Information Collection

Prior Authorization Process (Facet Joint Interventions)

IC 254983 under ICR 202405-0938-022 · OMB 0938-1368.

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IC Title:	Prior Authorization Process (Facet Joint Interventions)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 419.80-419.83

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: 2,487	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	369,225	0	369,225
Annual IC Time Burden (Hours)	176,972	15,667	161,305
Annual IC Cost Burden (Dollars)	553,838	0	553,838

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