2900-0702

A. JUSTIFICATION

1. Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.

Circumstances: Health care providers for veterans in the private sector (non-VA providers) are asking local VA medical centers for the National Provider Identifier (NPI) numbers for VA facilities and VA clinicians who have referred patients to them. The non-VA providers (many are home health and nursing home providers) need these NPIs in order to receive payments from Medicare or other payers. The consequence of VA’s not providing this information is that these non-VA providers cannot get the Medicare payments and other insurance payments they deserve; some have indicated that if NPIs are not furnished, they may refuse to take care of our veterans. The VHA Chief Business Office (CBO) NPI Team has developed a form for VA field offices to use in responding to these requests; the form enables VA field staff to receive complete information and to fulfill Privacy Act of 1974 requirements for accounting of disclosures.

Legal requirements include the following: 1) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires, as of May 23, 2007, that large payers and all health care providers use the new National Provider Identifiers (NPIs) for health care organizations and individual practitioners on all HIPAA-standard electronic health care transactions, which include reimbursement claims. Likewise, many payers are requiring the use of NPIs on paper reimbursement claims. Without NPIs, payers will reject these claims, thus putting the claimant’s revenue at risk. 2) NPIs for individual practitioners are contained in the Privacy Act of 1974, System of Records entitled “The Revenue Program—Billing and Collections Records-VA” (114VA16). The Privacy Act of 1974, 5 U.S.C. § 552a (c), requires an accounting of disclosures with respect to each system of records under its control. The VHA Privacy Office’s Release of Information (ROI) Record Management software was established in part to manage this accounting of disclosures. A written request is needed to provide the information necessary for entry into the ROI software. The CBO first found out that written requests would require a “wet” signature (original signature acceptable, for example, via fax) in January 2007. This occurred as a result of discussions, then underway with the VHA Privacy Office and Office of General Counsel, to develop guidance and tools, such as the currently proposed faxable request form, that would enable VA field staff to meet the needs of non-VA providers and help support the care of veterans by these providers.

2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.

How: the information received on the proposed faxable request form (VA Form 10-0449A) will be used to determine the precise information needed in order to fulfill the request, and to make accurate entries into the VHA Privacy Office’s ROI Record Management software.

By whom: the information will be used by VHA designees at VA medical centers who are tasked with managing the NPI effort at their facility.

For what purposes: the information is requested 1) in order to help determine the validity of the requester and to reduce the risk of fraudulent requests, 2) to know what specific information is requested, 3) to know where the information should be sent.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

VA Form 10-0449A was developed in order to reduce respondent burden by enabling the requester to quickly provide the needed information by fax, and likewise to shorten the time for the requester to receive a return response (by secure fax, per guidelines in VHA Handbook 1605.1, Section 35e.)

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

These requests from non-VA providers are essentially one-time requests; once the non-VA provider has a VA practitioner’s NPI on file, that same request would not be made again. Duplication of requests can be identified by the local NPI designee in charge of the NPI effort, by consulting entries in the ROI Record Management software. No similar information is already available.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

The faxable nature of this form and its simplicity (the information is all readily known by the requester; most is simple contact information) minimizes the burden on small entities.

6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.

VA would not be responsive to the needs of our veterans, and care by non-VA providers might be denied. VA would not be responsive to the legal requirements for accounting of disclosures if this information is not collected.

7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.

There are no such special circumstances.

8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.

The Federal Register Notice soliciting comments on this collection of information was published on October 1, 2007, Volume 72, Number 189, pages 55860-55861. There were no comments received.

b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.

This form was developed with input from VA medical centers as a result of their dialogue with non-VA providers.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No payment or gift is provided to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

Information provided by respondents (Part I of the proposed form) is non-confidential: it defines the request and provides contact information for the requester.

11. Provide additional justification for any questions of a sensitive nature (Information that, with a reasonable degree of medical certainty, is likely to have a serious adverse effect on an individual's mental or physical health if revealed to him or her), such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature.

12. Estimate of the hour burden of the collection of information:

a. The number of respondents, frequency of responses, annual hour burden, and explanation for each form is reported as follows:

This is a one-time form whose use is triggered by a non-VA provider’s request; total number of requests can only be estimated.

VA Form	No. of respondents	x No. of responses	/ by 60	Number of Hours
10-0449A	200 (est.)	200	3 min each	10 total hours

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form. .

This request covers only one form.

c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

The cost to the respondents for completing these forms is $ .75 X 200 respondents = $150.00.

13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

a. There are no capital, start-up, operation or maintenance costs.

c. There is no anticipated recordkeeping burden.

14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.

The estimated annual cost of VA Form 10-0449A processing to the Federal Government is $424.00

Processing 200 claims X $12.73/hr (Clerk) x 10 min. = $424.00

15. Explain the reason for any burden hour changes since the last submission.

This is a new collection and all burden hours are considered a program increase.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

We do not plan to publish this data.

17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

VA seeks to minimize the cost to itself of collecting, processing and using the information by not displaying the expiration date. We seek an exemption that waives the displaying of the expiration date on this VA Form. The VA Form may be reproduced by the respondents and VA field facilities from the Internet and then stocked. If we are required to display an expiration date, it would result in unnecessary waste of existing stock of the forms. Inclusion of the expiration date would place an unnecessary burden on the respondent (since they would find it necessary to obtain a newer version, while VA would have accepted the old one).

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.

There are no exceptions.

B. Collection of Information Employing Statistical Methods

This collection of information does not employ statistical methods.

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