CMS Real-Time Eligibility Agreement and MDCN Access Request

Forms and Documents

Document Name	Status
Form CMS-10157 CMS Real-Time Eligibility Agreement and MDCN Access Request Form and Instruction	Modified
CMS-10157.REVISED-Supporting Statement-Pt A (8-18-09).doc Supporting Statement A	2009-08-18

IC Document Collections

IC ID	Document Title	Status
8819	CMS Real-Time Eligibility Agreement and MDCN Access Request Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0960	ICR Reference No: 200906-0938-014
Status: Historical Active	Previous ICR Reference No: 200601-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: CMS Real-Time Eligibility Agreement and MDCN Access Request
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 with change	Conclusion Date: 08/24/2009
	Date Received in OIRA: 06/25/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	36 Months From Approved	08/31/2009
Responses	2,000	0	122,000
Time Burden (Hours)	500	0	45,000
Cost Burden (Dollars)	0	0	0

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Abstract: CMS is requiring that trading partners who wish to conduct the eligibility transaction on a real-time basis to access Medicaid beneficiary information provide certain assurances as a condition of receiving access to the Medicare database for the purpose of conducting eligibility verification. Health care providers, clearinghouses, and health plans that wish to access the Medicare database are required to complete the access request form. The information will be used to assure that those entities that access the Medicare database are aware of applicable provision and penalties.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PUBLIC HEALTH SERVICE
  

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:
	74 FR 11959	03/20/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 27041	06/05/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
CMS Real-Time Eligibility Agreement and MDCN Access Request	CMS-10157, CMS-10157	CMS-10157.Revised HETS Access Request Form ,   CMS-10157.Revised Trading Partner Agreement

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ICR Summary 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	2,000	122,000	0	0	-120,000	0
Annual Time Burden (Hours)	500	45,000	0	0	-44,500	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: The original information collection request and the subsequent extension request in 2006, we listed a burden estimate of maximum 122,000 respondents replying electronically. At 15 minutes per form, the total burden was estimated at 45,000 hours. At the time, it appears that CMS was underestimating the percentage of transaction volume that would be submitted via clearinghouses or third party vendor type aggregators. Nearly 92% of HETS 270/271 volume today is submitted by clearinghouses or Medicare FFS contractors. Provider’s choice to rely on aggregators for HETS connectivity has minimized the number of submitter applications (and HETS direct submitters). When preparing the version of the ICR that OMB is currently reviewing, we amended the burden estimate to 2,000 respondents annually with 90% electronic reply. Still assuming 15 minutes per form, the total burden is estimated at 500 hours. We based our estimate of 2,000 applications on the average number of new HETS 270/271 submitter requests that were being received each month in Q4 2008.

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Annual Cost to Federal Government: $100,000

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)? No

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: 06/25/2009

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