Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65 (CMS-R-240)

Forms and Documents

Document Name	Status
Supporting Statement - Part A-Final.docx Supporting Statement A	2019-02-06

IC Document Collections

IC ID	Document Title	Status
8576	(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65	Modified

ICR Details

OMB Control No: 0938-0798	ICR Reference No: 201902-0938-006
Status: Active	Previous ICR Reference No: 201310-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-R-240
Title: Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65 (CMS-R-240)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2019
	Date Received in OIRA: 02/12/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time CMS will request approval to extend or revise the collection if the Agency seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved
Responses	13,648,400	0	0
Time Burden (Hours)	682,420	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 413.65(b)(3) states that a provider which is seeking a determination of provider-based status for a facility not located on the provider's campus must submit an attestation of compliance with applicable provider-based requirements and must supply documentation supporting its attestation at the time the attestation is made. Section 413.65(a)(1)(ii) establishes a listing of specific facilities for which determinations for provider-based status for payment purposes are not made. As CMS removed certain CAH-based facilities from this list, such facilities are allowed to apply for provider-based determination and are required to meet all provider-based requirements before billing for hospital or CAH based services.

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Authorizing Statute(s): PL: Pub.L. 105 - 33 4523 Name of Law: Prospective Payment System for Hospital Outpatient Services
   US Code: 42 USC 1395cc(b)(2) Name of Law: Agreements with providers of services; enrollment processes
  

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:
	83 FR 56085	11/09/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 734	01/31/2019
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
(CMS-R-240) Prospective Payments for Hospital Outpatient Services and Supporting Regulations in 42 CFR 413.65

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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	13,648,400	0	0	0	13,147,945	500,455
Annual Time Burden (Hours)	682,420	0	0	0	655,857	26,563
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:

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Annual Cost to Federal Government: $68,557

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

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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: 02/12/2019

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