OMB No 0917-0002 SUPPORTING STATEMENT A 1-15-2013[1]

SUPPORTING STATEMENT FOR

INDIAN HEALTH SERVICE CONTRACT HEALTH SERVICES REPORT

(OMB No. 0917-0002)

(SUPPORTING REGULATIONS CONTAINED IN

42 C.F.R. § 136.24)

A. Justification:

1. Circumstances Making the Collection of Information Necessary

This is a request for an approval by OMB on revision to a previously approved information collection activity titled “Indian Health Service Contract Health Services Report” (OMB No. 0917-0002), which expires February 28, 2013. The Snyder Act (25 U.S.C. § 13), the Transfer Act (Pub. L. 83-568; 42 U.S.C. § 2001) and 42 C.F.R. § 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.

2. Purpose and Use of the Information

The form, “IHS-843-1A, Order for Health Services,” is used to authorize contract health care providers to provide health care services to eligible IHS patients. IHS staff complete the majority of this form using information from existing IHS automated patient and vendor data files. Contract health care providers complete and sign the 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 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; to certify that the health care services requested and authorized have been performed by the contract provider(s); to process payments for health care services performed by such providers; to obtain program data; and to 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; keeping an accurate record of the patient’s health status and health services received and recommended; planning future health care programs; communicating among members of the health care team; evaluating the health care rendered; continuing education and research; and providing program health statistics.

3. Use of Information Technology and Burden Reduction

Currently the form may be downloaded and completed electronically by IHS staff, but is submitted via mail to the contracted health provider and fiscal intermediary. The methodology of submitting the form via mail continues, due to incompatibility between the IHS system and private providers’ systems.

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 poses minimal impact on such entities.

6. Consequences of Collecting Information Less Frequently

Respondents will respond to the data collection as necessary. 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 requirements, and claims processing would be unnecessarily delayed. There are no technical or legal obstacles to reducing burden.

7. Special Circumstances Relating to Guidelines 5 C.F.R. § 1320.5

This information collection is consistent with the guidelines in 5 C.F.R. § 1320.5(d)(2).

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

A 60-day notice Federal Register Notice was published in the Federal Register,

77 FR 69865, on November 21, 2012. There were no comments received.

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, Medical, Health and Billing Records Systems, 75 FR 1625, January 12, 2010, found at Internet Website: http://www.gpo.gov/fdsys/pkg/FR-2010-01-12/pdf/2010-285.pdf . 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 2010, the FI reported that it processed approximately 414,804 forms for 7,977 respondents. On the average CHS providers completed 52 forms each.

A. The table below provides annual burden hour information for this collection:

Data Collection Instrument	Estimated Number of Respondents	Responses per Respondent	Average Burden Hour per Response*	Total Annual Burden Hours
IHS-843-1A	7977	52	3/60	20,740
TOTAL	7977	---	---	20,740

*For ease of understanding, burden hours are also provided in actual minutes.

B. The table below provides estimated annual costs to respondents for this collection.

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
Medical Providers (e.g., Physicians)	20,740	$80.00	$1,659,200.00
Total Respondent Cost			$1,659,200.00

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

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, disclosing or providing the information.

14. Annualized Cost to the Federal Government

ITEM HOURS COST

Printing/Mailing N/A $ 31,841

Processing/Audit* 54,257 $ 1,007,381

TOTAL $ 1,039,222

*Cost based on $17.00 per hour (estimated professional and clerical/secretarial average hourly rates to process and audit approximately seven forms per hour): 414,804 (forms) ÷ 7 (forms per hour) = 59,257 (hours) x 17 (dollars per hour) = $1,007,381.

15. Explanation for Program Changes or Adjustments

The annual burden hours for this information collection increased 1809 hours from the previously approved 18,931 hours to the current 20,740 hours. This increase in burden hours is due to an Adjustment in OPDIV Estimates, and reflects an increase in numbers of AI/ANs returning to the community; Tribal compacting/contracting of IHS programs usage; number of patient visits; claims submitted; and providers utilized. Additionally, while there were minor text changes (i.e., updating of statute/regulatory citations), there were no significant changes to the form. Also, the previously approved collection listed a "Inpatient Discharge Summary" form on the Estimates of Hour Burden Including Annualized Hourly Cost table. However, it is not included on this collection because the program stated it is a non-federal government document that non-Federal providers submit to any third party when seeking reimbursement for medical services provided to a patient.

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. There 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 displayed on the information collection form.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

No exceptions to the certification.

B. Collections of Information Employing Statistical Methods

This information collection will not employ statistical methods.

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