Federal Funding of Emergency Health Services (Section 1011); Provider Payment Determination and On-Call Cost Forms

Forms and Documents

Document Name	Status
Form CMS-10130A Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A) Form and Instruction	Modified
Form CMS-10130B Federal Funding of Emergency Health Services;Request for Section 1011 Hospital On-call Payments to Physicians (CMS-10130B) Form and Instruction	New
0938-0952 burden change QandA Jan 2009.doc Supplementary Document	2009-01-14
SUMMARY OF CHANGES TO 1011 PPD & On-Call.doc Supplementary Document	2008-10-30
PRA Supporting Statement Provider Payment Determination and On-Call Form.doc Supporting Statement A	2009-01-14

IC Document Collections

IC ID	Document Title	Status
8808	Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A) Form and Instruction	Modified
187085	Federal Funding of Emergency Health Services;Request for Section 1011 Hospital On-call Payments to Physicians (CMS-10130B) Form and Instruction	New

ICR Details

OMB Control No: 0938-0952	ICR Reference No: 200811-0938-003
Status: Historical Active	Previous ICR Reference No: 200511-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Federal Funding of Emergency Health Services (Section 1011); Provider Payment Determination and On-Call Cost Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/30/2009
	Date Received in OIRA: 11/04/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2012	36 Months From Approved	01/31/2009
Responses	300,148	0	7,512,000
Time Burden (Hours)	75,007	0	634,000
Cost Burden (Dollars)	0	0	0

---

Abstract: The Section 1011 Provider Payment Determination form allows hospitals, physicians and ambulance providers to ascertain and document a patient's eligibility status under Section 1011 of the Medicare Modernization Act of 2003. The form is maintained by the provider as documentation of patient eligibility, for payment and related policy determinations and is used by the Centers for Medicate & Medicaid Services to ensure program payments are made only for eligible patients. The "Request for Section 1011 Hospital On-Call Payments to Physicians" form allows hospitals to calculate and request federal reimbursement under section 1011 of the MMA for on-call payments made to physicians, on a quarterly basis.

---

Authorizing Statute(s): PL: Pub.L. 108 - 179 1011 Name of Law: Federal reimbursement of emergency health services furnished to undocumented aliens
  

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:
	73 FR 47954	08/15/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 63478	10/24/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Federal Funding of Emergency Health Services (Section 1011) Provider Payment Determination (CMS-10130A)	CMS-10130A	Section 1011 Provider Payment Determination
Federal Funding of Emergency Health Services;Request for Section 1011 Hospital On-call Payments to Physicians (CMS-10130B)	CMS-10130B	REQUEST FOR SECTION 1011 HOSPITAL ON-CALL PAYMENTS TO PHYSICIANS

---

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	300,148	7,512,000	0	0	-7,211,852	0
Annual Time Burden (Hours)	75,007	634,000	0	0	-558,993	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

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

---

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: 11/04/2008

---