ESRD BENEFICIARY SELECTION

ICR 199105-0938-004

OMB: 0938-0372

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
113578 Migrated
ICR Details
0938-0372 199105-0938-004
Historical Active 198709-0938-004
HHS/CMS
ESRD BENEFICIARY SELECTION
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 07/18/1991
Retrieve Notice of Action (NOA) 05/29/1991
  Inventory as of this Action Requested Previously Approved
07/31/1994 07/31/1994
4,000 0 0
1,000 0 0
0 0 0

ESRD FACILITIES HAVE EACH NEW HOME DIALYSIS PATIENT SELECT ONE OF TWO METHODS TO HANDLE MEDICARE REIMBURSEMENT. THE INTERMEDIARIES PAY FOR THE BENEFICIARIES SELECTING REIMBURSEMENT UNDER METHOD I AND THE CARRIERS PAY FOR THE BENEFICIARIES SELECTING REIMBURSEMENT UNDER METHOD II. THIS SYSTEM WAS DEVELOPED TO AVOID DUPLICATE BILLING BY BOTH THE INTERMEDIARY AND THE CARRIER.

None
None


No

1
IC Title Form No. Form Name
ESRD BENEFICIARY SELECTION HCFA-382

  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 4,000 0 0 0 4,000 0
Annual Time Burden (Hours) 1,000 0 0 0 1,000 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
05/29/1991


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