OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Request for External Review

ICR 201708-3206-001 · OMB 3206-0263 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form OPM 1841 Authorized Representative Form Form and Instruction Unchanged Available
Form OPM 1840 Intake Form Form and Instruction Unchanged Repair queued
Revised OPM Form 1840_Highlighted Edits_2016_version.pdf Supplementary Document Uploaded 2017-10-05 Available
Current OPM Form 1840_2014_version.pdf Supplementary Document Uploaded 2017-10-05 Available
60-Day FRN External Review Form_signed by Kathy McGettigan_2.28.17.pdf Supplementary Document Uploaded 2017-10-05 Available
OMB Statement A_MSP ER Case Intake Form Clearance_10.5.17.docx Supporting Statement A Uploaded 2017-10-05 Available
OPM_FRDOC_0001-1299_3206-0263.pdf Supplementary Document Uploaded 2017-08-03 Available
IC Document Collections
IC IDCollectionTypeStatusForm
210151 Authorized Representative Form Form and Instruction Unchanged
210150 Intake Form Form and Instruction Unchanged
210149 Model Notice Other-Model Notice Unchanged
ICR Details
3206-0263 201708-3206-001
Historical Active 201401-3206-007
OPM
Request for External Review
Reinstatement without change of a previously approved collection   No
Emergency 08/14/2017
Approved without change 10/18/2017
Retrieve Notice of Action (NOA) 08/03/2017
This collection should be reported in the Information collection budget.
  Inventory as of this Action Requested Previously Approved
04/30/2018 6 Months From Approved
5,488 0 0
1,175 0 0
0 0 0
Section 1334 of the Patient Protection and Affordable Care Act, Pub. L. 111-148, as amended by the Health Care Education Reconciliation Act, Pub. L. 111-152 (together, "Affordable Care Act"), directed OPM to enter into contracts with health insurance issuers to offer coverage on Exchanges (also called "Health Insurance Marketplaces") throughout the 50 States and the District of Columbia. OPM issued final regulations for the establishment of the Multi-State Plan (MSP) Program on March 11, 2013, 78 Fed. Reg. 15560, which outlined an external review process that would be available to MSP enrollees. The regulations state that "OPM will conduct external review of adverse benefit determinations using a process similar to OPM review of disputed claims under [the Federal Employees Health Benefits Program] . . . ." 45 C.F.R. 800.503(a). A necessary part of conducting external review of adverse benefit determinations is accepting requests for external review from MSP enrollees. OPM is submitting to OMB a request for review and clearance of a new information collection, Request for External Review, comprising three forms: (1) Model Notice of Final Internal Adverse Benefit Determination ("Model Notice"), (2) External Review Intake Form ("Intake Form"), and (3) External Review Authorized Representative Form ("Authorized Representative Form").
This is the first renewal for this program office and form is required for "Open Season" for external review of a disputed adverse benefit decision.
PL: Pub.L. 111 - 148 1334 Name of Law: Patient Protection and Affordable Care Act
  
PL: Pub.L. 111 - 148 1334 Name of Law: Patient Protection and Affordable Care Act
Not associated with rulemaking
  82 FR 38 02/28/2017
82 FR 105 06/02/2017
No
3
IC Title Form No. Form Name
Model Notice
Authorized Representative Form OPM 1841 External Review Authorized Representative Form
Intake Form OPM 1840 External Review Intake Form
  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 5,488 0 0 0 0 5,488
Annual Time Burden (Hours) 1,175 0 0 0 0 1,175
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$119,275
No
    Yes
    Yes
Yes
No
No
Uncollected
Charles Conyers 202 606-0125 [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.
08/03/2017