BERC-024 - FN COVERAGE OF OXYGEN FOR USE IN A PATIENT'S HOME

ICR 198504-0938-004

OMB: 0938-0422

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0422 198504-0938-004
Historical Active
HHS/CMS
BERC-024 - FN COVERAGE OF OXYGEN FOR USE IN A PATIENT'S HOME
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/05/1985
Retrieve Notice of Action (NOA) 04/05/1985
  Inventory as of this Action Requested Previously Approved
05/31/1988 05/31/1988
1 0 0
1 0 0
0 0 0

THE LACK OF UNIFORM CRITERIA FOR DETERMINING WHEN HOME USE OF OXYGEN I MEDICALLY NECESSARY AND THUS COVERED AS A MEDICARE BENEFIT, HAS PROMPT THIS REGULATION. IT REQUIRES SPECIFIC DOCUMENTATION ON THE BENEFICIARIES HEALTH CONDITION. THE DOCUMENTATION INCLUDES A BLOOD GA STUDY AND A STATEMENT OR PRESCRIPTION WRITTEN BY THE PHYSICIAN. THIS INFORMATION IS SUBMITTED TO THE CARRIER THROUGH THE DME SUPPLIER WITH THEIR CLAIM FOR REIMBURSEMENT.

None
None


No

1
IC Title Form No. Form Name
BERC-024 - FN COVERAGE OF OXYGEN FOR USE IN A PATIENT'S HOME HCFA-R-60

  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 1 0 0 1 0 0
Annual Time Burden (Hours) 1 0 0 1 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
04/05/1985


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