View Information Collection Request (ICR) Package

OMB Control No: 0720-0006	ICR Reference No: 201501-0720-001
Status: Historical Active	Previous ICR Reference No: 200911-0720-006
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/03/2015
	Date Received in OIRA: 02/04/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2018	36 Months From Approved
Responses	774,000	0	0
Time Burden (Hours)	193,500	0	0
Cost Burden (Dollars)	4,992,300	0	0

Abstract: This collection is for use only by beneficiaries under the TRICARE Program. The form is required to determine CHAMPUS eligibility, other health insurance liability and if medical services and/or supplies were received by the beneficiary so that reimbursement may be made to the CHAMPUS/TRICARE beneficiary for authorized care/supplies.

Authorizing Statute(s): US Code: 10 USC chaper 55

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:
	79 FR 32240	06/04/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 4906	01/29/2015
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment	DD From 2642

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	774,000	-2,226,000	0	3,000,000
Annual Time Burden (Hours)	193,500	-556,500	0	750,000
Annual Cost Burden (Dollars)	4,992,300	0	4,992,300	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: Changing Forms

Short Statement: The DD Form 2642 was designed for use by only the beneficiary, but replaces another form used by both the beneficiary and the provider of care. For several years now, providers were required to submit claims on nationally approved claims, not Department of Defense (DoD) medical claim forms. This has resulted in a decrease of providers utilizing DoD medical claim forms. In addition, the National Defense Authorization Act for FY92 (10 U.S.C. Section 1106) mandates that providers file all claims with certain exceptions. The burden decreased from 3,000,000 forms reported in FY2007 to 774,000 in FY2012 (See Supporting Data for DD2642 included with renewal package). This decrease may be attributed to fewer beneficiaries accessing medical services and supplies from non-TRICARE authorized providers.

Annual Cost to Federal Government: $4,179,600

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: Shelly Finke 571 372-7574 shelly.finke.ctr@whs.mil

View ICR - OIRA Conclusion