Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee; Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site Visit and Rescreening

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10357.Transmittal 371.pdf	Supplementary Document	Uploaded 2011-06-23	Available
CMS-10357.Instrument Elements.doc	Supplementary Document	Uploaded 2011-06-23	Available
CMS-10357 Supporting Statement Part A (clean) (1-31-11)[1].doc	Supporting Statement A	Uploaded 2011-03-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194901	State Medicaid Agency Processing of Rescreening Application		Modified
194900	Provider Rescreening		Modified
194899	Site Visits		Modified
194898	Collection of SSN and DOBs		Modified
194897	Fingerprints - Medicaid		Modified
194896	Fingerprints - Medicare		Modified
194895	Medicare Enrollment Application Fee Waiver Request		Modified

ICR Details

OMB Control No: 0938-1137	ICR Reference No: 201103-0938-001
Status: Historical Active	Previous ICR Reference No: 201010-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee; Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site Visit and Rescreening
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 with change	Conclusion Date: 07/20/2011
	Date Received in OIRA: 03/01/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved
Responses	960,981	0	0
Time Burden (Hours)	1,248,082	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act (Affordable Care Act), Public Law 111-148. Section 6401 of the law establishes a number of important payment safeguard provisions, several of which have been incorporated into CMS Proposed Rule 6028, entitled "Medicare, Medicaid, and Children's Health Insurance Programs (CHIP); Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers," and published in the Federal Register on September 23, 2010. The provisions are designed to improve the integrity of the Medicare, Medicaid, and CHIP programs so as to reduce fraud, waste and abuse.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 6401 Name of Law: Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid & CHIP
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 6401 Name of Law: Provider Screening and Other Enrollment Requirements Under Medicare, Medicaid & CHIP

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ20	Final or interim final rulemaking	76 FR 5862	02/02/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Fingerprints - Medicare
Medicare Enrollment Application Fee Waiver Request
Fingerprints - Medicaid
Collection of SSN and DOBs
Site Visits
Provider Rescreening
State Medicaid Agency Processing of Rescreening Application

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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	960,981	0	889,481	71,500	0	0
Annual Time Burden (Hours)	1,248,082	0	1,105,082	143,000	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: This is a new information collection request.

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Annual Cost to Federal Government: $11,990,572

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]? Yes

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

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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: 03/01/2011

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