2012-27609. Agency Information Collection Activities; Submission for OMB Review; Comment Request; Health Insurance Claim Form

ACTION:

Notice.

SUMMARY:

The Department of Labor (DOL) is submitting the Office of Workers' Compensation Programs (OWCP) sponsored information collection request (ICR) revision titled, “Health Insurance Claim Form,” (Form OWCP-1500) to the Office of Management and Budget (OMB) for review and approval for use in accordance with the Paperwork Reduction Act (PRA) of 1995.

DATES:

Submit comments on or before December 14, 2012.

ADDRESSES:

A copy of this ICR with applicable supporting documentation; including a description of the likely respondents, proposed frequency of response, and estimated total burden may be obtained from the RegInfo.gov Web site, http://www.reginfo.gov/​public/​do/​PRAMain,, on the day following publication of this notice or by contacting Michel Smyth by telephone at 202-693-4129 (this is not a toll-free number) or sending an email to [e-mail].

Submit comments about this request to the Office of Information and Regulatory Affairs, Attn: OMB Desk Officer for DOL-OWCP, Office of Management and Budget, Room 10235, 725 17th Street NW., Washington, DC 20503, Fax: [phone] (this is not a toll-free number), email: [e-mail].

FOR FURTHER INFORMATION CONTACT:

Michel Smyth by telephone at 202-693-4129 (this is not a toll-free number) or by email at [e-mail].

Authority: 44 U.S.C. 3507(a)(1)(D).

SUPPLEMENTARY INFORMATION:

OWCP and contractor bill payment staff use Form OWCP-1500 to process bills for medical services provided by medical professionals other than medical services provided by hospitals, pharmacies, or certain other medical providers. This information is required to pay health care providers for services rendered to injured employees covered under OWCP-administered programs. Appropriate payment cannot be made without documentation of the medical services provided by the health care provider billing the OWCP. The OWCP uses information obtained to identify the patient and determine benefit eligibility. The OWCP also uses the information to decide whether services and supplies received are covered by OWCP programs and to assure that proper payment is made.

This information collection is subject to the PRA. A Federal agency generally cannot conduct or sponsor a collection of information, and the public is generally not required to respond to an information collection, unless it is approved by the OMB under the PRA and displays a currently valid OMB Control Number. In addition, notwithstanding any other provisions of law, no person shall generally be subject to penalty for failing to comply with a collection of information if the collection of information does not display a valid Control Number. See 5 CFR 1320.5(a) and 1320.6. The DOL obtains OMB approval for this information collection under Control Number 1240-0044. The current approval is scheduled to expire on November 30, 2012; however, it should be noted that existing information collection requirements submitted to the OMB receive a month-to-month extension while they undergo review. For additional information, see the related notice published in the Federal Register on August 27, 2012 (77 FR 51828).

Interested parties are encouraged to send comments to the OMB, Office of Information and Regulatory Affairs at the address shown in the ADDRESSES section within 30 days of publication of this notice in the Federal Register. In order to help ensure appropriate consideration, comments should mention OMB Control Number 1240-0044. The OMB is particularly interested in comments that:

• Evaluate whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information will have practical utility;
• Evaluate the accuracy of the agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used;
• Enhance the quality, utility, and clarity of the information to be collected; and
• Minimize the burden of the collection of information on those who are to respond, including through the use of appropriate automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses.

Agency: DOL-OWCP.

Title of Collection: Health Insurance Claim Form.

OMB Control Number: 1240-0044.

Affected Public: Private Sector—businesses or other for-profits.

Total Estimated Number of Respondents: 71,304.

Total Estimated Number of Responses: 3,036,067.

Total Estimated Annual Burden Hours: 322,838.

Total Estimated Annual Other Costs Burden: $0.

Dated: November 7, 2012.

Michel Smyth,

Departmental Clearance Officer.