Information Collection

Recognition of pass-through payment for additional (new) categories of devices under the Outpatient Prospective Payment System and Supporting Regulations (CMS-10052)

IC 8672 under ICR 202106-0938-011 · OMB 0938-0857.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0857 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10052 Recognition of pass-through payment for additional (new) categories of devices under the Outpatient Prospective Payment System and Supporting Regulations (CMS-10052)	Form and Instruction
CMS-10052 Medicare Electronic Application Request Information Syst Device Pass-through.pdf	Form and Instruction
CMS-10052 Medicare Electronic Application Request Information Syst Device Pass-through.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Recognition of pass-through payment for additional (new) categories of devices under the Outpatient Prospective Payment System and Supporting Regulations (CMS-10052)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 419.66

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10052	Medicare Electronic Application Request Information System	Device Pass-through.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 2

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	160	160
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.