Electronic Submission of Medicare GME Affiliation Agreements

ICR 201310-0938-002

OMB: 0938-1111

Federal Form Document

IC Document Collections
IC ID
Document
Title
Status
193422 Modified
193421 Modified
193420 Modified
ICR Details
0938-1111 201310-0938-002
Historical Active 201009-0938-005
HHS/CMS 20696
Electronic Submission of Medicare GME Affiliation Agreements
Extension without change of a currently approved collection   No
Regular
Approved without change 04/21/2014
Retrieve Notice of Action (NOA) 10/25/2013
  Inventory as of this Action Requested Previously Approved
04/30/2017 36 Months From Approved 04/30/2014
375 0 375
166 0 166
0 0 0

As discussed in the FY2011 Inpatient Prospective Payment System final rule, we will allow hospitals to electronically submit the copy of the affiliation agreement that is required to be sent to the CMS Central Office. The electronic submission process consists of either an email mailbox or a Web site where hospitals must submit their Medicare GME affiliation agreements to the CMS Central Office to a designated online mailbox. A copy of the Medicare GME affiliation agreement must be received through the electronic system no later than 11:59 p.m. on July 1 of each academic year. The electronic affiliation agreement must be submitted either as a scanned copy or a Printer-Friendly Display (PDF) version of that hard copy agreement; we will not accept an agreement in any electronic format that could be subject to manipulation. The scanned and/or PDF format will enable CMS to ensure that the agreements are signed and dated as required in the regulations at 42 CFR 413.75. Hospitals will have the option to continue to submit a hard copy of its affiliation agreement to the CMS Central Office. In addition, each fiscal intermediary or MAC will continue to have the authority to specify its requirements for submittal of the Medicare GME affiliation agreement by hospitals that are part of the affiliation.

PL: Pub.L. 105 - 32 4623 Name of Law: Limitation of Number of Residents and Rolling Average FTE Count
   US Code: 42 USC 1395ww Name of Law: Payment to Hospitals for Inpatient Hospital Services
  
None

Not associated with rulemaking

  78 FR 45205 07/26/2013
78 FR 61846 10/04/2013
No

3
IC Title Form No. Form Name
Hardcopy Submission to FI or MAC CMS-10326 SAMPLE Affiliation Agreement
Electronic Submission to CMS CMS-10326 SAMPLE Affiliation Agreement
Development of Agreement CMS-10326 SAMPLE Affiliation Agreement

  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 375 375 0 0 0 0
Annual Time Burden (Hours) 166 166 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$5,972
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/25/2013


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