Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10126 CMN for ENTERAL AND PARENTERAL NUTRITION	Form and Instruction	Modified	Available
Form CMS-10125 CMN for EXTERNAL INFUSION PUMPS	Form and Instruction	Modified	Available
Form CMS-849 CMN for SEAT LIFT MECHANISMS	Form and Instruction	Modified	Available
Form CMS-848 CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)	Form and Instruction	Modified	Available
Form CMS-847 CMN for OSTEOGENESIS STIMULATORS	Form and Instruction	Modified	Available
Form CMS-846 CMS for PNEUMATIC COMPRESSION DEVICES	Form and Instruction	Modified	Available
Form CMS-854 CMS-854 -- CONTINUATION FORM	Form and Instruction	Modified	Available
Form CMS-484 Certificate of Medical Necessity - Oxygen	Form and Instruction	Modified	Available
CMS-484-10126 - Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2020-02-27	Available
CMS-484-10126 - Appendix A - Response to Public Comments.pdf	Supplementary Document	Uploaded 2020-02-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMN for ENTERAL AND PARENTERAL NUTRITION
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMN for EXTERNAL INFUSION PUMPS
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMN for SEAT LIFT MECHANISMS
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS)
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMN for OSTEOGENESIS STIMULATORS
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS for PNEUMATIC COMPRESSION DEVICES
37897	Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	Form and Instruction	Modified	CMS-854 -- CONTINUATION FORM
221459	Oxygen and Supplies	Form and Instruction	Modified	Certificate of Medical Necessity - Oxygen

ICR Details

OMB Control No: 0938-0679	ICR Reference No: 202002-0938-014
Status: Historical Active	Previous ICR Reference No: 201605-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/04/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/27/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved	06/30/2020
Responses	1,335,658	0	2,094,000
Time Burden (Hours)	267,131	0	418,800
Cost Burden (Dollars)	0	0	0

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Abstract: This information is needed to correctly process claims and ensure that claims are properly paid. These forms contain medical information necessary to make an appropriate claim determination. Suppliers and physicians will complete these forms and as needed supply additional routine supporting documentation to process claims.

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Authorizing Statute(s): US Code: 42 USC 1395m(j)(2) Name of Law: Certificates of Medical Necessity
   US Code: 42 USC 1395m(j)(2)(A)(iii) Name of Law: Penalty
   US Code: 42 USC 1395j(5) Name of Law: Special Payment Rules for Particular Items and Services
   US Code: 42 USC 1395y(a)(1)(A) Name of Law: Items or Services Specifically Excluded
   US Code: 42 USC 1395y(a) Name of Law: Items or Services Specifically Excluded
   US Code: 42 USC 1395x(n) Name of Law: Durable medical equipment
   US Code: 42 USC 1395l(e) Name of Law: Information for Determination of Amounts Due
  

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 57734	10/28/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 10442	02/24/2020
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
Durable Medical Equipment Medicare Administrative Contractors (MAC) Regional Carrier, Certificate of Medical Necessity and Supporting Documentation	CMS-846, CMS-847, CMS-848, CMS-849, CMS-10125, CMS-10126, CMS-854	CMS-854 -- CONTINUATION FORM ,   CMS for PNEUMATIC COMPRESSION DEVICES ,   CMN for OSTEOGENESIS STIMULATORS ,   CMN for TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) ,   CMN for SEAT LIFT MECHANISMS ,   CMN for EXTERNAL INFUSION PUMPS ,   CMN for ENTERAL AND PARENTERAL NUTRITION
Oxygen and Supplies	CMS-484	Certificate of Medical Necessity - Oxygen

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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	1,335,658	2,094,000	0	0	-758,342	0
Annual Time Burden (Hours)	267,131	418,800	0	0	-151,669	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: As a result in decreasing the annual number of CMN submissions, CMS is decreasing the burden from 418,800 hours to 267,131 hours. Therefore, there is a total burden hour decrease of 151,669.

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Annual Cost to Federal Government: $333,915

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? No

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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: 02/27/2020

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