SUPPORTING STATEMENT - PART A
Statement of Personal Injury: Possible Third Party Liability; DD-2527 – 0720-0003
1. Need for the Information Collection
The Federal Medical Care Recovery Act, 42 U.S.C. 2651-2653 provides for recovery of the reasonable value of medical care provided by the United States to a person who is injured or suffers a disease under circumstances creating tort liability in some third person. The DD Form 2527, “Statement of Personal Injury: Possible Third Party Liability,” is required for investigating and asserting claims in favor of the United States arising out of such incidents.
When a claim for TRICARE benefits is identified as involving possible third party liability and the information is not submitted with the claim the TRICARE contractors request that the injured party (or a designee) complete DD Form 2527. To protect the interests of the Government the contractor suspends claims processing until the requested third party liability information is received. The contractor conducts a preliminary evaluation based upon the collection of information and refers the case to a designated appropriate legal officer of the Uniformed Services. The responsible Uniformed Services legal officer uses the information as a basis for asserting and settling the Government’s claim. When appropriate the information is forwarded to the Department of Justice as the basis for litigation.
2. Use of the Information
Respondents to this collection are TRICARE beneficiaries. Beneficiaries complete the DD-2527 on the occasion of submitting a claim which involves possible third party liability. Beneficiaries submit the completed DD-2527 to their regional TRICARE contractor. The regional TRICARE contractor (ManageCare, HealthNet, Humana or Wisconsin Physician) use the information supplied by the completed DD-2527 to conduct a preliminary evaluation and appropriately refer cases to a legal officer of the Uniformed Services.
Respondents access the DD-2527 in three ways: (1) the TRICARE regional contractor will mail a copy of the DD-2527 to the respondent’s home address, (2) respondents may also download a copy of the DD-2527 from the regional contractor’s website or (3) respondents may download and print a copy of the DD-2527 from the Department of Defense’s (DoD) Forms Management Program website (http://www.esd.whs.mil/Directives/forms/). Respondents may either type in their responses onto the fillable PDF version of the DD-2527 and print it, or print the form and complete it by hand. No associated invitations or communications are sent to respondents. Respondents complete the DD-2527 and submit it to their regional contractor by mail. Once received by the regional contractor, the DD-2527 is reviewed and a determination is made to evaluate if the claim should go forward. The regional contractor will refer claims cases to the Military Claims Office, as appropriate, to be reviewed by a Uniformed Services legal officer. The legal officer uses this information as a basis to assert and settle the U.S. government’s claim. In some instances, this information is forwarded to the U.S. Department of Justice as the basis for litigation. The successful collection of this information allows the TRICARE regional contractors to effectively process claims identified as involving possible third party liability and helps protect the interests of the U.S. government.
3. Use of Information Technology
0% of responses are collected electronically. At this time there are no information technology options to allow respondents to electronically submit the DD-2527 to their regional TRICARE contractor. However, fillable PDF versions of the DD-2527 are made available to respondents via the regional contractor’s and DoD Forms Management Program’s websites.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
This information is collected upon occasion, as required, of a TRICARE beneficiary’s accidental injury that may involve third party liability. Should this information be collected less frequently, TRICARE regional contractors will be unable to process beneficiary claims which would adversely affect the interests of the respondents and the U.S. government.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on Thursday, February 14, 2019. The 60-Day FRN citation is 83 FRN 64335.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Thursday, February 28, 2019. The 30-Day FRN citation is 84 FRN 6773.
Part B: CONSULTATION
No additional consultation apart from soliciting public comments through the Federal Register Notice was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
A Privacy Act Statement is required and located at the upper section of the DD-2527.
This information collection requires a System of Record Notice (SORN). The SORN, EDTMA 04, “Medical/ Dental Claim History Files,” is published on the U.S. DoD Defense Privacy, Civil Liberties, and Transparency Division website, and can be found here: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/.
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
The Records Retention and Disposition Schedule is as follows: Close out at end of the calendar year in which received. Destroy 10 years after cutoff (DAA-0330-0214-0014-0001,911-01). When subject to one or more Litigation Holds, preserve records in compliance with the time constraints of the hold(s).
11. Sensitive Questions
The DD-2527 collects the respondent’s Social Security Number (SSN) to identify the beneficiary’s medical and claims records in the Military Health System (MHS) databases and records systems. An SSN Justification Memorandum has been submitted with this information collection request.
12. Respondent Burden and its Labor Costs
DD-2527
Number of Respondents: 188,090
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 188,090
Response Time: 15 minutes
Respondent Burden Hours: 47,023 hours
Total Submission Burden
Total Number of Respondents: 188,090
Total Number of Annual Responses: 188,090
Total Respondent Burden Hours: 47,023 hours
Part B: LABOR COST OF RESPONDENT BURDEN
DD-2527
Number of Total Annual Responses: 188,090
Response Time: 15 minutes
Respondent Hourly Wage: $8.50
Labor Burden per Response: $2.13
Total Labor Burden: $399, 691.25
Overall Labor Burden
Total Number of Annual Responses: 188,090
Total Labor Burden: $399, 691.25
The Respondent hourly wage was determined by using the Department of Labor Wage Website in 2019 ([http://www.dol.gov/dol/topic/wages/index.htm]).
13. Respondent Costs Other Than Burden Hour Costs
Respondents incur postage costs when submitting the DD-2527 to their regional TRICARE contractor. We estimate respondents will incur $92,164.10 in postage costs when completing this collection.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
DD-2527
Number of Total Annual Responses: 188,090
Processing Time per Response: 15 minutes
Hourly Wage of Workers Processing Responses : $15.00
Cost to Process Each Response: $3.75
Total Cost to Process Responses: $705,337.5
Overall Labor Burden to the Federal Government
Total Number of Annual Responses: 188,090
Total Labor Burden: $705,337.5
The Worker’s hourly wage was determined by using the Department of Labor Wage Website in 2019 ([http://www.dol.gov/dol/topic/wages/index.htm]).
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0.00
Printing: $0.00
Postage: $0.00
Software Purchases: $0.00
Licensing Costs: $0.00
Other: $0.00
Total Operational and Maintenance Cost: $0.00
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $705,337.5
Total Operational and Maintenance Costs: $0.00
Total Cost to the Federal Government: $705,337.5
15. Reasons for Change in Burden
There has been no change in burden since the last approval.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |