Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 (CMS-R-138)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-R-138 Screensh CMS-R-138 Screenshot	Form	Modified	Available
Form CMS-R-138 Statewide Application Affadavit	Form	Modified	Available
CMS-R-138 Supporting Statement_final.docx	Supporting Statement A	Uploaded 2026-02-11	Available
CMS-R-138 Supporting Statement.docx	Supporting Statement A	Uploaded 2025-08-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8175	Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	Form	Modified	CMS-R-138 Screenshot
8175	Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	Form	Modified	Statewide Application Affadavit
8175	Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)		Modified

ICR Details

OMB Control No: 0938-0573	ICR Reference No: 202507-0938-026
Status: Active	Previous ICR Reference No: 201710-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 (CMS-R-138)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/11/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/01/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2029	36 Months From Approved
Responses	850	0	0
Time Burden (Hours)	850	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1886(d)(10) of the Social Security Act established the Medicare Geographic Classification Review Board (MGCRB), an entity with the authority to accept short-term hospital inpatient prospective payment system applications from hospitals requesting geographic reclassification for wage index or standardized amount payment purposes and issue decisions on these requests. This regulation sets up the application process for prospective payment system hospitals that choose to appeal their geographic status to the MGCRB.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1886
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 20304	05/13/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 35529	07/28/2025
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	CMS-R-138, CMS-R-138 Screenshot	Statewide Application Affadavit ,   CMS-R-138 Screenshot

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	850	0	0	550	0	300
Annual Time Burden (Hours)	850	0	0	550	0	300
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: Due to the change in regulation that permitted hospitals with rural status via § 412.103 to apply for MGCRB reclassification, there are now on average 800 applications to the MGCRB with an anticipated upward submission trend of 50 additional applications/year.

---

Annual Cost to Federal Government: $31,433

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

---

Common Form ICR:  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:

(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: 08/01/2025

---