Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10242 Supporting Statement Part A (Accepting all BP edits 12-7-16).docx	Supporting Statement A	Uploaded 2016-12-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184092	Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)		Modified

ICR Details

OMB Control No: 0938-1049	ICR Reference No: 201612-0938-017
Status: Historical Active	Previous ICR Reference No: 201610-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10242
Title: Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)
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: 04/19/2017
	Date Received in OIRA: 12/15/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2020	36 Months From Approved	04/30/2017
Responses	14,155,617	0	15,633,781
Time Burden (Hours)	1,180,578	0	1,303,857
Cost Burden (Dollars)	0	0	0

---

Abstract: Because it is very difficult to obtain a beneficiary's signature (or the signature of a person authorized to sign on behalf of the beneficiary) on a claim when the beneficiary is being transported by ambulance in emergency situations, we are proposing that, for emergency ambulance transport services, an ambulance provider or supplier may submit the claim without a beneficiary's signature, as long as certain documentation requirements are met.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1814 Name of Statute: null
   Statute at Large: 18 Stat. 1835 Name of Statute: null
   Statute at Large: 18 Stat. 1842 Name of Statute: null
   Statute at Large: 18 Stat. 1848 Name of Statute: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 49958	07/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 69828	10/07/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)

---

ICR Summary of Burden

table that charts list 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	14,155,617	15,633,781	0	0	-1,478,164	0
Annual Time Burden (Hours)	1,180,578	1,303,857	0	0	-123,279	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: No

Burden Reduction Due to:

Short Statement: We updated the burden estimate in section A.12 from the last burden estimate to reflect changes in the number of ambulance suppliers, the number of claims, and the addition of 100% of the hourly wage for the cost calculations used to account for fringe and overhead. We have not changed the information collection requirements in any way. The number of Medicare-enrolled ambulance suppliers decreased from 11,564 to 10,402. The total estimated number of ambulance transports for Part B-paid claims in 2015 was 14,155,617. This number represents a 9.46% decrease in the number of Part B-paid ambulance transport claims from 2011. In light of these facts, we have adjusted the annual time and cost burden estimates accordingly. The total number of burden hours decreased from 1,303,857 to 1,180,578. The estimated average hourly wage for emergency medical technicians and paramedics increased from $16.53 to $34.08. The total estimated cost for obtaining the documentation requirements in 42 CFR 424.36(b) (6) increased from approximately $1,863.78 to $3867.92 per ambulance supplier.

---

Annual Cost to Federal Government: $0

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

---

Common Form ICR:  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:

(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: 12/15/2016

---