Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)

Forms and Documents

Document Name	Status
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report Form and Instruction	Modified
CMS 370 and 377 Supporting Statement. 08.21.24.docx Supporting Statement A	2024-08-27

IC Document Collections

IC ID	Document Title	Status
7913	Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0266	ICR Reference No: 202408-0938-021
Status: Received in OIRA	Previous ICR Reference No: 202102-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/29/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,946	0
Time Burden (Hours)	1,559	0
Cost Burden (Dollars)	0	0

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Abstract: The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. No edits were made to this agreement form. The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form is utilized to collect facility-specific characteristics that facilitate CMS’ oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC’s existing certification information. Minor edits to form were made for clarification of data being requested.

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Authorizing Statute(s): US Code: 18 USC 1832 Name of Law: Social Security Act
   US Code: 18 USC 1864 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 50589	06/14/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 68618	08/27/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	CMS-377, CMS-370	Health Insurance Benefits Agreement ,   Ambulatory Surgical Center Request for Initial Certification or Update of Certification Information in the Medicare Program

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ICR Summary of Burden

	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	1,946	0	0	379	0	1,567
Annual Time Burden (Hours)	1,559	0	0	547	0	1,012
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total annual number of responses for both the CMS-370 & CMS-377 forms has been increased from 1,567 in the previous PRA package to 1,946 in the current PRA package. This is an increase of 151 responses. The total burden hours increased from 1,012 to 1,559. The time burden estimate for completion of each CMS-370 form increased from five (5) minutes to 15 minutes. We made this change because the time estimate in the previous PRA package is too low. The CMS-370 form is a Health Insurance Benefits Agreement, in which the ASC facility agrees to comply with six (6) specifically enumerated requirements which are set forth on the form. The CMS-370 form also contains four (4) additional paragraphs regarding the terms for acceptance and effective date of the agreement. Also, there is a warning about proving false or misleading statements. We have increased the time burden for the CMS-377 form from 15 minutes to 30 minutes. We have made this change the CMS-377 form requires the ASC staff to provide information about the ASC and the type of services it provides. It may not be possible for the ASC staff member completing the form to obtain all necessary information required to complete the CMS-377 form in 15 minutes.

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Annual Cost to Federal Government: $71,219

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/29/2024

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