Request for External Review

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OPM 1841 Authorized Representative Form	Form and Instruction	Unchanged	Available
Form OPM 1840 Intake Form	Form and Instruction	Unchanged	Available
Revised OPM Form 1840_Highlighted Edits_2016_version.pdf	Supplementary Document	Uploaded 2017-10-05	Available
Current OPM Form 1840_2014_version.pdf	Supplementary Document	Uploaded 2017-10-05	Available
60-Day FRN External Review Form_signed by Kathy McGettigan_2.28.17.pdf	Supplementary Document	Uploaded 2017-10-05	Available
OMB Statement A_MSP ER Case Intake Form Clearance_10.5.17.docx	Supporting Statement A	Uploaded 2017-10-05	Available
OPM_FRDOC_0001-1299_3206-0263.pdf	Supplementary Document	Uploaded 2017-08-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
210151	Authorized Representative Form	Form and Instruction	Unchanged
210150	Intake Form	Form and Instruction	Unchanged
210149	Model Notice	Other-Model Notice	Unchanged

ICR Details

OMB Control No: 3206-0263	ICR Reference No: 201708-3206-001
Status: Historical Active	Previous ICR Reference No: 201401-3206-007
Agency/Subagency: OPM	Agency Tracking No:
Title: Request for External Review
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 08/14/2017
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/18/2017
	Date Received in OIRA: 08/03/2017
Terms of Clearance: This collection should be reported in the Information collection budget.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2018	6 Months From Approved
Responses	5,488	0	0
Time Burden (Hours)	1,175	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1334 of the Patient Protection and Affordable Care Act, Pub. L. 111-148, as amended by the Health Care Education Reconciliation Act, Pub. L. 111-152 (together, "Affordable Care Act"), directed OPM to enter into contracts with health insurance issuers to offer coverage on Exchanges (also called "Health Insurance Marketplaces") throughout the 50 States and the District of Columbia. OPM issued final regulations for the establishment of the Multi-State Plan (MSP) Program on March 11, 2013, 78 Fed. Reg. 15560, which outlined an external review process that would be available to MSP enrollees. The regulations state that "OPM will conduct external review of adverse benefit determinations using a process similar to OPM review of disputed claims under [the Federal Employees Health Benefits Program] . . . ." 45 C.F.R. 800.503(a). A necessary part of conducting external review of adverse benefit determinations is accepting requests for external review from MSP enrollees. OPM is submitting to OMB a request for review and clearance of a new information collection, Request for External Review, comprising three forms: (1) Model Notice of Final Internal Adverse Benefit Determination ("Model Notice"), (2) External Review Intake Form ("Intake Form"), and (3) External Review Authorized Representative Form ("Authorized Representative Form").

Emergency Justfication: This is the first renewal for this program office and form is required for "Open Season" for external review of a disputed adverse benefit decision.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1334 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1334 Name of Law: Patient Protection and Affordable Care Act

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 38	02/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 105	06/02/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Model Notice
Authorized Representative Form	OPM 1841	External Review Authorized Representative Form
Intake Form	OPM 1840	External Review Intake Form

---

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	5,488	0	0	0	0	5,488
Annual Time Burden (Hours)	1,175	0	0	0	0	1,175
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:

---

Annual Cost to Federal Government: $119,275

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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

---

Common Form ICR:  No

---

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: 08/03/2017

---