Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)

Forms and Documents

Document Name	Status
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report Form and Instruction	Modified
CMS-370 -377 Supporting Statement A RevisedFINAL 7 2 2014.doc Supporting Statement A	2014-07-02

IC Document Collections

IC ID	Document Title	Status
7913	Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0266	ICR Reference No: 201407-0938-002
Status: Historical Active	Previous ICR Reference No: 201106-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2014
	Date Received in OIRA: 07/03/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	09/30/2014
Responses	1,833	0	2,090
Time Burden (Hours)	633	0	647
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form as revised will be utilized to collect facility-specific characteristics that facilitate CMS' oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. The data base that supports survey and certification activities will be revised to reflect changes in the data fields on this revised form, such as the data on the types of surgical procedures performed in the ASC. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC's existing certification information.

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Authorizing Statute(s): US Code: 18 USC 1832 Name of Law: Social Security Act
   US Code: 18 USC 1864 Name of Law: Social Security Act
  

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:
	79 FR 18555	04/02/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 36518	06/27/2014
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
Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	CMS-370, CMS-377	Health Insurance Benefits Agreement ,   Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program

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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	1,833	2,090	0	-257	0	0
Annual Time Burden (Hours)	633	647	0	-14	0	0
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden is adjusted to account for a reduction in annual growth in the number of ASCs.

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Annual Cost to Federal Government: $33,288

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: 07/03/2014

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