Authorization Request Forms/Certification/Letter of Medical Necessity

ICR 201610-1240-004

OMB: 1240-0055

Federal Form Document

ICR Details
1240-0055 201610-1240-004
Historical Active 201606-1240-003
DOL/OWCP
Authorization Request Forms/Certification/Letter of Medical Necessity
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/02/2016
Retrieve Notice of Action (NOA) 10/31/2016
  Inventory as of this Action Requested Previously Approved
10/31/2019 10/31/2019 10/31/2019
170,000 0 170,000
85,000 0 85,000
0 0 0

The forms, Authorization Request Form and Certification/Letter of Medical Necessity for Compounded Drugs (CA-26) and Authorization Request Form and Certification/Letter of Medical Necessity Certification/Letter of Medical Necessity for Opioid Medications (CA-27), require an injured worker’s treating physician to answer a number of questions about the prescribed opioids and/or compounded drugs and certify that they are medically necessary to treat the work-related injury. The responses to the questions on the forms are intended to ensure that treating physicians have considered non-opioid and non-compounded drug alternatives, and are only prescribing the most cost effective and medically necessary drugs. The forms will also permit OWCP to more easily track the volume, type, and characteristics of opioids and compounded drugs authorized by the FECA program. The forms will serve as a means for injured workers to continue receiving opioids and compounded drugs only where medically necessary and simultaneously give OWCP greater oversight in monitoring their appropriate use and gather additional data about their use.

US Code: 5 USC 8103 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8145 Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8124 (a) (2) Name of Law: Federal Employees' Comensation Act
   US Code: 5 USC 8149 Name of Law: Federal Employees' Comensation Act
  
None

Not associated with rulemaking

  81 FR 40721 06/22/2016
81 FR 61255 09/06/2016
Yes

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 170,000 170,000 0 0 0 0
Annual Time Burden (Hours) 85,000 85,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$17,818,719
No
No
No
No
No
Uncollected
Marcus Sharpless 202 693-0998 sharpless.marcus@dol.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/31/2016


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