Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60 (CMS-339)

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 (Exhibit 2) Form and Instruction	Modified
CMS-339 Supporting Statement Part A - FINAL 4-18-17.doc Supporting Statement A	2017-04-20

IC Document Collections

IC ID	Document Title	Status
37886	Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 1) Form and Instruction	Modified
188369	Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 2) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0301	ICR Reference No: 201704-0938-004
Status: Historical Active	Previous ICR Reference No: 201611-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: Medicare Provider Cost Report Reimbursement Questionnaire and Supporting Regulations in 42 CFR 413.20, 413.24, and 415.60 (CMS-339)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/26/2017
	Date Received in OIRA: 04/20/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2020	36 Months From Approved
Responses	4,546	0	0
Time Burden (Hours)	15,911	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:
	81 FR 46080	07/15/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 75409	10/31/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 1)	CMS-339	Medicare Provider Cost Reimbursement Questionnaire - Exhibit 1
Medicare Provider Cost Report Reimbursement Questionnaire (Exhibit 2)	CMS-339	Medicare Provider Cost Reimbursement Questionnaire - Exhibit 2

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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	4,546	0	0	-3,179	-15,666	23,391
Annual Time Burden (Hours)	15,911	0	0	-12,716	-46,998	75,625
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: As part of this reinstatement, there are several revisions since the last OMB approval. The number of respondents decreased by 15,666, from 17,939 to 2,273. The decrease is attributed to the removal of home health agencies (HHA), federally qualified health centers (FQHC) and hospices (Hospices) from the respondent total. Specifically, the difference is due to the decrease in the number of respondents required to complete Exhibits 1 and 2 due to the incorporation of the Form CMS-339 into Forms 1728-94 (HHA); 1984-14 (Hospice); and 224-14 (FQHC). Similarly, the previous burden estimate was 75,625 hours and has been revised to 15,911 hours, a change of 59,714.

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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]? 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: 04/20/2017

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