Independent Rural Health Clinic Cost Report (CMS-222-17)

ICR 202112-0938-011

OMB: 0938-0107

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2022-01-05
IC Document Collections
IC ID
Document
Title
Status
7853 Modified
ICR Details
0938-0107 202112-0938-011
Received in OIRA 201709-0938-008
HHS/CMS CM-FFS
Independent Rural Health Clinic Cost Report (CMS-222-17)
Reinstatement without change of a previously approved collection   No
Regular 01/06/2022
  Requested Previously Approved
36 Months From Approved
1,724 0
94,820 0
0 0

The Form CMS-222-17 cost report is needed to determine program reimbursement and the amount of reasonable cost due to providers for furnishing medical services to Medicare beneficiaries.

US Code: 42 USC 1395g Name of Law: Payment to Providers of services
   US Code: 42 USC 1395h Name of Law: Provisions relating to the administration of Part A
   US Code: 42 USC 1395i Name of Law: Payment of Benefits
   US Code: 42 USC 1395x Name of Law: Definitions of services, Institutions, etc
  
None

Not associated with rulemaking

  86 FR 57149 10/14/2021
86 FR 73785 12/28/2021
No

1
IC Title Form No. Form Name
Rural Health Clinic Cost Report (CMS-222-17) CMS-222-17 Rural Health Clinic Cost Report

  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 1,724 0 0 0 -20 1,744
Annual Time Burden (Hours) 94,820 0 0 0 -1,100 95,920
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Burden has decreased due to a decrease in the number of respondents from 1,744 in 2017 to 1,724 in 2021 as a result of voluntary and involuntary terminations and the option for RHC providers to file consolidated cost reports.

$2,630,000
No
    No
    No
No
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/06/2022


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