Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256

Forms and Documents

Document Name	Status
Form CMS-R-138 Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138) Form	Unchanged
CMS-R-138-MGCRB Procedures PRA_Supporting_Statement_updated September 2017.docx Supporting Statement A	2017-10-03

IC Document Collections

IC ID	Document Title	Status
8175	Medicare Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138) Form	Unchanged

ICR Details

OMB Control No: 0938-0573	ICR Reference No: 201710-0938-001
Status: Active	Previous ICR Reference No: 201612-0938-023
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-R-138
Title: Medicare Geographic Classification Review Board Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256
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: 01/03/2018
	Date Received in OIRA: 10/04/2017
Terms of Clearance: Before this ICR is renewed, CMS should ensure that each IC and/or form includes the OMB Control Number, estimated time to complete the form, and expiration date.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved	06/30/2018
Responses	300	0	300
Time Burden (Hours)	300	0	300
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1886(d)(10) of the Social Security Act established the Medicare Geographic Classification Review Board (MGCRB), an entity with the authority to accept short-term hospital inpatient prospective payment system applications from hospitals requesting geographic reclassification for wage index or standardized amount payment purposes and issue decisions on these requests. This regulation sets up the application process for prospective payment system hospitals that choose to appeal their geographic status to the MGCRB.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1886 Name of Statute: null
  

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:
	82 FR 31331	07/06/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 43378	09/15/2017
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 Geographic Classification Review Board (MGCRB) Procedures and Criteria and Supporting Regulations in 42 CFR, Section 412.256 & 412.230 (CMS-R-138)	CMS-R-138, CMS-R-138, CMS-R-138, CMS-R-138, CMS-R-138, CMS-R-138, CMS-R-138, CMS-R-138	Statewide Application ,   Statewide Affidavit ,   Individual Application ,   Individual - Special Access (Driving Time) ,   Individual - Special Access (Distance) ,   Individual - Proximity (Employee Commuting Pattern) ,   Individual - Proximity (Distance) ,   Group Application

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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	300	300	0	0	0	0
Annual Time Burden (Hours)	300	300	0	0	0	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:

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Annual Cost to Federal Government: $19,200

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 10/04/2017

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