CMS-1696.Supporting Statement Part A

Supporting Statement For Paperwork Reduction Act Submissions
CMS-1696 (0938-0950)
A.

Background
This application requests re-approval of an information collection associated with
regulations that permit individuals or entities to appoint representatives to exercise their
rights to appeal an initial determination. These regulations are described below.

B. Justification
1.

The authority for collecting this information is under 42 CFR §405.910 (a) of the Medicare
Claims Appeal Procedures.
An appointment of representative must:
• be in writing
• be signed and dated by both the party and individual agreeing to be the
representative;
• provide a statement appointing the representative to act on behalf of the party, and
in the case of a beneficiary, authorize the adjudicator to release personally identifiable
health information;
• include a written explanation of the purpose and scope of the representation;
• contain the party’s and appointed representative's name, phone number, and
address;
• provide the beneficiary's Medicare health insurance claim number or the National
Provider Identifier number;
• include the appointed representative's professional status or relationship to the
party; and
• be filed with the entity processing the party's initial determination.

2. Information Users
This form would be completed by beneficiaries and providers and suppliers who wish
to appoint representatives to assist them with their initial determinations and filing
appeals.
3. Use of Information Technology
There is no provision for alternative uses of information technology.
To comply with the Government Paperwork Elimination Act (GPEA), you must also
include the following information in this section:
Is this collection currently available for completion electronically? No
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Does this collection require a signature from the respondent(s)? Yes

If CMS had the capability of accepting electronic signature(s), could this collection be made
available electronically? No, currently, many Medicare contractors and healthplans do not
have the ability to receive forms electronically. Because the form requires the signature of th
respondent and the respondent’s prospective representative, this form currently cannot be
made available for electronic submission.
If this collection isn’t currently electronic but will be made electronic in the future, please
give a date (month & year) as to when this will be available electronically and explain why
it can’t be done sooner. Not applicable.
If this collection cannot be made electronic or if it isn’t cost beneficial to make it
electronic, please explain. This collection requires a signature from both the respondent
and the respondent’s prospective representative and therefore cannot currently be made
electronic.
4. Duplication of Efforts
The CMS-1696 does not duplicate any existing information collection.
5. Small Businesses
This collection does not have a significant economic impact on a substantial number of
small entities.
6. Less Frequent Collection
This form is submitted on an as needed basis, therefore we cannot conduct this collection
less frequently.
7. Special Circumstances
This information collection is in accordance with the guidelines in 5 CFR § 1320.6.
8. Federal Register/Outside Consultation
A 60-day Federal Register notice published on October 7, 2011.
9. Payments/Gifts to Respondents
We do not plan to provide any payment or gifts to respondents.

10. Confidentiality
Beneficiaries who choose to appoint a representative are required by regulation (42 CFR
§405.910 (c)(5)) to provide their Medicare Health Insurance Claim Number (which is
derived from the beneficiary’s Social Security Number) on the AOR form. Contractors
collect and maintain this information for CMS under the provisions of the Privacy Act.
11. Sensitive Questions
There are no questions of a sensitive nature associated with this request.

12. Burden Estimates (Hours & Wages)
We must estimate the burden for the Appointment of Representative (AOR) form because
we do not maintain data on the use of appointed representatives. Therefore, our estimates
are derived from anecdotal information.
Our estimates are limited to beneficiary appeals involving appointed representatives.
Providers and suppliers rarely invoke the use of appointed representatives, and when
they do, it is most often during the higher levels of the appeals process. Providers and
suppliers ar required to submit requests for initial determinations electronically, often
employing a billing service to handle the accounts. Therefore, we believe that providers
and suppliers are likely t use the AOR form for initial determinations in limited
circumstances.
We believe that when parties appoint representatives, they generally do so at the start of the
appeals process. For FY 2010, 2,654,807 requests for first level appeals were received (this
figure is obtained from the CROWD (Contractor Reporting of Operational & Workload
Data system used by contractors to report to CMS their annual claims processed data). We
estimat that 10% of all appellants (265,481) will appoint a representative.
Since we have developed the optional standardized form, we estimate that it should take
approximately 15 minutes to supply the information needed to comply with the
requirements for a valid Appointment of Representative. Therefore, we estimate the total
burden to be 66,370 hours on an annual basis.
Total burden hours computed as follows:
Burden Hours = (265,481 (10% of all appellants) multiplied by 15 minutes to complete
form) = 3,982,215 total minutes
Burden Hours = (3,982,215 total minutes) divided by 60 minutes per hour =
Total Number Burden Hours = 66,370
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Computation of Wages:
We estimate that 90% of all AOR forms will be completed by providers or suppliers. As
noted previously, providers and suppliers are likely to use a billing service to file claims
and appeals. We also estimate that the AOR form would most likely be prepared by a staff
perso with professional skills at the GS-9, Step1 level with an hourly salary of $19.92, so
we computed the wage burden as follows:
90% multiplied by Total of all Appointment of Representatives (0.9 multiplied by
265,481) = 238,933AORs completed by providers or suppliers annually
Burden Hours = (238,933 provider or supplier AORs multiplied by 15 minutes to
complete form) = 3,583,995 total minutes
Burden Hours = (3,583,995total minutes) divided by 60 minutes per hour =
Total Number Burden Hours = 59,733.25
GS-9 (Step 1) hourly rate 2010 = $19.92
Total Burden Hours x Hourly Rate = 59,733.25 multiplied by 19.92 =
$1,189,886 wage burden

The remaining 10% of the AOR forms filled out would be completed by beneficiaries and
would have no wage burden associated with their completion. However, the following is
a breakdown of the burden hours associated with the portion of forms completed by
beneficiaries:
10% multiplied by Total of all Appointment of Representatives (0.1 multiplied by
265,481) = 26,548AORs completed by beneficiaries annually
Burden Hours = (26,548 beneficiary AORs multiplied by 15 minutes to complete form) =
398,220 total minutes
Total Burden Hours = (398,220 total minutes) divided by 60 minutes per hour =
Total Burden Hours = 6,637
13. Capital Costs
There are no capital costs associated with this collection.
14. Cost to Federal Government
There is no cost to the Federal Government for this collection.
15. Changes to Burden
The burden hours are computed based on relevant available data for Medicare appeals, and
those figures are updated annually. Current appeals data indicates that the number of first
level
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appeals has decreased since 2007. While the total time to complete the form has not changed the
hourly burden estimates have decreased for all respondents due to fewer appeals being filed, but
the wage burden estimate has increased, due to an increase in wages since the last collection.
These figures are reflected in separate OMB Forms 83 – Part II, included in this collection.
There are no capital costs or costs to the Federal Government associated with the information
collected using this form.
16. Publication/Tabulation Dates
The standardized form will be published on the Internet; however, no aggregate or
individual data will be tabulated from them.
7.
Expiration Date
We are not requesting exemption.
8.
Certification Statement
There are no exceptions to the certification statement.
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