Letter to OIRA Regarding DHA Form 780

DEFENSE HEALTH AGENCY
7700 ARLINGTON BOULEVARD, SUITE 5101
FALLS CHURCH, VIRGINIA 22042-5101

OGC-AC

January 31, 2022

Mr. Dominic Mancini
Deputy Administrator
Office of Information and Regulatory Affairs (OIRA)
RE: DHA Form 780 Review

Dear Mr. Mancini:
This letter is in reference to the pending review of DHA Form 780 (OMB Control
Number 0720-0005. The form is used by KePRO (Keystone Peer Review Organization), a
government contractor, to determine the qualifications of medical professionals in order to
ensure they are properly qualified to rending medical necessity determinations appropriate to a
particular subject matter under review. This information is necessary so that KePRO can
perform its basic function as detailed in the Tricare Operations Manual (TOM) Chapter 12,
Section 3. The form has been in use for many years and until last year there had been no
significant objections or questions raised by the Office of Management and Budget (OMB)
Desk Officer concerning its clarity or necessity of purpose. However, last year the desk officer
raised a number of issues claiming medical professionals would encounter confusion as to what
information is required. An exchange took place with the then Director of Appeals Hearings
and Claims Collection which resulted in a one-year extension of the review process. I have
been assigned by the new Director of Appeals, Hearings, and Claims Collection to review the
pending comments and provide additional input in response to the WHS comments from last
year.
The following is a supplemental response to the OMB Desk Officer comments:
1. Desk Officer Comment: Compared to the old version of the form, the new version of the
form removed the header "Medical Education" and instead now says "Medical Information."
To me, the new version of the form is confusing because it is not clear to me, for example, if
the respondent is supposed to tell you what state they are licensed in or what state the medical
school they attended was located.
Response: Concur. The draft form will be amended to change the header to “Medical
Experience” from “Medical Information.”
2. Desk Officer Comment: The form seems very physician-focused, despite the supporting
statement saying that it will be used by a number of healthcare professionals. Is it possible to
consider adding the language to the form that indicates it is used by multiple professionals, so
that folks don't believe that have received the wrong form?

Response: No change is necessary. The form asks for Degree, Year of Degree, School, and
License Type. These categories include all medical professionals and are not limited
exclusively to doctors. After speaking with representatives at KePRO they report there has
been no indication of confusion on the part of healthcare professionals in filling out the form.
We do not concur that a change for the sake of clarity is necessitated by the existing language.
Those in the medical profession understand their credentials without the need for further
explanation.
3. Desk Officer Comment: For the education information, it may be worth considering allowing
the respondent to report additional professional education. For example, a nurse's eligibility for
license may derive from a bachelor's or master's degree in nursing. However, they may also
have a PhD in Nursing, which would be relevant to their qualifications, but not necessarily
sufficient for licensure. Similarly, generally speaking, a master's degree in social work is
required for clinical licensure, and there are those who earn doctorates in social work who are
not eligible for licensure as a social worker because they do not have the master's degree. So, I
assume DoD would generally want to know both 1. The degree that confers eligibility for
licensure, and 2. Additional professional training in the field, even if not required for licensure
per se. A final example is a dentist earns a DDS or DMD for eligibility for licensure. However,
they may earn a post-doctoral Master's degree in a field/specialty such as orthodontics. I
assume, then, that DoD would want to know about both the first professional degree
(DDS/DMD) and the specialty training.
Response: No change is necessary. The form has an entry for “Specialties/Other Relevant
Education”, which would allow an applicant to include all relevant educational information.
DoD does indeed want to know the applicant’s educational history and the section entitled
“Specialties/Other Relevant Education” covers this.
4. Desk Officer Comment: For certain fields, you may wish to ask more specifically about what
type of license. For example, advanced practice nursing versus just RN, LCSW or LICSW
versus LSW or LMSW (although this varies by state).
Response: No change is necessary. There is no need to specify license type as Block 4 section
d. of the form asks for, “d. License Type/State/Year”, medical professionals have no difficulty
in understanding this block requires their specific type of license. Additionally, section g.
“Type of Practice”, permits expansion if there is a need to provide additional clarification.
5. Desk Officer Comment: How does DoD use the "year of birth" information?
Response: Concur. A query to KePRO indicates they sometimes use the applicant’s age to
distinguish medical professionals who applied with the same name. However, distinctions
between applications can be achieved using licensure information so we concur in eliminating
this block.
6. Desk Officer Comment: I am not seeing the following information from 5 CFR 1320.8(b)(3):

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(iv) Whether responses to the collection of information are voluntary, required to obtain or
retain a benefit (citing authority), or mandatory (citing authority); (v) The nature and extent of
confidentiality to be provided, if any (citing authority);
Response: Concur. This information can be included within the section under the header of the
form. Filling out the form is voluntary, but declining to do so will result in the applicant being
ineligible for being hired.

Sincerely,
/s/ Christopher D. Jung
Christopher D. Jung, J.D., L.L.M.
Chief, Appeals Branch
Defense Health Agency
Office of General Counsel

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