Certificate of Medical Necessity

Forms and Documents

Document Name	Status
Form CM-893 Certificate of Medical Necessity Form	Modified
20 CFR 725.707.pdf Supplementary Document	2021-03-15
20 CFR 725.706.pdf Supplementary Document	2021-03-15
20 CFR 725.705.pdf Supplementary Document	2021-03-15
20 CFR 725.701.pdf Supplementary Document	2021-03-15
30 USC Subchapter IV (Sections 901-951).pdf Supplementary Document	2021-03-15
30-day FRN (1240-0024) published.pdf Supplementary Document	2021-03-15
60-day FRN (1240-0024) published.pdf Supplementary Document	2021-03-15
Supporting Statement 1240-0024 (022021).docx Supporting Statement A	2021-03-10
System of Record Notice.pdf Supplementary Document	2017-11-21

IC Document Collections

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

ICR Details

OMB Control No: 1240-0024	ICR Reference No: 202012-1240-007
Status: Received in OIRA	Previous ICR Reference No: 202008-1240-041
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Certificate of Medical Necessity
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/15/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2021
Responses	1,300	1,500
Time Burden (Hours)	488	563
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

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 79223	12/09/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 14341	03/15/2021
Did the Agency receive public comments on this ICR? No

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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

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ICR Summary 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	1,300	1,500	0	0	-200	0
Annual Time Burden (Hours)	488	563	0	0	-75	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 decrease in burden hours and number of responses are due to fewer CMNs submitted.

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Annual Cost to Federal Government: $190,964

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

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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: 03/15/2021

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