SUPPORTING STATEMENT (0720-0006)
Public Information Collection requirements Submitted for Public Comments and Recommendations: TRICARE DoD/CHAMPUS Medical Claim-Patient’s Request for Medical Payment (DD Form 2642)
JUSTIFICATION
Need and Use
This form is used solely by beneficiaries claiming reimbursement for medical expenses under the TRICARE Program [formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)]. The information collected will be used by TRICARE to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary received the care, and reimbursement for the medical services received. This program is authorized by 10 USC Chapter 55.
Purpose and users of the information
This collection instrument is for use by beneficiaries under the TRICARE Program. TRICARE is a health benefits entitlement program for the dependents of active duty Uniform Services members and deceased sponsors, retirees and their dependents, dependents of Department of Transportation (Coast Guard) sponsors and certain North Atlantic Treaty Organizations, National Oceanic and Atmospheric Administration, and Public Health Service eligible beneficiaries . DD 2642 is used solely by TRICARE beneficiaries to file for reimbursement of out of pocket costs paid to providers and suppliers for authorized health care services or supplies.
Information Collection Techniques
Most claims for medical services are filed directly by the providers of care (e.g., doctors, hospitals) on different claim forms than the DD 2642. The DD 2642 is designed to be a low use form that is filed only occasionally by TRICARE/CHAMPUS beneficiaries. As of FY2014 less than 1% of all TRICARE claims are filed on the DD Form 2642. For FY12 .66% of claims were filed on the DD2642; .51% in FY13 and .41% in FY14. Typically the claims are for care and treatment from a non-participating provider or claims incurred while the beneficiary is traveling. The DD Form 2642 is available for data entry and printing on the Department of Defense forms web page located at:
http://www.dtic.mil/whs/directives/infomgt/forms/dd/ddforms2500-2999.htm
Duplication and Similar Information
There is no duplication of data collection.
Small Business
This collection of information does not involve small business or other small entities.
Less Frequent Collections
There is no required frequency of collection of information. Each claim is submitted as deemed appropriate by beneficiaries. There is a claim filing deadline and any claims received after that date may be denied.
Special Circumstances
There are not special circumstances that require the collection to be conducted in a manner inconsistent with the guidelines in 5 CFR 1320.6.
Federal Register Notice/Consultations
The Federal Register Notice for this collection of information was published on June 4, 2014, (79 FR 32240). No comments were received.
Payment/Gift to Respondents
No payments or Gifts are given to respondents.
Confidentiality
The form "TRICARE DoD/CHAMPUS Medical Claim-Patient's Request for Medical Payment" is used to collect personally identifiable information (PII) and protected health information (PHI) and is covered by System of Records Notice EDTMA 04, Medical/Dental Claims History Files (November 18, 2013, 78 FR 69706), as a Privacy Act of 1974 system of records pursuant to DoD 5400.11-R. "Department of Defense Privacy Program," May 14, 2007. http://dpclo.defense.gov/Privacy/SORNsIndex/tabid/5915/Article/6869/edtma-04.aspx
The Privacy Act Statement on the form indicates the many possible authorized conditions on disclosure of information. In addition, the signature of the patient or authorized person on the claim form authorizes the “release of medical or other insurance information.” In all other circumstances, information will be protected as described in the system of records notice.
Sensitive Questions
Historically, the SSN has been the primary identifier on the DD Form 2642 which the health care contractors use to verify beneficiary eligibility through the Defense Eligibility Enrollment Reporting System (DEERS).
The Defense Health Agency (DHA), as successor to the TRICARE Management Activity, has a SSN Reduction Plan for its Purchased Care Operations. The DHA plan is in-line and consistent with the Defense Manpower Data Center's (DMDC) plan to remove SSNs from DoD Identification (ID) Cards. Starting in late 2011, visibly printed SSNs were removed from DoD ID Cards. Two new codes (alternative ID numbers) are printed on the ID Card -- the DoD Benefits Number (DBN) and the Electronic Data Interchange-Personal Identifier (EDIPI). While both of these codes currently exist, they are not known to all DoD beneficiaries. Due to the ID card lifecycle, we estimated a three to four year process before alternative ID numbers replace the visibly printed SSN on the card. Now that we are four years into the process almost all active duty service members or active duty family member’s cards have been updated. We acknowledge updates to retiree cards will be on-going for years, as they have “indefinite” card expiration dates. We anticipate those updates will be done as retirees received word on the SSN removal and opt to update their cards or when they update due to damage or lost cards.
Burden Estimated (hour)
The burden is based on an estimate of 15 minutes to complete the form. The annual projected use of the DD 2642 forms is 774,000. The total annual hour burden for the respondents is 193,500 hours (774,000 forms x 15 minutes = 11,610,000 minutes / 60 minutes = 193,500 hours).
Labor Cost to Respondents
Based on the average US salary being $53,320/year, we figured the loss of labor for 15 minutes (estimate time needed to complete the form) to be $6.45. Timing that number ($6.45) by the number of annual responses (774,000) makes the cost to respondents $4,992,300/year. Source: http://www.deptofnumbers.com/income/us/
Costs to Respondent Other Than Burden Costs
While rare, the DD Form 2642 is still accepted via traditional mail. Postage to mail the form to the government may increase this cost by a slim/undeterminable amount.) Other than this, no additional cost to the respondent is required.
Cost to the Federal Government
There are no start-up costs because the TRICARE claims process is an established process. Additionally, there are no an annual maintenance fees.
The government contractors have indicated that the cost of processing one from is $5.40. The annualized cost to the Federal Government is based on the total number of DD Form 2642 received for processing (774,000 for a 12-month period-Based on FY2012 data).
The cost is as follows: $5.40 per claim. $5.40 x 774,000 = $4,179,600 per 12-month period.
Change in Burden
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.
Publication/Tabulation
There are no plans to publish or tabulate the information collected.
Expiration Date
Approval is not sought for avoiding display of the expiration date.
Certification for Paperwork Reduction Act Submissions
There are no exceptions to the Certification statement.
Collections of Information Employing Statistical Methods
Statistical methods are not employed for this collection of information.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |