Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10179.REVISED-Supporting Statement 12-6-06.doc	Supporting Statement A	Uploaded 2006-12-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178499	Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)		New

ICR Details

OMB Control No: 0938-1020	ICR Reference No: 200701-0938-017
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2007
	Date Received in OIRA: 01/26/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2010	36 Months From Approved
Responses	18	0	0
Time Burden (Hours)	144	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Because of the extensive gaming of outlier payments, CMS implemented new regulations in section 412.84 (i)(2) of the Code of Federal Regulations for Inpatient Prospective Payment System (IPPS)hospitals and section 412.525(a)(4)(ii) and 412.529(c)(5)(ii) of the Code of Federal Regulations for Long Term Care Hospitals (LTCH) to allow a hospital to contact its FI to request that its cost to charge ratio (CCR) (operating and/or capital CCR for IPPS hospitals or the total (combined operating and capital) CCR for LTCHs), otherwise applicable, be changed if the hospital presents substantial evidence that the ratios are inaccurate for IPPS hospitals. Any such requests would have to be approved by the CMS RO with jurisdiction over that FI.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 41448	07/21/2005
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 77026	12/22/2006
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
Requirements for Requests by Hospitals for an Alternative Cost-to-Charge Ratio and Supp. Regs. in 42CFR412.84(i)(2),412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A)

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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	18	0	0	18	0	0
Annual Time Burden (Hours)	144	0	0	144	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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: CMS implemented regulations in section 412.84 (i)(2) of the Code of Federal Regulations for IPPS hospitals and sections 412.525(a)(4)(ii), 412.525(a)(4)(iv)(A), 412.529(c)(3)(ii) and 412.529(c)(3)(iv)(A) of the Code of Federal Regulations for LTCHs to allow a hospital to contact its FI to request that its cost to charge ratio (operating and/or capital CCR for IPPS hospitals or the total (combined operating and capital) CCR for LTCHs), otherwise applicable, be changed if the hospital presents substantial evidence that the ratios are inaccurate for IPPS hospitals. Any such requests would have to be approved by the CMS RO with jurisdiction over that FI.

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Annual Cost to Federal Government: $2,350

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: 12/28/2006

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