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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
113939	ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY	Form	Migrated

ICR Details

OMB Control No: 0938-0534	ICR Reference No: 199207-0938-009
Status: Historical Active	Previous ICR Reference No: 199003-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/03/1992
	Date Received in OIRA: 07/06/1992
Terms of Clearance: 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.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/1993	01/31/1993
Responses	600,000	0	0
Time Burden (Hours)	15,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
ATTENDING PHYSICIAN'S CERTIFICATION OF MEDICAL NECESSITY FOR HOME OXYGEN THERAPY	HCFA-484

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ICR Summary of Burden

table that charts list of burden

	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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/06/1992

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