Medicare Fee-for-Service Early Review of Medical Records

Forms and Documents

Document Name	Status
Base MR PRA Comments clean final 829.docx Supplementary Document	2012-10-01
Supporting Statement A 327 clean.doc Supporting Statement A	2012-10-01

IC Document Collections

IC ID	Document Title	Status
8829	Probe Review (Provider Specific) Instruction	Modified
201492	Attestation Instruction	Modified
201491	Prepayment Review Instruction	Modified
201490	Probe Review (Serivce Specific) Instruction	Modified

ICR Details

OMB Control No: 0938-0969	ICR Reference No: 201210-0938-005
Status: Historical Active	Previous ICR Reference No: 201112-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Fee-for-Service Early Review of Medical Records
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 with change	Conclusion Date: 10/31/2012
	Date Received in OIRA: 10/02/2012
Terms of Clearance: This approval for this collection does not include any demonstration projects associated with prepayment review.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved
Responses	2,220,434	0	0
Time Burden (Hours)	1,105,109	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The information required under this collection is requested by Medicare contractors to determine proper payment or if there is a suspicion of fraud. Medicare contractors request the information form providers or suppliers submitting claims for payment from the Medicare program when data analysis indicates aberrant billing patterns or other information which may present a vulnerability to the Medicare program.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1833 Name of Statute: null
   Statute at Large: 18 Stat. 1893 Name of Statute: null
   Statute at Large: 18 Stat. 1862 Name of Statute: null
  

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:
	77 FR 25181	04/27/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58558	09/21/2012
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Probe Review (Provider Specific)
Probe Review (Serivce Specific)
Prepayment Review
Attestation

---

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	2,220,434	0	0	0	0	2,220,434
Annual Time Burden (Hours)	1,105,109	0	0	0	0	1,105,109
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: $111,000,000

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]? No

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: 10/02/2012

---