Medicare Fee-for-Service Early Review of Medical Records

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10417 OMB Emergency Justification [rev 12-08-2011].doc	Supplementary Document	Uploaded 2011-12-16	Available
CMS-10417.(0938-0969) - REVISED Supporting Statement Part A (CLEAN-1-30-12).doc	Supporting Statement A	Uploaded 2012-03-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8829	Probe Review	Instruction	Modified
201492	Attestation	Instruction	New
201491	Prepayment Review	Instruction	New
201490	Probe Review (Service Specific)	Instruction	New

ICR Details

OMB Control No: 0938-0969	ICR Reference No: 201112-0938-008
Status: Historical Active	Previous ICR Reference No: 200608-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Fee-for-Service Early Review of Medical Records
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 12/20/2011
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/19/2012
	Date Received in OIRA: 12/19/2011
Terms of Clearance: This collection is approved for 6 months and does not include any demonstration projects associated with prepayment review. When CMS renews this collection, the 60-day Federal Register notice will specifically seek public comments to inform the burden estimates associated with this collection. CMS will revise the burden estimate if public comments include persuasive data to suggest that the estimates are insufficient.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	6 Months From Approved
Responses	2,220,434	0	0
Time Burden (Hours)	1,105,109	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information required under this collection is requested by Medicare contractors to determine proper payment or if there is a suspicion of fraud. Medicare contractors request the information form providers or suppliers submitting claims for payment from the Medicare program when data analysis indicates aberrant billing patterns or other information which may present a vulnerability to the Medicare program.

Emergency Justfication: See the attached emergency justification.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1862 Name of Statute: null
   Statute at Large: 18 Stat. 1833 Name of Statute: null
   Statute at Large: 18 Stat. 1893 Name of Statute: null
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 76737	12/08/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Probe Review
Attestation
Prepayment Review
Probe Review (Service Specific)

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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	2,220,434	0	0	0	-679,566	2,900,000
Annual Time Burden (Hours)	1,105,109	0	0	0	138,442	966,667
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:

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Annual Cost to Federal Government: $67,500,000

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

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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: 12/19/2011

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