This form is used to claim reimbursement for out-of-pocket medical expenses pertaining to the treatment of an accepted condition covered by the Federal Employees' Compensation Act, the Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program Act of 2000.  Use this form to request reimbursement for medical expenses, transportation costs, loss of wages, and incidental expenses.  If the employee has paid bills for medical, surgical or dental services, supplies or appliances due to an injury sustained in the performance of duty and seeks reimbursement for those expenses, he or she may submit a request for reimbursement on Form OWCP-915, together with an itemized bill on Form OWCP-1500, CMS-1500, OWCP-04 or UB-04 prepared by the provider and a medical report to OWCP.  If the employee does not quality for continuation of pay (for 45 days), this form should be completed and filed with the OWCP as soon as pay stops.  The form should also be submitted when the employee reaches maximum improvement and claims a schedule award.  If the employee is receiving continuation of pay and will continue to be disabled after 45 days, the form should be filed with OWCP 5 working days prior to the end of the 45-day period.  The CA-7 also should be used to claim continuing compensation, when a previous CA-7 claim has been made.

 

The provider of such service shall state each diagnosed condition and furnish the applicable ICD-9-CM or ICD-10-CM code, and identify each service performed using the applicable code, with a brief narrative description of the service performed, or, where no code is applicable, a detailed description of that service.  If no code or description is received, OWCP will deny the reimbursement request and correction and resubmission will be required.  The reimbursement request must be accompanied by evidence that the provider received payment for the service from the employee and a statement of the amount paid.  Acceptable evidence that payment was received includes, but is not limited to, a signed statement by the provider, a mechanical stamp or other device showing receipt of payment, a copy of the employee's canceled check (both front and back) or a copy of the employee's credit card receipt or a form indicating a balance of zero to the provider.

 

If services were provided by a hospital, pharmacy or nursing home, the employee should submit the bill.  Any request for reimbursement must be accompanied by evidence, as described in the above paragraph, that the provider received payment for the service from the employee and a statement of the amount paid.

 

OWCP may waive the requirements of listed above,  if extensive delays in the filing or the adjudication of a claim make it unusually difficult for the employee to obtain the required information.

 

OWCP will not accept copies of bills for reimbursement unless they bear the signature of the provider, with evidence of payment.  Payment for medical and surgical treatment, appliances or supplies shall be no greater than the maximum allowable charge for such service determined by the Director's schedule.

 

An employee will be only partially reimbursed for a medical expense if the amount he or she paid to a provider for the service exceeds the maximum allowable charge set by the Director's schedule.  If this happens, OWCP shall advise the employee of the maximum allowable charge for the service in question and of his or her responsibility to ask the provider to refund, or credit to the employee's account, the amount he or she paid which exceeds the maximum allowable charge.  The provider may request reconsideration of the fee determination.

 

If the provider fails to make appropriate refund to the employee, or to credit the employee's account, within 60 days after the employee requests a refund of any excess amount, or the date of a subsequent reconsideration decision which continues to disallow all or a portion of the appealed amount, the provider shall be subject to exclusion procedures.

 

If the provider does not refund to the employee or credit to his or her account the amount of money paid in excess of the charge which OWCP allows, the employee should submit documentation of the attempt to obtain such refund or credit to OWCP.  OWCP may make reasonable reimbursement to the employee after reviewing the facts and circumstances of the case.

 

If an employee seeks reimbursement for transportation costs, loss of wages or incidental expenses related to medical treatment under this part, that employee may submit a reimbursement request on Form OWCP-957: Medical Travel Refund Request to OWCP along with all proof of payment.  Requests for reimbursement for lost wages under this subsection must include an official statement from the employing agency indicating the amount of wage loss.

 

Form OWCP-915 must be accompanied by original receipts.  Tax identification numbers may be written in above the pharmacy???s name.  Do not submit bills on small pieces of paper.  If the receipt is small, tape (not staple) it to a full size sheet of paper with claimant???s name and case number indicated in the upper right hand corner.

 

Mail the completed OWCP-915 and related documentation to:

U.S. Department of Labor

Office of Workers' Compensation Programs

PO Box 8300

London, KY 40742-8300

 

Be sure to include your name and claim number on EVERY page you send.