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Prior Authorization Process (Facet Joint Interventions)
Proposed Prior Authorization Process and Requirements for Certain Hospital Outpatient Department (OPD) Services (CMS-10711)
OMB: 0938-1368
IC ID: 254983
OMB.report
HHS/CMS
OMB 0938-1368
ICR 202405-0938-022
IC 254983
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
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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
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:
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
369,225
0
0
0
0
369,225
Annual IC Time Burden (Hours)
176,972
0
0
15,667
0
161,305
Annual IC Cost Burden (Dollars)
553,838
0
0
0
0
553,838
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.