SUPPORTING STATEMENT FOR
INDIAN HEALTH SERVICE CONTRACT HEALTH SERVICES REPORT
AND SUPPORTING REGULATIONS CONTAINED IN
42 CFR 136.24
A. Justification:
1. Circumstances Making the Collection of Information Necessary
This is a request for 3-year renewal, without change, of previously approved information collection activity, 0917-0002, “Indian Health Service (IHS) Contract Health Services Report, for which approval expires January 31, 2010. The Snyder Act (25 U.S.C. 13), the Transfer Act (Public Law 83-568, 42 U.S.C. 2001) and the IHS Regulations at 42 CFR 136.24, Subpart C, authorize the IHS to contract for health care services for American Indian and Alaska Native (AI/AN) people eligible to receive such care (Attachment 1).
2. Purpose and Use of the Information
The form, “IHS-843-1A, Order for Health Services” is used to authorize contract health care providers to provide health care services to eligible IHS patients. Other than revising the form Provider section #26 e. to add DUNS No., reduce the number of pages from 5 pages to 4 pages, the contract clauses contained on page 3 of the form, the acquisition terms on page 4, the act statements (Burden Time, Privacy Act, & Contract Disputes Act), the form has not been revised and there is no change in the substance or in the use of the form. A copy of the form is at Attachment 2.
The majority of the information contained on this form is completed by IHS staff from existing IHS automated patient and vendor data files. Contract health care providers complete and sign the streamlined form and submit it, along with a completed standard Centers for Medicaid and Medicare Services (CMS) health claim form (CMS 1450 (UB 92) and, CMS 1500), to IHS for verification and payment. The CMS forms are used and accepted nation-wide by the health care industry and IHS is an approved user.
The information collected is needed to administer and manage the contract health care services provided to eligible AI/AN patients. The form is used to: authorize contract health care services for eligible patients; certify that the health care services requested and authorized have been performed by the contract provider(s); process payments for health care services performed by such providers; obtain program data; and, serve as a legal document for health and medical care authorized by the IHS and rendered by health care providers under contract with the IHS.
The information collected is also used for planning for further care of the patient, for keeping an accurate record of the patient’s health status and health services received and recommended, for planning future health care programs, for communicating among members of the health care team, for evaluating the health care rendered, for research and continuing education and for the provision of program health statistics.
3. Use of Information Technology and Burden Reduction
As appropriate, automated information technology will be used to collect and process this data; however, currently the most appropriate methodology is written responses to an information collection form. An electronic generating form is being developed as part of automated information technology. Only the methodology of written responses for information collection form continues, due to incompatibility between the IHS system and private providers system.
4. Efforts to Identify Duplication and Use of Similar Information
Duplication is not a problem. Only the IHS can initiate the authorization form, and only one form is completed for each patient episode. In addition, a series of audits are conducted throughout the process cycle, from initiation to final payment.
5. Impacts on Small Businesses or Other Small Entities
The form is completed by self-employed health care providers as well as by partnerships and corporations formed by health professionals. These may be considered “small business or other small entities;” however, provider response burden posses minimal impact on such entities.
6. Consequences of Collecting Information Less Frequently
If this information collection was not documented, the functions described in item 2 above (as well as the payment of contractors for services rendered) would be curtailed. If collected less frequently, the IHS would not be in compliance with procurement requirement, and claims processing would be unnecessarily delayed. There are no technical or legal obstacles to reducing burden.
7. Special Circumstances Relating to Guidelines 5 CFR 1320.5
This information collection is consistent with the guidelines in 5 CFR 1320.5(d)(2).
8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside Agency
A 60-day notice Federal Register Notice was published in the Federal Register on September 9, 2009, 74 FR 47801. There were no comments received.
9. Explanation of Any Payment or Gift to Respondents
The respondents will not receive any payments or gifts for providing the information. However, the form IHS-843-1A, along with other required documentation as described in A.2, provides the information and data required to reimburse contract health care providers for health care services provided to eligible patients.
10. Assurance of Confidentiality Provided to Respondents
The information collected is maintained as part of Privacy Act System of Records,
09-17-0001, Medical, Health and Billing Records Systems, HHS/IHS/ OHP, published in Privacy Act Issuances, 2006 Compilation, online via GPO Access (Attachment 4).
A Privacy Act Notification Statement is contained in the subject form.
11. Justification for sensitive questions
There are no questions of a sensitive nature solicited in this information collection.
12. Estimates of Hour Burden Including Annualized Hourly Cost
The burden estimate is based on feedback from contract health care providers (respondents) who have completed the form and the fiscal intermediary (FI) contractor that processes the IHS CHS claim forms. For fiscal year 2007, the FI reported that it processed approximately 329,506 forms for 7,399 respondents (average response per respondent - 44) and 15,157 Inpatient Discharge Summaries, Tribes 53,168 forms for 7399 (average response respondent 7).
A. The table below provides annual burden hour information for this collection:
Data Collection Instrument |
Estimated Number of Respondents |
Responses per Respondent |
Annual Number of Responses |
Average Burden Hour per Response* |
Total Annual Burden Hours |
IHS-843-1A |
7,424 |
51 |
378,624 |
0.05 ( 3 mins) |
18,931 |
IDS** |
15,157 |
1 |
15,157 |
0.05 ( 3 mins) |
758 |
TOTAL |
22, 581 |
--- |
--- |
--- |
19,689 |
*For ease of understanding, burden hours are also provided in actual minutes.
**Inpatient Discharge Summary (IDS)
B. The table below provides estimated annual costs to respondents for this collection.
Type of Respondent |
Total Burden Hours |
Hourly Wage Rate |
Total Respondent Costs |
Physicians |
18,931 |
$79.00 |
$1,495,549.00 |
IDS |
758 |
$15.00 |
$11,370.00 |
Total Respondent Cost |
$1,506,919.00 |
||
13. Estimate of Other Total Annual Cost Burden to Respondents or Record Keepers
This information collection places no additional computer or record keeping requirements upon the respondents. It will not require any capital equipment or create any start-up costs, and will not create additional costs associated with generating, maintaining, and disclosing or providing the information.
14. Annualized Cost to the Federal Government
ITEM HOURS COST
Printing/Mailing N/A $ 29,758
Processing/Audit 1/ 54,089 $ 811,335
TOTAL $ 841,093
1/ Cost based on $15.00 per hour average of professional and clerical/secretarial hourly rates combined to process and audit approximately seven forms per hour: 378,624 forms divided by seven forms per hour = 54,089 hours times (x) $15.00 = $811,335.
15. Explanation for Program Changes or Adjustments
The annual burden hours for this information collection increased 3,465 hours from the previously approved 16,224 hours to the current 19,689 hours. This program change is the result of increased AI/AN population returning to community and Tribal compacting/contracting of IHS programs usage.
16. Plans for Tabulation, Publication and Project Time Schedule
Information collected and tabulated is distributed to IHS Area/Program Office and Headquarters staff for internal program planning, management and evaluation purposes. There are no plans for publication of this information.
17. Reason(s) Display of OMB Expiration Date is Inappropriate
The OMB approval number and expiration date will be appropriately displayed on the information collection form.
18. Exceptions to Certification for Paperwork Reduction Act Submissions
No exceptions to the certification.
B. Collections of Information Employing Statistical Methods
This information collection will not employ statistical methods.
LIST OF ATTACHMENTS
ATTACHMENT 1:
A. Snyder Act (25 U.S.C.) 13)
B. Transfer Act (P.L. 82-568, 42 U.S.C. 2001)
C. Indian Health Service Contract Health Services Regulations, 42 CFR 136.24
ATTACHMENT 2:
A. IHS-843-1A, Order For Health Services
(updated form name, terms on form cover, clauses updated back of copy #3)
ATTACHMENT 3:
A. Federal Register 60-Day Notice
Draft Federal Register 30-Day Notice
ATTACHMENT 4:
Privacy Act System of Records: 09-17-0001, “IHS Medical, Health and Billing Records, HHS/IHS/OHP”
ATTACHMENT 1:
A. Snyder Act (25 U.S.C.) 13)
B. Transfer Act (P.L. 82-568, 42 U.S.C. 2001)
C. Indian Health Service Contract Health Services Regulations, 42 CFR 136.24
ATTACHMENT 2:
A. IHS-843-1A Order For Health Services
(updated form to add DUNS No. requirement on form cover, contract clauses updated back of copy #3)
ATTACHMENT 3:
A. Federal Register 60-Day Notice
B. Draft Federal Register 30-Day Notice
ATTACHMENT 4:
Privacy Act System of Records: 09-17-0001, “IHS Medical, Health and Billing Records, HHS/IHS/OHP”
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT |
| Subject | OMB 3-YEAR RENEWAL |
| Author | CLF |
| Last Modified By | Janet Ingersoll |
| File Modified | 2010-01-08 |
| File Created | 2010-01-08 |