Temporary Extraordinary Circumstances Exception for Excepted Provider-Based Departments (CMS-10730)

Forms and Documents

Document Name	Status
CMS-10730. Emergency Justification - PBDs - FINAL.docx Supplementary Document	2020-05-19
CMS-10730.Emergency Justification Document.docx Supplementary Document	2020-05-08
CMS-10730.Supporting Statement Part A - FINAL (5-19-20).docx Supporting Statement A	2020-05-19

IC Document Collections

IC ID	Document Title	Status
241751	Request for Temporary Extraordinary Circumstances Exception	New

ICR Details

OMB Control No: 0938-1376	ICR Reference No: 202005-0938-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Temporary Extraordinary Circumstances Exception for Excepted Provider-Based Departments (CMS-10730)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 05/15/2020
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/20/2020
	Date Received in OIRA: 05/11/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	6 Months From Approved
Responses	450	0	0
Time Burden (Hours)	113	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: If hospitals want to continue to bill under the outpatient prospective payment system (OPPS) (vs. the PFS), hospitals that relocate excepted on- or off-campus provider based departments (PBDs) to off-campus locations in response to the COVID-19 public health emergency (PHE) will be required to contact their CMS Regional Office by email to request a temporary extraordinary circumstances exception. CMS will collect the necessary information from all hospitals that request temporary extraordinary circumstances exceptions for one or more on-campus or excepted off-campus provider-based departments during the COVID-19 PHE. CMS will use this information to review the hospitals’ justification for the relocation and the role of the relocation in the hospital’s response to COVID-19 to ensure efficient and legal use of Medicare program funds.

Emergency Justfication: Please see the attached emergency justification.

---

Authorizing Statute(s): PL: Pub.L. 114 - 74 603 Name of Law: Bipartisan Budget Act of 2015
  

Citations for New Statutory Requirements: PL: Pub.L. 114 - 74 603 Name of Law: Bipartisan Budget Act of 2015

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU32	Final or interim final rulemaking	85 FR 27550	05/08/2020

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Request for Temporary Extraordinary Circumstances Exception

---

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	450	0	450	0	0	0
Annual Time Burden (Hours)	113	0	113	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 information collection request.

---

Annual Cost to Federal Government: $11,710

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

---

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: 05/11/2020

---