eRx Incentive Program Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment

Forms and Documents

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Collection	Type	Status	Form
197992	Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment		Modified

ICR Details

OMB Control No: 0938-1138	ICR Reference No: 201108-0938-005
Status: Historical Inactive	Previous ICR Reference No: 201106-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: eRx Incentive Program Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment
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: Preapproved	Conclusion Date: 09/06/2011
	Date Received in OIRA: 08/29/2011
Terms of Clearance: CMS will update this collection (via non-substantive change request) with the instruments (including screen shots of the web tool), within 1 month of this approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	36 Months From Approved
Responses	110,106	0	0
Time Burden (Hours)	220,212	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This information collection request covers requets from physician & non-physician practitioners for a hardship exemption to avoid the electronic prescribing (eRx) payment adjustment.

---

Authorizing Statute(s): PL: Pub.L. 110 - 275 132 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
   PL: Pub.L. 111 - 5 Division B Name of Law: Medicare and Medicaid Health Information Technology; Miscellaneous Medicare Provisions
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 132 Name of Law: Medicare Improvements for Patients and Providers Act of 2008

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR00	Final or interim final rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Submission of Significant Hardship Exemption to Avoid the eRx Payment Adjustment	CMS-10397

---

ICR Summary of Burden

	Total Request	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	110,106	0	0	110,106	0	0
Annual Time Burden (Hours)	220,212	0	0	220,212	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: Changing Regulations

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: $2,511,017

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: 08/29/2011

---