(CMS-437A and 437B) Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-437 A Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B) Form and Instruction	Modified
CMS-437A and B Supporting Statement A .05.14.19.docx Supporting Statement A	2019-07-01

IC Document Collections

IC ID	Document Title	Status
8848	Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0986	ICR Reference No: 201906-0938-011
Status: Active	Previous ICR Reference No: 201507-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-437A and 437B) Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations
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: 09/19/2019
	Date Received in OIRA: 07/02/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved
Responses	1,126	0	0
Time Burden (Hours)	1,126	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The rehabilitation hospital and rehabilitation unit criteria work sheets are necessary to verify that these facilities/units comply and remain in compliance with the exclusion criteria for the Medicare perspective payment system.

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Authorizing Statute(s): US Code: 42 USC 412.20 Name of Law: Hospital Services Subject to PPS
  

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:
	84 FR 9526	03/15/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 30122	06/26/2019
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
Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)	CMS-437B, CMS-437 A	REHABILITATION UNIT CRITERIA WORK SHEET ,   REHABILITATION HOSPITAL CRITERIA WORK SHEET

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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	1,126	0	0	0	648	478
Annual Time Burden (Hours)	1,126	0	0	0	1,006	120
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: In the previous PRA package, the total number of IRF units and hospitals was stated to be 478. At this time, there are 846 IRF units and 280 IRF hospitals, which combined adds up to a total number of 1,126 IRFs. The number of IRFs have increased by 648 since the last PRA package was filed. The increased number of IRFs contributes to the increased time and cost burden stated in this PRA package. Also, we have increased the estimated time burden for completion of the CMS-437A and CMS-437B forms to 45 minutes per form. This increased time burden estimate contributes to the increased time and cost burdens stated in this PRA package.

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Annual Cost to Federal Government: $5,209

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: 07/02/2019

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