View Information Collection Request (ICR) Package
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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:
0720-0020
ICR Reference No:
201604-0720-001
Status:
Historical Active
Previous ICR Reference No:
200609-0720-001
Agency/Subagency:
DOD/DODOASHA
Agency Tracking No:
Title:
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/02/2016
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/07/2016
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2019
36 Months From Approved
Responses
300
0
0
Time Burden (Hours)
100
0
0
Cost Burden (Dollars)
1,710
0
0
Abstract:
The information collection requirement is necessary to ensure that applicants for TRICARE-Provider Status meet the conditions for authorization as a TRICARE Corporate Services Provider. The collected nformation will be used by TRICARE contractors to process claims and verify authorization status.
Authorizing Statute(s):
None
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:
80 FR 61396
10/13/2015
30-day Notice:
Federal Register Citation:
Citation Date:
81 FR 18842
04/01/2016
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
Application for TRICARE-Provider Status: CORPORATE SERVICES PROVIDER
DD Form X644
Corporate Services Provider Application for TRICARE Provider Status
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
300
0
0
-700
0
1,000
Annual Time Burden (Hours)
100
0
0
-233
0
333
Annual Cost Burden (Dollars)
1,710
0
0
1,710
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:
Changing Forms
Short Statement:
This is a reinstatement with changes in the time interval required for a respondent to fill out the provider authorization form (i.e., from one hour to 20 minutes). It was felt that this change was justified due to the simplicity of form design which minimizes the administrative burden upon the corporate entity. The number of respondents was also changed from 1,000 to 300 respondents based on the increasing popularity of less restrictive treatment settings. Governmental and facility costs were increased for inflation.
Annual Cost to Federal Government:
$18,235
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:
Caitlyn Borghi 571 372-0492 caitlyn.a.borghi.ctr@mail.mil
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:
04/07/2016
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