Requirements for the Medicare Incentive Reward Program and Provider Enrollment

Forms and Documents

Document Name	Status
CMS-10481_Supporting_Statement_Part_A.doc Supporting Statement A	2013-05-03

IC Document Collections

IC ID	Document Title	Status
208196	Attestation	New

ICR Details

OMB Control No: 0938-1227	ICR Reference No: 201308-0938-012
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 19460
Title: Requirements for the Medicare Incentive Reward Program and Provider Enrollment
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: Comment filed on proposed rule	Conclusion Date: 04/07/2014
	Date Received in OIRA: 08/13/2013
Terms of Clearance: The information collection requirements contained in this proposed rule are not approved at this time. CMS will respond to comments received and resubmit the collection at the final rule stage.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request pertains to our proposed revision to 42 CFR 420.405(d). Upon notification of reward eligiblity under the Incentive Reward Program, an individual would be required to submit an attestation stating that he or she has or will do all of the following: (i) Is not participating and has not participated in the sanctionable conduct. (ii) Is not otherwise ineligible to receive a reward under paragraph 420.405(c)(2). (iii) Has furnished information that is accurate and truthful to the best of his or her knowledge. (iv) Acknowledges that knowingly failing to provide truthful information could subject him or her to potential criminal and civil liability.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 203(b)(1-2) Name of Law: HIPAA
  

Citations for New Statutory Requirements: PL: Pub.L. 104 - 191 203(b)(1-2) Name of Law: HIPAA

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP01	Proposed rulemaking	78 FR 25013	04/29/2013

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Federal Register Notices & Comments

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
Attestation

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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 information collection request.

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Annual Cost to Federal Government: $6,026

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: 08/13/2013

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