Provider Reimbursement Manual, Sections 2721, 2722 and 2725, Requests for Exception to End Stage Renal Disease Composite Rates "Medicare"

ICR 199502-0938-004

OMB: 0938-0296

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0296 199502-0938-004
Historical Active 199107-0938-002
HHS/CMS
Provider Reimbursement Manual, Sections 2721, 2722 and 2725, Requests for Exception to End Stage Renal Disease Composite Rates "Medicare"
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 05/05/1995
Retrieve Notice of Action (NOA) 02/07/1995
  Inventory as of this Action Requested Previously Approved
05/31/1998 05/31/1998
400 0 0
19,200 0 0
0 0 0

Sections 2721, 2722, and 2725 of the Provider Reimbursement Manual describes the information End State Renal Disease facilities must submit in justifying an exception request to their composite rate for outpatient dialysis services.

None
None


No

1
IC Title Form No. Form Name
Provider Reimbursement Manual, Sections 2721, 2722 and 2725, Requests for Exception to End Stage Renal Disease Composite Rates "Medicare" HCFA-9044

  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 400 0 0 400 0 0
Annual Time Burden (Hours) 19,200 0 0 19,200 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.
02/07/1995


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