End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-685 CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC	Form	Modified	Available
Form CMS-685 CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls	Form	Modified	Available
Form CMS-685 CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC	Form	Modified	Available
Form CMS-685 CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS	Form	Modified	Available
Form CMS-685 Updated J 6 A Instructions with Disclosure statement	Instruction	Modified	Repair queued
CMS-685.Supporting Statement-6-6-06.doc	Supporting Statement A	Uploaded 2006-08-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8237	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form	Modified	CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC
8237	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form	Modified	CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls
8237	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form	Modified	CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC
8237	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Form	Modified	CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS
8237	End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	Instruction	Modified	Updated J 6 A Instructions with Disclosure statement

ICR Details

OMB Control No: 0938-0657	ICR Reference No: 200609-0938-001
Status: Historical Active	Previous ICR Reference No: 200308-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/08/2006
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/13/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	36 Months From Approved	12/31/2006
Responses	36	0	36
Time Burden (Hours)	108	0	108
Cost Burden (Dollars)	0	0	0

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Abstract: Submission of semi-annual cost reports allow CMS to review, compare, and project ESRD network costs. The reports are used as an early warning system to determine whether the networks are in danger of exceeding the total cost of the contract. Additionally, CMS can analyze line item costs to identify any significant aberations.

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Authorizing Statute(s): US Code: 42 USC 1395rr Name of Law: End Stage Renal Disease Program
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 34938	06/16/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 50427	08/25/2006
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
End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112	CMS-685, CMS-685, CMS-685, CMS-685, CMS-685	Updated J 6 A Instructions with Disclosure statement ,   CMS-685.FINAL J 6 E-NW 719 Semi Annual Cost Report with SIMS ,   CMS-685.FINAL J 6 D-NW 719 Semi Annual Voucher Version with NCC ,   CMS-685.FINAL J 6 C-NW 719 Monthly Voucher Version with SIMS_20060215.xls ,   CMS-685.FINAL J 6 B-NW 719 Monthly Voucher Version with NCC

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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	36	36	0	0	0	0
Annual Time Burden (Hours)	108	108	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

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: $1,512

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: 08/17/2006

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