Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60

Forms and Documents

Document Name	Status
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1) Form and Instruction	Modified
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 6) Form and Instruction	New
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 5) Form and Instruction	New
Form CMS-339 Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 2 through 4) Form and Instruction	New
CMS-339 Supporting Statement 2008.doc Supporting Statement A	2009-03-04

IC Document Collections

IC ID	Document Title	Status
37886	Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1) Form and Instruction	Modified
188371	Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 6) Form and Instruction	New
188370	Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 5) Form and Instruction	New
188369	Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 2 through 4) Form and Instruction	New

ICR Details

OMB Control No: 0938-0301	ICR Reference No: 200903-0938-003
Status: Historical Active	Previous ICR Reference No: 200604-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60
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 without change	Conclusion Date: 08/25/2009
	Date Received in OIRA: 03/10/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2012	36 Months From Approved
Responses	93,471	0	0
Time Burden (Hours)	431,148	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Form CMS-339 assists providers in the preparation of an acceptable cost report and minimizes subsequent contact between the providers and their intermediaries. Form CMS-339 provides the data necessary to support the information in cost reports. This includes information the providers use to develop the provider and professional components of physician compensation so that compensation can be properly allocated between the Part A and the Part B trust funds. CMS is seeking approval of the attached, revised of Form CMS-339.

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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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 77701	12/19/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 8546	02/25/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Medicare Provider Cost Report Reimbursement Questionnaire (exhibit 1)	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire
Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 2 through 4)	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire
Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 5)	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire
Medicare Provider Cost Report Reimbursement Questionnaire (exhibits 6)	CMS-339	Medicare Provider Cost Report Reimbursement Questionnaire

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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	93,471	0	0	0	57,567	35,904
Annual Time Burden (Hours)	431,148	0	0	0	-172,158	603,306
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:

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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)? No

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: 03/10/2009

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