TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

Forms and Documents

Document Name	Status
Form 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction	Modified
0720-0006_SS-A_10.23.2021.docx Supporting Statement A	2021-10-25
DD 2642 SSN Justification Memo_For Signature_08.28.2018signed.pdf Supplementary Document	2021-10-22

IC Document Collections

IC ID	Document Title	Status
43597	TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form and Instruction	Modified

ICR Details

OMB Control No: 0720-0006	ICR Reference No: 202110-0720-001
Status: Received in OIRA	Previous ICR Reference No: 201808-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0006
Title: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/25/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2021
Responses	144,876	830,000
Time Burden (Hours)	36,219	207,500
Cost Burden (Dollars)	262,588	1,504,375

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Abstract: The DD-2642, “TRICARE DoD/ CHAMPUS Medical Claim Patient’s Request for Medical Payment” form is used by TRICARE beneficiaries to claim reimbursement for medical expenses under the TRICARE Program (formerly the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)).

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Authorizing Statute(s): US Code: 10 USC 55 Name of Law: Medical and Dental Care
  

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:
	86 FR 47302	08/24/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 58645	10/22/2021
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
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	2642	TRICARE DoD/CHAMPUS MEDICAL CLAIM PATIENT'S REQUEST FOR MEDICAL PAYMENT

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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	144,876	830,000	0	-685,124	0	0
Annual Time Burden (Hours)	36,219	207,500	0	-171,281	0	0
Annual Cost Burden (Dollars)	262,588	1,504,375	0	-1,241,787	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden has decreased since the previous approval due to the limited necessity for this form as more providers file on behalf of patients.

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Annual Cost to Federal Government: $262,588

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: 10/25/2021

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