Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)

Forms and Documents

Document	Type	Status	Availability
CMS-10364 Supporting Statement [rev 07-06-11].doc	Supporting Statement A	Uploaded 2011-07-06	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
197985	Provider-Preventable Conditions under 42 CFR 447.26(c)(2)		New
197984	Provider-Preventable Conditions under 447.26(c)(1) and Payment for Services Preprint	Other-CMS-10364 Preprint	New
197983	Provider-Preventable Conditions under 42 CFR 438.6(f)(2)		New

ICR Details

OMB Control No: 0938-1136	ICR Reference No: 201106-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Provider-Preventable Conditions under 42 CFR 438.6 and 447.26 and Title 2702 Non-Payment Preprint (Attachment 4.19)
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 without change	Conclusion Date: 07/07/2011
	Date Received in OIRA: 06/06/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved
Responses	158	0	0
Time Burden (Hours)	2,089	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: These collections are required because they will allow States to know when provider payment penalty is warranted as a result of a provider preventable condition (PPC). The collection will also allow CMS to ensure that States are not making payments to providers for PPCs. In CMS-2400-F (published June 1, 2011), section 438.6(f)(2) will require States which provide medical assistance using a managed care delivery system to modify their managed care contracts to reflect the PPCs payment adjustment policies as applied through these regulations. Section 447.26(c)(1) will require States to submit SPAs for CMS approval that would reduce payments to providers by amounts related to PPCs. The burden associated with this requirement will be the time and effort necessary for a State to submit its SPA and an associated pre-print. Section 447.26(c)(2) will also require States to implement provider reporting requirements to ensure that PPCs are identified in claims for Medicaid payment.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 2702 Name of Law: Payment Adjustment for Health Care-Acquired Conditions
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2702 Name of Law: Payment Adjustment for Health Care-Acquired Conditions

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ34	Final or interim final rulemaking	76 FR 32816	06/06/2011

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 9283	02/17/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 32816	06/06/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Provider-Preventable Conditions under 42 CFR 438.6(f)(2)
Provider-Preventable Conditions under 447.26(c)(1) and Payment for Services Preprint
Provider-Preventable Conditions under 42 CFR 447.26(c)(2)

---

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	158	0	158	0	0	0
Annual Time Burden (Hours)	2,089	0	2,089	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: This is a new collection.

---

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]? 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

---

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: 06/06/2011

---