SUPPORTING STATEMENT – PART A
Active Duty Dental Program (ADDP)—OMB#0720-0053
A. JUSTIFICATION
1. Need for the Information Collection
This form is used by dental providers and Active Duty Service Members (ADSM) to document provided dental care and request reimbursement for the care provided. Authority to provide dental care to ADSMs is found in 10 U.S.C. 1074(a)(1), “Medical and Dental Care for Members and Certain Former Members”. The Department is further authorized to contract for claims processing services under 10 U.S.C. 1074(c)(2)(B). Obtaining Personally Identifying Information (PII) on the claim form is necessary to provide identifying information necessary to validate eligibility for care, plus providing detailed information regarding the care provided and for which reimbursement is being requested. Care under this program must be authorized by a military Dental Treatment Facility (DTF) or by a Dental Service Point of Contact (DSPOC). Care not authorized may not be approved for payment under the ADDP.
2. Use of the Information
Following completion of authorized dental care services, the provider or member must submit a claim to the ADDP contractor to request reimbursement for authorized dental care delivered by dental providers under the ADDP. Claim forms may be filed electronically by providers or in hardcopy paper form by providers or ADSMs. Respondents may find the form at https://secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm. When clicking on the claim form link, the user receives a pop up box with the Privacy Act Statement. If the respondent clicks “I Agree” the claim form will open. If the respondent clicks “I Don’t Agree” the user is returned to the main menu.
All dental care for ADSMs is paid by the Government based on the claims submitted and verified through the claims processing system. The ADDP is offered by the Department of Defense through the Defense Health Agency. The ADDP offers dental care to ADSMs not available through a military Dental Treatment Facility (DTF), or for members who live and work more than 50 miles from a DTF. Collected information will be gathered from the claim form submitted by a dental provider or the ADSM requesting reimbursement for provided dental care. The information will be used to verify eligibility for the program, and validate the care provided is an authorized benefit under the ADDP. Once a member has had care completed, either the member or the provider will submit the claim for reimbursement. If the work was completed by a network provider, the network provider will submit the claim. If the work was completed by a non-network provider, the provider or the member may submit the claim. Historically on ADDP, the non-network providers submit the vast majority of claims on behalf of the member. Either party will access the web site to download the form to complete. Members receive information from UCCI explaining the process for filing a claim in addition to briefings at the unit level on the claim process. Detailed claim filing information is also available on the ADDP website, available to members and providers. The member may provide guidance to the non-network provider if the provider is not aware of the claim filing process. Alternatively, the non-network provider may contact UCCI for direction on submitting a claim. Generally, providers only need the insurance information to determine the claim filing process.
3. Use of Information Technology
Claims may be submitted to the contractor electronically or in hardcopy paper form. Both methods provide the same information necessary to validate the eligibility for care and that the care provided is a covered benefit. These claim forms are necessary to document the request for payment of authorized services. Approximately 60% of claims are submitted electronically. Claims submitted electronically are completed and submitted through a contractor provided HIPAA compliant web based application. The contractor is responsible for increasing electronic claim submission and are encouraged to do so due to the lower cost of processing electronic claims.
4. Non-duplication
There is no duplication of effort involved in the collection of information using the ADDP claim form. This form is to support accurate claims processing for dental care provided under the ADDP and no other Government agency is involved in processing claims for the ADDP.
This information collection does not have a significant economic impact on small businesses or entities.
6. Less Frequent Collection
Less frequent collection is not possible. Collection is based on care delivered and submittal of claims for reimbursement of services.
7. Paperwork Reduction Act Guidelines
This collection of information is consistent with the guidelines in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
a. A 60-day notice was published in the Federal Register on May 6, 2015; 80 FR 26008 – 26009. No comments were received. A 30-day notice was published in the Federal Register on April 20, 2016; 81 FR 23278.
b. The claim form required to support reimbursement of delivered dental care is a standard business practice in the commercial world. The hardcopy form used is a standard American Dental Association claim form.
No payment or gift will be provided to the respondents.
10. Confidentiality
Claim forms include Personally Identifiable Information and Person Health Information and are subject to the Privacy Act and the Health Insurance Portability and Affordability Act. The claim form is available for download from the UCCI website. To access the form, the user must first view the Privacy Act Statement associated with the claim form. The form and PAS may be viewed at https://secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm by clicking on the “ADDP Claim Form” link. The user must agree to the PAS before going to the claim form.
SORN ID number: ED TMA 04. Title: Medical/Dental Claim History Files.
For copy of this SORN go to: http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570707/edtma-04.aspx
Retention: Close out at end of the calendar year in which received. Destroy 10 years after cutoff. When subject to one or more Litigation Holds, preserve records in compliance with the time constraints of the hold(s).
Applicable Privacy Impact Assessment (PIA):http://www.health.mil/Reference-Center/Forms/2014/07/29/PIA-Summary-United-Concordia-Companies-Inc-Active-Duty-Dental-Program
11. Sensitive Questions
Personally Identifiable Information and Personal Health Information is included on the claim form to allow for accurate claim adjudication and to ensure care is only provided to eligible ADSMs. The collection includes Social Security Numbers required to accurately identify the member and validate the member is eligible for care under the ADDP. A Social Security Number Memorandum for Record has been completed.
12. Respondent Burden, and its Labor Costs
Information is drawn from historical claims data and information provided from the contractor based on its feedback from network providers included in its ADDP dental network.
a. Estimation of Respondent Burden
The estimated burden for the claim form is approximately 15 minutes to complete; i.e. 1) 300,000 claims or responses annually; 2) an average of four responses per respondent; 3) approximately 75,000 respondents; and 4) for a total estimated burden of 75,000 hours per annum.
b. Labor Cost of Respondent Burden
Claims are generally prepared by dental assistants working in the provider’s office. Based on the Bureau of Labor Statistics May 2014 National Occupational Employment and Wage Estimates United States, the mean hourly wage for dental assistants is $17.43. labor category 31-9091, which may be viewed at (http://www.bls.gov/oes/current/oes_nat.htm#31-0000). With an estimated labor hour requirement of 75,000 hours, the estimated labor cost to complete the claim form annually is $1,307,250.00.
13. Respondent Costs Other Than Burden Hour Costs
a. There are no capital or start-up costs annualized over the expected useful life of the form by the respondent.
b. The analysis and revisions suggested for the claim form was conducted as part of the existing ADDP contract. There are no costs to respondents other than burden hour costs. Claims submitted via hardcopy paper form are mailed by the provider or ADSM to the contractor. An estimated 120,000 claims are submitted by mail at $0.49 per claim the total estimated mailing cost is $58,800.00.
14. Cost to the Federal Government
The cost for claims is included in the individual Common Dental Terminology (CDT) pricing in the contract and is not broken out separately. Although these costs are not broken out during contract negotiations between the Government and the contractor they are estimated to be approximately $15.00 per paper claim, or 120,000 paper claims x $15.00 equals an annual cost of $1,800,000.00.
15. Reasons for Change in Burden
The estimated burden has been updated in accordance with current ADDP utilization rates. This estimated burden relies on historical usage patterns over the preceding two contract years. There is no record as to how the previous burden estimate was determined as the contract was in its first iteration in 2012 so there was very little history and utilization. For the current estimate, the Agency used the number of claims received in the prior one year period as a volume estimate, and applied the contractor’s estimated time to complete of 15 minutes per claim form. Thus, 300,000 claims at 15 minutes each equals 75,000 hours per year.
16. Publication of Results
There is no plan to publish or tabulate the information collected in an independent report.
17. Non-Display of OMB Expiration Date
Approval not to display the expiration date is not being sought.
18. Exceptions to "Certification for Paperwork Reduction Submissions"
There are no exceptions to the certification statement in Item 19, “Certification for Paperwork Reduction Act Submission,” of OMB Form 83-I.
| File Type | application/msword |
| File Modified | 2016-11-28 |
| File Created | 2016-11-28 |