Proposed Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process and Requirements for a Potential National Model (CMS-10708)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10708 Ambulance Prior Authorization	Form and Instruction	New	Available
Appendix 1 - Reponse to Public Comments 01-13-2020.docx	Supplementary Document	Uploaded 2020-03-11	Available
CMS-10708 - Supporting Statement - Finalx.docx	Supporting Statement A	Uploaded 2020-08-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
240694	Ambulance Prior Authorization	Form and Instruction	New

ICR Details

OMB Control No: 0938-1380	ICR Reference No: 202003-0938-006
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI-10708
Title: Proposed Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Process and Requirements for a Potential National Model (CMS-10708)
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: 08/25/2020
	Date Received in OIRA: 03/12/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023	36 Months From Approved
Responses	216,380	0	0
Time Burden (Hours)	113,706	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services (CMS) is currently testing the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model, in limited states, under the authority of section 1115A of the Social Security Act (the Act). Section 515(b) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) added paragraph (16) to section 1834(l) of the Act, which requires that, beginning January 1, 2017, the Secretary expand the model to all states if the model expansion meets certain statutory requirements for expanding models that are tested by the Center for Medicare and Medicaid Innovation (Innovation Center) under the authority of section 1115A of the Act. The expansion criteria, described in paragraphs (1) through (3) of section 1115A(c) of the Act, require that; (1) the Secretary determines that such expansion is expected to—(A) reduce spending under applicable title without reducing the quality of care; or (B) improve the quality of patient care without increasing spending; and (2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce (or would not result in any increase in) net program spending under applicable titles; and (3) the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under the applicable title for applicable individuals. Because section 1834(l)(16) of the Act requires the Secretary to expand the RSNAT Prior Authorization Model to all States if it meets the statutory expansion criterial in 1115A(c)(1 through 3) of the Act, the exemption from Paperwork Reduction Act (PRA) process in 1115A(d)(3) is not applicable for the purposes of the nationwide expansion of this model. Therefore, in order to move forward with potential nationwide expansion, contingent on the Secretary’s determination that the expansion criteria are met, CMS must complete the PRA approval process, as required by chapter 35 of title 44, United States Code. As part of the process for working towards potential expansion of the RSNAT Prior Authorization Model under section 1834(1)(16) of the Act, CMS is seeking approval for the collection of information under PRA.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: PL: Pub.L. 114 - 20 515(a) Name of Law: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

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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 57875	10/29/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 9473	02/19/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Ambulance Prior Authorization	CMS-10708	Ambulatory Prior Authorization

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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	216,380	0	216,380	0	0	0
Annual Time Burden (Hours)	113,706	0	113,706	0	0	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: This is a new collection of information.

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Annual Cost to Federal Government: $39,100,000

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]? Yes

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: 03/12/2020

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