(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-R-240 Supporting Statement dss_MH.docx	Supporting Statement A	Uploaded 2010-09-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8576	(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65		Modified
46622	(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.24, 413.65		Removed

ICR Details

OMB Control No: 0938-0798	ICR Reference No: 201009-0938-013
Status: Historical Active	Previous ICR Reference No: 200701-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/29/2010
	Date Received in OIRA: 09/28/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2013	36 Months From Approved	10/31/2010
Responses	500,405	0	500,355
Time Burden (Hours)	26,563	0	26,063
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 413.65(b)(3) states that a provider which is seeking a determination of provider-based status for a facility not located on the provider's campus must submit an attestation of compliance with applicable provider-based requirements and must supply documentation supporting its attestation at the time the attestation is made. Section 413.65(a)(1)(ii) establishes a listing of specific facilities for which determinations for provider-based status for payment purposes are not made. As CMS removed certain CAH-based facilities from this list, such facilities are allowed to apply for provider-based determination and are required to meet all provider-based requirements before billing for hospital or CAH based services.

---

Authorizing Statute(s): PL: Pub.L. 105 - 33 4523 Name of Law: Prospective Payment System for Hospital Outpatient Services
   US Code: 42 USC 1395cc(b)(2) Name of Law: Agreements with providers of services; enrollment processes
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 39696	07/12/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 57035	09/17/2010
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65
(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.24, 413.65

---

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	500,405	500,355	0	50	0	0
Annual Time Burden (Hours)	26,563	26,063	0	500	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The previous version of CMS-R-240 referenced regulations at sections 413.65(b)(3) and (c) for facilities seeking provider-based status. These application requirements referenced criteria at 42 CFR 413.65(a)(1)(ii) that describes types of facilities excluded by CMS from provider-based determinations, and by extension are not required to comply with any provider-based regulations. CAHs previously did not have to meet the provider-based rules in order to be paid under reasonable costs for clinical diagnostic laboratory services. 413.65(a)(1)(ii)(G) has been amended to require clinical diagnostic laboratories operating as parts of critical access hospitals (CAHs) to comply with provider-based rules for the CAH to be paid under reasonable costs for clinical diagnostic laboratory tests. CAH may seek a provider-based determination under 413.65(a)(1)(ii)(G) beginning after October 1, 2010.

---

Annual Cost to Federal Government: $13,476

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 09/28/2010

---