Medicare Subsidy Quality Review Case Analysis, 20 CFR 418(b)(5)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-9314 Notice of Quality Review Acknowledgement Form for those without Phones	Form and Instruction	New	Available
Form SSA-9313 Notice of Quality Review Acknowledgement Form for those with Phones	Form and Instruction	New	Available
Form SSA-8510 Authorization for the Social Security Administration to Obtain Personal Information	Form and Instruction	Modified	Available
Form SSA-9310 Request for Documents	Form and Instruction	Modified	Available
Form SSA-9309 Life Insurance Verification	Form and Instruction	Modified	Available
Form SSA-9308 Request for Release of Information	Form and Instruction	Modified	Available
Form SSA-9312 Notice of Appointment -Denial- Please Call Reviewer	Form and Instruction	Modified	Available
Form SSA-9311 Notice of Appointment -Denial- Reviewer Will Call	Form and Instruction	Modified	Available
Form SSA-9303 Notice of Appointment-Please Call Reviewer	Form and Instruction	Modified	Available
Form SSA-9302 Notice of Appointment - Reviewer Will Call	Form and Instruction	Modified	Available
(2007) 0960-0707 supporting statement.doc	Supporting Statement A	Uploaded 2007-09-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9763	SSA-9301	Other-Telephone Interview Script	Modified
182005	Notice of Quality Review Acknowledgement Form for those without Phones	Form and Instruction	New	Notice of Quality Review Acknowledgement Form for those without Phones
182004	Notice of Quality Review Acknowledgement Form for those with Phones	Form and Instruction	New	Notice of Quality Review Acknowledgement Form for those with Phones
179417	SSA-8510	Form and Instruction	Modified	Authorization for the Social Security Administration to Obtain Personal Information
179416	SSA-9310	Form and Instruction	Modified	Request for Documents
179415	SSA-9309	Form and Instruction	Modified	Life Insurance Verification
179414	SSA-9308	Form and Instruction	Modified	Request for Release of Information
179412	SSA-9312	Form and Instruction	Modified	Notice of Appointment -Denial- Please Call Reviewer
179411	SSA-9311	Form and Instruction	Modified	Notice of Appointment -Denial- Reviewer Will Call
179409	SSA-9303	Instruction	Modified
179409	SSA-9303	Form and Instruction	Modified	Notice of Appointment-Please Call Reviewer
179406	SSA-9302	Instruction	Modified
179406	SSA-9302	Form and Instruction	Modified	Notice of Appointment - Reviewer Will Call

ICR Details

OMB Control No: 0960-0707	ICR Reference No: 200708-0960-007
Status: Historical Active	Previous ICR Reference No: 200704-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Subsidy Quality Review Case Analysis, 20 CFR 418(b)(5)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/02/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/18/2007
Terms of Clearance: This ICR is approved consistent with revisions made to forms SSA-9313 and SSA-9314. This ICR is also approved on the understanding that none of the other ICs in this collection are being modified from what was previously approved. Therefore, previous terms of clearance remain in effect.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2010	36 Months From Approved	04/30/2009
Responses	74,500	0	69,500
Time Burden (Hours)	18,625	0	17,375
Cost Burden (Dollars)	0	0	0

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Abstract: To validate its Medicare Part D subsidy determinations, SSA uses the Medicare Subsidy Quality Review Case Analysis system, in which it calls selected applicants and insurance/other companies to confirm certain information reported on form SSA-1020 (OMB No. 0960-0696). This submission is for two new forms SSA will use to conduct quality reviews with beneficiaries who recently underwent a Medicare Part D subsidy redetermination. The respondents are applicants for and recipients of the Medicare Part D subsidy information, insurance companies, and other third parties.

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Authorizing Statute(s): US Code: 42 USC 1395w-114
  

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:
	72 FR 28543	05/21/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 52594	09/14/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
Notice of Quality Review Acknowledgement Form for those with Phones	SSA-9313	Notice of Quality Review Acknowledgement Form for those with Phones
Notice of Quality Review Acknowledgement Form for those without Phones	SSA-9314	Notice of Quality Review Acknowledgement Form for those without Phones
SSA-8510	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information
SSA-9301
SSA-9302	SSA-9302	Notice of Appointment - Reviewer Will Call
SSA-9303	SSA-9303	Notice of Appointment-Please Call Reviewer
SSA-9308	SSA-9308	Request for Release of Information
SSA-9309	SSA-9309	Life Insurance Verification
SSA-9310	SSA-9310	Request for Documents
SSA-9311	SSA-9311	Notice of Appointment -Denial- Reviewer Will Call
SSA-9312	SSA-9312	Notice of Appointment -Denial- Please Call Reviewer

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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	74,500	69,500	0	5,000	0	0
Annual Time Burden (Hours)	18,625	17,375	0	1,250	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The burden for this ICR is increasing due to the addition of two new forms.

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Annual Cost to Federal Government: $507,213

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: 09/18/2007

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