Medicare Participating Physician or Supplier Agreement

Forms and Documents

Document Name	Status
Form CMS-460 Medicare Participating Physician or Supplier Agreement Form and Instruction	Modified
CMS-460 Supporting_Statement_Part_A [rev 7-1-2013].docx Supporting Statement A	2013-07-03

IC Document Collections

IC ID	Document Title	Status
8015	Medicare Participating Physician or Supplier Agreement Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0373	ICR Reference No: 201307-0938-001
Status: Historical Active	Previous ICR Reference No: 201008-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: 19893
Title: Medicare Participating Physician or Supplier Agreement
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: 07/26/2013
	Date Received in OIRA: 07/03/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	09/30/2013
Responses	120,000	0	8,000
Time Burden (Hours)	30,000	0	2,000
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-460 is completed by nonparticipating physicians and suppliers if they choose to participate in Medicare Part B. By signing the agreement, the physician or supplier agrees to take assignment on all Medicare claims. To take assignment means to accept the Medicare allowed amount as payment in full for the services they furnish and to charge the beneficiary no more than the deductible and coinsurance for the covered service. In exchange for signing the agreement, the physician or supplier receives a signficiant number of program benefits not available to nonparticipating suppliers. The information associated with this collection is needed to identify the recipients of the program benefits.

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Authorizing Statute(s): PL: Pub.L. 98 - 369 a Name of Law: The Deficit Reduction Act of 1984
  

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:
	78 FR 21956	04/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 37545	06/21/2013
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Medicare Participating Physician or Supplier Agreement	CMS-460	Medicare Participating Physician or Supplier Agreement

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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	120,000	8,000	0	0	112,000	0
Annual Time Burden (Hours)	30,000	2,000	0	0	28,000	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: There are no program changes and the burden per response remains unchanged. However, we are adjusting our burden estimate from 8,000 agreements to 120,000 agreements and from 2,000 hr to 30,000 hr.

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Annual Cost to Federal Government: $92,391

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

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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: 07/03/2013

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