Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10269 CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA	Form and Instruction	Modified	Available
Form CMS-10126 CMS-10126 -- ENTERAL AND PARENTERAL NUTRITION	Form and Instruction	Modified	Available
Form CMS-10125 CMS-10125 -- EXTERNAL INFUSION PUMPS	Form and Instruction	Modified	Available
Form CMS-854 CMS-854 -- CONTINUATION FORM	Form and Instruction	Modified	Repair queued
Form CMS-849 CMS-849 -- SEAT LIFT MECHANISMS	Form and Instruction	Modified	Available
Form CMS-848 CMS-848 -- TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)	Form and Instruction	Modified	Available
Form CMS-846 CMS-846 -- PNEUMATIC COMPRESSION DEVICES	Form and Instruction	Modified	Available
Form CMS-847 CMS-847 -- OSTEOGENESIS STIMULATORS	Form and Instruction	Modified	Available
Justification for Non-material change-12-18-09.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2009-12-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-10126 -- ENTERAL AND PARENTERAL NUTRITION
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-10125 -- EXTERNAL INFUSION PUMPS
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-854 -- CONTINUATION FORM
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-849 -- SEAT LIFT MECHANISMS
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-848 -- TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-846 -- PNEUMATIC COMPRESSION DEVICES
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-847 -- OSTEOGENESIS STIMULATORS

ICR Details

OMB Control No: 0938-0679	ICR Reference No: 201001-0938-001
Status: Historical Active	Previous ICR Reference No: 200909-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/13/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	10/31/2012	10/31/2012
Responses	6,480,000	0	6,480,000
Time Burden (Hours)	1,296,000	0	1,296,000
Cost Burden (Dollars)	0	0	0

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Abstract: This information is needed to correctly process claims and ensure that claims are properly paid. These forms contain medical information necessary to make an appropriate claim determination. Suppliers and physicians will complete these forms and as needed supply additional routine supporting documentation to process claims.

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Authorizing Statute(s): US Code: 42 USC 1395y(a) Name of Law: Items or Services Specifically Excluded
   US Code: 42 USC 1395x(n) Name of Law: Durable medical equipment
   US Code: 42 USC 1395m(j)(2)(A)(iii) Name of Law: Penalty
   US Code: 42 USC 1395j(5) Name of Law: Special Payment Rules for Particular Items and Services
   US Code: 42 USC 1395l(e) Name of Law: Information for Determination of Amounts Due
   US Code: 42 USC 1395m(j)(2) Name of Law: Certificates of Medical Necessity
   US Code: 42 USC 1395y(a)(1)(A) Name of Law: Items or Services Specifically Excluded
  

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 30574	06/26/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 44368	08/28/2009
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
Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	CMS-847, CMS-846, CMS-848, CMS-849, CMS-854, CMS-10125, CMS-10126, CMS-10269	CMS-847 -- OSTEOGENESIS STIMULATORS ,   CMS-846 -- PNEUMATIC COMPRESSION DEVICES ,   CMS-848 -- TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) ,   CMS-849 -- SEAT LIFT MECHANISMS ,   CMS-854 -- CONTINUATION FORM ,   CMS-10125 -- EXTERNAL INFUSION PUMPS ,   CMS-10126 -- ENTERAL AND PARENTERAL NUTRITION ,   CMS-10269: POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR OBSTRUCTIVE SLEEP APNEA

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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	6,480,000	6,480,000	0	0	0	0
Annual Time Burden (Hours)	1,296,000	1,296,000	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: $1,166,000

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: 01/11/2010

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