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.

Black Lung Medical Benefits:

Frequently Asked Questions about the Federal Black Lung Program

U.S. Department of Labor 

Employment Standards Administration

Office of Workers' Compensation Programs

Division of Coal Mine Workers' Compensation

December 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)

i

(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 the

U.S. Department of Labor's Federal

Black Lung Program, you are entitled to

medical benefits to cover the reasonable

cost of treatment, services or supplies for

your pneumoconiosis and disability

(your black lung condition). Spouses,

family members, and survivors of coal

miners are not entitled to medical benefits. You have the right to seek treatment

from the medical provider (physicians,

pharmacies, hospitals, etc.) of your

choice. Most providers who are enrolled

in the Federal Black Lung Program will

bill the Federal Black Lung Program

directly for you. But if the provider is

not enrolled in the Federal Black Lung

Program (or chooses not to bill directly),

it will be necessary for you to pay for the

services yourself then file with the

Federal Black Lung Program on your

own for reimbursement of these out-ofpocket payments.

The questions presented here are those

most often asked by Black Lung Program

beneficiaries about:

 The U.S. Department of Labor Black

Lung Benefits Identification Card

(medical treatment card);

 Medical benefits - covered and noncovered services; and,

 Reimbursement for medical care and

associated travel.

While this material gives you basic information about your medical benefits, it is

neither intended to cover every possible

exception or special case, nor have the

effect of law. Additionally, this information applies only if your medical benefits

are being paid by the U.S. Department of

Labor. 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

write or call the U.S. Department of

Labor, Division of Coal Mine Workers'

Compensation (DCMWC) District

Office with which your claim is filed. For

further information about special circumstances or individual cases, please

write or call the District Office with

which your claim is filed. If you are not

sure which District Office handles your

claim, you may find out by calling tollfree, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):

1-800-638-7072.

1
What does the Black Lung

Benefits Identification Card

look like?

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 previously 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

your identification number. For privacy

reasons, your Social Security number

does not appear on your card. However,

you will need to give your Social Security

number to your medical treatment

providers so they can bill correctly.

Sample 1. Black Lung Benefits 

Identification Card 

2

1

1. This card is the property of the U.S. Government and its counterfeiting, alteration

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

when 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 authorized

under 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 Black

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

safe? What does my doctor

need to know?

Your Social Security number and address

are not printed on the card, and this is

information only you will know and will

need to give to your medical providers.

There is a 10-digit number printed on

the back of the card that is unique to

you. The purpose of this number is to

allow the medical providers to access our

2

secure web site to get information about

your eligibility for benefits and about

bills they have filed. Your providers will

probably want to photocopy both sides

of the card for their records, because

without the card ID number they will be

unable to access the secure part of our

web site.
When do I use my U.S.

Department of Labor Black

Lung Benefits Identification

Card?

You should present your black lung card

whenever you seek treatment for your

lung condition. Showing a medical

provider your card will identify you as a

Federal Black Lung Program beneficiary,

and will help the medical provider determine the proper way to bill for services.

I receive my black lung benefits through the U.S.

Department of Labor around

the middle of each month, but

I do not have a black lung card. What

should I do?

Write or call the DCMWC District Office

with which your claim is filed. If you 

are not sure which office handles your

claim, call toll-free, Mon.-Fri., 8:00 a.m.-

8:00 p.m. (ET), and the operator can tell

you which District Office to contact:

1-800-638-7072.

I was awarded black lung benefits by the Federal Black Lung

Program. I also filed a claim

with the state where I worked

as a coal miner and was awarded benefits for black lung. Am I still entitled to

medical coverage under the Federal

Black Lung Program?

Expenses for the treatment of your black

lung condition that are not covered by

the state program may be covered by the

Federal Black Lung Program. However,

bills or reimbursement requests must

first be submitted under the state program which awarded your benefits.

If your medical providers' bills or your

own reimbursement requests are denied

under your state award, send the bill or

the reimbursement request and original

receipts (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 the

DCMWC District Office that handles

your Federal Black Lung Program claim.

If you do not have the address or phone

number of that office, you may get them

by calling toll-free, Mon.- Fri., 8:00 a.m.-

8:00 p.m. (ET): 1-800-638-7072.

I have been awarded black

lung benefits under both the

Federal Black Lung Program

and a State Workers' Compensation Program. Should I have received

a black lung card?

If you have been awarded benefits for

your black lung condition under a State

Workers' Compensation Program, you

will NOT receive an identification card

from the Federal Black Lung Program.

Expenses for the treatment of your black

lung condition that are not covered by

the state program may be covered by the

Federal Black Lung Program. (See

Question 5.)

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5

6
What costs are covered under

my Federal Black Lung

Program medical benefits?

The cost of medical treatment services

and associated travel for the treatment of

your black lung condition is covered

under the Federal Black Lung Benefits

Act. Payment for medical treatment services is subject to a maximum allowable

fee. There is no deductible or co-payment. Payment for travel is limited to

reasonable costs.

The following is a list of services that

MAY be covered when they are performed for the treatment of your black

lung condition:

 Doctor's office calls, hospital visits,

and consultations;

 Inpatient and outpatient hospital

charges, including emergency room

visits for ACUTE black lung related

conditions, diagnostic laboratory

testing and chest x-rays;

 Federal Black Lung Program

APPROVED prescription drugs, both

brand name and generic;

 Ambulance services limited to transportation to the hospital for emergency ACUTE black lung related

care; and,

 Travel to the doctor, hospital, clinic,

or other medical facility for round

trips of 150 miles or less.

The following items require special

approval:

 The purchase or rental of home

medical equipment such as oxygen

systems exceeding $300 (requires

Certificate of Medical Necessity—See

Question 10—completed by prescribing physician);

 Pulmonary rehabilitation (breathing

retraining) programs (requires

Certificate of Medical Necessity completed by prescribing physician);

 Home health care visits for skilled

nursing (requires Certificate of

Medical Necessity completed by prescribing physician); and,

 Overnight travel, related meals and

lodging, and/or mileage that exceeds

150 miles round trip (requires special

approval from your DCMWC

District Office).

What prescription drugs are

covered? 

Most drugs prescribed by your doctor

for the treatment of your black lung condition will be covered (brand name or

generic). However, there are some exceptions. In order to be sure a drug is covered, you or your pharmacist may call

toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.

(ET): 1-800-638-7072. Your pharmacist

will also be able to learn at once if a drug

is covered if the bill is submitted by

Point-of-Sale technology.

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7

8
Do I need prior approval for

certain services? 

Yes. Whether you or a medical provider

does the billing, your doctor must complete the U.S. Department of Labor

Certificate of Medical Necessity, CM-893

(CMN), for oxygen and other durable

medical equipment, pulmonary rehabilitation, or skilled nursing care at home.

The doctor should send the completed

form, with the results of the required

medical tests attached, to the DCMWC

District Office with which your claim is

filed.

CMNs for rental items must be reapproved periodically (a prescription for

oxygen concentrator, for example). All

CMNs must have the DOCTOR'S ORIGINAL SIGNATURE. Your treating physician's original signature is the ONLY 

signature acceptable on the CMN. You,

your physician, and the medical provider

(if billing the Federal Black Lung

Program for you) will be notified if

the CMN has been approved or denied.

Where can my doctor get a

Certificate of Medical

Necessity (CMN)?

Your doctor may call the Federal Black

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 downloading and printing from our website, at

http://www.dol.gov/esa/regs/compliance/owcp/cm-893.pdf.

What costs are NOT covered

by my Federal Black Lung

Program medical benefits?

The following are among the costs NOT

covered under the Federal Black Lung

Program:

 Treatment of medical problems NOT

related to your black lung condition

—for example, arthritis, diabetes,

and most heart conditions;

 Medical treatment for your spouse or

other family members;

 Dental or eye care, and X-rays other

than chest X-rays;

 Nurse's aid (non-skilled nursing

care) 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 nursing

facilities; and,

 Home medical equipment not

authorized for coverage under the

Federal Black Lung Program.

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10

9
What is the best way to get my

medical bills paid?

WHENEVER POSSIBLE, have your doctor, hospital, pharmacy and other medical providers bill the Federal Black Lung

Program directly. If they are enrolled in

the Federal Black Lung Program as

providers, the Federal Black Lung

Program will pay them directly. ALWAYS

show your Black Lung Benefits Identification Card when seeking treatment.

How can a medical provider

get enrollment and billing

information from the Federal

Black Lung Program?

Medical providers not already participating in the Federal Black Lung Program

may apply for enrollment at any time.

Those having questions about enrollment

or billing may call the Federal Black Lung

Program, toll-free, Mon.-Fri., 8:00 a.m.-

8:00 p.m. (ET): 1-800-638-7072. They

may also apply online at http://owcp.dol.

acs-inc.com/portal/providerEnrollment.do.

Where should medical

providers send Black Lung

related bills?

Answer: ALL Federal Black Lung

Program medical treatment bills should

be sent to the following address:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302

Does the medical provider

need special Department of

Labor billing forms?

NO. The doctor, clinic, laboratory,

ambulance and nursing service can bill

using the standard OWCP-1500 form.

The pharmacy can bill using the standard

OWCP-1500 form or the Universal Pharmacy Billing Form. They may also bill

directly at the Point-of-Sale for most drugs.

The hospital can bill using the UB-92

form for all inpatient charges and outpatient charges for emergency room,

chemotherapy and ambulatory surgical

care. The OWCP-1500 form should be

used for other outpatient charges.

What if the medical provider

wants to bill Medicare,

UMWA, or other insurance

carriers instead of the Black 

Lung Program?

Other insurance carriers should NOT be

billed first for treatment of your black

lung condition, because Federal Black

Lung Program medical benefits represent

primary coverage for beneficiaries

(unless there is a black lung award under

a state program. See Question 5).

Medicare and many other insurance carriers have a "workers' compensation

exclusion clause." This means that they

will not pay for treatment of occupational disease, like black lung disease, if a

patient has medical coverage under a

workers' compensation program or the

Federal Black Lung Program.

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The U.S. Department of Labor

has notified me that the coal

company has agreed to pay for

medical treatment for my

black lung. How is this handled? 

You will need to ask the coal company or

its insurance carrier how and where both

you and medical providers who might

bill for you should submit medical

claims. Usually, a medical benefit identification card is NOT issued by the coal

company. If you need help, you may

write or telephone the DCMWC District

Office that handles your claim.

What if I have to pay the medical provider? How do I get

reimbursed by the Federal

Black Lung Program?

Present your Black Lung Benefits

Identification Card to the medical

provider whenever you seek treatment

for your lung condition. A medical

provider may bill directly, if already

enrolled in the Federal Black Lung

Program.

If you must pay for the medical services

out-of-pocket then you may request

reimbursement by completing the U.S.

Department of Labor Medical

Reimbursement Form, OWCP-915, as

shown in Sample 2. Up to eight visits or

services can be listed on this form.

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.

Send the completed Medical

Reimbursement Form with your itemized 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 statements MUST include the following

information:

 Your full name;

 Name and address of the medical

provider;

 Signature of the medical provider;

 Description of medical service performed;

 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" to

show specifically who paid the charges.

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

A copy of the front and back of your

canceled check may serve as proof of

payment ONLY when accompanied by

an itemized statement or copy of the

doctor's ledger record. (See Sample 3.)

7

17

18
How do I get reimbursed for

prescription drugs? 

To obtain reimbursement, fill out a

Medical Reimbursement Form, OWCP915, as shown in Sample 4. Up to nine

individual prescription drugs may be

listed on this form. 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.

Send the completed Medical

Reimbursement Form, along with the

original pharmacy receipts, securely

attached, to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302 

These are acceptable receipts: a pharmacy

bag or sticker, a computerized printout,

or an itemized listing on the pharmacy's

letterhead. 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 liquid medication, and/or mg per tablet

and total number of tablets per prescription;

 Date purchased;

 Name of each drug;

 11-digit National Drug Code (NDC)

number for the prescribed medication;

 Charge actually paid for each drug

less any discount (for example, senior citizen, coupon, etc.); a

 A statement, marked "patient paid"

or "paid by patient," showing specifically who paid the charges. "Paid" or

"paid in full" are NOT acceptable.

(See Sample 5.)

NOTE: If you send an itemized computerized printout, it MUST include all of

the information already listed, as well as

the PHARMACIST'S ORIGINAL SIGNATURE.

(See Sample 6.)

Your own itemized listing or cash register receipt is NOT considered proof of

payment.

A copy of the front and back of your

canceled check may serve as proof of

payment, ONLY when accompanied by

an itemized statement or pharmacist's

ledger record.

If you need help getting or completing

forms for the reimbursement of prescription drugs, please call toll-free,

Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): 1-

800-638-7072.

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19
Can I be reimbursed for the

cost of travel to get medical

treatment related to my black

lung?

Mileage costs for most travel to obtain

medical treatment for your lung condition may be reimbursed. To get reimbursement, you must complete a Medical

Travel Refund Request, OWCP-957, as

shown in Sample 7. You may submit up

to three trips on each form. However,

you MUST have the MEDICAL

PROVIDER, or an authorized representative, complete and SIGN block "H" for

each visit.

Mail the completed Medical Travel

Refund Request to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302

LONDON, KY 40742-8302 

NOTE: Overnight travel, related meals

and lodging, and/or mileage that exceeds

150 miles round trip requires special

prior approval from the DCMWC

District Office. If you are not sure which

office to contact, call the toll-free number, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET):

1-800-638-7072.

Travel to a pharmacy to pick up prescriptions is NOT covered.

Sample 7. Medical Travel Refund

Request, OWCP-957 

How much time will my reimbursement requests take to be

processed?

Reimbursement requests which are submitted correctly will be processed by the

Federal Black Lung Program within 30

days.

Will I be notified if the reimbursement requests I send in

are going to be paid? 

You will be notified by mail if your reimbursement requests will be paid or

denied, through a form called a

Remittance Voucher, as shown in

Samples 8.a. and 8.b. This statement will

contain 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 will

also appear on your check, if you

receive a payment, so you can match

payments with your reimbursement

requests.); and,

 A "Message Code" which will explain

why you were not paid for any portion of the reimbursement request.

 You will NOT receive a Remittance

Voucher if your medical provider

bills the Federal Black Lung Program

directly.

9

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21
What will happen if I have not

submitted my reimbursement

request forms or receipts correctly? Will I still receive a 

Remittance Voucher?

Any reimbursement request forms and

receipts that need correction or additional information will be returned to

you along with a letter explaining what is

wrong or missing. It is very important

that you correct and mail back these

forms and receipts as soon as possible.

You cannot be paid by the Federal Black

Lung Program until you submit all

forms and receipts properly. All corrected reimbursement forms and receipts

should be mailed to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302

If you need help correcting reimbursement requests which have been returned,

you may call toll-free, Mon.-Fri., 8:00

a.m.-8:00 p.m. (ET): 1-800-638-7072.

Will a check come with the

Remittance Voucher (RV)?

No, the check is always mailed

separately. Checks are issued by the U.S.

Treasury Department. The RV is sent

from the Federal Black Lung Program

office where your reimbursement 

requests are processed. The RV will usually arrive shortly after your check.

Please remember to allow enough time

(10 to 14 days) for both the check and

the RV to arrive before making inquiries.

If you have questions about your RV, if

you fail to receive either a check or an

RV, or if your payment is incorrect and

requires an adjustment, you may call

toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m.

(ET): 1-800-638-7072.

Whom should I notify if my

mailing address changes?

Any changes in your mailing address

should be reported to the DCMWC

District Office with which your claim is

filed. If you are not sure which office

handles your claim, call toll free, Mon.-

Fri., 8:00 a.m.-8:00 p.m. (ET), and the

operator will tell you whom to contact:

1-800-638-7072.

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25

24
Should I keep copies of the

bills that I send to the Federal

Black Lung Program?

YES, if possible. Keeping a copy will give

you a record of the reimbursement

requests and receipts you have submitted.

Will I be notified when payments are made directly to my

doctor, pharmacist, or other

provider?

You will only receive Remittance

Vouchers for reimbursements paid

directly to you. However, once a year

you will be mailed a record of all payments made on your behalf. You should

review this record carefully.

Whom do I call if I have questions about my medical bills;

if I need reimbursement

forms for treatment, prescriptions or travel; or, if my Black Lung

Benefits Identification Card has been

lost 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.

11

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27

28
Sample 2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)

12
Sample 3. Proof of Payment for Doctor Visit 

13

 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.
14

Sample 4. Medical Reimbursement Form, OWCP-915 

(Prescription Drugs)
15

Sample 5. Pharmacy Bill Receipt

Prescription Drugs

Receipts can be the pharmacy bag or

sticker, a computerized printout, or an

itemized listing on the pharmacy's letterhead. 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 liquid

medication, and/or mg per tablet

and total number of tablets per prescription

 Date purchased

 Name of each drug

 11-digit National Drug Code (NDC)

number for the prescribed medication

 Charge actually paid for each drug

less any discount (e.g., senior citizen

or coupon)

 A statement showing specifically who

paid the charges (PATIENT PAID or

PAID BY PATIENT). "PAID" or

"PAID IN FULL" are not acceptable.
16

Sample 6. Proof of Payment: Computerized Printout 

Pharmacy Receipt
17

Sample 7. Medical Travel Refund Request, OWCP-957 
18

Sample 8.a. Remittance Voucher (Front of Form)
19

Sample 8.b. Remittance Advice (Back of Form)
www.dol.gov

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