Business Proposal Forms For Quality Improvement Organizations (QIOs)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-718-721 CMS-718-721.BP9SOW - Forms - OCN-0938-0579	Form	Modified	Available
Form CMS-718-721 CMS-718-721.Travel Detail Chart	Form	Modified	Available
Form CMS-718-721 CMS-718-721.J-8a 9th SOW Patient Pathways Spreadsheet	Form	Modified	Available
Form CMS 718-721 CMS 718-721.J-8a 9th SOW CKD Spreadsheet	Form	Modified	Available
Form CMS 718-721 CMS 718-721.J-8a 9th SOW Disparities Spreadsheet	Form	Modified	Available
CMS_718-721.Supporting_Statement_Part_A-revised.doc	Supporting Statement A	Uploaded 2010-10-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Form	Modified	CMS-718-721.BP9SOW - Forms - OCN-0938-0579
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Form	Modified	CMS-718-721.Travel Detail Chart
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Instruction	Modified
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Form	Modified	CMS-718-721.J-8a 9th SOW Patient Pathways Spreadsheet
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Form	Modified	CMS 718-721.J-8a 9th SOW CKD Spreadsheet
43659	Business Proposal Forms For Quality Improvement Organizations (QIOs)	Form	Modified	CMS 718-721.J-8a 9th SOW Disparities Spreadsheet

ICR Details

OMB Control No: 0938-0579	ICR Reference No: 201104-0938-005
Status: Historical Active	Previous ICR Reference No: 200605-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Business Proposal Forms For Quality Improvement Organizations (QIOs)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/24/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/26/2011
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	21	0	0
Time Burden (Hours)	1,785	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The submission of proposal information by current Quality Improvement Organizations and other bidders on the appropriate forms will satisfy CMS' need for meaningful, consistent, and verifiable data, which aids Federal procurement awards.

---

Authorizing Statute(s): US Code: 42 USC 1320c-3 Name of Law: Functions of Peer Review Organizations
   US Code: 42 USC 1395ww Name of Law: Payment to Hospitals for Inpatient Hospital Services
  

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 2547	01/15/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 15435	03/28/2010
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
Business Proposal Forms For Quality Improvement Organizations (QIOs)	CMS 718-721, CMS 718-721, CMS-718-721, CMS-718-721, CMS-718-721	CMS 718-721.J-8a 9th SOW CKD Spreadsheet ,   CMS 718-721.J-8a 9th SOW Disparities Spreadsheet ,   CMS-718-721.J-8a 9th SOW Patient Pathways Spreadsheet ,   CMS-718-721.Travel Detail Chart ,   CMS-718-721.BP9SOW - Forms - OCN-0938-0579

---

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	21	0	0	21	0	0
Annual Time Burden (Hours)	1,785	0	0	1,785	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 increase in burden is associated with an increased number of respondents.

---

Annual Cost to Federal Government: $0

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: 04/26/2011

---