QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with Suppliers

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10633 QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys	Form and Instruction	New	Available
Form CMS-10633 QIC Demonstration Evaluation Contractor (QDEC): Key Informant Interviews	Form and Instruction	New	Available
QDEC SSA_1-18-2018 - -Final.docx	Supporting Statement A	Uploaded 2018-01-25	Available
Memo -Response to Comments on CMS-10633.docx	Supplementary Document	Uploaded 2017-06-27	Available
QDEC SSB_1-18-2018 -Final.docx	Supporting Statement B	Uploaded 2018-01-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227305	QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys	Form and Instruction	New
227304	QIC Demonstration Evaluation Contractor (QDEC): Key Informant Interviews	Form and Instruction	New

ICR Details

OMB Control No: 0938-1348	ICR Reference No: 201706-0938-005
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10633
Title: QIC Demonstration Evaluation Contractor (QDEC): Analyze Medicare Appeals to Conduct Formal Discussions and Reopenings with Suppliers
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/29/2018
	Date Received in OIRA: 06/28/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved
Responses	2,640	0	0
Time Burden (Hours)	473	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Formal Telephone Discussion Demonstration and Reopenings Process is authorized under Section 402(a)(1)(F), U.S.C.§ 1395-1(a)(1)(F)1, of the Social Security Amendments of 1967. Primary and secondary data are needed to understand the effectiveness of the Demonstration in improving suppliers’ understanding of claims denial during Level 2 of the appeals process and facilitating more accurate claim submission over time. Primary data are necessary to determine, from the perspective of participating suppliers, the quality of the formal telephone discussions, satisfaction with the formal telephone discussion process, and the effect of the formal telephone discussions on suppliers’ understanding of submitting accurate claims.

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Authorizing Statute(s): None

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:
	81 FR 95614	12/28/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 25608	06/02/2017
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
QIC Demonstration Evaluation Contractor (QDEC): Key Informant Interviews	CMS-10633	Key Informant Interviews
QIC Demonstration Evaluation Contractor (QDEC): Web Based Surveys	CMS-10633	Web Based Surveys

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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	2,640	0	0	2,640	0	0
Annual Time Burden (Hours)	473	0	0	473	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Reason: This is for a new information collection request

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Annual Cost to Federal Government: $390,588

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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.     Yes

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

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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: 06/28/2017

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