OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment

ICR 201501-0720-001 · OMB 0720-0006 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form DD From 2642 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form Modified Repair queued
Signed SSN MFR_Jan2014.pdf Supplementary Document Uploaded 2015-01-29 Available
Response to Comments from OMB_0720-0006 TRICARE Claim-Pt reimbursement Supp Stmnt FINAL_clean.docx Supporting Statement A Uploaded 2015-08-03 Available
IC Document Collections
IC IDCollectionTypeStatusForm
43597 TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment Form Modified
ICR Details
0720-0006 201501-0720-001
Historical Active 200911-0720-006
DOD/DODOASHA
TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 08/03/2015
Retrieve Notice of Action (NOA) 02/04/2015
  Inventory as of this Action Requested Previously Approved
08/31/2018 36 Months From Approved
774,000 0 0
193,500 0 0
4,992,300 0 0
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.
US Code: 10 USC chaper 55 Name of Law: null
  
None
Not associated with rulemaking
  79 FR 32240 06/04/2014
80 FR 4906 01/29/2015
No
  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 774,000 0 0 -2,226,000 0 3,000,000
Annual Time Burden (Hours) 193,500 0 0 -556,500 0 750,000
Annual Cost Burden (Dollars) 4,992,300 0 0 0 4,992,300 0
No
Yes
Changing Forms
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.
$4,179,600
No
No
No
No
No
Uncollected
Shelly Finke 571 372-7574 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/04/2015