Authorization Request Forms/Certification/Letter of Medical Necessity

Forms and Documents

Document Name	Status
Form CA-26 (Length of T CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs Form	Modified
Supporting Statement 1240-0055.docx Supporting Statement A	2020-01-14
Privacy Act Systems-FECA.docx Supplementary Document	2019-06-10
OPM Salary Table 2019.pdf Supplementary Document	2019-06-10
Physicians and Surgeons, All Other occupational employment and wages 2018.htm Supplementary Document	2019-06-10

IC Document Collections

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

ICR Details

OMB Control No: 1240-0055	ICR Reference No: 201906-1240-001
Status: Received in OIRA	Previous ICR Reference No: 201705-1240-001
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization Request Forms/Certification/Letter of Medical Necessity
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/12/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	45,600	0
Time Burden (Hours)	22,800	0
Cost Burden (Dollars)	0	0

---

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.

---

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

---

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:
	84 FR 59842	11/06/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 8029	02/12/2020
Did the Agency receive public comments on this ICR? No

---

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 (Length of Therapy Detail, CA-26 (Method of Administration Detail), CA-26, CA-26, CA-27	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail) ,   Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail ,   Authorization Request form and Certification/Letter of Medical Necessity for Compounded Drugs ,   Authorization Request form and Certification/Letter of Medical Necessity for Compounded Drugs ,   Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	CA-27 (Web), CA-27	Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications ,   Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications

---

ICR Summary of Burden

	Total Request	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	45,600	0	0	0	-124,400	170,000
Annual Time Burden (Hours)	22,800	0	0	0	-62,200	85,000
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: There is a reduction in the number of respondents from the previous submission of 170,000 to 45,600, a difference of 124,400. Accordingly, the previous burden hours of 85, 000 is adjusted to 22,800, a decrease of 62,200. There are no associated burden costs. The adjustments are reflective of enhanced oversight by OWCP for both compound and opioid prescriptions that includes the implementation of the four point strategic plan noted above.

---

Annual Cost to Federal Government: $7,032,502

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.     No

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.     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? No

---

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: 02/12/2020

---