Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

ICR 200303-0938-007

OMB: 0938-0679

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0679 200303-0938-007
Historical Active 200207-0938-006
HHS/CMS
Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity and Supporting Documentation
Revision of a currently approved collection   No
Regular
Approved with change 06/06/2003
Retrieve Notice of Action (NOA) 03/21/2003
This information collection request is approved for 18 months, as amended by CMS. As agreed, CMS will revise Chapter 3 of its program integrity manual to incorporate language that describes the circumstances under which it may request supplementary information from respondents to support the CMN.
  Inventory as of this Action Requested Previously Approved
12/31/2004 12/31/2004 06/30/2003
6,800,000 0 6,700,000
1,530,000 0 1,130,000
0 0 0

This information is needed to correctly process claims and ensure that claims are properly paid. These forms contain medical information necessary to make an appropriate claim determination. Suppliers and physicians will complete these forms and as needed supply additional routine supporting documentation necessary to process claims.

None
None


No

1
IC Title Form No. Form Name
Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity and Supporting Documentation CMS-841, 842, 844-853

  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 6,800,000 6,700,000 0 42,500 57,500 0
Annual Time Burden (Hours) 1,530,000 1,130,000 0 170,000 230,000 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.
03/21/2003


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