SUPPORTING STATEMENT - PART A
TRICARE DoD/CHAMPUS Medical Claim Patient’s Request for Medical Payment – OMB Control Number 0720-0006
Summary of Changes from Previously Approved Collection:
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1. Need for the Information Collection
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)) when it has not been done through the provider. The information collected will be used by TRICARE to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary has received care, and reimbursement for medical services received. This collection is authorized by 10 USC 55, “Medical and Dental Care.”
2. Use of the Information
The respondents of this information collection are TRICARE beneficiaries which include Active Duty Service Members (ADSMs), retirees, family members, and others. The DD-2642 is used by beneficiaries to file for reimbursement of out-of-pocket costs paid to providers and suppliers for authorized health care services or supplies. The information collected by the DD-2642 also aids TRICARE in determining beneficiary eligibility, health insurance liability, and to certify the beneficiary has received the medical care as indicated.
Respondents may obtain the DD-2642 by various methods. The DD-2642 may be completed online via the TRICARE website, tricare.mil. Additionally, respondents may print the form from the TRICARE website or the Department of Defense (DoD) forms webpage, www.esd.whs.mil/Directives/forms/ and complete the DD-2642 by hand. Respondents may also call their designated regional contractor who can direct respondents on how to obtain the DD-2642. Respondents can identify their regional contractor through the TRICARE website. Respondents residing overseas may visit their local military medical treatment facility (MTF) Tricare Service Center to request a copy of the DD-2642. Respondents may complete the DD-2642 online and submit it immediately, or in some cases, choose to mail their completed DD-2642 to their regional contractor. The regional contractor then enters the information into the TRICARE Record Encounter Data System. No associated invitations or communications are sent to respondents.
3. Use of Information Technology
75% of responses are collected electronically. Electronic responses are submitted through the tricare.mil website.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
This information is collected as required. In the United States (U.S.) and U.S. territories, claims must be filed within one year from the date of service, or one year from the date of discharge for inpatient care. The timely filing deadline for overseas claims is three years from the date of service. If a claim is returned for additional information, respondents must resubmit the claim within the timely filing deadline, or within 90 days of the notice - whichever date is later. Should this information be collected less frequently TRICARE beneficiaries may experience a delay in processing of medical claims and potentially may not receive reimbursement for out-of-pocket medical costs.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on (Tuesday, August 24, 202). The 60-Day FRN citation is 86 FRN 47302.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Friday, October 22, 2021. The 30-Day FRN citation is 86 FRN 58645.
Part B: CONSULTATION
No additional consultation apart from soliciting public comments through the Federal Register was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
A Privacy Act Statement is required for this collection and is provided on the DD-2642 form.
This information collection requires a System of Record Notice (SORN). This collection is covered by EDTMA 04, “Medical/ Dental Claims History Files” and can be reviewed at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570707/edtma-04/.
This information collection requires a Privacy Impact Assessment (PIA); Purchased Care Operations System (PCOS) – TRICARE Encounter Data (TED) is available here: https://health.mil/Reference-Center/Forms/2014/07/29/PIA-Summary-Purchased-Care-Operations-System-TRICARE-Encounter-Data.
Records Retention and Disposition:
File number 911-01:
FILE TITLE: TRICARE Contractor Claims Records
DISPOSITION: Temporary. Cut off at end of the calendar year in which received. Destroy 10 years after cutoff.
11. Sensitive Questions
This information collection does collect sensitive information, specifically Social Security Numbers (SSN). Historically, the SSN has been the primary identifier on the DD-2642 which the health care contractors use to verify beneficiary eligibility through the Defense Eligibility Enrollment Reporting System (DEERS).
The Defense Health Agency (DHA), as successor to the TRICARE Management Activity, has a SSN Reduction Plan for its Purchased Care Operations. The DHA plan is in-line and consistent with the Defense Manpower Data Center's (DMDC) plan to remove SSNs from DoD Identification (ID) Cards. Starting in late 2011, visibly printed SSNs were removed from DoD ID Cards. Two new codes (alternative ID numbers) are printed on the ID Card -- the DoD Benefits Number (DBN) and the Electronic Data Interchange-Personal Identifier (EDIPI). While both of these codes currently exist, they are not known to all DoD beneficiaries. Due to the ID card lifecycle, almost all ADSM’s or Active Duty Family Member’s cards have been updated. We acknowledge updates to retiree cards will be on-going for years, as they have “indefinite” card expiration dates. We anticipate those updates will be done as retirees received word on the SSN removal and opt to update their cards or when they update due to damage or lost cards. A SSN Justification Memo has been provided as part of the collection submission package to OMB.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
DD-2642
Number of Respondents: 144,876
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 144,876
Response Time: 15 minutes
Respondent Burden Hours: 36,220 hours
Total Submission Burden
Total Number of Respondents: 144,876
Total Number of Annual Responses: 144,876
Total Respondent Burden Hours: 36,220 hours
Part B: LABOR COST OF RESPONDENT BURDEN
DD-2642
Number of Total Annual Responses: 144,876
Response Time: 15 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $1.81
Total Labor Burden: $262,588.51
Overall Labor Burden
Total Number of Annual Responses: 144,876
Total Labor Burden: $262,588.51
Federal minimum wage was used to estimate respondent labor burden.
13. Respondent Costs Other Than Burden Hour Costs
Upon occasion, respondents may choose to submit their completed DD-2642 by mail. Using the current U.S. Postal Service Postage Rate of $0.55 for a 1 oz First Class Mail Letter, we estimate respondents will spend $19,920.51 annually on postage.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
DD-2642
Number of Total Annual Responses: 144,876
Processing Time per Response: 15 minutes
Hourly Wage of Worker(s) Processing Responses : $7.25
Cost to Process Each Response: $1.81
Total Cost to Process Responses: $262,588.51
Overall Labor Burden to the Federal Government
Total Number of Annual Responses: 144,876
Total Labor Burden: $262,588.51
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0.00
Printing: $0.00
Postage: $0.00
Software Purchases: $0.00
Licensing Costs: $0.00
Other: $0.00
Total Operational and Maintenance Cost: $0.00
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $262,588.51
Total Operational and Maintenance Costs: $0.00.
15. Reasons for Change in Burden
The burden has decreased since the previous approval due to the limited necessity for this form as more providers file on behalf of patients.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-10-26 |