Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity

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
8698	Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity Form	Migrated

ICR Details

OMB Control No: 0938-0875	ICR Reference No: 200207-0938-007
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/13/2002
	Date Received in OIRA: 07/16/2002
Terms of Clearance: Approval of this information collection request is being granted for a period of three months. During the review period, OMB and the agency have begun discussions about possible modifications to the CMN form and the agency has also undertaken its own review. In light of this ongoing interagency discussion and agency review, and the possibility that they will result in proposed modification to the form(s), CMS is being given a three month approval. If the current discussion and review results in significant proposed changes to the form(s), then the agency will seek public comment on any resulting proposed changes to the CMN via the Federal Register, as established in the Paperwork Reduction Act. The agency must also resubmit the collection to OMB for approval prior to the expiration of its approval. Because compliance with these public comment and OMB review procedures would require additional time, OMB will reassess the status of the interagency discussion and agency review near the end of this 90-day approval period, and we will determine the appropriate action to take with respect to an extension of the current approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2002	12/31/2002
Responses	129,000	0	0
Time Burden (Hours)	32,250	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information is needed to correctly process claims and ensure that claims are properly paid. These forms contain medical information necessary to make an appropriate claim determinatin. Suppliers and physicians will complete these forms.

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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
Durable Medical Equipment Regional Carrier, Certificate of Medical Necessity	CMS-843

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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	129,000	0	0	129,000	0	0
Annual Time Burden (Hours)	32,250	0	0	32,250	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: 07/16/2002

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