Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)

Forms and Documents

Document Name	Status
CMS-10242 PRA Justification - Supporting Statement for 424.36 on bene signatures.doc Supporting Statement A	2008-02-20

IC Document Collections

IC ID	Document Title	Status
184092	Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)	New

ICR Details

OMB Control No: 0938-1049	ICR Reference No: 200803-0938-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)
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 without change	Conclusion Date: 08/04/2008
	Date Received in OIRA: 03/11/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved
Responses	6,500,000	0	0
Time Burden (Hours)	541,667	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Because it is very difficult to obtain a beneficiary's signature (or the signature of a person authorized to sign on behalf of the beneficiary) on a claim when the beneficiary is being transported by ambulance in emergency situations, we are proposing that, for emergency ambulance transport services, an ambulance provider or supplier may submit the claim without a beneficiary's signature, as long as certain documentation requirements are met.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1835 Name of Statute: null
   Statute at Large: 18 Stat. 1814 Name of Statute: null
   Statute at Large: 18 Stat. 1842 Name of Statute: null
   Statute at Large: 18 Stat. 1848 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AO65	Final or interim final rulemaking	72 FR 66580	11/27/2007

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 38601	07/13/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 8877	02/15/2008
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
Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)

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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	6,500,000	0	0	6,500,000	0	0
Annual Time Burden (Hours)	541,667	0	0	541,667	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: Changing Regulations

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

Burden Reduction Due to:

Short Statement: CMM is adding 424.36(b)(6), so that, in certain emergency ambulance transport situations, an ambulance provider or supplier may submit a claim to Medicare without the beneficiary's signature if certain documentation requirements are met.

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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: 03/11/2008

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