Application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement

Forms and Documents

Document Name	Status
Form CMS-10392 Re-application Form and Instruction	Removed
Form CMS-10394 Application and Re-application processes Form and Instruction	Modified
CMS-10394.REVISED-Suppoorting Statement Part A (1-20-12).doc Supporting Statement A	2012-04-18

IC Document Collections

IC ID	Document Title	Status
198018	Re-application Form and Instruction	Removed
198017	Application and Re-application processes Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1144	ICR Reference No: 201112-0938-006
Status: Historical Active	Previous ICR Reference No: 201106-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application to Be a Qualified Entity to Receive Medicare Data for Performance Measurement
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: 04/24/2012
	Date Received in OIRA: 12/16/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2015	36 Months From Approved
Responses	35	0	0
Time Burden (Hours)	6,833	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 10332 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary to make standardized extracts of Medicare claims data under Parts A, B, and D available to ''qualified entities'' for the evaluation of the performance of providers of services and suppliers. The statute provides the Secretary with discretion to establish criteria to determine whether an entity is qualified to use claims data to evaluate the performance of providers of services and suppliers. We are proposing at section CFR 401.703 to evaluate an organization's eligibility across three areas: organizational and governance capabilities, addition of claims data from other sources (as required in the statute), and data privacy and security. This is the application through which organizations will provide information to CMS to determine whether they will be approved as a qualified entity.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 10332 Name of Law: Availability of Medicare Data for Performance Measurement
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10332 Name of Law: Availability of Medicare Data for Performance Measurement

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ17	Final or interim final rulemaking	76 FR 76542	12/07/2011

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 33566	06/08/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 76542	12/07/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application and Re-application processes	CMS-10394	Application for Qualified Entity Certification
Re-application	CMS-10392, CMS-10394	Qualified Entity Application ,   Revised QE Application

---

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	35	0	35	0	0	0
Annual Time Burden (Hours)	6,833	0	6,833	0	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: This is a new information collection request.

---

Annual Cost to Federal Government: $743,000

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 12/08/2011

---