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OMB Control No: 0938-1049	ICR Reference No: 201309-0938-005
Status: Historical Active	Previous ICR Reference No: 200803-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: 20418
Title: Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)
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: 02/14/2014
	Date Received in OIRA: 09/10/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	15,633,781	0	0
Time Burden (Hours)	1,303,857	0	0
Cost Burden (Dollars)	0	0	0

Abstract: Because it is very difficult to obtain a beneficiary's signature (or the signature of a person authorized to sign on behalf of the beneficiary) on a claim when the beneficiary is being transported by ambulance in emergency situations, we are proposing that, for emergency ambulance transport services, an ambulance provider or supplier may submit the claim without a beneficiary's signature, as long as certain documentation requirements are met.

Authorizing Statute(s): Statute at Large: 18 Stat. 1814
   Statute at Large: 18 Stat. 1835
   Statute at Large: 18 Stat. 1842
   Statute at Large: 18 Stat. 1848

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 34387	06/07/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 50057	08/16/2013
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
Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	15,633,781	9,133,781	6,500,000
Annual Time Burden (Hours)	1,303,857	762,190	541,667
Annual Cost Burden (Dollars)	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: We updated the burden estimate in SS section A.12 from the last burden estimate. The number of Medicare-enrolled ambulance providers and suppliers increased from 9,000 to 11,564. The total number of burden hours increased from 541,667 to 1,303,857. The total estimated number of ambulance transports for Part B-paid claims in 2011 was 15,633,781. This number represents a 9.07% increase from the number of Part B-paid ambulance transport claims in 2007. We also made note that the total number of burden hours may be overstated, because not every beneficiary who receives an emergency or nonemergency ambulance transport service is unable to sign the claim form. The estimated average hourly wage for Emergency Medical Technicians and Paramedics increased from $14.61 to $16.53. Thus, the total ambulance provider and supplier burden estimate is 1,303,857 total nationwide hours times $16.53/hour equals $21,552,756 divided by 11,564 ambulance providers and suppliers which equals an approximate cost of $1,863.78 per ambulance provider or supplier. Therefore, the total estimated cost for obtaining the documentation requirements in 42 CFR 424.36(b)(6) is approximately $1,863.78 per ambulance provider or supplier.

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

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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