2006revisedsupportingstatement

SUPPORTING STATEMENT

INDIAN HEALTH SERVICE CONTRACT HEALTH SERVICE REPORT

A. Justification:

1. Circumstances Making the Collection of Information Necessary

The Indian Health Service requests reinstatement, without change, of previously approved information collection activity, 0917-0002, “Indian Health Service (IHS) Contract Health Service Report, for which approval has expired. The Snyder Act (25 U.S.C. 13), the Transfer Act (Public Law 83-568, 42 U.S.C. 2001) and the IHS Regulations at 42 CFR 136.24, Subpart C, authorize the IHS to contract for health care services for American Indian and Alaska Native (AI/AN) people eligible to receive such care (Attachment 1).

2. Purpose and Use of the Information

The purpose for the collection is to authorize contract health care providers to provide health care services to eligible IHS patients. The IHS form, “IHS-843-1A, Order for Health Services” was developed specifically for this collection of information. Other than revising the title “Purchase-Delivery Order for Health Services” to read “Order for Health Services”, acquisition terms on the front of the form, the contract clauses contained on the back of copy 3 of the form, the form has not been revised and there is no change in the substance or in the use of the form. A copy of the form is at Attachment 2.

The majority of the information contained in this form is completed by IHS staff from existing IHS automated patient and vendor data files. Contract health care providers complete and sign the streamlined form and submit it, along with a completed standard Centers for Medicaid and Medicare Services (CMS) health claim form (CMS 1450 (UB 92) and, CMS 1500), to the IHS for verification and payment. The CMS forms are used and accepted nation-wide by the health care industry and IHS is an approved user.

The information collected is needed to administer and manage the contract health care services provided to eligible AI/AN patients. The form is used to: authorize contract health care services for eligible patients; certify that the health care services requested and authorized have been performed by the contract provider(s); process payments for health care services performed by such providers; obtain program data; and, serve as a legal document for health and medical care authorized by the IHS and rendered by health care providers under contract with the IHS.

The information collected is also used for planning for further care of the patient, for keeping an accurate record of the patient’s health status and health services received and recommended, for planning future health care programs, for communicating among members of the health care team, for evaluating the health care rendered, for research and continuing education and for the provision of program health statistics.

3. Use of Information Technology and Burden Reduction

As appropriate, automated information technology will be used to collect and process this data; however, currently the most appropriate methodology is written responses to an information collection form.

4. Efforts to Identify Duplication and Use of Similar Information

Duplication is not a problem. Only the IHS can initiate the authorization form and, only one form is completed for each patient episode. In addition, a series of audits are conducted throughout the process cycle, from initiation to final payment.

5. Impacts on Small Businesses or Other Small Entities

The form is completed by self-employed health care providers as well as by partnerships and corporations formed by health professionals. These may be considered “small business or other small entities”, however, provider response burden posses minimal impact on such entities.

6. Consequences of Collecting Information Less Frequently

If this information collection was not documented, the functions described in item 2 above (as well as the payment of contractors for services rendered) would be curtailed. If collected less frequently, the IHS would not be in compliance with procurement requirement, and claims processing would be unnecessarily delayed. There are no technical or legal obstacles to reducing burden.

7. Special Circumstances Relating to Guidelines 5 CFR 1320.5

This information collection is consistent with the guidelines in 5 CFR 1320.5(d)(2).

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside Agency

The 60-day notice soliciting comments on the information collection prior to submission to OMB was published in the Federal Register on July 13, 2006. No public comments were received in response to the notice.

Feedback received from respondents indicates that the form is easy to understand and complete, including the instructions on the reverse side of the form.

Albuquerque Area, CHS Program	R.C. Begay, CHS Officer
Navajo Area, CHS Program	Marie Begay, CHS Officer
Headquarters Division of Acquisitions	Lyska Welbourne, Procurment

9. Explanation of Any Payment or Gift to Respondents

The respondents will not receive any payments or gifts for providing the information. However, the form IHS-843-1A, along with other required documentation as described in A.2, provides the information and data required to reimburse contract health care providers for health care services provided to eligible patients.

10. Assurance of Confidentiality Provided to Respondents

The information collected is maintained as part of Privacy Act System of Records, 09-17-0001, Health and Medical Records Systems, HHS/IHS/ OHP, published in Privacy Act Issuances, 1999 Compilation, online via GPO Access (Attachment 4). A Privacy Act Notification Statement is contained in the subject form.

11. Justification for sensitive questions

There are no questions of a sensitive nature solicited in this information collection.

12. Estimates of Hour Burden Including Annualized Hourly Cost

The burden estimate is based on feedback from contract health care providers (respondents) who have completed the form and the fiscal intermediary (FI) contractor that processes the IHS CHS claim forms. For fiscal year 2004, the FI reported that it processed approximately 272,506 forms for 7,399 respondents (average response per respondent - 42) and 13,717 Inpatient Discharge Summaries. The table below provides burden hour information:

TABLE

Data Collection Instrument	Estimated Number of Respondents	Responses per Respondent	Annual Number of Responses	Average Burden Hour per Response	Total Annual Burden Hours
IHS-843-1A	7,399	42	310,758	0.05	15,538
IDS*	13,717	1	13,717	0.05	686
TOTAL	21,116	---	---	---	16,224

*Inpatient Discharge Summary (IDS)

13. Estimate of Other Total Annual Cost Burden to Respondents or Record Keepers

The annualized cost to respondents (contract health care providers) is estimated to be $214,665.00 (14,311 burden hours times (x) $15.00 per burden hour). This information collection is part of the respondents’ customary and usual business practices.

This information collection places no additional computer or record keeping requirements upon the respondents. It will not require any capital equipment or create any start-up costs, and will not create additional costs associated with generating, maintaining, and disclosing or providing the information.

14. Annualized Cost to the Federal Government

ITEM HOURS COST

Printing/Mailing N/A $ 29,758

Processing/Audit 1/ 41,073 583,935

TOTAL $ 613,693

1/ Cost based on $15.00 per hour average of professional and clerical/secretarial hourly rates combined to process and audit approximately 7 forms per hour: 272,506 forms divided by 7 forms per hour = 44,394 hours times (x) $15.00 = $613,693.

15. Explanation for Program Changes or Adjustments

The annual burden hours for this information collection decreased 2,045 hours from the previously approved 16,356 hours to the current 14,311 hours. This program change is the result of Tribal compacting/contracting of the Indian Health Service Programs.

16. Plans for Tabulation, Publication and Project Time Schedule

Information collected and tabulated is distributed to IHS Area/Program Office and Headquarters staff for internal program planning, management and evaluation purposes. The are no plans for publication of this information.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB approval number and expiration date will be appropriately display on the information collection form.

18. Exceptions to Certification for Paperwork Reduction Act Submissions," of 0MB Form 83-1

No exceptions to the Certification Statement in OMB 83-1 Question # 19 are being requested.

B. Collections of Information Employing Statistical Methods

This information collection will not employ statistical methods.

LIST OF ATTACHMENTS

ATTACHMENT 1:

A. Snyder Act (25 U.S.C.) 13)

B. Transfer Act (P.L. 82-568, 42 U.S.C. 2001)

C. Indian Health Service Contract Health Services Regulations, 42 CFR 136.24

ATTACHMENT 2:

A. IHS-843-1A, Order For Health Services

(updated form name, terms on form cover, clauses updated back of copy #3)

ATTACHMENT 3:

A. Federal Register 60-Day Notice (U.S.C. 3506 (c) (2) (A))

B. Draft Federal Register 30-Day Notice (U.S.C. 3507 (a) (1) (D))

ATTACHMENT 4:

Privacy Act System of Records: 0917-0001, “IHS Health and Medical Records, HHS/IHS/ OHP”

ATTACHMENT 1:

A. Snyder Act (25 U.S.C.) 13)

B. Transfer Act (P.L. 82-568, 42 U.S.C. 2001)

C. Indian Health Service Contract Health Services Regulations, 42 CFR 136.24

ATTACHMENT 2:

A. IHS-843-1A Purchase-Delivery Order For Health Services

(updated form name, terms on form cover, contract clauses updated back of copy #3)

ATTACHMENT 3:

A. Federal Register 60-Day Notice (U.S.C. 3506(c)(2)(A))

B. Draft Federal Register 30-day Notice (U.S.C. 3507(a)(1)(D))

ATTACHMENT 4:

Privacy Act System of Records: 0917-0001, “IHS Health and Medical Records, HHS/IHS/ OHP”