DOL BlackLung 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 doctormust use the following Card ID Number: 1234567830. Claimants can also usethis Card ID Number to access the DOL OWCP bill payment website.

MISUSE OF CARD IS PUNISHABLE BY LAW

Is my personal informationsafe? What does my doctorneed to know?

Your Social Security number and addressare not printed on the card, and this isinformation only you will know and willneed to give to your medical providers.There is a 10-digit number printed onthe back of the card that is unique toyou. The purpose of this number is toallow the medical providers to access our

2secure web site to get information aboutyour eligibility for benefits and aboutbills they have filed. Your providers willprobably want to photocopy both sidesof the card for their records, becausewithout the card ID number they will beunable to access the secure part of ourweb site.

When do I use my U.S.Department of Labor BlackLung Benefits IdentificationCard?

You should present your black lung cardwhenever you seek treatment for yourlung condition. Showing a medicalprovider your card will identify you as aFederal Black Lung Program beneficiary,and will help the medical provider deter-mine the proper way to bill for services.

I receive my black lung bene-fits through the U.S.Department of Labor aroundthe middle of each month, but

I do not have a black lung card. Whatshould I do?

Write or call the DCMWC District Officewith which your claim is filed. If you are not sure which office handles yourclaim, call toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET), and the operator can tellyou which District Office to contact:1-800-638-7072.

I was awarded black lung ben-efits by the Federal Black LungProgram. I also filed a claimwith the state where I worked

as a coal miner and was awarded bene-fits for black lung. Am I still entitled tomedical coverage under the FederalBlack Lung Program?

Expenses for the treatment of your blacklung condition that are not covered bythe state program may be covered by the

Federal Black Lung Program. However,bills or reimbursement requests mustfirst be submitted under the state pro-gram which awarded your benefits.

If your medical providers' bills or yourown reimbursement requests are deniedunder your state award, send the bill orthe reimbursement request and originalreceipts (as discussed in Question 18),along with a copy of the denial letter, to:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302 LONDON, KY 40742-8302

If you have questions, please call theDCMWC District Office that handlesyour Federal Black Lung Program claim.If you do not have the address or phonenumber of that office, you may get themby calling toll-free, Mon.- Fri., 8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.

I have been awarded blacklung benefits under both theFederal Black Lung Programand a State Workers' Compen-

sation Program. Should I have receiveda black lung card?

If you have been awarded benefits foryour black lung condition under a StateWorkers' Compensation Program, youwill NOT receive an identification cardfrom the Federal Black Lung Program.Expenses for the treatment of your blacklung condition that are not covered bythe state program may be covered by theFederal Black Lung Program. (SeeQuestion 5.)

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What costs are covered undermy Federal Black LungProgram medical benefits?

The cost of medical treatment servicesand associated travel for the treatment ofyour black lung condition is coveredunder the Federal Black Lung BenefitsAct. Payment for medical treatment serv-ices is subject to a maximum allowablefee. There is no deductible or co-pay-ment. Payment for travel is limited toreasonable costs.

The following is a list of services thatMAY be covered when they are per-formed for the treatment of your blacklung condition:� Doctor's office calls, hospital visits,

and consultations;� Inpatient and outpatient hospital

charges, including emergency roomvisits for ACUTE black lung relatedconditions, diagnostic laboratorytesting and chest x-rays;

� Federal Black Lung ProgramAPPROVED prescription drugs, bothbrand name and generic;

� Ambulance services limited to trans-portation to the hospital for emer-gency ACUTE black lung relatedcare; and,

� Travel to the doctor, hospital, clinic,or other medical facility for roundtrips of 150 miles or less.

The following items require specialapproval:� The purchase or rental of home

medical equipment such as oxygensystems exceeding $300 (requiresCertificate of Medical Necessity—SeeQuestion 10—completed by pre-scribing physician);

� Pulmonary rehabilitation (breathingretraining) programs (requiresCertificate of Medical Necessity com-pleted by prescribing physician);

� Home health care visits for skillednursing (requires Certificate ofMedical Necessity completed by pre-scribing physician); and,

� Overnight travel, related meals andlodging, and/or mileage that exceeds150 miles round trip (requires specialapproval from your DCMWCDistrict Office).

What prescription drugs arecovered?

Most drugs prescribed by your doctorfor the treatment of your black lung con-dition will be covered (brand name orgeneric). However, there are some excep-tions. In order to be sure a drug is cov-ered, you or your pharmacist may calltoll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.(ET): 1-800-638-7072. Your pharmacistwill also be able to learn at once if a drugis covered if the bill is submitted byPoint-of-Sale technology.

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Do I need prior approval forcertain services?

Yes. Whether you or a medical providerdoes the billing, your doctor must com-plete the U.S. Department of LaborCertificate of Medical Necessity, CM-893(CMN), for oxygen and other durablemedical equipment, pulmonary rehabili-tation, or skilled nursing care at home.

The doctor should send the completedform, with the results of the requiredmedical tests attached, to the DCMWCDistrict Office with which your claim isfiled.

CMNs for rental items must be re-approved periodically (a prescription foroxygen concentrator, for example). AllCMNs must have the DOCTOR'S ORIG-INAL SIGNATURE. Your treating physi-cian's original signature is the ONLY signature acceptable on the CMN. You,your physician, and the medical provider(if billing the Federal Black LungProgram for you) will be notified ifthe CMN has been approved or denied.

Where can my doctor get aCertificate of MedicalNecessity (CMN)?

Your doctor may call the Federal BlackLung Program, toll-free, Mon.-Fri., 8:00a.m.-8:00 p.m. (ET): 1-800-638-7072.The form is also available for download-ing and printing from our website, athttp://www.dol.gov/esa/regs/compli-ance/owcp/cm-893.pdf.

What costs are NOT coveredby my Federal Black LungProgram medical benefits?

The following are among the costs NOTcovered under the Federal Black LungProgram:

� Treatment of medical problems NOTrelated to your black lung condition—for example, arthritis, diabetes,and most heart conditions;

� Medical treatment for your spouse orother family members;

� Dental or eye care, and X-rays otherthan chest X-rays;

� Nurse's aid (non-skilled nursingcare) services in the home;

� Home health aides� Medicine that you can buy without a

doctor's prescription;� Medicine for problems other than

your black lung condition;� Personal services in the hospital, such

as TV or telephone;� Rental or purchase of an Intermittent

Positive Pressure Breathing (IPPB)machine for home use;

� Travel to and from your drugstore;� Residence costs (room and board)

for nursing homes or skilled nursingfacilities; and,

� Home medical equipment notauthorized for coverage under theFederal Black Lung Program.

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What is the best way to get mymedical bills paid?

WHENEVER POSSIBLE, have your doc-tor, hospital, pharmacy and other med-ical providers bill the Federal Black LungProgram directly. If they are enrolled inthe Federal Black Lung Program asproviders, the Federal Black LungProgram will pay them directly. ALWAYSshow your Black Lung Benefits Identi-fication Card when seeking treatment.

How can a medical providerget enrollment and billinginformation from the FederalBlack Lung Program?

Medical providers not already participat-ing in the Federal Black Lung Programmay apply for enrollment at any time.Those having questions about enrollmentor billing may call the Federal Black LungProgram, toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072. Theymay also apply online at http://owcp.dol.acs-inc.com/portal/providerEnrollment.do.

Where should medicalproviders send Black Lungrelated bills?

Answer: ALL Federal Black LungProgram medical treatment bills shouldbe sent to the following address:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302 LONDON, KY 40742-8302

Does the medical providerneed special Department ofLabor billing forms?

NO. The doctor, clinic, laboratory,ambulance and nursing service can billusing the standard OWCP-1500 form.

The pharmacy can bill using the standardOWCP-1500 form or the Universal Phar-macy Billing Form. They may also billdirectly at the Point-of-Sale for most drugs.

The hospital can bill using the UB-92form for all inpatient charges and outpa-tient charges for emergency room,chemotherapy and ambulatory surgicalcare. The OWCP-1500 form should beused for other outpatient charges.

What if the medical providerwants to bill Medicare,UMWA, or other insurancecarriers instead of the Black Lung Program?

Other insurance carriers should NOT bebilled first for treatment of your blacklung condition, because Federal BlackLung Program medical benefits representprimary coverage for beneficiaries(unless there is a black lung award undera state program. See Question 5).Medicare and many other insurance car-riers have a "workers' compensationexclusion clause." This means that theywill not pay for treatment of occupation-al disease, like black lung disease, if apatient has medical coverage under aworkers' compensation program or theFederal Black Lung Program.

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The U.S. Department of Laborhas notified me that the coalcompany has agreed to pay formedical treatment for my

black lung. How is this handled?

You will need to ask the coal company orits insurance carrier how and where bothyou and medical providers who mightbill for you should submit medicalclaims. Usually, a medical benefit identi-fication card is NOT issued by the coalcompany. If you need help, you maywrite or telephone the DCMWC DistrictOffice that handles your claim.

What if I have to pay the med-ical provider? How do I getreimbursed by the FederalBlack Lung Program?

Present your Black Lung BenefitsIdentification Card to the medicalprovider whenever you seek treatmentfor your lung condition. A medicalprovider may bill directly, if alreadyenrolled in the Federal Black LungProgram.

If you must pay for the medical servicesout-of-pocket then you may requestreimbursement by completing the U.S.Department of Labor MedicalReimbursement Form, OWCP-915, asshown in Sample 2. Up to eight visits orservices can be listed on this form.However, each line used MUST be filledin COMPLETELY. Therefore, statementssuch as "see attached" or "see attached

receipts" are NOT acceptable, when usedin any of the boxes on the form.

Send the completed MedicalReimbursement Form with your item-ized paid statements or detailed receipts,securely attached, to:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302 LONDON, KY 40742-8302

Your detailed receipts or itemized state-ments MUST include the followinginformation:� Your full name;� Name and address of the medical

provider;� Signature of the medical provider;� Description of medical service per-

formed;� Date of service;� Primary diagnosis or condition treated;� Charge for each individual service;

and,� Total amount you paid.

Receipts and statements must be marked"patient paid" or "paid by patient" toshow specifically who paid the charges.

"Paid" or "paid in full" are NOT acceptable.

A copy of the front and back of yourcanceled check may serve as proof ofpayment ONLY when accompanied byan itemized statement or copy of thedoctor's ledger record. (See Sample 3.)

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How do I get reimbursed forprescription drugs?

To obtain reimbursement, fill out aMedical Reimbursement Form, OWCP-915, as shown in Sample 4. Up to nineindividual prescription drugs may belisted on this form. However, each lineused MUST be filled in COMPLETELY.Therefore, statements such as "seeattached" or "see attached receipts" areNOT acceptable when used in any of theboxes on the form.

Send the completed MedicalReimbursement Form, along with theoriginal pharmacy receipts, securelyattached, to:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302 LONDON, KY 40742-8302

These are acceptable receipts: a pharmacybag or sticker, a computerized printout,or an itemized listing on the pharmacy'sletterhead. These receipts MUST include:� Your full name, address, and social

security number;� Name of the prescribing doctor;� Name and address of the pharmacy;� Prescription number;� Amount prescribed - mg/ml or cc

and total ml or cc per bottle for liq-uid medication, and/or mg per tabletand total number of tablets per pre-scription;

� Date purchased;� Name of each drug;

� 11-digit National Drug Code (NDC)number for the prescribed medica-tion;

� Charge actually paid for each drugless any discount (for example, sen-ior citizen, coupon, etc.); a

� A statement, marked "patient paid"or "paid by patient," showing specifi-cally who paid the charges. "Paid" or"paid in full" are NOT acceptable.

(See Sample 5.)

NOTE: If you send an itemized comput-erized printout, it MUST include all ofthe information already listed, as well asthe PHARMACIST'S ORIGINAL SIG-NATURE.

(See Sample 6.)

Your own itemized listing or cash regis-ter receipt is NOT considered proof ofpayment.

A copy of the front and back of yourcanceled check may serve as proof ofpayment, ONLY when accompanied byan itemized statement or pharmacist'sledger record.

If you need help getting or completingforms for the reimbursement of pre-scription drugs, please call toll-free,Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.

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Can I be reimbursed for thecost of travel to get medicaltreatment related to my blacklung?

Mileage costs for most travel to obtainmedical treatment for your lung condi-tion may be reimbursed. To get reim-bursement, you must complete a MedicalTravel Refund Request, OWCP-957, asshown in Sample 7. You may submit upto three trips on each form. However,you MUST have the MEDICALPROVIDER, or an authorized represen-tative, complete and SIGN block "H" foreach visit.Mail the completed Medical TravelRefund Request to:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302LONDON, KY 40742-8302

NOTE: Overnight travel, related mealsand lodging, and/or mileage that exceeds150 miles round trip requires specialprior approval from the DCMWCDistrict Office. If you are not sure whichoffice to contact, call the toll-free num-ber, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):1-800-638-7072.Travel to a pharmacy to pick up pre-scriptions is NOT covered.

Sample 7. Medical Travel RefundRequest, OWCP-957

How much time will my reim-bursement requests take to beprocessed?

Reimbursement requests which are sub-mitted correctly will be processed by theFederal Black Lung Program within 30days.

Will I be notified if the reim-bursement requests I send inare going to be paid?

You will be notified by mail if your reim-bursement requests will be paid ordenied, through a form called aRemittance Voucher, as shown inSamples 8.a. and 8.b. This statement willcontain the following information:� The date of service;� The amount of your reimbursement

request;� The amount you will be paid;� A Remittance Voucher number at the

top of the form. (This number willalso appear on your check, if youreceive a payment, so you can matchpayments with your reimbursementrequests.); and,

� A "Message Code" which will explainwhy you were not paid for any por-tion of the reimbursement request.

� You will NOT receive a RemittanceVoucher if your medical providerbills the Federal Black Lung Programdirectly.

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What will happen if I have notsubmitted my reimbursementrequest forms or receipts cor-rectly? Will I still receive a Remittance Voucher?

Any reimbursement request forms andreceipts that need correction or addi-tional information will be returned toyou along with a letter explaining what iswrong or missing. It is very importantthat you correct and mail back theseforms and receipts as soon as possible.You cannot be paid by the Federal BlackLung Program until you submit allforms and receipts properly. All correct-ed reimbursement forms and receiptsshould be mailed to:FEDERAL BLACK LUNG PROGRAM P.O. BOX 8302 LONDON, KY 40742-8302

If you need help correcting reimburse-ment requests which have been returned,you may call toll-free, Mon.-Fri., 8:00a.m.-8:00 p.m. (ET): 1-800-638-7072.

Will a check come with theRemittance Voucher (RV)?

No, the check is always mailedseparately. Checks are issued by the U.S.Treasury Department. The RV is sentfrom the Federal Black Lung Programoffice where your reimbursement requests are processed. The RV will usu-ally arrive shortly after your check.Please remember to allow enough time(10 to 14 days) for both the check andthe RV to arrive before making inquiries.

If you have questions about your RV, ifyou fail to receive either a check or anRV, or if your payment is incorrect andrequires an adjustment, you may calltoll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.(ET): 1-800-638-7072.

Whom should I notify if mymailing address changes?

Any changes in your mailing addressshould be reported to the DCMWCDistrict Office with which your claim isfiled. If you are not sure which officehandles your claim, call toll free, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET), and theoperator will tell you whom to contact:1-800-638-7072.

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Should I keep copies of thebills that I send to the FederalBlack Lung Program?

YES, if possible. Keeping a copy will giveyou a record of the reimbursementrequests and receipts you have submitted.

Will I be notified when pay-ments are made directly to mydoctor, pharmacist, or otherprovider?

You will only receive RemittanceVouchers for reimbursements paiddirectly to you. However, once a yearyou will be mailed a record of all pay-ments made on your behalf. You shouldreview this record carefully.

Whom do I call if I have ques-tions about my medical bills;if I need reimbursementforms for treatment, prescrip-

tions or travel; or, if my Black LungBenefits Identification Card has beenlost or destroyed?

You may call the Federal Black Lung Program's toll-free number, Mon.-Fri.,8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072.

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Sample 2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)

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Sample 3. Proof of Payment for Doctor Visit

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� Your full name� Your address� Your Social Security Number� Name and address of medical provider� Signature of medical provider� Diagnosis or Condition Treated� Date of Service� Description of Service Performed� Charges for each type of service� Total amount you paid� A statement showing specifically who paid the charges (PATIENT PAID or � 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.

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Sample 4. Medical Reimbursement Form, OWCP-915 (Prescription Drugs)

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Sample 5. Pharmacy Bill Receipt

Prescription DrugsReceipts can be the pharmacy bag orsticker, a computerized printout, or anitemized listing on the pharmacy's letter-head. These receipts must include:� Your full name, address, and social

security number� Name of the prescribing doctor� Name and address of the pharmacy� Prescription number� Amount prescribed-mg/ml or cc and

total ml or cc per bottle for liquidmedication, and/or mg per tabletand total number of tablets per pre-scription

� Date purchased� Name of each drug� 11-digit National Drug Code (NDC)

number for the prescribed medica-tion

� Charge actually paid for each drugless any discount (e.g., senior citizenor coupon)

� A statement showing specifically whopaid the charges (PATIENT PAID orPAID BY PATIENT). "PAID" or"PAID IN FULL" are not acceptable.

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Sample 6. Proof of Payment: Computerized Printout Pharmacy Receipt

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Sample 7. Medical Travel Refund Request, OWCP-957

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Sample 8.a. Remittance Voucher (Front of Form)

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Sample 8.b. Remittance Advice (Back of Form)

www.dol.gov

Employment Standards Administration U.S. Department of Labor Office of Workers’ Compensation Programs