This ICR seeks approval under the PRA
for revisions to the Provider Enrollment Form (Form OWCP-1168). The
form requests profile information on providers that enroll in one
or more of OWCP's benefit programs so its billing contractor can
pay them for services rendered to beneficiaries using its automated
bill processing system. In addition to the enrollment form
information collection, the OWCP bill processing contractor
currently collects electronic data interchange (EDI) information
from the provider only if the provider chooses a data exchange
submission method. Once the new OWCP-1168 form is in place, the
existing EDI template will no longer be applicable. The current EDI
template collects information that is duplicative to information
collected on Form OWCP-1168, such as names, addresses, and NPI.
Collecting EDI information with the enrollment information in one
form will improve efficiency in collecting the information from
providers, reduce the time required for processing by operational
staff, and will significantly reduce errors associated with
mismatching provider enrollments to their EDI information. This
information collection will be submitted to OMB under the emergency
processing request procedures, as outlined by 5 C.F.R. Part 1320
Section 13, to allow for implementation of the revisions to the
Provider Enrollment Form as soon as possible, and to incorporate
regulatory updates implementing the Black Lung benefits Act which
becomes applicable on April 26, 2020.
This ICR seeks approval
under the PRA for revisions to the Provider Enrollment Form (Form
OWCP-1168). The form requests profile information on providers that
enroll in one or more of OWCP's benefit programs so its billing
contractor can pay them for services rendered to beneficiaries
using its automated bill processing system. In addition to the
enrollment form information collection, the OWCP bill processing
contractor currently collects electronic data interchange (EDI)
information from the provider only if the provider chooses a data
exchange submission method. Once the new OWCP-1168 form is in
place, the existing EDI template will no longer be applicable. The
current EDI template collects information that is duplicative to
information collected on Form OWCP-1168, such as names, addresses,
and NPI. Collecting EDI information with the enrollment information
in one form will improve efficiency in collecting the information
from providers, reduce the time required for processing by
operational staff, and will significantly reduce errors associated
with mismatching provider enrollments to their EDI information.
This information collection will be submitted to OMB under the
emergency processing request procedures, as outlined by 5 C.F.R.
Part 1320 Section 13, to allow for implementation of the revisions
to the Provider Enrollment Form as soon as possible, and to
incorporate regulatory updates implementing the Black Lung benefits
Act which becomes applicable on April 26, 2020.
US Code:
30
USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
US Code: 5 USC
8101 Name of Law: The Federal Employees' Compensation Act
(FECA)
US Code: 42
USC 7384 Name of Law: The Energy Employees Occupational Illness
Compensation Program Act of 2000 (EEOICPA)
There has been an increase in
the number of respondents seeking to provide medical or vocational
services to beneficiaries. Accordingly, the burden hours increased
from 8,555 to 32,162.50, an adjustment of 23,608 hours and the
operational and maintenance costs increased from $33,449 to
$37,309, an adjustment of $3,860. In addition, the final BLBA rule
continues the current information collection requirements but would
change where the regulatory authorities are codified. This ICR
updates the regulatory citation for the BLBA program’s authority to
collect the information.
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:
(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;
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.
Form OWCP-1168 Provider Enrollment Form
OWCP-1168_V21_Apr 30 - Updated_V22_Feb 14 - REVISED.docx
Signed Emergency Memo - 2-13-20.pdf
How to Complete a Provider Enrollment Application - Facility.pptm
Provider Enrollment Form