(CMS-437) Psychiatric Unit Criteria Work Sheet and Supporting Regulations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-437 (437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	Form and Instruction	Modified	Available
CMS 437 Supporting Statement 5-3-18.docx	Supporting Statement A	Uploaded 2018-05-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7996	(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0358	ICR Reference No: 201712-0938-004
Status: Active	Previous ICR Reference No: 201407-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-437) Psychiatric Unit Criteria Work Sheet and Supporting Regulations
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: 05/14/2018
	Date Received in OIRA: 12/05/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved
Responses	1,616	0	0
Time Burden (Hours)	1,212	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The psychiatric unit criteria work sheets are necessary to verify, on an annual basis, that these units meet the requirements to be excluded from payment under the Medicare Inpatient Prospective Payment System (IPPS) for the purpose of receiving payment under the Inpatient Psychiatric Prospective Payment System (IPF PPS).

---

Authorizing Statute(s): US Code: 42 USC 412 Name of Law: 25-27
  

Citations for New Statutory Requirements: None

---

EO 13771 Designation: Deregulatory

---

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 43549	09/18/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 56243	11/28/2017
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
(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	CMS-437	Psychiatric Unit Criteria Worksheet

---

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	1,616	0	0	2	0	1,614
Annual Time Burden (Hours)	1,212	0	0	808	0	404
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: In the prior PRA package, the annual hourly burden was estimated to be 404 hours. Due to our increase in the estimated time required to complete the CMS-437 worksheet and the increased number of IPFs we have estimated the current hourly burden to be 1,212 hours. These factors have increased the estimated annual hour burden by 808 hours.

---

Annual Cost to Federal Government: $0

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: 12/05/2017

---