2019-13468. Proposed Collection; Comment Request

AGENCY:

Office of the Assistant Secretary of Defense for Health Affairs, DoD.

ACTION:

Information collection notice.

SUMMARY:

In compliance with the Paperwork Reduction Act of 1995, the Defense Health Agency announces a proposed public information collection and seeks public comment on the provisions thereof. Comments are invited on: Whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information shall have practical utility; the accuracy of the agency's estimate of the burden of the proposed information collection; ways to enhance the quality, utility, and clarity of the information to be collected; and ways to minimize the burden of the information collection on respondents, including through the use of automated collection techniques or other forms of information technology.

DATES:

Consideration will be given to all comments received by August 26, 2019.

ADDRESSES:

You may submit comments, identified by docket number and title, by any of the following methods:

Federal eRulemaking Portal: http://www.regulations.gov. Follow the instructions for submitting comments.

Mail: Department of Defense, Office of the Chief Management Officer, Directorate for Oversight and Compliance, 4800 Mark Center Drive, Mailbox #24, Suite 08D09, Alexandria, VA 22350-1700.

Instructions: All submissions received must include the agency name, docket number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the internet at http://www.regulations.gov as they are received without change, including any personal identifiers or contact information.

FOR FURTHER INFORMATION CONTACT:

To request more information on this proposed information collection or to obtain a copy of the proposal and associated collection instruments, please write to Defense Health Agency Uniform Business Office, 8111 Gatehouse Road, Suite 200, Falls Church, VA 22042 Attn: DeLisa E. Prater, Program Manager, or call 703-275-6380.

SUPPLEMENTARY INFORMATION:

 

Title; Associated Form; and OMB Number: Third Party Collection Program (Insurance Information); DD Form 2569; OMB Control Number 0720-0055.

Needs and Uses: The information collection requirement is necessary to obtain health insurance policy information used for coordination of health care benefits and billing third party payers and other federal agencies for health care provided to their beneficiaries and also to civilian non-Uniformed Service beneficiaries for health care provided to them. DoD is authorized to collect from third-party payers the cost of inpatient and outpatient services rendered to DoD beneficiaries who have other health insurance. Military treatment facilities (MTFs) are required to make this form available to third-party payers upon request. A third-party payer may not request any other assignment of benefits form from the subscriber. Also, for civilian non-Uniformed Services beneficiary and interagency patients, DD Form 2569 is necessary and serves as an assignment of benefits approval to submit claims to payers on behalf of the patient and authorization to release medical information.

Affected Public: Individuals or households.

Annual Burden Hours: 394,000.

Number of Respondents: 3,940,000.

Responses per Respondent: 1.5.

Annual Responses: 5,910,000.

Average Burden per Response: 4 minutes.

Frequency: On occasion.

Dated: June 20, 2019.

Morgan E. Park,

Alternate OSD Federal Register, Liaison Officer, Department of Defense.