OMB_83I Supporting Document_03272013_WHS revisions

Supporting Document for Paperwork Reduction Act Submission

Third Party Collection Program/Medical Services Account/Other Health Insurance

A. Justification

1. Need and Use

DoD implemented the Third Party Collection Program (TPCP) in FY87 based on the authority granted in 10 USC 1095 and implemented by 32 CFR 220 in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) (Public Law 99–272, section 2001, April 7, 1986). Under the TPCP, DoD is required to collect from third-party payers the cost inpatient and outpatient services rendered to DoD beneficiaries who have other health insurance. Military treatment facilities (MTFs) are required to make this form available to third-party payers upon request. A third-party payer may not request any other assignment of benefits form from the subscriber. Copies of the statute and regulatory provision accompany this submission.

2. Purpose and Users of the Information

This information will be collected by administrative support staff, including but not limited to, admissions, patient registration, and scheduling clerks, and clinic staff at MTFs. The requested information will be collected from military retirees, dependents, and others seeking medical care at the MTF at the time of outpatient visit and/or admission to the MTF. It will help the local MTF commander identify circumstances in which a claim for services may be submitted to a proper third-party payer and facilitate the collection of reasonable charges from that payer.

3. Improved Information Techniques

This form may now be stored either in hard copy or electronically. We anticipate that an estimated 35% of all forms collected will be completed, signed, and stored electronically. The form itself will serve as documentation that the requirements of 10 USC 1095 and 32 CFR 220 have been satisfied.

4. Duplication and Similar Information

This information is not being collected by any other agency or component nor is it currently available in any other format. This form simplifies and standardizes the process for collecting the required information. Duplication of information to be collected has been eliminated.

5. Small Business

No small business or other small entities are involved in this collection of information.

6. Less Frequent Collections

Currently, this form is the only way to identify potential third-party payers. This information must be collected at least annually from each individual seeking medical care in an MTF. It is crucial to collect the most up-to-date information on potential third-party payers. Therefore, data cannot be collected on a less frequent basis.

7. Special Circumstances

There are no special circumstances that require the collection to be conducted in a matter inconsistent with the guidelines in 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

8. Federal Notice and Consultations

The Federal Register Notice for this collection of information was published December 13, 2012, (Vol. 77, No. 240, pp. 74176). Copy attached. No public comments to the notice were received. This collection is being conducted in accordance with the guidelines outlined in 5 CFR 1320.8 and 5 CFR 1320.9.

9. Payment/Gift to Respondents

There will be no payment or gifts furnished to respondents.

10. Confidentiality

A Privacy Act statement is provided on the form. The specific uses for the information are stated on the form. The form also states that disclosure is required and lists the consequences of non-disclosure and/or submitting false information.

11. Sensitive Questions

This form requires disclosure of a beneficiary’s social security number (SSN). The SSN is the most critical data element for uniquely identifying an individual so that his or her third party health insurance status can be researched. SSN is the most critical, because it is the most effective at uniquely identifying an individual. There is significantly more duplication for names and dates of birth. Other data elements including spouse's name and address are sometimes helpful but are much less reliable as a means of uniquely identifying an individual. A memo from the TRICARE Deputy Director detailing additional necessity for the use of beneficiaries’ SSN in this collection accompanies this submission.

12. Burden Estimate

The information collected on this form is not required for active duty uniformed service members (including National Guard members and reservists on active duty) or beneficiaries receiving care at locations other than an MTF. Of the current 9.6 million TRICARE beneficiaries, it is expected that only 2,936,905 beneficiaries will be asked to complete the form annually.

To document program compliance, all patients must complete at least a portion of the questionnaire, which is entered into the medical record. We estimate that it will take no more than an average of three minutes to complete the form. In many cases, that time will diminish if the beneficiary has his or her insurance card since the front and back of the card can then be photocopied and stapled to the form, thereby relieving the beneficiary from having to write all of the information. The estimated annual burden is 146,845 hours.

The cost to the respondent of providing the information is negligible and beyond our ability to calculate.

13. Cost of Respondents

None.

14. Cost of the Federal Government

The average annualized costs are itemized as follows:

(Printing = $.05 X 2,936,905) $ 146,845
(Clerical Costs = $.74¹ X 2,936,905) $2,173,310
__________

TOTAL ANNUAL COST $2,320,155

15. Changes

The estimated total burden hours for collecting the information requested on this form has been reduced to more accurately reflect the volume of the collection. The information collected on this form is not required for active duty service members (including National Guard members and reservists on active duty) or beneficiaries receiving care at locations other than an MTF. Number of persons receiving care in MTFs has decreased. Therefore, an adjustment to the number of respondents has been made accordingly. The reduced burden hours will support information collection from all eligible beneficiaries.

16. Publication/Tabulation

There are no plans to publish or tabulate the information collected.

17. Expiration Date

Approval is not sought for avoiding the display of the expiration date for OMB approval.

18. Certification Statement

There are no exceptions in the certification statement identified in Item 19. “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

B. Collections of Information Employing Statistical Methods

Statistical methods are not employed for collection of this information.

1 Prorated salary based on GS-5, step 5, admissions clerk