Physician Certifications/Recertifications in Skilled Nursing Facilities Manual Instructions and Supporting Regs.

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-R-5 - Supporting Statement Part A-2020 clean.docx	Supporting Statement A	Uploaded 2020-04-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43658	Physician Certifications/Recertifications		Modified
190006	Physician Initial Certification		Modified

ICR Details

OMB Control No: 0938-0454	ICR Reference No: 201912-0938-016
Status: Active	Previous ICR Reference No: 201612-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-R-5
Title: Physician Certifications/Recertifications in Skilled Nursing Facilities Manual Instructions and Supporting Regs.
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/08/2020
	Date Received in OIRA: 12/19/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2023	36 Months From Approved	04/30/2020
Responses	2,746,550	0	2,711,136
Time Burden (Hours)	615,149	0	624,515
Cost Burden (Dollars)	0	0	0

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Abstract: Medicare, Skilled Nursing Facilities. 42 CFR 424.20 requires SNFs to keep record of physician certifications and recertification of information such as the need for care and services, estimated duration of the SNF stay, and plan for home care.

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Authorizing Statute(s): PL: Pub.L. 101 - 239 1814(a)(2) Name of Law: Requirement of Requests and Certifications
  

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:
	84 FR 48145	09/12/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 68936	12/17/2019
Did the Agency receive public comments on this ICR? No

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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
Physician Certifications/Recertifications
Physician Initial Certification

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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	2,746,550	2,711,136	0	0	35,414	0
Annual Time Burden (Hours)	615,149	624,515	0	0	-9,366	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: The total number of responses have increased from 2,711,136 to 2,746,550 and the total number of annual hour burden decreased from 624, 515 to 615,149 from the previously approved submission in 2016 to 2019.

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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

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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: 12/19/2019

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