SSB-Update-91321

SSB-Update-91321.docx

[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB: 0920-0891

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0891 can be found here:

2024-09-11 - Revision of a currently approved collection

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World Trade Center Health Program

Enrollment, Treatment, Appeals & Reimbursement

Revision

Supporting Statement B

Emily Hurwitz

Communications Unit Chief

Bryn Higdon

Public Health Advisor/Communications Specialist

National Institute for Occupational Safety and Health

395 E ST NW, Suite 9000

Washington, DC 20201

nff3@cdc.gov or nji9@cdc.gov

202-245-0619 or 404-498-1008

April 5, 2021

Table of Contents

Section B. Collections of Information Employing Statistical Methods

B1. Respondent Population and Selection of Respondents

B2. Procedures for the Collection of Information

B3. Methods to Maximize Response Rates and Deal with Nonresponse

B4. Tests of Procedures or Methods to be Undertaken

B5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or References

Appendices

Appendix A World Trade Center Health Program FDNY Responder

Application for Enrollment

Appendix B World Trade Center Health Program Responder Application for Enrollment (Other than FDNY) English

Appendix C World Trade Center Health Program Responder Application for Enrollment (Other than FDNY) Spanish

Appendix D World Trade Center Health Program Responder Application for Enrollment (Other than FDNY) Polish

Appendix E World Trade Center Health Program Pentagon/Shanksville Application for Enrollment

Appendix F World Trade Center Health Program Survivor Application for Enrollment English

Appendix G World Trade Center Health Program Survivor Application for Enrollment Spanish

Appendix H World Trade Center Health Program Survivor Application for Enrollment Polish

Appendix I World Trade Center Health Program Survivor Application for Enrollment Chinese

Appendix J General Responder Clinic Selection Postcard

Appendix K Designated Representative Appointment Form

Appendix L Designated Representative HIPAA Authorization form

Appendix M Petition for the Addition of a New WTC-Related Health Condition for

Coverage under the World Trade Center (WTC) Health Program Form

Appendix N Member Satisfaction Survey

Appendix O WTCHP HIPAA Authorization for Deceased Individuals

Appendix P WTCHP General HIPAA Authorization to Third Parties

Appendix Q Designated Representative Revocation Form

Supporting Documentation

Appendix R Zadroga Act (Sec 3301)

Appendix S Summary of Covered Health Benefits, Health Conditions, Treatments, and Payments

Appendix T Web Based Application Screen Shots (samples)

Appendix U Initial Request for Additional Information

Appendix V 30 Day Letter Reminder for Additional Information

Appendix W 60 Day Letter Reminder for Additional Information

Appendix X 90 Day Letter Reminder for Additional Information

Appendix Y 180 Day Letter Reminder for Information

Appendix Z WTC-5 Code or Procedure Request

Appendix AA WTC-3 Request for Certification

Appendix BB Prior Authorization Form – Standard

Appendix CC Prior Authorization Form – Dental

Appendix DD Prior Authorization Form – Transplant

Appendix EE Transcranial Magnetic Stimulation (TMS) Treatment Request Form

Appendix FF Non-Emergency General Transportation Request Form

Appendix GG Non-Emergency Medical Transportation Reimbursement Form

Appendix HH Non-Emergency Medical Transportation Request Form

Appendix II Prior Authorization General Level 2

Appendix JJ Prior Authorization General Level 3

Appendix KK Home Health Aid Prior Authorization Level 3

Appendix LL Long-term Care Hospitalization Prior Authorization Level 3

Appendix MM In-Patient Rehabilitation Prior Authorization Level 3

Appendix NN Hospice Respite Care Prior Authorization Level 3

Appendix OO Outpatient Prescription Pharmaceuticals

Appendix OO-1 Non-Formulary Prior Authorization - Prescription (General and Renewal)

Appendix OO-2 Non-Formulary Prior Authorization – Airway Medications

Appendix OO-3 Non-Formulary Prior Authorization – Antidepressants

Appendix OO-4 Non-Formulary Prior Authorization – Antiemetics

Appendix OO-5 Non-Formulary Prior Authorization – Antipsychotics

Appendix OO-6 Non-Formulary Prior Authorization – Epinephrine

Appendix OO-7 Non-Formulary Prior Authorization – Diabetes Insulin

Appendix OO-8 Non-Formulary Prior Authorization – Methadone

Appendix OO-9 Non-Formulary Prior Authorization – Airway Biologics

Appendix OO-10 Non-Formulary Prior Authorization – Abuse Deterrents

Appendix PP Enrollment Denial Letter and Appeal Notification

Appendix QQ Certification Denial Letter and Appeal Notification

Appendix RR Treatment Denial Letter and Appeal Notification

Appendix SS-1 Federal Register Notice

Appendix TT IRB Determination

Appendix UU Translated Initial Request for Information (Spanish, Chinese, Polish)

Appendix VV Translated 30 Day Request for Information (Spanish, Chinese, Polish)

Appendix WW Translated 60 Day Request for Information (Spanish, Chinese, Polish)

Appendix XX Translated 90 Day Request for Information (Spanish, Chinese, Polish)

Appendix YY Translated 180 Day Request for Information (Spanish, Chinese, Polish)

Appendix ZZ Translated Enrollment Denial and Appeal Notification (Spanish)

Appendix AAA Disenrollment Letter and Appeal Notification

Appendix BBB Decertification Letter Template—Administrative Error

Appendix CCC Decertification Letter Template—Denial and Decertification Exposure

Appendix DDD Decertification Letter Template—Latency Prostate Cancer/Cancer

Appendix EEE Overview of WTC Health Program Forms, Standard Correspondence

and Changes to the Information Collection Request

Appendix FFF Reimbursement Denial Letter and Appeal Notification

B. Collections of Information Employing Statistical Methods

The World Trade Center (WTC) Health Program is a limited healthcare program administered by the National Institute for Occupational Safety and Health (NIOSH) at the Centers for Disease Control and Prevention (CDC). The goal of the WTC Health Program is to provide healthcare, medical monitoring, and treatment to responders of the terrorist attacks that occurred on September 11, 2011 (“9/11”) at the World Trade Center in New York City; the Pentagon in Washington, D.C.; and Shanksville, Pennsylvania, as well as survivors in the New York City area. Healthcare monitoring and treatment services are provided to all eligible and enrolled WTC Health Program members. Information is collected to determine applicants’ eligibility, provide the services and payments authorized by the Program, and adjudicate appeals. Statistical methods are not used to select respondents.

1. Respondent Universe and Sampling Methods

There are five categories of members in the WTC Health Program.

"FDNY responder" is defined as a member of the Fire Department of New York City (whether fire or emergency personnel, active, or retired) who participated at least one day in the rescue and recovery effort at any of the former World Trade Center sites.
"General Responder" is a worker or volunteer who provided Rescue, Recovery, Demolition, Debris, Removal and related support services in the aftermath of the September 11, 2001 attacks on the World Trade Center but was not affiliated with the Fire Department of New York.
"Survivor" is a person who was present in the disaster area in the aftermath of the September 11, 2001 attacks on the World Trade Center as a result of their work, residence, or attendance at school, childcare, or adult daycare.
“Pentagon Responder” is a person who was a member of a fire or police department (whether fire or emergency personnel, active or retired), who worked for a recovery or cleanup contractor, or was a volunteer; and performed rescue, recovery, demolition, debris cleanup, or other related services at the Pentagon site of the terrorist-related aircraft crash of September 11, 2001, during the period beginning on September 11, 2001, and ending on November 19, 2001.
“Shanksville Responder” is a person who was a member of a fire or police department (whether fire or emergency personnel, active or retired), worked for a recovery or cleanup contractor, or was a volunteer; and performed rescue, recovery, demolition, debris cleanup, or other related services at the Shanksville, Pennsylvania site of the terrorist-related aircraft crash of September 11, 2001, during the period beginning on September 11, 2001, and ending on October 3, 2001.

Respondents also include other individuals who may be selected as a member’s designated representative and other advocates or interested parties in submitting a petition to add a condition to the List of WTC-Related Health Conditions for coverage under the World Trade Center (WTC) Health Program.

2. Procedures for the Collection of Information

Modes of information collection include web-based forms, hardcopy (mailed) submissions, facsimile submissions, and electronic data transfers. Information collection procedure have been designed to maximize flexibility and convenience to respondents. An overview of WTC forms and supplemental correspondence is provided in Appendix EEE.

Enrollment (Required) and Designation of an Authorized Representative (Optional)

3. Methods to Maximize Response Rates and Deal with No Response

WTC Health Program procedures have been designed to maximize flexibility and convenience to users. Modes of information collection include electronic, hardcopy, fax, and oral statements. The majority of requirements can be met through one or more modes of information collection.

To facilitate the initial determination of eligibility for services, the WTC Health Program sends follow-up reminder letters when application forms are incomplete. The WTC Health Program also makes key forms available in multiple languages and provides translations of other forms or communications as needed.

Finally, the WTC Health Program allows members to identify a Designated Representative to act on their behalf. This provides flexibility to members who experience barriers due to their health conditions, cognitive status, difficulties with language or communication, or other factors.

4. Tests of Procedures or Methods to be Undertaken

The program has been operating since 2011. Current information collection procedures reflect the experience of WTC Health Program members, program management staff, and NIOSH’s data collection contractor.

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

Roy Fleming, Quality Assurance Officer