(CMS-437A and 437B) Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-437 A Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B) Form and Instruction	Modified
CMS-437 A and B Supporting Statement_Passback Final.docx Supporting Statement A	2016-03-30

IC Document Collections

IC ID	Document Title	Status
8848	Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0986	ICR Reference No: 201507-0938-014
Status: Historical Active	Previous ICR Reference No: 201206-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-437A and 437B) Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/06/2016
	Date Received in OIRA: 07/28/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	36 Months From Approved	04/30/2016
Responses	478	0	1,164
Time Burden (Hours)	120	0	291
Cost Burden (Dollars)	0	0	0

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Abstract: The rehabilitation hospital and rehabilitation unit criteria work sheets are necessary to verify that these facilities/units comply and remain in compliance with the exclusion criteria for the Medicare perspective payment system.

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Authorizing Statute(s): US Code: 42 USC 412.20 Name of Law: Hospital Services Subject to PPS
  

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:
	80 FR 27971	05/15/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44131	07/24/2015
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
Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)	CMS-437B, CMS-437 A	REHABILITATION UNIT CRITERIA WORK SHEET ,   REHABILITATION HOSPITAL CRITERIA WORK SHEET

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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	478	1,164	0	-686	0	0
Annual Time Burden (Hours)	120	291	0	-171	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: . However, we have implemented a policy change to only require reporting once every three years. State survey agencies have been instructed to collect the attestation from one third of IRFs in their State annually. Therefore, the number of IRFs submitting the form annually is 478. The annual hourly burden rate has subsequently decreased from 290 to 120, a total reduction of 170 hours annually.

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Annual Cost to Federal Government: $5,209

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: 07/28/2015

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