Certificate of Medical Necessity

Forms and Documents

Document Name	Status
Form CM-893 Certificate of Medical Necessity Form and Instruction	Modified
Justification - Certificate of Medical Necessity (CM-893).docx Justification for No Material/Nonsubstantive Change	2020-08-25
1240-0024 Certification of Medical Necessity (CM-893).pdf Supplementary Document	2020-08-26
CM-893 Certificate of Medical Necessity.pdf Supplementary Document	2020-02-19
System of Record Notice.pdf Supplementary Document	2017-11-21
1240-0024 Supporting Statement 2018 ver.2.docx Supporting Statement A	2018-02-28
Pages from 2000 Regs for 1215-0113.pdf Supplementary Document	2008-09-09

IC Document Collections

IC ID	Document Title	Status
13782	Certificate of Medical Necessity Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0024	ICR Reference No: 202008-1240-041
Status: Active	Previous ICR Reference No: 202002-1240-007
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Certificate of Medical Necessity
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/22/2020
	Date Received in OIRA: 10/20/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2021	04/30/2021	04/30/2021
Responses	1,500	0	1,500
Time Burden (Hours)	563	0	563
Cost Burden (Dollars)	0	0	0

---

Abstract: Request for address change. The Certificate of Medical Necessity is completed by the coal miner's doctor and is used by OWCP to determine if the miner meets impairment standards to qualify for durable medical equipment or home nursing.

---

Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits 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:
	82 FR 48532	10/18/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 9798	03/01/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Certificate of Medical Necessity	CM-893	Certificate of Medical Necessity

---

ICR Summary 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	1,500	1,500	0	0	0	0
Annual Time Burden (Hours)	563	563	0	0	0	0
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: The overall request is a revision because the forms were revised. The decrease (adjustment) in the burden hours, number of responses, cost burden is due to fewer CMNs being submitted for processing.

---

Annual Cost to Federal Government: $184,391

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]? 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: 10/20/2020

---