0720-0005_ssa_4.29.22

SUPPORTING STATEMENT - PART A

Professional Qualification Medical Peer Reviewers – 0720-0005

Summary of Changes from Previously Approved Collection

• A letter to OIRA has been submitted with this package to address OMB’s comments from the last approval

• Privacy Act Statement was added to the form

• Number 4 on the form was changed to “Medical Experience” from “Medical Information”

• “Year of Birth” block was eliminated from the form

1. Need for the Information Collection

The information collected on the “Professional Qualifications Medical/Peer Reviewers” form, DHA 780, is required by Chapter 12, Section 3, Paragraph 4.2, TRICARE Operations Manual (TOM), 6010.56-M (2008 Edition), 10 U.S.C. 1102, Confidentiality of Medical Quality Assurance Records: Qualified Immunity for Participants; 42 U.S.C. 11112, Encouraging Good Faith Professional Review Activities; DoDI 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS); and DoDM 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS).The review of case files by qualified medical professionals is fundamental to the effective administration of the TRICARE appeal and hearing process.

TOM Chapter 12, Section 3, details reconsideration procedures the TRICARE Quality Monitoring Contractor (TQMC) must follow to properly respond to requests for review concerning benefits for TRICARE beneficiaries. The TQMC is responsible for providing clinical specialty credentialed reviewers who render opinions concerning the medical necessity of care provided to a TRICARE beneficiary. The expert opinion of a reviewer is used as a basis for making decisions about whether provided care is covered.

The information collected in DHA Form 780 is essential for beneficiaries to receive a full and fair assessment of their claims. The policy requirements of Chapter 12 are in place to ensure reviewers have appropriate medical expertise to address medical necessity issues raised in a reconsideration requests. The DHA Form 780 is necessary in order to ensure the TQMC utilizes the correct medical expert to assess a case. Without collecting the information required by Form 780, the TQMC would be unable to assign an appropriate medical expert and TRICARE would be unable to verify that assigned reviewers are properly qualified to render opinions.

TOM Chapter 12, Section 3, paragraph 4.0, establishes the requirements for the reconsideration reviewer qualifications and administrative requirements. Paragraph 4.1 establishes the reviewer qualifications and mandates the reviewer be qualified under Chapter 7, Section 1, paragraph 3.0. Chapter 7, Section 1, paragraph 3.0, of the TOM requires reviewers to be properly licensed in a like specialty of the original treating care provider. A treating provider may be a licensed doctor of medicine, osteopathy, a doctor of dentistry, or other appropriately credentialed health care practitioner.

TOM Chapter 12, Section 3, paragraph 4.2 specifically requires the name and title of the medical expert reviewer as an essential requirement to any written opinion that is forwarded to the Defense Health Agency (DHA). Paragraph 4.2 requires completion of a “Professional Qualifications” form, Addendum A, Figure 12.A-3, which is the old TMA Form 780. DHA Form 780 is updated to reflect the reorganization of Tricare Management Activity into the Defense Health Agency. The underlying policy need for the requested information remains the same under the reorganization of DHA, as the process for conducting TQMC reviews is unchanged.

2. Use of the Information

The Form, DHA 780 documents the qualifications of the medical professionals who conducted medical/peer reviews in support of TRICARE appeal and hearing cases, and is retained in the relevant case's file. The form is published in the TRICARE Operations Manual, available online and transmitted to the medical professional by the TRICARE contractor. This collection process requires the medical professional to complete and submit a simple, two-page form. Respondents are required to complete the Form once and provide updates as necessary. The form is published in the TRICARE Operations Manual. The TRICARE Operations manual is available online at https://manuals.health.mil/pages/DisplayManual.aspx?SeriesId=TO15.

The TRICARE Operations Manual is provided as PDF to the medical professional by the TRICARE contractor.

The information collected using form DHA 780 provides a record to confirm the qualifications of the medical/peer reviewers who participated in the case. The Defense Health Agency, appealing parties, medical care providers associated with an appeal or hearing case, and other authorized persons reference this Form to confirm the qualifications of the medical/peer reviewers.

The respondents are peer reviewers (i.e. Physicians, Nurses, Social Workers, Physical Therapists, CRNA's, Nurse Practitioners, etc.) identified/secured at the time each requested review is received by the TQMC from DHA. Respondents (reviewers) are identified/selected specifically for each requested review and are board certified/specialty matched to each case. The reviewers fill out the form in order to qualify as experts in their respective fields so they can be employed by the TQMC to conduct peer reviews.

The reviewers receive the form by email, and return it to the TQMC via email or secured encrypted fax. The form goes directly to the TQMC credentialing specialists. Less than 1% of the forms are returned to the TQMC via regular mail or overnight Federal Express.

Once the reviewer returns the form to the TQMC they are contacted by email or phone to determine their availability to conduct the review within the required timeframe. The following format is used when emailing the reviewer to request services:

Request for Peer Review

Dear Dr./Ms./Mr.

KEPRO is the Total Quality Management Contractor (TQMC) for the TRICARE purchased care contract. We are in need of an expedited (Insert Specialty Here, e.g., Internal Medicine, Emergency Medicine, etc.) Peer Reviewer to determine Medical Necessity/Standard of Care for a TRICARE Beneficiary.

The deadline for this review to be completed/faxed/emailed to KEPRO will be (Insert Time AM/PM on (Insert Date).

If you are interested in performing this review, please respond to this email by COB today (Insert Date) and KEPRO will provide you with the necessary paperwork to process/complete the review.

Once your availability is confirmed, KEPRO will have the record delivered to your home address by (insert date) via FedEx. Return FedEx packaging for returning all received materials to KEPRO will also be included.

Thank you for your consideration of our request and please contact us (see below) should you have additional questions.

Insert Name

Administrative Assistant

KEPRO-Harrisburg

777 East Park Drive

Harrisburg, PA 17111-2754

http://tricare.kepro.com/mh/

TRICARE Hotline #: 1-877-841-6413

TRICARE Fax #: 1-877-841-6414

Form DHA 780 will be used by TQMC support staff and credentialing specialists within the department. The form is used to identify a peer reviewer by specialty and any sub certifications the respondent may have. It is also used to confirm and support credentialing files. The TQMC also sends a copy of the completed form with each completed review to DHA. At the TQMC the following individuals specifically manage use and administration of the form: (1) Administrative Assistant- Schedules the Peer Reviews based on the specialty requested by TRICARE; Invites appropriate Peer Reviewers to perform reviews based on experience and availability; (2) Credentialing Specialist- Tasked with collecting all information required for the TWMC’s credentialing process prior to sending to the TQMC Medical Director for final review/approval. The Credentialing Specialist maintains the master data base for tracking information regarding all of the TQMC’s credentialed reviewers.

3. Use of Information Technology

99% of responses are collected electronically. Less than 1% of the forms are returned to the TQMC via regular mail or overnight Federal Express.

4. Non-duplication

The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.

5. Burden on Small Businesses

This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.

6. Less Frequent Collection

This information is collected on occasion, less frequent collection would prevent the creation of a record to confirm and document the qualifications of the medical/peer reviewers who participated in an appeal or hearing case.

7. Paperwork Reduction Act Guidelines

This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).

8. Consultation and Public Comments

Part A: PUBLIC NOTICE

A 60-Day Federal Register Notice (FRN) for the collection published on Friday, February 11, 2022. The 60-Day FRN citation is 87 FRN 8005-8006.

No comments were received during the 60-Day Comment Period.

A 30-Day Federal Register Notice for the collection published on Friday, April 29, 2022. The 30-Day FRN citation is 87 FRN 25471.

Part B: CONSULTATION

No additional consultation apart from soliciting public comments through the Federal

Register was conducted for this submission.

9. Gifts or Payment

No payments or gifts are being offered to respondents as an incentive to participate in the collection.

10. Confidentiality

A Privacy Act Statement is required for this collection and is located on page 3 of the form.

The System of Records Notice (SORN) for this collection is DHA 09 Medical Credentials/Risk Management Analysis System. The Link is provided below: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570674/edha-09/

The Privacy Impact Assessment (PIA), “Centralized Credentials Quality Assurance System (CCQAS)” can be accessed here: https://www.health.mil/Military-Health-Topics/Privacy-and-Civil-Liberties/Privacy-Impact-Assessments/MHS-PIA-List

Records Retention and Disposition:

File number 911-01:

FILE TITLE: TRICARE Contractor Claims Records

DISPOSITION: Temporary. Cut off at end of the calendar year in which received.

Destroy 10 years after cutoff.

AUTHORITY: DAA-0330-2014-0014-0001

PRIVACY ACT: EDTMA 04

FORMER FILE NUMBER(s): 911-01.1, 911-01.2, 911-01.3

11. Sensitive Questions

No questions considered sensitive are being asked in this collection.

12. Respondent Burden and its Labor Costs

Part A: ESTIMATION OF RESPONDENT BURDEN

1. Collection Instrument(s)

[DHA Form 780]

1. Number of Respondents: 60

2. Number of Responses Per Respondent: 1

3. Number of Total Annual Responses: 60

4. Response Time: 20 minutes

5. Respondent Burden Hours: 20 hours

2. Total Submission Burden

   1. Total Number of Respondents: 60

   2. Total Number of Annual Responses: 60

   3. Total Respondent Burden Hours: 20 hours

Part B: LABOR COST OF RESPONDENT BURDEN

1. Collection Instrument(s)

[DHA Form 780]

1. Number of Total Annual Responses: 60

2. Response Time: 20 minutes

3. Respondent Hourly Wage: $100.00

4. Labor Burden per Response: $33.33

5. Total Labor Burden: $2,000.00

2. Overall Labor Burden

   1. Total Number of Annual Responses: 60

   2. Total Labor Burden: $2,000.00

Respondent hourly wage was determined by using the Department of Labor Wage, Bureau of Labor Statistics Website (http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm#tab-1).

13. Respondent Costs Other Than Burden Hour Costs

There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.

14. Cost to the Federal Government

Part A: LABOR COST TO THE FEDERAL GOVERNMENT

1. Collection Instrument(s)

[DHA Form 780]

1. Number of Total Annual Responses: 60

2. Processing Time per Response: 2 minutes

3. Hourly Wage of Worker(s) Processing Responses: $31.87

4. Cost to Process Each Response: $1.06

5. Total Cost to Process Responses: $63.74

2. Overall Labor Burden to the Federal Government

   1. Total Number of Annual Responses: 60

   2. Total Labor Burden: $63.74

Defense Health Agency Employee Administrative Processing Cost: GS-8, Step 9 employee (Denver): https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2021/DEN_h.pdf

Part B: OPERATIONAL AND MAINTENANCE COSTS

1. Cost Categories

   1. Equipment: $0

   2. Printing: $2.40

   3. Postage: $33.00

   4. Software Purchases: $0

   5. Licensing Costs: $0

   6. Other: $0

2. Total Operational and Maintenance Cost: $35.40

Part C: TOTAL COST TO THE FEDERAL GOVERNMENT

1. Total Labor Cost to the Federal Government: $63.74

2. Total Operational and Maintenance Costs: $35.40

3. Total Cost to the Federal Government: $99.15

15. Reasons for Change in Burden

The burden has not changed since the last approval.

16. Publication of Results

The results of this information collection will not be published.

17. Non-Display of OMB Expiration Date

We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.

18. Exceptions to “Certification for Paperwork Reduction Submissions”

We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.