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November 4, 2004    DOL Home > ESA > OWCP > DCMWC   

Black Lung Medical Benefits:
Questions and Answers about the
Federal Black Lung Program

U.S. Department of Labor (ESA)
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation
March, 2002

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

(Click on Question Number to move right to the Question)

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 .................................. Keeping Copies for Your Records

27 .................................. Information Service

Samples...

Sample ............... Question

(These items may be obtained from the District Office which handles your claim.)

1. Black Lung Benefits Identification Card (Question #1)

2. Miner Medical Reimbursement Form, CM-915(Doctor Visit) (Question #18)

3. Proof of Payment for Doctor Visit (Question #18)

4. Miner Medical Reimbursement Form, CM-915(Prescription Drugs) (Question #19)

5. Pharmacy Bill Receipt (Question #19)

6. Proof of Payment: Computerized Printout Pharmacy Receipt (Question #19)

7. Medical Travel Refund Request, CM-957 (Question #20)

8. a. Remittance Advice (Front of Form) (Question #22)

8. b. Remittance Advice (Back of Form) (Question #22)

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-of-pocket 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 non-covered 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 toll-free, Mon.-Fri., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

1. Question:What does the Black Lung Benefits Identification Card look like?

Answer:The U.S. Department of Labor Black Lung Benefits Identification Card is red and white, and is imprinted with your name, claim number, an effective date, and possibly an expiration date. A block for your signature also appears on the face of the card. Be sure that you have signed your name in this area.

Sample 1. Black Lung Benefits Identification Card

Not all cards will look exactly like the sample shown above.

Many of the cards originally issued had an "I.D. Number" imprinted in the lower left-hand corner. These older cards are still valid for identification purposes. However, the "I.D. Number" should NOT be used for medical billing or miner reimbursement.

When medical providers bill the Federal Black Lung Program or when you submit reimbursement requests, your nine digit claim number is the ONLY identification number which should be used.

2. Question:When do I use my U.S. Department of Labor Black Lung Benefits Identification Card?

Answer: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.

3. Question: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?

Answer: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., 8:15 a.m.-4:45 p.m. (ET), and the operator can tell you which District Office to contact: 1-800-638-7072.

4. Question: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?

Answer: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 828
LANHAM-SEABROOK, MD 20703-0828

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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

5. Question: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?

Answer: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 progam may be covered by the Federal Black Lung Program. See Question 4

6. Question:I receive my black lung benefits through the Social Security Administration at the beginning of each month. Am I entitled to medical benefits?

Answer:If you are a miner or former miner receiving monthly black lung benefits from the Social Security Administration, you are not automatically entitled to receive medical benefits. You must have filed a claim for medical benefits with the U.S. Department of Labor on or before December 31, 1980 (unless you had good cause for later filing), in order to be considered and approved for medical benefits.

7. Question:What costs are covered under my Federal Black Lung Program medical benefits?

Answer: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 limited to the prevailing rate in the community. 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).

8. Question:What prescription drugs are covered?

Answer: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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

9. Question:Do I need prior approval for certain services?

Answer: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 re-approved 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.

10. Question:Where can my doctor get a Certificate of Medical Necessity (CMN)?

Answer:Your doctor may call the Federal Black Lung Program, toll-free, Mon.-Fri., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

11. Question:What costs are NOT covered by my Federal Black Lung Program medical benefits?

Answer: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;
  • 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.

12. Question:What is the best way to get my medical bills paid?

Answer: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 Program Identification Card when seeking treatment.

13. Question:How can a medical provider get enrollment and billing information from the Federal Black Lung Program?

Answer: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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

14. Question: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 828
LANHAM-SEABROOK, MD 20703-0828


15. Question:Does the medical provider need special Department of Labor billing forms?

Answer:NO. The doctor, clinic, laboratory, ambulance and nursing service can bill using the standard HCFA-1500 form.

The pharmacy can bill using the standard HCFA-1500 form or the Universal Pharmacy Billing Form.

The hospital can bill using the UB-82 form for all inpatient charges and those outpatient charges for emergency room, chemotherapy and ambulatory surgical care; and, the standard HCFA-1500 form for other outpatient charges.

16. Question:What if the medical provider wants to bill Medicare, UMWA, or other insurance carriers instead of the Black Lung Program?

Answer: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 4). 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.

17. Question: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?

Answer: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.

18. Question:What if I have to pay the medical provider? How do I get reimbursed by the Federal Black Lung Program?

Answer: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 green U.S. Department of Labor Miner Medical Reimbursement Form, CM-915, as shown in Sample 2. Up to nine 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 green Miner Medical Reimbursement Form with your itemized paid statements or detailed receipts, securely attached, to:

FEDERAL BLACK LUNG PROGRAM
P.O. BOX 828
LANHAM-SEABROOK, MD 20703-0828


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.)


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

Click on the image for full size view.


Sample 3. Proof of Payment for Doctor Visit

1. Your full name


2. Your address


3. Your Social Security Number


4. Name and address of medical provider


5. Signature of medical provider


6. Diagnosis or Condition Treated


7. Date of Service


8. Description of Service Performed


9. Charges for each type of service


10. Total amount you paid


11. 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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.


19. Question:How do I get reimbursed for prescription drugs?

Answer:

To obtain reimbursement, fill out a green Miner Medical Reimbursement Form, CM-915, 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 Miner Medical Reimbursement Form, along with the original pharmacy receipts, securely attached, to:

FEDERAL BLACK LUNG PROGRAM
P.O. BOX 828
LANHAM-SEABROOK, MD 20703-0828


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.); and,
  • 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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.


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

Click on the image for full size view.


Sample 5. Pharmacy Bill Receipt

Prescription Drugs:

Receipts can be either 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-mgm/ml or cc and total ml or cc per bottle for liquid medication, and/or mgm 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.


Sample 6. Proof of Payment: Computerized Printout Pharmacy Receipt

Click on the image for full size view.


20. Question:Can I be reimbursed for the cost of travel to get medical treatment related to my black lung?

Answer:Mileage costs for most travel to obtain medical treatment for your lung condition may be reimbursed. To get reimbursement, you must complete a pink Medical Travel Refund Request, CM-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 pink Medical Travel Refund Request to:

FEDERAL BLACK LUNG PROGRAM

P.O. BOX 828

LANHAM-SEABROOK, MD 20703-0828


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., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

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


Sample 7. Medical Travel Refund Request, CM-957

Click on the image for full size view.


21. Question:How much time will my reimbursement requests take to be processed?

Answer:Reimbursement requests which are submitted correctly will be processed by the Federal Black Lung Program within 30 days.

22. Question:Will I be notified if the reimbursement requests I send in are going to be paid?

Answer:You will be notified by mail if your reimbursement requests will be paid or denied, through a form called a Remittance Advice, 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 Advice number on the top right-hand side 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 Advice if your medical provider bills the Federal Black Lung Program directly.


Sample 8.a. Remittance Advice

(Front of Form)

Click on the image for full size view.


Sample 8.b. Remittance Advice

(Back of Form)

Click on the image for full size view.


23. Question:What will happen if I have not submitted my reimbursement request forms or receipts correctly? Will I still receive a Remittance Advice?

Answer: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 828
LANHAM-SEABROOK, MD 20703-0828


If you need help correcting reimbursement requests which have been returned, you may call toll-free, Mon.-Fri., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

24. Question:Will a check come with the Remittance Advice (RA)?

Answer:No, the check is always mailed separately. Checks are issued by the U.S. Treasury Department. The RA is sent from the Federal Black Lung Program office in Lanham, Maryland, where your reimbursement requests are processed. The RA will usually arrive shortly after your check. Please remember to allow enough time (10 to 14 days) for both the check and the RA to arrive before making inquiries.

If you have questions about your RA, if you fail to receive either a check or an RA, or if your payment is incorrect and requires an adjustment, you may call toll-free, Mon.-Fri., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.

25. Question:Whom should I notify if my mailing address changes?

Answer:Any changes in your mailing address should be reported IN WRITING 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., 8:15 a.m.-4:45 p.m. (ET), and the operator will tell you whom to contact: 1-800-638-7072.

26. Question:Should I keep copies of the bills that I send to the Federal Black Lung Program?

Answer:YES, if possible. Keeping a copy will give you a record of the reimbursement requests and receipts you have submitted.

27. Question: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?

Answer: You may call the Federal Black Lung Program's toll-free number, Mon.-Fri., 8:15 a.m.-4:45 p.m. (ET): 1-800-638-7072.



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