IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206

ICR 200510-0938-013

OMB: 0938-0565

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0565 200510-0938-013
Historical Active 200209-0938-007
HHS/CMS
IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206
Extension without change of a currently approved collection   No
Regular
Approved without change 12/13/2005
Retrieve Notice of Action (NOA) 10/26/2005
  Inventory as of this Action Requested Previously Approved
12/31/2008 12/31/2008 12/31/2005
341,065 0 327,947
1,986,810 0 1,096,466
0 0 0

Employers identified through a match of IRS, SSA and Medicare records will be contacted concerning group health plan coverage of identified individuals to ensure compliance with Medicare Secondary Payer provisions found at 42 USC 1395y(b).

None
None


No

1
IC Title Form No. Form Name
IRS/SSA/CMS Data Match and Supporting Regulations in 42 CFR Sections 411.20-411.206 CMS-R-137

  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 341,065 327,947 0 0 13,118 0
Annual Time Burden (Hours) 1,986,810 1,096,466 0 0 890,344 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.
10/26/2005


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