Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and 42 CFR 424.5

ICR 201410-0938-006

OMB: 0938-0534

Federal Form Document

Forms and Documents
ICR Details
0938-0534 201410-0938-006
Historical Active 201303-0938-014
HHS/CMS 19157
Attending Physician's Certification of Medical Necessity for Home Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and 42 CFR 424.5
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/13/2014
Retrieve Notice of Action (NOA) 10/09/2014
  Inventory as of this Action Requested Previously Approved
06/30/2016 06/30/2016 06/30/2016
1,632,000 0 1,632,000
326,500 0 326,500
0 0 0

This form is used to determine of oxygen is reasonable and necessary pursuant to Medicare Statute, Medicare claims for home oxygen therapy must be supported by the treating physician's statement and other information including estimate length of need (#of months), diagnosis codes (ICD-9) etc.

US Code: 42 USC 1395y(a) Name of Law: Items or Services Specifically Excluded
   US Code: 42 USC 1395x(n) Name of Law: Durable Medical Equipment
   US Code: 42 USC 1395j(5) Name of Law: Special Payment Rules for Particular Items and Services
   US Code: 42 USC 1395l(e) Name of Law: Information for Determination of Amounts Due
   US Code: 42 USC 1395m(j)(2) Name of Law: Certificates of Medical Necessity
   US Code: 42 USC 1395m(j)(2)(A)(iii) Name of Law: null
  
None

Not associated with rulemaking

  77 FR 47852 08/10/2012
78 FR 16270 03/14/2013
No

  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 1,632,000 1,632,000 0 0 0 0
Annual Time Burden (Hours) 326,500 326,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$294,000
No
No
No
No
No
Uncollected
Kayla Williams 410 786-5887 [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.
10/09/2014


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