OMB Supporting Statement (0720-0005)_final 12.21.2017

Supporting Statement Outline

SUPPORTING STATEMENT – PART A

0720-0005 – Professional Qualification Medical Peer Reviewers

A.  JUSTIFICATION

1.  Need for the Information Collection

The information collected on the Professional Qualifications Medical/Peer Reviewers form (DHA 780) is required by Chapter 12, Section 3, Paragraph 4.2, TRICARE Operations Manual, 6010.56-M (2008 Edition). The review of case files by qualified medical professionals is fundamental to the effective administration of the TRICARE appeal and hearing process.

TOM Chapter 12, Section 3, details reconsideration procedures the TRICARE Quality Monitoring Contractor (TQMC) must follow to properly respond to requests for review concerning benefits for TRICARE beneficiaries. The TQMC is responsible for providing clinical specialty credentialed reviewers who render opinions concerning the medical necessity of care provided to a TRICARE beneficiary. The expert opinion of a reviewer is used as a basis for making decisions about whether provided care is covered.

The information collected in DHA Form 780 is essential for beneficiaries to receive a full and fair assessment of their claims. The policy requirements of Chapter 12 are in place to ensure reviewers have appropriate medical expertise to address medical necessity issues raised in a reconsideration requests. The DHA Form 780 is necessary in order to ensure the TQMC utilizes the correct medical expert to assess a case. Without collecting the information required by Form 780, the TQMC would be unable to assign an appropriate medical expert and TRICARE would be unable to verify that assigned reviewers are properly qualified to render opinions.

TOM Chapter 12, Section 3, paragraph 4.0, establishes the requirements for the reconsideration reviewer qualifications and administrative requirements. Paragraph 4.1 establishes the reviewer qualifications and mandates the reviewer be qualified under Chapter 7, Section 1, paragraph 3.0. Chapter 7, Section 1, paragraph 3.0, of the TOM requires reviewers to be properly licensed in a like specialty of the original treating care provider. A treating provider may be a licensed doctor of medicine, osteopathy, a doctor of dentistry, or other appropriately credentialed health care practitioner.

TOM Chapter 12, Section 3, paragraph 4.2 specifically requires the name and title of the medical expert reviewer as an essential requirement to any written opinion that is forwarded to the Defense Health Agency (DHA). Paragraph 4.2 requires completion of a “Professional Qualifications” form, Addendum A, Figure 12.A-3, which is the old TMA Form 780. DHA Form 780 is updated to reflect the reorganization of Tricare Management Activity into the Defense Health Agency. The underlying policy need for the requested information remains the same under the reorganization of DHA, as the process for conducting TQMC reviews is unchanged.

2.  Use of the Information

The Form, DHA 780 documents the qualifications of the medical professionals who conducted medical/peer reviews in support of TRICARE appeal and hearing cases, and is retained in the relevant case's file. The form is published in the TRICARE Operations Manual, available online and transmitted to the medical professional by the TRICARE contractor.

The information collected using form DHA 780 provides a record to confirm the qualifications of the medical/peer reviewers who participated in the case.

The Defense Health Agency, appealing parties, medical care providers associated with an appeal or hearing case, and other authorized persons reference this Form to confirm the qualifications of the medical/peer reviewers.

The respondents are peer reviewers (i.e. Physicians, Nurses, Social Workers, Physical Therapists, CRNA's, Nurse Practitioners, etc.) identified/secured at the time each requested review is received by the TQMC from DHA. Respondents (reviewers) are identified/selected specifically for each requested review and are board certified/specialty matched to each case. The reviewers fill out the form in order to qualify as experts in their respective fields so they can be employed by the TQMC to conduct peer reviews.

The reviewers receive the form by email, and return it to the TQMC via email or secured encrypted fax. The form goes directly to the TQMC credentialing specialists. Less than 1% of the forms are returned to the TQMC via regular mail or overnight Federal Express.

The amended DHA Form 780 does not require a Privacy Act disclosure. The required Agency Disclosure Notice (ADN) is displayed on the DHA 780.

Once the reviewer returns the form to the TQMC they are contacted by email or phone to determine their availability to conduct the review within the required timeframe. The following format is used when emailing the reviewer to request services:

Request for Peer Review

Dear Dr./Ms./Mr.

KEPRO is the Total Quality Management Contractor (TQMC) for the TRICARE purchased care contract. We are in need of an expedited (Insert Specialty Here, e.g., Internal Medicine, Emergency Medicine, etc) Peer Reviewer to determine Medical Necessity/Standard of Care for a TRICARE Beneficiary.

The deadline for this review to be completed/faxed/emailed to KEPRO will be (Insert Time AM/PM on (Insert Date).

If you are interested in performing this review, please respond to this email by COB today (Insert Date) and KEPRO will provide you with the necessary paperwork to process/complete the review.

Once your availability is confirmed, KEPRO will have the record delivered to your home address by (insert date) via FedEx. Return FedEx packaging for returning all received materials to KEPRO will also be included.

Thank you for your consideration of our request and please contact us (see below) should you have additional questions.

Insert Name

Administrative Assistant

KEPRO-Harrisburg

777 East Park Drive

Harrisburg, PA 17111-2754

http://tricare.kepro.com/mh/

TRICARE Hotline #: 1-877-841-6413

TRICARE Fax #: 1-877-841-6414

Form DHA 780 form will be used by TQMC support staff and credentialing specialists within the department. The form is used to identify a peer reviewer by specialty and any sub certifications the respondent may have. It is also used to confirm and support credentialing files. The TQMC also sends a copy of the completed form with each completed review to DHA. At the TQMC the following individuals specifically manage use and administration of the form: (1) Administrative Assistant- Schedules the Peer Reviews based on the specialty requested by TRICARE; Invites appropriate Peer Reviewers to perform reviews based on experience and availability; (2) Credentialing Specialist- Tasked with collecting all information required for the TWMC’s credentialing process prior to sending to the TQMC Medical Director for final review/approval. The Credentialing Specialist maintains the master data base for tracking information regarding all of the TQMC’s credentialed reviewers.

3.  Use of Information Technology

This collection process requires the medical professional to complete and submit a simple, two-page form. Respondents are required to complete the Form once and provide updates as necessary. The form is published in the TRICARE Operations Manual. The TRICARE Operations manual is available online at http://manuals.tricare.osd.mil/pages/DisplayManual.aspx?SeriesId=OPERATIONS. The TRICARE Operations Manual is provided as PDF to the medical professional by the TRICARE contractor.

The forms are primarily received electronically by the TQMC. 100% of the responses come in electronically.

4.  Non-duplication

There is no duplication. Medical professionals complete the Form once and provide updates as necessary. Similar information is not otherwise available. Occasionally, a medical professional will have a resume or curriculum vitae which can serve as a substitute for the Form. In such cases, the Form is not required. When available, however, resumes and curricula vitae may not contain all the necessary information.

Consequently, the Form provides a standardized method of collecting and retaining the required information.

5.  Burden on Small Business

The collection of this information does not significantly impact small businesses or other entities.

6.  Less Frequent Collection

The Form is completed once and updated as necessary. The information cannot be collected less frequently.

7.  Paperwork Reduction Act Guidelines

There are no special circumstances requiring collection inconsistent with the guidelines at

8. C.F.R. § 1320.5(d)(2).

8.  Consultation and Public Comments

Part A: PUBLIC NOTICE

The 60-Day Federal Register Notice for this collection of information was published October 13, 2015; 80 FR 61388-61389. No public comments were received.

The 30-Day Federal Register Notice for this collection of information was published January 17, 2017; 82 FR 4863.

Part B: CONSULTATION

In developing the amended version the Defense Health Agency engaged in development discussions with the TQMC team lead. The primary change to the form was to eliminate the need for the Privacy Act statement and update the agency name from TMA to DHA in accordance with agency realignment.

9.  Gifts or Payment

No payments or gifts will be provided to respondents.

10.  Confidentiality

The System of Records Notice (SORN) for this collection is DHA 09 Medical Credentials/Risk Management Analysis System. The Link is provided below: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570674/edha-09/. A Privacy Impact Assessment (PIA) is provided for Centralized Credentials Quality Assurance System at the following Link: https://health.mil/Military-Health-Topics/Privacy-and-Civil-Liberties/Privacy-Impact-Assessments/MHS-PIA- The Record retention schedule is consistent with the Appeals file which is six years. Per DoD and DHA Privacy offices, a Privacy Act Statement will not be required for this collection.

11.  Sensitive Questions

Sensitive information such as the SSN will not be collected.

12.  Respondent Burden, and its Labor Costs

a.  Estimation of Respondent Burden

Estimation of Respondent Burden Hours
	Number of Respondents	Number of Responses per Respondent	Number of Total Annual Responses	Response Time (Amount of time needed to complete the collection instrument)	Respondent Burden Hours (Total Annual Responses multiplied by Response Time) Please compute these into hours)
Collection Instrument: DHA780	60	1	60	20 minutes	20
Total	60	1	60	20 minutes	20

b.  Labor Cost of Respondent Burden

Labor Cost of Respondent Burden
	Number of Responses	Response Time per Response	Respondent Hourly Wage	Labor Burden per Response (Response Time multiplied by Respondent Hourly Wage)	Total Labor Burden (Number of Respondents multiplied by Response Time multiplied by Respondent Hourly Wage)
Collection Instrument: DHA780	60	20 minutes	$90.00*	$30.00	$1,800
Total	60	20 minutes	$90.00*	$30.00	$1,800

*Source: http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm#tab-1

13.  Respondent Costs Other Than Burden Hour Costs

There are no additional costs to respondents.

.

14.  Cost to the Federal Government

The only administrative processing by Defense Health Agency employees is to place the Form in a compendium of forms upon receipt and photocopy and place the Form in a case file as needed. Each of these actions takes approximately one minute.

Defense Health Agency Employee Administrative Processing Cost: $.48 (per minute wage of a GS-8, Step 9 employee $58,397 Denver annual salary (2016).

Labor Cost to the Federal Government
	Collection Instrument: DHA 780	Total
Number of Responses	60	60
Processing Time Per Response (in hours)	2 minutes	2 minutes
Hourly Wage of Worker(s) Processing Responses	$28.93*	$28.93
Cost to Process Each Response (Processing Time Per Response multiplied by Hourly Wage of Worker(s) Processing Responses)	$0.48	$0.48
Total Cost to Process Responses (Cost to Process Each Response multiplied by Number of Responses	$57.60	$57.60

*Source: https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2016/DEN_h.pdf

Operational and Maintenance Costs
Equipment	Printing	Postage	Software Purchases	Licensing Costs	Other	Total
0	$2.40	$28.20	0	0	0	$30.60

Mailing the Form to respondents per 2016 postage rates: (60 x $.47) = $28.20.

Reproducing the Form: (2 pages x 60 copies x $.02 per page) = $2.40

Total Cost to the Federal Government
Operational and Maintenance Costs	Labor Cost to the Federal Government	Total Cost (O&M Costs + Labor Cost)
$30.60	$57.60	$88.20

15.  Reasons for Change in Burden

This is a reinstatement of a previously approved collection for which approval has expired and the OMB burden inventory is zero. The burden hours increased from when the collection was last activated because after reviewing the collection instrument (DHA 780) and the information needed to complete the form, we have re-estimated that it takes approximately 20 minutes per response.

16.  Publication of Results

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

17.  Non-Display of OMB Expiration Date

Approval is not sought to avoid displaying the OMB approval expiration date.

18.  Exceptions to "Certification for Paperwork Reduction Submissions"

There are no exceptions to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-1.

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