Medicare EDI Enrollment Form and EDI Registration

Forms and Documents

Document Name	Status
Form CMS-10164 Medicare EDI Enrollment Form and EDI Registration Form and Instruction	Modified
Changes_to_the_EDI_enrollment_Package.pdf Supplementary Document	2013-02-24
CMS-10164 Supporting Statement9.7.12.pdf Supporting Statement A	2013-02-24

IC Document Collections

IC ID	Document Title	Status
8845	Medicare EDI Enrollment Form and EDI Registration Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0983	ICR Reference No: 201302-0938-010
Status: Historical Active	Previous ICR Reference No: 200903-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: 18916
Title: Medicare EDI Enrollment Form and EDI Registration
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: 06/10/2013
	Date Received in OIRA: 02/27/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	240,000	0	0
Time Burden (Hours)	80,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Federal law requires that CMS minimize the security risk to federal information systems. CMS is requiring that trading partners who wish to conduct the Electronic Data Interchange (EDI) transactions provide certain assurance as a condition of receiving access to the Medicare system for the purpose of conducting EDI exchanges. Health care providers, clearinghouses, and health plans that wish access to the Medicare system are required to complete this form. The information will be used to assure that those entities that access the Medicare system are aware of applicable provisions and penalties.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 261 Name of Law: Purpose
   PL: Pub.L. 104 - 191 262 Name of Law: Administrative Simplification
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 57090	09/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 12322	02/22/2013
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Medicare EDI Enrollment Form and EDI Registration	CMS-10164, CMS-10164	Accesible EDI Registration Form ,   Accessible EDI Enrollment Form

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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	240,000	0	0	0	0	240,000
Annual Time Burden (Hours)	80,000	0	0	0	0	80,000
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: $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

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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: 02/27/2013

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