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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1240-0055
ICR Reference No:
201610-1240-004
Status:
Historical Active
Previous ICR Reference No:
201606-1240-003
Agency/Subagency:
DOL/OWCP
Agency Tracking No:
Title:
Authorization Request Forms/Certification/Letter of Medical Necessity
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/02/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/31/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2019
10/31/2019
10/31/2019
Responses
170,000
0
170,000
Time Burden (Hours)
85,000
0
85,000
Cost Burden (Dollars)
0
0
0
Abstract:
The forms, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs (CA-26) and Authorization Request Form and Certification/Letter of Medical Necessity Certification/Letter of Medical Necessity for Opioid Medications (CA-27), require an injured worker’s treating physician to answer a number of questions about the prescribed opioids and/or compounded drugs and certify that they are medically necessary to treat the work-related injury. The responses to the questions on the forms are intended to ensure that treating physicians have considered non-opioid and non-compounded drug alternatives, and are only prescribing the most cost effective and medically necessary drugs. The forms will also permit OWCP to more easily track the volume, type, and characteristics of opioids and compounded drugs authorized by the FECA program. The forms will serve as a means for injured workers to continue receiving opioids and compounded drugs only where medically necessary and simultaneously give OWCP greater oversight in monitoring their appropriate use and gather additional data about their use.
Authorizing Statute(s):
US Code:
5 USC 8103
Name of Law: Federal Employees' Comensation Act
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 8149
Name of Law: Federal Employees' Comensation Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
81 FR 40721
06/22/2016
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 61255
09/06/2016
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
CA-26, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs
CA-26 (Length of Therapy Detail, CA-26 (Method of Administration Detail), CA-26
Authorization Request form and Certification/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-27, Authorization Request form and Certification/Letter of Medical Necessity for Opioie Medications
CA-27
Authoriization/Request Form and Certification/Letter of Medical Necessity for Opioid Medications
ICR Summary 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
170,000
170,000
0
0
0
0
Annual Time Burden (Hours)
85,000
85,000
0
0
0
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:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$17,818,719
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
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?
Uncollected
Agency Contact:
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov
Common Form ICR:
No
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:
10/31/2016
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