Authorization Request Forms/Certification/Letter of Medical Necessity

Forms and Documents

Document Name	Status
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications Form and Instruction	New
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction	New
OMB_Response to September 16 notice_10052016.pdf Supplementary Document	2016-10-13
2016 09 14 PMG letter to Thomas E Perez Secretary of Labor re Uncontroll....pdf Supplementary Document	2016-10-13
Response to Postal Comment and House Letter.docx Supplementary Document	2016-10-12
OPM Salary Table 2016-RUS.pdf Supplementary Document	2016-06-15
BLS OES Salary Table for Physicians May 2015.docx Supplementary Document	2016-06-15
Privacy Act Systems.doc Supplementary Document	2016-06-15
Supporting Statement 1240-XXXX FOR AUTHORIZATION FORMS FOR LETTER OF AUTHORIZATION-MEDICAL NECESSITY FOR PRESCRIPTIONS October 2016.docx Supporting Statement A	2016-10-12

IC Document Collections

IC ID	Document Title	Status
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications Form and Instruction	New
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form and Instruction	New

ICR Details

OMB Control No: 1240-0055	ICR Reference No: 201606-1240-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization Request Forms/Certification/Letter of Medical Necessity
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/13/2016
	Date Received in OIRA: 09/06/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	36 Months From Approved
Responses	170,000	0	0
Time Burden (Hours)	85,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The forms, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs (CA-26) and Authorization Request Form and Certification/Letter of Medical Necessity Certification/Letter of Medical Necessity for Opioid Medications (CA-27), require an injured worker’s treating physician to answer a number of questions about the prescribed opioids and/or compounded drugs and certify that they are medically necessary to treat the work-related injury. The responses to the questions on the forms are intended to ensure that treating physicians have considered non-opioid and non-compounded drug alternatives, and are only prescribing the most cost effective and medically necessary drugs. The forms will also permit OWCP to more easily track the volume, type, and characteristics of opioids and compounded drugs authorized by the FECA program. The forms will serve as a means for injured workers to continue receiving opioids and compounded drugs only where medically necessary and simultaneously give OWCP greater oversight in monitoring their appropriate use and gather additional data about their use.

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Authorizing Statute(s): US Code: 5 USC 8103 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8124 (a) (2) Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees' Comensation Act
  

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:
	81 FR 40721	06/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 61255	09/06/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	CA-26	Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications	CA-27	Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications

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ICR Summary 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	170,000	0	0	170,000	0	0
Annual Time Burden (Hours)	85,000	0	0	85,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $17,818,719

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: 09/06/2016

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