Prior Authorization Process (Five Original Categories)

Proposed Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services (CMS-10711)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1368 can be found here:

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Prior Authorization Process (Five Original Categories)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 419.80-83

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,982	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 70 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	194,785	43,334	151,451
Annual IC Time Burden (Hours)	108,108	0	108,108
Annual IC Cost Burden (Dollars)	292,175	292,175	0

Documents for IC

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.