Provider Enrollment Form

ICR 202004-1240-004

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Justification for No Material/Nonsubstantive Change
2020-04-08
Supplementary Document
2020-03-04
Supplementary Document
2020-02-14
Supporting Statement A
2020-02-28
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
IC Document Collections
IC ID
Document
Title
Status
38462
Modified
ICR Details
1240-0021 202004-1240-004
Historical Active 202002-1240-001
DOL/OWCP
Provider Enrollment Form
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/14/2020
Approved without change 04/15/2020
Retrieve Notice of Action (NOA) 04/13/2020
  Inventory as of this Action Requested Previously Approved
09/30/2020 09/30/2020 09/30/2020
64,325 0 64,325
32,163 0 32,163
37,309 0 37,309
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: 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)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
  
None
Not associated with rulemaking
85 FR 8609 02/14/2020
No
1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168
  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 64,325 64,325 0 0 0 0
Annual Time Burden (Hours) 32,163 32,163 0 0 0 0
Annual Cost Burden (Dollars) 37,309 37,309 0 0 0 0
No
No
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.
$1,864,692
No
    Yes
    Yes
No
No
No
Uncollected
Frederick Licari 571 372-0493 [email protected]
  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:
 
 
 
 
 
 
 
    (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.
04/13/2020
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