201412-2900-007_MbM Order Forms Justification (CR 1 27 15)_2015-06-10 Ed...

Department of Veterans Affairs Meds by Mail Order Form
VA Form 10-0426

OMB 2900-XXXX

A. JUSTIFICATION

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

CHAMPVA, VA Form 10-0426, Meds by Mail (MbM) Order Form:

1. VA Form 10-0426, Meds by Mail (MbM) Order Form, is used by eligible CHAMPVA and Spina Bifida beneficiaries (also referred to as patient) in accordance with 38 CFR Sections 17.270, 17.271 and 17.272 when submitting a paper prescription written by their medical provider for fulfillment through the Meds by Mail Program. Information collected on this form is necessary for proper patient identification and medical record review.

2. The provisions of VHA Handbook 1108.05, Outpatient Pharmacy Services, require that, as a condition for dispensing a prescription, the prescription must contain the following patient identifiers:

1. Patient’s full name

2. Social Security Number

3. Patient’s current address

3. Local Meds by Mail Desk Procedure utilizes date of birth as an additional patient identifier.

4. The provisions of VHA Handbook 1108.05, Outpatient Pharmacy Services require pharmacists to review the patient medical record for the presence of allergy information and the potential for adverse drug events prior to the dispensing of medication to the patient.

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.

.

CHAMPVA: 10-0426: The information requested on this form is required for Meds by Mail staff to provide mail outpatient pharmacy services to eligible CHAMPVA and Spina Bifida beneficiaries in a safe and timely manner. This form is used to verify patient identifiers, and to update patient demographics and allergy information in the patient’s medical record.

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.

CHAMPVA:

1. VA Form 10-0426 currently meets the basic goals of the Government Paperwork Elimination Act (GPEA) because the beneficiary can complete the form electronically via the Internet. The form is then printed and mailed to MbM with the original paper prescription. Fill in versions on the web reduce the amount of outgoing paper from MbM and the Chief Business Office Purchased Care (CBOPC). With the advent of online forms, the beneficiary can simply print the form after completing it in online and then mail it to MbM. They do not need to request the form from MbM or CBOPC and therefore we save money in printing and storage of hard copy forms, postage and man hours required to mail the forms to the public.

2. MbM is in the process of developing a method to receive electronic prescription information transmitted directly from the beneficiary’s medical provider, thereby lessening the need for use of VA Form 10-0426 with a paper prescription.

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.

2. CHAMPVA10-0426: No other method currently exists for obtaining correct patient identifiers, patient demographics and allergy information at the time of submission of a new paper prescription.

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

• The collection of information on CHAMPVA Form 10-0426 is limited to beneficiary supplied information—there is no involvement of small businesses or other 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.

Without this information we could not provide mail outpatient pharmacy services to eligible CHAMPVA beneficiaries and in a safe and timely manner. The frequency of collecting information is determined by beneficiary utilization.

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 notice of Proposed Information Collection Activity was published in the Federal Register on October 8, 2014, Vol. 79, Number 195, Page 60896. VA received no comments in response to this notice.

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.

Outside consultation is conducted with the public through the 60-day Federal Register notice.

Staff at the CBOPC provided the expertise and advice gained in reviewing numerous public and private health insurance forms.

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 privacy, to the extent permitted by law, provided to respondents and the basis for the assurance in statue, regulation, or agency policy.

CHAMPVA: Information collected on this form is protected by the Privacy Act of 1974, VA confidentiality statutes 38 USC 5701 and 38 USC 7332 and 45 CFR Parts 160 and 164, Health Insurance Portability and Accountability Act. Respondents are informed that the information collected will be included as a part of the system of records identified as 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA as set forth in the 2005 Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html and disclosures made in accordance with the statute.

11. Provide additional justification for any questions of a sensitive nature, 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.

Neither VA Form 10-10068d, nor VA Form 10-0426 collects this type of information.

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

a. The annualized burden for this collection is 18,333 hours.

VA Forms	Respondents	X Response	Responses	X Minutes ÷ 60	Total Hours
CHAMPVA MbM 10-0426	110,000	2	220,000	5	18,333
Total	110,000			5

b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.

This request covers one form.

3. 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 annualized cost to CHAMPVA 10-0426 respondents is estimated at $421,659 ($23 x 18,333 burden hours). The combined annual cost equals $427,409.

Source: Department of Labor statistics

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

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

b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.

c. There is no anticipated recordkeeping burden beyond that which is considered usual and customary.

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 cost to the federal government for CHAMPVA 10-0426 is currently estimated at approximately $633,006.88

Form			Hourly Salary		Responses		Time to Complete		Total Hours	Cost
Contact Rep. review		$19.02		220,000		2 minutes		7,333		$139,473.66
Pharm Tech. review		$19.02		220,000		4 minutes		14,666		$278,947.32
Pharmacist review		$57.70		220,000		1 minute		3,667		$211,585.90
Printing/Distribution/Supplies											$3000.00
			TOTAL								$633,006.88
	TOTAL									$8,621.00

The combined total for all forms equals

15. Explain the reason for any changes reported in Items 13 or 14 of OMB 83-I.

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.

There are no plans to publish the results of the information collected.

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

A valid expiration date has been included on the form in compliance with OMB policy.

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. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS

The number of requests for MbM prescription benefits determines the frequency of data collection, there are no statistical methods employed.

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