TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Form	Modified	Repair queued
Signed SSN MFR_Jan2014.pdf	Supplementary Document	Uploaded 2015-01-29	Available
Response to Comments from OMB_0720-0006 TRICARE Claim-Pt reimbursement Supp Stmnt FINAL_clean.docx	Supporting Statement A	Uploaded 2015-08-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43597	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	Form	Modified

ICR Details

OMB Control No: 0720-0006	ICR Reference No: 201501-0720-001
Status: Historical Active	Previous ICR Reference No: 200911-0720-006
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/03/2015
	Date Received in OIRA: 02/04/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved
Responses	774,000	0	0
Time Burden (Hours)	193,500	0	0
Cost Burden (Dollars)	4,992,300	0	0

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Abstract: This collection is for use only by beneficiaries under the TRICARE Program. The form is required to determine CHAMPUS eligibility, other health insurance liability and if medical services and/or supplies were received by the beneficiary so that reimbursement may be made to the CHAMPUS/TRICARE beneficiary for authorized care/supplies.

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Authorizing Statute(s): US Code: 10 USC chaper 55 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 32240	06/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 4906	01/29/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	DD From 2642	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	774,000	0	0	-2,226,000	0	3,000,000
Annual Time Burden (Hours)	193,500	0	0	-556,500	0	750,000
Annual Cost Burden (Dollars)	4,992,300	0	0	0	4,992,300	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: The DD Form 2642 was designed for use by only the beneficiary, but replaces another form used by both the beneficiary and the provider of care. For several years now, providers were required to submit claims on nationally approved claims, not Department of Defense (DoD) medical claim forms. This has resulted in a decrease of providers utilizing DoD medical claim forms. In addition, the National Defense Authorization Act for FY92 (10 U.S.C. Section 1106) mandates that providers file all claims with certain exceptions. The burden decreased from 3,000,000 forms reported in FY2007 to 774,000 in FY2012 (See Supporting Data for DD2642 included with renewal package). This decrease may be attributed to fewer beneficiaries accessing medical services and supplies from non-TRICARE authorized providers.

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Annual Cost to Federal Government: $4,179,600

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/04/2015

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