OMHA Annual Appellant Climate Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
OMHA OMB Package Part A 10 26 20.docx	Supporting Statement A	Uploaded 2021-05-26	Missing upstream
0990-0330 30-Day FRN.doc	Supplementary Document	Uploaded 2018-01-09	Repair queued
OMHA OMB Package Part B 10 26 20.docx	Supporting Statement B	Uploaded 2021-03-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184626	Beneficiaries	Other-letter	Modified
184625	Health Care Providers and Suppliers	Other-survey	Modified

ICR Details

OMB Control No: 0990-0330	ICR Reference No: 202103-0990-004
Status: Received in OIRA	Previous ICR Reference No: 201709-0990-001
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: OMHA Annual Appellant Climate Survey
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/26/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2021
Responses	800	400
Time Burden (Hours)	200	100
Cost Burden (Dollars)	0	0

---

Abstract: The Office of Medicare Hearings and Appeals (OMHA)requests a three year programmatic clearance from the OMB to conduct customer research through external surveys by means of telephone interviews and web-based suveys. The proposed information collection request covers all types of OMHA appellants, with a primary focus on the three appellant types who receive benefits from OMHA-beneficiares, providers, and suppliers.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
   EO: EO 12862 Name/Subject of EO: September 11, 1993
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 10587	02/22/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 26738	05/17/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Beneficiaries
Health Care Providers and Suppliers

---

ICR Summary of Burden

table that charts list of burden

	Total Request	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	800	400	0	400	0	0
Annual Time Burden (Hours)	200	100	0	100	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of respondents has been increased in this upcoming data collection cycle. As new field offices have been created and staffed to fulfill the increase in Medicare appeals, the targeted number of completed surveys increased from 400 in the previous cycle to 800 in each FY of the upcoming data collection cycle. This increase in sample size will provide data for process improvements in each field office for the purpose of improving the Medicare appellants’ customer experience. The estimated number of burden hours is 200 burden hours for each FY.

---

Annual Cost to Federal Government: $30,301

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 05/26/2021

---