Authorization Request Form/Certification/Letter of Medical Necessity

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CA-27 (Web) Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified	Available
Form CA-27 Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified	Available
Form CA-27 CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified	Repair queued
Form CA-26 CA-26_Letter of Medical Necessity for Compounded Drugs_new 20240422	Form and Instruction	Removed	Available
Form CA-26 (Length of T Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)	Form	Removed	Available
Form CA-26 (Method of A Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail	Form	Removed	Available
Form CA-26 Authorization Request form/Letter of Medical Necessity for Compounded Drugs	Form	Removed	Available
Form CA-26 CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form	Removed	Missing upstream
60 day FRN.corrected for 1240-055 03.26.2024.pdf	Supplementary Document	Uploaded 2024-05-06	Repair queued
60 day FRN for 1240-0055. published 01.26.2024.pdf	Supplementary Document	Uploaded 2024-05-06	Available
Privacy Act Systems-FECA.docx	Supplementary Document	Uploaded 2024-05-06	Repair queued
OPM 2024 Salary Table.pdf	Supplementary Document	Uploaded 2024-05-06	Repair queued
Physians And Surgeons, All Other Occupational Employment And Wages 2022.pdf	Supplementary Document	Uploaded 2024-05-06	Repair queued
Supporting Statement 1240-0055.updated 20240506_MN.clean copy.docx	Supporting Statement A	Uploaded 2024-05-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified	Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified	Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Form and Instruction	Modified
221978	CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	Instruction	Modified
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form and Instruction	Removed	CA-26_Letter of Medical Necessity for Compounded Drugs_new 20240422
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form	Removed	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail)
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form	Removed	Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form	Removed	Authorization Request form/Letter of Medical Necessity for Compounded Drugs
221977	CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	Form	Removed

ICR Details

OMB Control No: 1240-0055	ICR Reference No: 202405-1240-002
Status: Historical Active	Previous ICR Reference No: 202404-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Authorization Request Form/Certification/Letter of Medical Necessity
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/02/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/30/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	490	0	45,600
Time Burden (Hours)	245	0	22,800
Cost Burden (Dollars)	0	0	0

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Abstract: The form, Authorization Request Form and Certification/Letter of Medical Necessity Certification/Letter of Medical Necessity for Opioid Medications (CA-27), requires an injured worker’s treating physician to answer a number of questions about the prescribed opioids and certify that they are medically necessary to treat the work-related injury. The responses to the questions on the form is intended to ensure that treating physicians have considered non-opioid drug alternatives, and are only prescribing the most cost effective and medically necessary drugs. The form will also permit OWCP to more easily track the volume, type, and characteristics of opioids authorized by the FECA program. The form will serve as a means for injured workers to continue receiving opioids drugs only where medically necessary and simultaneously give OWCP greater oversight in monitoring their appropriate use and gather additional data about their use.

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Authorizing Statute(s): US Code: 5 USC 8145 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8124 (a) (2) Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8103 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees' Comensation 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:
	89 FR 5263	01/26/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 46910	05/30/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs	CA-26, CA-26 (Method of Administration Detail), CA-26 (Length of Therapy Detail, CA-26	Authorization Request form/Letter of Medical Necessity for Compounded Drugs ,   Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Methods of Administration Detail ,   Authorization Request Form and Certification/Letter of Medical Necessity for Compunded Drugs (Length of Therapy Detail) ,   CA-26_Letter of Medical Necessity for Compounded Drugs_new 20240422
CA-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications	CA-27 (Web), CA-27	Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications ,   Authorization Request form and Certification/Letter of Medical Necessity for Opioid Medications

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	490	45,600	0	-500	-44,610	0
Annual Time Burden (Hours)	245	22,800	0	-250	-22,305	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We attribute the decrease in CA-27 responses and burden to OWCP’s enhanced oversight in the approval of these medications. There were no changes to the form CA-27. There is an additional overall decrease in burden for this Information Collection Request (ICR) due to OWCP's decision to remove Form CA-26 from this collection. Form OWCP-26 will supersede the CA-26 and its burden will be addressed in a separate ICR.

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Annual Cost to Federal Government: $951,382

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.     No

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.     No

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: 05/30/2024

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