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Federal forms, ICRs, and supporting documents

Information Collection Request

Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377, 378, 370)

ICR 201106-0938-018 · OMB 0938-0266 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Supporting Statement A
2011-06-16
IC Document Collections
IC ID
Document
Title
Status
7913 Modified
ICR Details
0938-0266 201106-0938-018
Historical Active 200802-0938-001
HHS/CMS
Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377, 378, 370)
Revision of a currently approved collection   No
Regular
Approved with change 09/05/2011
Retrieve Notice of Action (NOA) 06/21/2011
  Inventory as of this Action Requested Previously Approved
09/30/2014 36 Months From Approved 09/30/2011
2,090 0 5,123
647 0 2,787
0 0 0
The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form as revised will be utilized to collect facility-specific characteristics that facilitate CMS' oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. The data base that supports survey and certification activities will be revised to reflect changes in the data fields on this revised form, such as the data on the types of surgical procedures performed in the ASC. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC's existing certification information. The CMS-378 is being discontinued.
US Code: 18 USC 1832 Name of Law: Social Security Act
   US Code: 18 USC 1864 Name of Law: Social Security Act
  
None
Not associated with rulemaking
  76 FR 16790 03/25/2011
76 FR 34075 06/10/2011
No
  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 2,090 5,123 0 -3,000 -33 0
Annual Time Burden (Hours) 647 2,787 0 -2,000 -140 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Cutting Redundancy
The reduction in burden is based on the program change regarding the discontinuance of Form CMS-378. The burden is also adjusted to account for the increased number of ASCs. The discontinuance of Form CMS-378 more than offsets burdens associated with growth in the number of ASCs.
$18,410
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/21/2011