Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form EE-32 EE-32 (Home Health Care Authorization Request)	Form and Instruction	New	Repair queued
Form EE-30 EE-30 (Transplant Authorization Request)	Form and Instruction	New	Repair queued
Form EE-28 EE-28 (Transportation Authorization Request)	Form and Instruction	New	Repair queued
Form EE-26 EE-26 (Rehabilitative Therapies Authorization Request)	Form and Instruction	New	Missing upstream
Form EE-24 EE-24 (Durable Medical Equipment Authorization)	Form and Instruction	New	Available
Form EE-22 EE-22 (General Medical Authorization Request)	Form and Instruction	New	Repair queued
Supporting Statement 1240-0NEW 4.12.21.docx	Supporting Statement A	Uploaded 2021-04-15	Missing upstream
1240-0NEW 30-day FRN published.pdf	Supplementary Document	Uploaded 2021-04-15	Repair queued
60-day FRN (1240-0NEW (DEEOIC)) published.pdf	Supplementary Document	Uploaded 2021-01-19	Repair queued
20 CFR Part 30.pdf	Supplementary Document	Uploaded 2020-09-24	Repair queued
42 USC 7384 et seq.pdf	Supplementary Document	Uploaded 2020-09-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243779	EE-32 (Home Health Care Authorization Request)	Form and Instruction	New
243778	EE-30 (Transplant Authorization Request)	Form and Instruction	New
243777	EE-28 (Transportation Authorization Request)	Form and Instruction	New
243776	EE-26 (Rehabilitative Therapies Authorization Request)	Form and Instruction	New
243775	EE-24 (Durable Medical Equipment Authorization)	Form and Instruction	New
243774	EE-22 (General Medical Authorization Request)	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202009-1240-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/15/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	66,770	0
Time Burden (Hours)	11,129	0
Cost Burden (Dollars)	0	0

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Abstract: The Office of Workers’ Compensation Programs (OWCP) is the primary agency responsible for administration of the Energy Employees Occupational Illness Compensation Program Act of 2000, as amended (EEOICPA), 42 U.S.C. § 7384 et seq. EEOICPA provides for the payment of compensation to covered employees and, where applicable, survivors of deceased employees, who sustained either an “occupational illness” or a “covered illness” in the performance of duty for the Department of Energy and certain of its contractors and subcontractors. One element of the compensation provided to covered employees is medical benefits for the treatment of their occupational or covered illnesses that are accepted as compensable. OWCP contracts with a private sector bill processing agent that handles many of the tasks associated with paying bills for medical treatment provided to covered employees under EEOICPA. This bill processing agent uses an automated system that matches incoming bills with the authorized medical treatment of covered employees before it issues payments, and a provider of medical treatment, supplies or services to covered employees must provide the bill processing agent with information necessary for creation of an authorization within the agent’s automated system before a bill can be paid. The collection of this information is authorized by 20 CFR 30.400(a) and (c), 30.403, 30.404(b) and 30.700. The information collected by these forms will be used by both OWCP and its bill processing agent in connection with the automated payment of bills submitted by providers of medical treatment, supplies or services. The information submitted, along with other supporting documentation, is used to determine the correct amount to be paid to a provider of medical treatment, supplies or services to beneficiaries under EEOICPA.

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Authorizing Statute(s): US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 62327	10/02/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 19903	04/15/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
EE-22 (General Medical Authorization Request)	EE-22	General Medical Authorization Request
EE-24 (Durable Medical Equipment Authorization)	EE-24	Durable Medical Equipment Authorization Request
EE-26 (Rehabilitative Therapies Authorization Request)	EE-26	Rehabiltative Therapies Authorization Request
EE-28 (Transportation Authorization Request)	EE-28	Transportation Authorization Request
EE-30 (Transplant Authorization Request)	EE-30	Transplant Authorization Request
EE-32 (Home Health Care Authorization Request)	EE-32	Home Health Care Authorization Request

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ICR Summary of Burden

table that charts list 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	66,770	0	0	66,770	0	0
Annual Time Burden (Hours)	11,129	0	0	11,129	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $1,673,872

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

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Common Form ICR:  No

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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: 04/15/2021

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