Authorization Request Forms
OMB Control No. 1240-0060
OMB Expiration Date: 05/31/2024
SUPPORTING STATEMENT FOR
EEOICPA AUTHORIZATION REQUEST FORMS
OMB CONTROL NO. 1240-0060
This ICR seeks to extend a currently approved collection.
A. JUSTIFICATION
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.
The Office of Workers’ Compensation Programs (OWCP) is the primary agency responsible for administration of the Energy Employees Occupational Illness Compensation Program Act of 2000, as amended (EEOICPA), 42 U.S.C. § 7384 et seq. EEOICPA provides for the payment of compensation to covered employees and, where applicable, survivors of deceased employees, who sustained either an “occupational illness” or a “covered illness” in the performance of duty for the Department of Energy and certain of its contractors and subcontractors. One element of the compensation provided to covered employees is medical benefits for their compensable occupational or covered illnesses.
OWCP contracts with a private sector bill processing agent that handles many of the tasks associated with paying bills for medical treatment provided to covered employees under EEOICPA. This bill processing agent uses an automated system that matches incoming bills with the authorized medical treatment of covered employees before it issues payments. Medical providers must provide the bill processing agent with information necessary for the system to create a payment authorization before a bill can be paid. EEOICPA implementing regulations, 20 CFR 30.400(a) and (c), 30.403, 30.404(b) and 30.700, authorize this collection of information.
The information collections in this ICR collect demographic, factual and medical information that OWCP needs to process bills for medical treatment, supplies, or services. We address each collection below:
EE-22 -- General Medical Authorization Request is used to request that the bill processing agent create an authorization for payment of routine bills in its automated system and is completed by the medical provider. It requests information about the medical treatment, supplies or services that are being provided to a covered employee, other billing elements and supporting documentation. (20 CFR 30.400(a), 30.700)
EE-24 -- Durable Medical Equipment Authorization is used to request that the bill processing agent create a special authorization for payment of bills for durable medical equipment provided. It is completed by the provider of the durable medical equipment and requests both diagnostic and estimated cost information, as well as supporting documentation. (20 CFR 30.400(a) and (c), 30.700)
EE-26 -- Rehabilitative Therapies Authorization Request is used to request a special authorization for payment of rehabilitative therapy provided to a covered employee and is completed by the provider of that therapy. It requests both diagnostic information and information regarding the specific therapy being provided, as well as supporting documentation. (20 CFR 30.400(a), 30.700)
EE-28 -- Transportation Authorization Request is used to request a special authorization for payment of bills for transporting a covered employee to obtain prescribed treatment. It is completed by the provider of the transportation and requests factual information about when and where the transportation will be used, the estimated costs of the transportation, and supporting documentation. (20 CFR 30.400(a), 30.404(b), 30.700)
EE-30 -- Transplant Authorization Request is used to request a special authorization for payment of transplant services and is completed by the transplant services provider. It requests information about the transplant services to be provided, including the specific organ that will be replaced, other billing elements and supporting documentation. (20 CFR 30.400(a), 30.700)
EE-32 -- Home Health Care Authorization Request is used to request a special authorization for payment of home health care services provided and is completed by the provider of those services. It requests both diagnostic information and information regarding the specific home health care services being provided, as well as supporting documentation. (20 CFR 30.400(a), 30.403, 30.700)
2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
The information collected by these forms will be used by both OWCP and its bill processing agent in connection with the automated payment of bills submitted by providers of medical treatment, supplies or services. The information submitted, along with other supporting documentation, is used to determine the correct amount to be paid to a provider of medical treatment, supplies or services to beneficiaries under EEOICPA.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.
In accordance with the Government Paperwork Elimination Act, all the forms are electronically available on the Internet at Medical Bill Processing Portal | Office of Workers' Compensation Programs (dol.gov). A provider will be able to complete the form online, and may either submit it electronically or by FAX.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item A.2 above.
The information requested in these collections is not duplicative of any information available elsewhere. The respondents are the only source of the required information.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
The information collections in OMB Control No. 1240-0060 have been streamlined to obtain the necessary information while imposing the minimum burden on the respondent. The forms in this collection do not impose any additional burden on small businesses or other small entities since providing medical and billing evidence is part of the providers’ usual business practice. This information collection does not have a significant economic impact on a substantial number of small businesses.
6. Describe the consequence to federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
If this information were not collected, or were collected less frequently, OWCP would be unable to properly provide timely and accurate payments of bills that providers submit for medical treatment, supplies and services they provide to EEOICPA claimants. If bills were paid in the absence of full information, there would be numerous incorrect payments.
7. Explain any special circumstances that would cause an information collection to be conducted in a manner:
requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;
requiring respondents to submit more than an original and two copies of any document;
requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;
requiring the use of statistical data classification that has not been reviewed and approved by OMB;
that includes a pledge of confidentially that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentially to the extent permitted by law.
Because respondents often have to travel multiple times in a single month to obtain medical treatment/supplies to which they are entitled, and some of this travel will require a substantial payment up front by these respondents, it is estimated that they will submit the EE-28 monthly in order to receive reimbursement quickly. There are no other special circumstances for conducting this information collection.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.
Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and recordkeeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported.
Consultation with representatives of those from whom information is to be obtained or those who must compile records should occur at least once every 3 years -- even if the collection-of-information activity is the same as in prior periods. There may be circumstances that may preclude consultation in a specific situation. These circumstances should be explained.
OWCP consulted with three internal and external users of the forms in this collection. The consultation asked for their feedback on burden estimates for information collection activities associated with the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32. None of the parties OWCP consulted had any changes or comments on the estimated burden, so OWCP is proceeding with the initial estimates contained in the 60-day notice published in the Federal Register on February 12, 2024 at 89 FR 9868. No comments on the 60-day notice were received. The individuals consulted with about the information collection in OMB Control No. 1240-0060 are listed in the table below.
Contact |
Organization |
Phone |
|
Emily XXX |
Medical Benefits Adjudication Unit, Branch of Medical Benefits, DEEOIC, OWCP, DOL |
XXX |
XXX |
Latrice XXX |
Medical Benefits Adjudication Unit, Branch of Medical Benefits, DEEOIC, OWCP, DOL |
XXX |
|
Brian XXX |
Atomic Weapons Employee Consultants, LLC |
XXX |
9. Explain any decision to provide any payments or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to a respondent, other than the appropriate payment of bills for the provision of medical treatment, supplies or services to EEOICPA beneficiaries.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.
The information collected by OMB Control No. 1240-0060 is fully protected under the Privacy Act in the system of records known as DOL/OWCP-11.
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature on these forms.
12. Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desirable. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. General, estimates should not include burden hours for customary and usual business practices.
If this request for approval covers more than one form, provide separate hour burden estimates for each form.
Provide estimates of annualized cost to respondents for the hour burdens for collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.
Estimated Annualized Respondent Cost and Hour Burden
The chart below shows the projected burden hours based on a total estimated number of authorization requests filed annually of 98,020. The estimated “Number of Responses” for each form (EE-22, EE-24, EE-26, EE-28, EE-30, and EE-32) is based on the average actual number of authorization requests (rounded up) that OWCP, Division of Energy Employees Occupational Illness Compensation (DEEOIC), received in Fiscal Years 2021-2023.
Requirement Time To Frequency Number of Number of Hours
Complete of Response Respondents Responses Burden
EE-22 10 minutes 2 annually 1500 3000 500
EE-24 10 minutes 6 annually 3333 20,000 3333*
EE-26 10 minutes 2 annually 1250 2500 417*
EE-28 10 minutes 4 annually 625 2500 417*
EE-30 10 minutes 1 annually 20 20 3*
EE-32 10 minutes 2 annually 35,000 70,000 11,667*
TOTALS 41,728 98,020 16,337
*rounded to the nearest whole number
The requirements have a total respondent burden estimate of 16,337 hours. Using the September 2023 national average nonfarm private hourly wage of $33.88 from the Bureau of Labor Statistics, the respondent cost estimate for these requirements is $553,497.56 (16,337 x $33.88 = $553,497.56).
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
The cost estimate should be split into two components: (a) a total capital
and start-up cost component (annualized over its expected useful life); and (b) a
total operation and maintenance and purchase of service component.
The estimates should take into account costs associated with generating,
maintaining, and disclosing or providing the information. Include descriptions of
methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.
If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection, as appropriate.
Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information or keep records for the government, or (4) as part of customary and usual business or private practices.
The medical and factual information requested by the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 is kept as a usual and customary business practice, so there is no additional recordkeeping or collection cost associated with these requirements. There are also no mailing costs for the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 because they are submitted to the bill processing agent either electronically through its portal or by FAX. Therefore, there are no operation and maintenance costs associated with OMB Control No. 1240-0060.
14. Provide estimates of the annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operational expenses (such as equipment, overhead, printing, and support staff), any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 into a single table.
There are no printing or mailing costs to OWCP associated with this collection of information because respondents will obtain the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 from the Internet at Medical Bill Processing Portal | Office of Workers' Compensation Programs (dol.gov).
The contract cost to OWCP for its bill processing agent to process the responses to this collection of information will be $5.32 for each response. Thus, OWCP’s contract cost for the bill processing agent to process the 98,020 estimated responses to the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32 will be $521,466.40.
Responses to this collection of information are also reviewed by a Medical Benefits Adjudication Unit consisting of 59 Federal employees (1 GS-14/6 manager, 6 GS-13/3 supervisors, and 52 medical benefits examiners: 30 GS-12/4s, 2 GS-11/4s, 20 GS-9/4s); approximately 60% of their time is spent reviewing responses to the EE-22, EE-24, EE-26, EE-28, EE-30 and EE-32. Therefore, using OPM Salary Table 2023-RUS, the cost to provide this Federal review function is $2,944,886.40 ([1 x $135,790.00/year per GS-14/4 x 60% = $81,474.00; 6 x $105,062.00/year per GS-13/3 x 60% = $378,223.20; 30 x $91,113.00/year per GS-12/4 x 60% = $1,640,034.00; 2 x $76,016.00/year per GS-11/4 x 60% = $91,219.20; and 20 x $62,828.00/year per GS-9/4 x 60% = $753,936.00]; $81,474 + $378,223.20 + $1,640,034 + $91,219.20 + $753,936 = $2,944,866.40).
Combining the contract and Federal staff costs, the annualized cost to OWCP for this collection of information is $3,466,352.80 ($521,466.40 + $2,944,886.40 = $ 3,466,352.80).
15. Explain the reasons for any program changes or adjustments.
Since the last iteration of this collection, the estimated total number of responses increased from 66,770 to 98,020. The increase of 31,250 responses reflects an increase in the actual number of responses received.
The estimated time burden to complete each authorization request has remained the same; thus, the estimated 5,208 increase in total burden hours is due solely to the increase in number of responses.
The estimated number of respondents has increased from 12,890 to 41,728 primarily because the overall number of responses increased, but also because DEEOIC reworked the “Frequency of Response” numbers to reflect a better operational estimate. Specifically, DEEOIC decreased the estimated response frequency of the EE-26 Rehabilitative Therapies Authorization Request from 4 to 2 times annually, decreased the EE-32 Home Health Care Authorization Requests from 12 to 2 times annually, and decreased the estimated response frequency of the EE-28 Transportation Authorization Request from 12 to 4 times annually because travel requests are not consistently submitted every month. DEEOIC also increased the estimated response frequency of the EE-24 Durable Medical Equipment authorization from 2 to 6 times annually.
16. For collections of information whose results will be published, outline plans for tabulations, and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
Data collected with these forms will not be published.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
The forms will display the OMB number and expiration date.
18. Explain each exception to the certification statement.
There are no exceptions to certification.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | March 6, 2007 |
| Author | Theda Kenney |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |