Supporting Statement 1240-0NEW 4.12.21

Authorization Request Forms

OMB Control No. 1240-0NEW

OMB Expiration Date: XX/XX/20XX

SUPPORTING STATEMENT FOR

DEEOIC AUTHORIZATION REQUEST FORMS

OMB CONTROL NO. 1240-0NEW

This ICR seeks to obtain OMB approval for a new collection.

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

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 collections in this ICR collect demographic, factual and medical information that OWCP and/or its bill processing agent needs to process bills for medical treatment, supplies or services. The various collections in this ICR and the purpose of each are listed below and include the associated regulatory citations given above:

EE-22 -- General Medical Authorization Request is used to request that the bill processing agent create an authorization for payment of routine bills in its automated system and is completed by the medical provider. It requests information about the medical treatment, supplies or services that are being provided to a covered employee, other billing elements and supporting documentation. (20 CFR 30.400(a), 30.700)

EE-24 -- Durable Medical Equipment Authorization is used to request that the bill processing agent create a special authorization in its automated system for payment of bills for durable medical equipment provided to a covered employee. It is completed by the provider of the durable medical equipment and requests both diagnostic and estimated cost information, as well as supporting documentation. (20 CFR 30.400(a) & (c), 30.700)

EE-26 -- Rehabilitative Therapies Authorization Request is used to request that the bill processing agent create a special authorization in its automated system for payment of bills for rehabilitative therapy provided to a covered employee and is completed by the provider of that therapy. It requests both diagnostic information and information regarding the specific therapy being provided, as well as supporting documentation. (20 CFR 30.400(a), 30.700)

EE-28 -- Transportation Authorization Request is used to request that the bill processing agent create a special authorization in its automated system for payment of bills for transporting a covered employee so he/she can obtain prescribed treatment. It is completed by the provider of the transportation and requests factual information about when and where the transportation will be used, the estimated costs of the transportation, and supporting documentation. (20 CFR 30.400(a), 30.404(b), 30.700)

EE-30 -- Transplant Authorization Request is used to request that the bill processing agent create a special authorization for payment of bills for transplant services in its automated system and is completed by the medical provider of those special services. It requests information about the transplant services that are being provided to a covered employee, including the specific organ that will be replaced, other billing elements and supporting documentation. (20 CFR 30.400(a), 30.700)

EE-32 -- Home Health Care Authorization Request is used to request that the bill processing agent create a special authorization in its automated system for payment of bills for home health care services provided to a covered employee and is completed by the provider of those services. It requests both diagnostic information and information regarding the specific home health care services being provided, as well as supporting documentation. (20 CFR 30.400(a), 30.403, 30.700)

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

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.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.

In accordance with the Government Paperwork Elimination Act, all the forms will be file-able and will be posted on the Internet at https://www.owcpmed.dol.gov. A provider will be able to complete the form online, and it will be submitted electronically to the bill processing agent.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.

The information requested in these collections is not duplicative of any information available elsewhere. The respondents are the only source of the required information.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The information collections in OMB Control No. 1240-0NEW have been streamlined to obtain the necessary information while imposing the minimum burden on the respondent. The forms in this collection do not impose any additional burden on small businesses or other small entities since providing medical and billing evidence is part of the providers’ usual business practice. This information collection does not have a significant economic impact on a substantial number of small businesses.

6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

If this information were not collected, or were collected less frequently, OWCP and its bill processing agent would be unable to properly provide timely and accurate payments of bills submitted by providers of medical treatment, supplies and services to EEOICPA claimants. If bills were paid in the absence of full information, there would be numerous incorrect payments.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.

Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.

Consultations with providers of medical treatment, supplies and services who will be submitting the information were privately conducted to evaluate the appropriateness and ease of collecting the information. Comments concerning the information collection requirements in No. 1240-0NEW were also solicited in a Federal Register notice published on October 2, 2020 ( 85 FR 62327). No comments were received.

9. Explain any decision to provide any payments or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to a respondent, other than the appropriate payment of bills for the provision of medical treatment, supplies or services to EEOICPA beneficiaries.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

The information collected by OMB Control No. 1240-0NEW is fully protected under the Privacy Act in the system of records known as DOL/OWCP-11.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature on these forms.

12. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. General, estimates should not include burden hours for customary and usual business practices.

• If this request for approval covers more than one form, provide separate hour burden estimates for each form.

• Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Estimated Annualized Respondent Cost and Hour Burden

The chart below shows the projected burden hours based on a total estimated number of authorization requests filed annually of 66,770.

Requirement Time To Frequency Number of Number of Hours

Complete of Response Respondents Responses Burden

EE-22 10 minutes 2 annually 7850 15700 2617

EE-24 10 minutes 2 annually 850 1700 283

EE-26 10 minutes 4 annually 100 400 67

EE-28 10 minutes 12 annually 188 2256 376

EE-30 10 minutes 1 annually 10 10 2

EE-32 10 minutes 12 annually 3892 46,704 7784

TOTALS 12,890 66,770 11,129

The requirements have a total respondent burden hour estimate of 11,129. Using the June 2020 national average nonfarm private hourly wage of $29.37 from the Bureau of Labor Statistics, the respondent cost estimate for these requirements is $326,858.73 (11,129x $29.37 = $326,858.73).

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

• The cost estimate should be split into two components: (a) a total capital

and start-up cost component (annualized over its expected useful life); and (b) a

total operation and maintenance and purchase of service component.

The estimates should take into account costs associated with generating,

maintaining, and disclosing or providing the information. Include descriptions of

methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

• If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.

• Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.

The medical and factual information requested by the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 is kept as a usual and customary business practice, so there is no additional recordkeeping or collection cost associated with these requirements. There are also no mailing costs for the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 because they are submitted to the bill processing agent electronically. Therefore, there are no operation and maintenance costs associated with OMB Control No. 1240-0NEW.

14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.

There are no printing or mailing costs to OWCP associated with this collection of information because respondents will obtain the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 from the Internet at https://www.owcpmed.dol.gov.

The contract cost to OWCP for its bill processing agent to process the responses to this collection of information will be $1.31 for each response. Thus, OWCP’s contract cost for the bill processing agent to process the 66,770 estimated responses to the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 will be $87,455.60.

Responses to this collection of information are also reviewed by a Medical Benefits Adjudication Unit consisting of 34 Federal employees (2 GS-14/4 managers, 2 GS-13/3 team leads, and 30 medical benefits examiners: 24 GS-12/2s, 1 GS-11/2, 2 GS-9/2s and 3 GS-7/2s); approximately 60% of their time is estimated to be spent reviewing responses to the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32. Therefore, using OPM Salary Table 2020-RUS, the cost to provide this Federal review function is $1,586,416.20 (2 x $118,587/year per GS-14/4 x 60% = $142,304.40; 2 x $97,313/year per GS-13/3 x 60% = $116,775.60; 24 x $79,278/year per GS-12/2 x 60% = $1,141,603.20; 1 x $66,143/year per GS-11/2 x 60% = $39,685.80; 2 x $54,668/year per GS-9/2 x 60% = $65,601.60; and 3 x $44,692/year per GS-7/2 x 60% = $80,445.60).

Combining the contact and Federal staff costs, the annualized cost to OWCP for this collection of information is $1,673,871.80 ($87,455.60 + $1,586,416.20 = $ 1,673,871.80).

15. Explain the reasons for any program changes or adjustments.

This is a new information collection.

16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

Data collected with these forms will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The forms will display the OMB number and expiration date.

18. Explain each exception to the certification statement.

There are no exceptions to certification.

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