Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)
Reinstatement with change of a previously approved collection
No
Regular
08/29/2024
Requested
Previously Approved
36 Months From Approved
1,946
0
1,559
0
0
0
The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. No edits were made to this agreement form.
The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form is utilized to collect facility-specific characteristics that facilitate CMS’ oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC’s existing certification information. Minor edits to form were made for clarification of data being requested.
US Code:
18 USC 1832
Name of Law: Social Security Act
US Code:
18 USC 1864
Name of Law: Social Security Act
The total annual number of responses for both the CMS-370 & CMS-377 forms has been increased from 1,567 in the previous PRA package to 1,946 in the current PRA package. This is an increase of 151 responses. The total burden hours increased from 1,012 to 1,559.
The time burden estimate for completion of each CMS-370 form increased from five (5) minutes to 15 minutes. We made this change because the time estimate in the previous PRA package is too low. The CMS-370 form is a Health Insurance Benefits Agreement, in which the ASC facility agrees to comply with six (6) specifically enumerated requirements which are set forth on the form. The CMS-370 form also contains four (4) additional paragraphs regarding the terms for acceptance and effective date of the agreement. Also, there is a warning about proving false or misleading statements.
We have increased the time burden for the CMS-377 form from 15 minutes to 30 minutes. We have made this change the CMS-377 form requires the ASC staff to provide information about the ASC and the type of services it provides. It may not be possible for the ASC staff member completing the form to obtain all necessary information required to complete the CMS-377 form in 15 minutes.
$71,219
No
No
No
No
No
No
No
Denise King 410 786-1013 Denise.King@cms.hhs.gov
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:
(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;
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.
Form CMS-370 Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report
CMS 370 and 377 Supporting Statement. 08.21.24.docx
Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report