QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICIARIES, MEDICARE SECONDARY PAYER

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
113139	QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICIARIES, MEDICARE SECONDARY PAYER Form	Migrated

ICR Details

OMB Control No: 0938-0214	ICR Reference No: 199304-0938-007
Status: Historical Active	Previous ICR Reference No: 199008-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICIARIES, MEDICARE SECONDARY PAYER
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/16/1993
	Date Received in OIRA: 04/19/1993
Terms of Clearance: The existing contractor claims development requirements in this submis sion are reinstated for use through 7/96. The five draft standard For and the intitial enrollment specifications as expressed in the contractor statement of work also are approved in concept by OMB throu 7/96. OMB, however, is unable to approve the five draft Forms for immediate implementation because this submission does not include: 1) a time line for phasing in or piloting the Forms (which HCFA has indicated in conversations is its intent); 2) final versions of the Forms that may differ in format to accomodate the contractor's technological needs, such as optical scanning; 3) supporting Form in- structions for beneficiaries, providers, and contractors, as well as the proposed beneficiary cover letter with the "800 number;" and 4) finally, a clear explanation of the frequency of and circumstances initiating provider responses and responses related to "claim specific instances where questions arise" (see pg. 9 of the Supporting Statement).These materials should be included in the next OMB sub- mission for approval at least 90 days prior to fielding these new standard Forms.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/1996	07/31/1996
Responses	2,600,000	0	0
Time Burden (Hours)	650,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: ADMINISTRATION'S ABILITIES TO ENSURE COMPLIANCE WITH 42 U.S.C. 1395Y(B BENEFICIARIES, THEIR REPRESENTATIVES, ETC., IN CLAIM SPECIFIC BENEFICIARY'S WILL BE REQUESTED TO SUPPLY INFORMATION TO DETERMINE IF MSP SITUATION APPLIES TO THEIR SPECIFIC CIRCUMSTANCES.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

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
QUESTIONS ON OTHER INSURANCE AVAILABLE TO MEDICARE BENEFICIARIES, MEDICARE SECONDARY PAYER	HCFA-250, THROUGH, FREQ, 254

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ICR Summary 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	2,600,000	0	0	2,600,000	0	0
Annual Time Burden (Hours)	650,000	0	0	650,000	0	0
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:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 04/19/1993

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