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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0685
ICR Reference No:
199602-0938-004
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Medicare Carrier Provider/Supplier Enrollment Application
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
04/19/1996
Retrieve Notice of Action (NOA)
Date Received in OIRA:
02/15/1996
Terms of Clearance:
The Medicare Carrier Provider/Supplier Enrollment Application is approved for use through 4/97 under the following conditions: 1) During the next year, HCFA continues to use the AMA database for validation purposes as it did for HCFA's UPIN files. In the next submission for OMB review, HCFA evaluates the validity of provider/supplier responses in the application and the cost effectiveness of continued use of the AMA file for validation purposes; 2) HCFA designs a second enrollment application form that would collect race on a voluntary basis. This application should be used for a representative random sample of new and existing Medicare providers/suppliers. HCFA should evaluate the validity of self reported race data by comparing application responses to the AMA database; 3) HCFA makes responses to Question 4 on Professional School Information and Question 2 on Provider/Supplier Specialty voluntary. In addition, HCFA shall add a voluntary question on board certification. OMB believes that these questions should be voluntary because it is unclear how they relate to enumeration and fundamental physician identification. In the next submission for OMB review, HCFA should reevaluate the practical utility of these data elements for HCFA and other Federal agencies such as DOL; 4) In the next submission for OMB review, HCFA further should evaluate whether the burden imposed by requirements for copies of certified physician qualifications and billing agency contracts exceeds benefits to the Federal government and beneficiaries/ recipients in reduced fraud and abuse; 5) HCFA amends the section pertaining to Independent Physiological Laboratories so that it is consistent with regulations at 42 CFR 440.30. In particular, as agreed in its response to public comments, HCFA shall amend the forms to clarify that physician supervision is not mandatory. In addition, unless HCFA can present compelling arguments supporting the regulatory and analytic basis for questions per- taining to CPT codes, these questions should be deleted; 6) Reverification procedures or additional revisions to the enrollment application forms must be submitted for PRA approval; 7) prior to fielding this form, HCFA submits its Privacy Act statements and privacy assurances for proprietary materials for OMB review and approval; 8) HCFA monitors the application's questions pertaining to financial interest and ownership and reevaluates the practical utility of these questions in the next submission for OMB review; 9) pursuant to public comment, no later than 5/96 HCFA amends its burden estimate for this enrollment application; and 10) HCFA incorporates the disclosure statements mandated by the Paperwork Reduction Act of 1995 and the implementing regulations at 5 CFR 1320 into the forms/instructions.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/1997
05/31/1997
Responses
160,000
0
0
Time Burden (Hours)
240,000
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
This information is needed to enroll providers/suppliers by identifying them, verifying their qualifications and eligibility to participate in Medicare, and to price and pay their claims correctly.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Medicare Carrier Provider/Supplier Enrollment Application
HCFA-R-186
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
160,000
0
0
160,000
0
0
Annual Time Burden (Hours)
240,000
0
0
240,000
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
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]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Common Form ICR:
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:
(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:
02/15/1996