ICR Documents

Supporting Statement A Document Date Uploaded SSA-Update-091321.docx 01/06/2022 Supporting Statement B Document Date Uploaded SSB-Update-91321.docx 01/06/2022 Supplementary Documents Title Document Document Type Date Uploaded Authorizing Legislation Appendix A Legislation.docx Supplementary Document 12/18/2014 Summary of WTC Health Program Covered Health Benefits App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document 09/20/2018 Initial Letter Requesting Information App M Initial Letter Requesting Information.docx Supplementary Document 09/20/2018 30-day Letter Requesting Information App N 30 Day Letter Requesting Information.docx Supplementary Document 09/20/2018 60-day Letter Requesting Information App O 60 Day Letter Requesting Information.docx Supplementary Document 09/20/2018 90-day Letter Requesting Information App P 90 Day Letter Requesting Information.docx Supplementary Document 09/20/2018 180-day Letter Requesting Information App Q 180 Day Letter Requesting Information.docx Supplementary Document 09/20/2018 WTC-5 Code or Procedure Request App T WTC_5 Code or Procedure Request.pdf Supplementary Document 09/20/2018 WTC-6 Medication Request App U WTC6 Medication Request.pdf Supplementary Document 09/20/2018 Prior Authorization Form - Standard App V Prior Authorization Form_Standard.pdf Supplementary Document 09/20/2018 Prior Authorization Form - Dental App W Prior Authorization Form_Dental.pdf Supplementary Document 09/20/2018 Prior Authorization Form - Transplant App X Prior Authorization Form_Transplant.pdf Supplementary Document 09/20/2018 60-day Federal Register Notice App DD-1 60-day FRN 05112018.pdf Supplementary Document 09/20/2018 IRB Determination App EE IRB Determination.pdf Supplementary Document 09/20/2018 Translated Initial Request for Information App FF - Translated Initial Request for Information.docx Supplementary Document 09/20/2018 Translated 30-day Request for Information App GG - Translated 30 Day Request for Information.docx Supplementary Document 09/20/2018 Translated 60-day Request for Information App HH - Translated 60 Day Request for Information.docx Supplementary Document 09/20/2018 Translated 90-day Request for Information App II - Translated 90 Day Request for Information.docx Supplementary Document 09/20/2018 Translated 180-day Request for Information App JJ - Translated 180 Day Request for Information.docx Supplementary Document 09/20/2018 Translated Enrollment Denial and Appeal Notification [Spanish] App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document 09/20/2018 Disenrollment and Decertification Template App PP Disenrollment and Decert Template.docx Supplementary Document 09/20/2018 Decertification Letter Template - Latency - Prostate Cancer App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document 09/20/2018 Summary of Forms and Changes in the ICR App SS Summary of Forms and Changes_100918.docx Supplementary Document 10/09/2018 Privacy Impact Assessment CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document 09/20/2018 Reimbursement Appeal Decision Letter App TT Reimbursement Appeal Decision Letter.docx Supplementary Document 09/20/2018 PA3 Form (Prior Authorization Level 3) - General App Y-1. General PA3 Form.pdf Supplementary Document 10/09/2018 PA3 Renewal form App Y-2. PA3 Renewal Form.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Airway Medications App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document 10/09/2018 Non-formular PA3 Form - Antidepressant Medications App Y-4. NF PA3 Antidepressants.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Antiemetic medications) App Y-5. NF PA3 Antiemetics.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Antipsychotic medications App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Injectable Epinephrine (Epi-pen) App Y-7. NF PA3 Epinephrine.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Diabetes Insulin App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Methadone App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Nucala App Y-10. NF PA3 Nucala.pdf Supplementary Document 10/09/2018 Non-formulary PA3 Form - Opioid Abuse Deterrent App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document 10/09/2018 60d FRN - published 30APR2021 60d FRN published.pdf Supplementary Document 01/06/2022 Summary Forms_Changes App DDD Summary of Forms and Changes.docx Supplementary Document 01/06/2022 Decertification Letter Notification Health Condition App AAA Decert Letter Template Admin Error.docx Supplementary Document 01/06/2022 Enrollment Denial Letter_Appeal Notification App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document 01/06/2022 Certification Denial Letter_Appeal Notification App QQ Certification Denial Letter and Appeal.docx Supplementary Document 01/06/2022 Treatment Denial Letter_Appeal Notification App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document 01/06/2022 Disenrollment Letter App ZZ Disenrollment Letter.docx Supplementary Document 01/06/2022 Initial Request - Additional Information App U Initial Request for Additional Information.docx Supplementary Document 01/06/2022 30 Day Suspend Letter App V 30 Day Suspend Letter.docx Supplementary Document 01/06/2022 60 Day Suspend Letter App W 60 Day Suspend Letter.docx Supplementary Document 01/06/2022 90 Day Suspend Letter App X Survivor 90 Day Suspend Letter.docx Supplementary Document 01/06/2022 180 Day Letter Reminder Additional Information App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document 01/06/2022 Non-Substantive Change Request Memo [12FEB2024] Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change 02/12/2024 Public Comments Author Name Comment Document Author Affiliation Sponsoring Org. Type Category Date of Comment Date Comment Received