Summary of Forms and Changes in the ICR

App SS Summary of Forms and Changes_100918.docx

World Trade Center Health Program Enrollment, Appeals & Reimbursement

Summary of Forms and Changes in the ICR

OMB: 0920-0891

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Summary of WTC Health Program Forms and Standard Correspondence, by Type/Function


Form Type

Form Name and Appendix ID

Translations

Eligibility Applications

Appendix C: World Trade Center Health Program FDNY Responder Eligibility Application English


Appendix D: World Trade Center Health Program Responder Eligibility Application (Other than FDNY) English

Appendix E: Spanish

Appendix F: Polish

Appendix G: World Trade Center Health Program Pentagon/Shanksville Eligibility Application


Appendix H: World Trade Center Health Program Survivor Eligibility Application English

Appendix I: Spanish

Appendix J: Polish

Appendix K: Chinese

Appendix L: Web based Application Screen Shots


Additional Information Needed to Assess Eligibility

Appendix M: Initial Request for Additional Information

Appendix FF: Translations initial request (Spanish, Chinese, Polish)

Appendix N: 30 Day Letter Reminder for Additional Information

Appendix GG: Translations 30 day request (Spanish, Chinese, Polish)

Appendix O: 60 Day Letter Reminder for Additional Information

Appendix HH: Translations 60 day request (Spanish, Chinese, Polish)

Appendix P: 90 Day Letter Reminder for Additional Information

Appendix II: Translations 90 day request (Spanish, Chinese, Polish)

Appendix Q: 180 Day Letter Reminder for Additional Information

Appendix JJ: Translations 180 day request (Spanish, Chinese, Polish)

Denials and Appeals

Appendix Z: Enrollment Denial Letter and Appeal Notification

Appendix KK: Spanish

Appendix AA: Certification Denial Letter and Appeal Notification


Appendix BB: Treatment Denial Letter and Appeal Notification


Appendix PP Decertification Letter Template—Administrative Error


Appendix QQ Decertification Letter Template—Denial and Decertification Exposure


Appendix RR Decertification Letter Template—Latency Prostate Cancer/Cancer


Appendix OO: Disenrollment Letter and Appeal Notification


Appendix TT: Reimbursement Denial Letter and Appeal Notification


Administration of Program Benefits to Eligible Members

Appendix R: Clinic Selection Postcard


Appendix V: Prior Authorization Form – Standard


Appendix W: Prior Authorization Form – Dental


Appendix X: Prior Authorization Form – Transplant


Appendix CC: WTC Health Program Medical Travel Refund Request


Appendix LL: Designated Representative Form


Appendix MM: HIPAA Release



Approval Process for Conditions, Procedures, or Medications Supported by the WTC Health Program

Appendix S: WTC-3 Request for Certification


Appendix T: WTC-5 Code or Procedure Request


Appendix U: WTC-6 Medication Request for Codebook


Appendix NN: Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program Form


Appendix DD: 1 Federal Register Notice


Appendix EE: IRB Determination


Appendix Y: Outpatient Prescription Pharmaceuticals


Appendix Y-1: Non Formulary Prior Authorization – Prescription (General)


Appendix Y-2 Non-Formulary Prior Authorization – Prescription (Renewal)


Appendix Y-3 Non-Formulary Prior Authorization – Airway Medication


Appendix Y-4 Non-Formulary Prior Authorization – Antidepressant


Appendix Y-5 Non-Formulary Prior Authorization – Antiemetic


Appendix Y-6 Non-Formulary Prior Authorization – Antipsychotic


Appendix Y-7 Non-Formulary Prior Authorization – Epinephrine


Appendix Y-8 Non-Formulary Prior Authorization – Insulin


Appendix Y-9 Non-Formulary Prior Authorization –Methadone


Appendix Y-10 Non-Formulary Prior Authorization – Nucala


Appendix Y-11 Non-Formulary Prior Authorization – Opioid Abuse




Summary of Changes to Information Collection Forms, and Impact on Burden Estimates


Type of

Respondent

(with burden table line number)

Form Name

Appendix

Status

Comments

No. of

Respondents

No.

Responses

per

Respondent

Average

Burden per

Response

(in hours)

Total Burden Hours

Change in Burden


1) FDNY Responder

World Trade Center Health Program

FDNY Responder Eligibility Application

C

No change


45

1

30/60

23

0

2) General Responder

World Trade Center Health Program

Responder Eligibility Application (Other than FDNY)

D, E, F

Modified

No change to form content or burden, but translations were added

2,475

1

30/60

1,238

0

3) Pentagon/ Shanksville Responder

World Trade Center Health Program Pentagon/ Shanksville Responder

G

No change


630

1

30/60

315

0


4) WTC Survivor

World Trade Center Health Program

Survivor Eligibility Application (all languages)

H, I, J, K

Modified

No change to form content or burden, but translations were added

1,350

1

30/60

675

0

5) General responder

Clinic Selection Postcard for new general responders in NY/NJ to select a clinic

R

No change


2,475

1

15/60

619

0

6) Program Medical Provider

Physician Request for Certification

(WTC-3)

S

No change


20,000

1

30/60

10,000

0

7) Responder (FDNY and General Responder)/ Survivor

Denial Letter and Appeal Notification – Enrollment

Z

No change


45

1

30/60

23

0

8) Responder (FDNY and General Responder)/ Survivor

Disenrollment Letter and Appeal Notification –

Enrollment

OO

New

Changes due to 42 CFR 88.14

3

1

30/60

2

+2

9) Responder (FDNY and General Responder)/

Survivor

Decertification Letter and Appeal Notification – Health Condition

QQ

New

Changes due to 42 CFR 88.21

5

1

1.5

8

+8

10) Responder (FDNY and General Responder)/

Survivor

Denial Letter and Appeal Notification – Health Condition Certification

AA

Modified

Due to clarification in 42 CFR 88.21, burden per response increased from 30 min to 90 min with resulting increase in total

60

1

1.5

90

+60

11) Responder (FDNY and General Responder)/Survivor

Denial Letter and Appeal Notification – Treatment Authorization

BB

Modified

Clarification of right to appeal under 42 CFR 88.21; burden per response increased from 30 min to 90 min with resulting change in total

26

1

1.5

39

+26

12) Responder (FDNY and General Responder)/Survivor

WTC Health Program Medical Travel Refund Request


CC

No change


10

1

10/60

2

0

13) Program Members

Designated Representative Form

LL

Modified

Form was modified but no change in average burden per response; number of forms increased resulting in increase in total burden

30

1

15/60

8

+5

14) Program Member

HIPAA Release Form to allow the sharing of member information with a third party

MM

New

This is a program-initiated change that allows the WTC program to interface with third parties

30

1

15/60

8

+8

15) Pharmacy

Outpatient prescription pharmaceuticals

Y

Form updated; No change to burden estimates


150

261

1/60

653

0

16) Program Medical Provider

Reimbursement Denial Letter and Appeal Notification –

Providers

TT

New

New appeals process under 88.23 Generated at CCE/NPN level

600

1

30/60

300

+300

17) Responder/ Survivor/ Advocate (physician)

Petition for the addition of health conditions

NN

Modified

Migrated from 0920-0929

60

1

1

60

+60

Total








14,063

+469








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AuthorMacaluso, Renita (CDC/OD/OADS)
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