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Federal forms, ICRs, and supporting documents

Information Collection Request

ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY

ICR 199207-0938-009 · OMB 0938-0534 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
113939 ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY Form Migrated
ICR Details
0938-0534 199207-0938-009
Historical Active 199003-0938-006
HHS/CMS
ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 10/03/1992
Retrieve Notice of Action (NOA) 07/06/1992
Approved for use through 1/93 under the condition that HCFA fully responds to the previous clearance conditions dated 6/90. In particular, HCFA should reestimate the burden based upon the average response time for data retrieval and completion of the Form. In its supporting statement, HCFA argues that the burden estimate should reflect best practices on the part of the physician, physician staff, and hospital discharge staff. OMB, however, argues that the burden should reflect the ACTUAL burden in the field, not what HCFA believes the burden should be under optimal records management. In addition, HCFA should clarify that at a minimum, RNs in a hospital setting may complete this Form, and should consider allowing qualified health professionals to complete this Form in all provider settings. Finally HCFA should explain in more detail its efforts to reevaluate the 3 month recertification requirements and alternative recertification frequencies dependent upon patient diagnosis, history of program abuse etc. Failure to comprehensively address these issues in the next package's Supporting Statement and timely resubmit it for OMB review shall result in a Disapproval Action.
  Inventory as of this Action Requested Previously Approved
01/31/1993 01/31/1993
600,000 0 0
15,000 0 0
0 0 0
S CERTIFICATION' MEDICARE CLAIMS FOR HOME OXYGEN THERAPY MUST BE SUPPORTED BY THE ATTENDING PHYSICIAN'S STATEMENT INCLUDING THE DIAGNOSIS, PRESCRIPTION DETAILS, AND THE RESULTS OF TESTING TO ESTABLISH THE EXTENT OF HYPOXEMIA. FORM HCFA-484 OBTAINS ALL PERTINENT INFORMATION AND SO PROMOTES NATIONAL CONSISTENCY IN COVERAGE DETERMINATIONS.
None
None
No
1
IC Title Form No. Form Name
ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY HCFA-484
  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 600,000 0 0 600,000 0 0
Annual Time Burden (Hours) 15,000 0 0 15,000 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.
07/06/1992