Medicare Prior Authorization of Power Mobility Devices (PMDs) Demonstration (CMS-10471)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10471 REVISED - Supporting Statement Part A 2017 Final.docx	Supporting Statement A	Uploaded 2017-08-07	Available
CMS-10471 Appendix A.docx	Supplementary Document	Uploaded 2017-05-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209056	State and Local governments	Instruction	Modified
209055	Practitioners, PMD Suppliers, and Advocates	Instruction	Modified

ICR Details

OMB Control No: 0938-1235	ICR Reference No: 201705-0938-012
Status: Historical Active	Previous ICR Reference No: 201407-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: 20684
Title: Medicare Prior Authorization of Power Mobility Devices (PMDs) Demonstration (CMS-10471)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/05/2018
	Date Received in OIRA: 08/07/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	36 Months From Approved
Responses	355	0	0
Time Burden (Hours)	495	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of the Demonstration is to ensure that payments for PMDs are appropriate before the claims are paid, thereby preventing the fraud, waste, and abuse in the seven states participating in the Demonstration: California, Florida, Illinois, Michigan, New York, North Carolina and Texas. Additional benefits of the Demonstration include ensuring that a beneficiary's medical condition warrants their medical equipment under existing coverage guidelines and preserving their ability to receive quality products from accredited suppliers.

---

Authorizing Statute(s): US Code: 42 USC 1395b-1(a)(1)(J) Name of Law: Incentives for economy while maintaining or improving quality in provision of health services
  

Citations for New Statutory Requirements: US Code: 42 USC 1395b-1(a)(1)(J) Name of Law: Incentives for economy while maintaining or improving quality in provision of health services

---

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:
	82 FR 11921	02/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 24350	05/26/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Practitioners, PMD Suppliers, and Advocates	CMS-10471	Revised PMD Stakeholders Screening and Scheduling Guide
State and Local governments	CMS-10471	Revised PMD Stakeholders Screening and Scheduling Guide

---

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	355	0	0	0	73	282
Annual Time Burden (Hours)	495	0	0	0	172	323
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: The burden has increased by 166 hours (from 323 hours to 495 hours). The primary reason for this increase is due to background research being conducted twice per project year instead of one time per project year.

---

Annual Cost to Federal Government: $76,400

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 08/07/2017

---