Summary Forms_Changes

App DDD Summary of Forms and Changes.docx

[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

Summary Forms_Changes

OMB: 0920-0891

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Summary of WTC Health Program Forms/Supporting Documentation and Standard Correspondence, by Type/Function


Form Type

Form Name and Appendix ID

Translations

Eligibility Applications

Appendix A: World Trade Center Health Program FDNY Responder Eligibility Application English

N/A

Appendix B: World Trade Center Health Program Responder Eligibility Application (Other than FDNY) English

Appendix C: Spanish

Appendix D: Polish

Appendix E: World Trade Center Health Program Pentagon/Shanksville Eligibility Application

N/A

Appendix F: World Trade Center Health Program Survivor Eligibility Application English

Appendix G: Spanish

Appendix H: Polish

Appendix I: Chinese

Appendix J: General Responder Clinic Selection Postcard

N/A

Administration of Program Benefits to Eligible Members

Appendix K: Designated Representative Appointment Form

N/A

Appendix L: Designated Representative HIPAA Authorization form

N/A

Appendix O: WTCHP HIPAA Authorization for Deceased Individuals

N/A

Appendix P: WTCHP General HIPAA Authorization to Third Parties

N/A

Appendix Q: Designated Representative Revocation Form

N/A



Supplemental Documentation (Ones that were included in past burden table are now here)

Supporting Documentation Name and Appendix ID

Translations

Approval Process for Conditions, Procedures, or Medications Supported by the WTC Health Program

Appendix R: Zadroga Act (Sec 3301)

N/A

Appendix S: Summary of Covered Health Benefits, Health Conditions, Treatments, and Payments

N/A

Appendix T: Web Based Application Screen Shots (samples)

N/A

Appendix U: Initial Request for Additional Information

N/A

Appendix V: 30 Day Letter Reminder for Additional Information

N/A

Appendix W: 60 Day Letter Reminder for Additional Information

N/A

Appendix X: 90 Day Letter Reminder for Additional Information

N/A

Appendix Y: 180 Day Letter Reminder for Information

N/A

Appendix Z: WTC-5 Code or Procedure Request

N/A

Appendix AA: WTC-3 Request for Certification

N/A

Appendix BB: Prior Authorization Form – Standard

N/A

Appendix CC: Prior Authorization Form – Dental

N/A

Appendix DD: Prior Authorization Form – Transplant

N/A

Appendix EE: Transcranial Magnetic Stimulation (TMS) Treatment Request Form

N/A

Appendix FF: Non-Emergency General Transportation Request Form

N/A

Appendix GG: Non-Emergency Medical Transportation Reimbursement Form

N/A

Appendix HH: Non-Emergency Medical Transportation Request Form

N/A

Appendix II: Prior Authorization General Level 2

N/A


Appendix JJ: Prior Authorization General Level 3

N/A


Appendix KK: Home Health Aid Prior Authorization Level 3

N/A


Appendix LL: Long-term Care Hospitalization Prior Authorization Level 3

N/A


Appendix MM In-Patient Rehabilitation Prior Authorization Level 3

N/A


Appendix NN Hospice Respite Care Prior Authorization Level 3

N/A


Appendix OO: Outpatient Prescription Pharmaceuticals

N/A


Appendix PP: Enrollment Denial Letter and Appeal Notification

N/A


Appendix QQ: Certification Denial Letter and Appeal Notification

N/A


Appendix RR: Treatment Denial Letter and Appeal Notification

N/A


Appendix SS-1: Federal Register Notice

N/A


Appendix TT: IRB Determination

N/A


Appendix UU: Translated Initial Request for Information (Spanish, Chinese, Polish)

Spanish, Chinese, Polish


Appendix VV: Translated 30 Day Request for Information (Spanish, Chinese, Polish)

Spanish, Chinese, Polish


Appendix WW: Translated 60 Day Request for Information (Spanish, Chinese, Polish)

Spanish, Chinese, Polish


Appendix XX: Translated 90 Day Request for Information (Spanish, Chinese, Polish)

Spanish, Chinese, Polish


Appendix YY: Translated 180 Day Request for Information (Spanish, Chinese, Polish)

Spanish, Chinese, Polish


Appendix ZZ: Translated Enrollment Denial and Appeal Notification (Spanish)

Spanish


Appendix: AAA Disenrollment Letter and Appeal Notification

N/A


Appendix BBB: Decertification Letter Template—Administrative Error

N/A


Appendix CCC: Decertification Letter Template—Denial and Decertification Exposure

N/A


Appendix DDD: Decertification Letter Template—Latency Prostate Cancer/Cancer

N/A


Appendix EEE: Overview of WTC Health Program Forms, Standard Correspondence and Changes to the Information Collection Request

N/A


Appendix FFF: Reimbursement Denial Letter and Appeal Notification

N/A




Summary of Changes to Information Collection Forms, and Impact on Burden Estimates


Type of

Respondent

(with burden table line number)

Form Name

Appendix

Status

Comments

No. of

Respondents

No.

Responses

per

Respondent

Average

Burden per

Response

(in hours)

Total Burden Hours

Change in Burden


1) FDNY Responder

World Trade Center Health Program

FDNY Responder Eligibility Application

A

Modified

Revised applications that improve potential members’ application experience and reduce confusion

140

1

30/60

70

+47

2) General Responder

World Trade Center Health Program

Responder Eligibility Application (Other than FDNY)

B-D

Modified

Revised applications that improve potential members’ application experience and reduce confusion

6,215

1

30/60

3,108

+1,870

3) Pentagon /Shanksville Responder

World Trade Center Health Program Pentagon/ Shanksville Responder

E

Modified

Revised applications that improve potential members’ application experience and reduce confusion

242

1

30/60

121

-194


4) WTC Survivor

World Trade Center Health Program

Survivor Eligibility Application (all languages)

F-I

Modified

Revised applications that improve potential members’ application experience and reduce confusion

9,240

1

30/60

4,620

+4,020

5) General responder

Clinic Selection Postcard for new general responders in NY/NJ to select a clinic

J

Modified

Made language updates

3,830

1

15/60

958

+348

6) Program Members

Designated Representative Appointment Form

K

Modified

Revised to include instructions to fill out the form

1,300

1

15/60

325

+317

7) Program Applicants or Members

Designated Representative HIPAA Release Form

L

Modified

Revised to include instructions to fill out the form

1,300

1

15/60

325

+317

8) Interested Party

Petition for the addition of health conditions

M

No changes


35

1

1

35

-25

9) Program Members

Member Satisfaction Survey

N

New

New Survey to be mailed to all Program members one time per year

6,600

1

30/60

3,300

+3,300

10) General Public

WTC Health Program HIPAA Authorization for Deceased Individuals

O

New

New HIPAA Authorization for Deceased Individuals Form

30

1

30/60

8

+8

11) Program Applicants or Members

WTC Health Program General HIPAA Authorization to Third Parties

P

New

New HIPAA Authorization to Third Parties Form

30

1

30/60

8

+8

12) Program Applicants or Members

Designated Representative Appointment Form that removes the members current designated representative.

Q

New

New Designated Representative Revocation Form

15

1

15/60

4

+4

Total








4,963

4,277







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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMacaluso, Renita (CDC/OD/OADS)
File Modified0000-00-00
File Created2024-07-20

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