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OMB Control No: 0938-1049	ICR Reference No: 201612-0938-017
Status: Historical Active	Previous ICR Reference No: 201610-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10242
Title: Emergency Ambulance Transports and Beneficiary Signature Requirements in 42 CFR 424.36(b)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/19/2017
	Date Received in OIRA: 12/15/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2020	36 Months From Approved	04/30/2017
Responses	14,155,617	0	15,633,781
Time Burden (Hours)	1,180,578	0	1,303,857
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:
	81 FR 49958	07/29/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 69828	10/07/2016
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	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	14,155,617	15,633,781	-1,478,164
Annual Time Burden (Hours)	1,180,578	1,303,857	-123,279
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 section A.12 from the last burden estimate to reflect changes in the number of ambulance suppliers, the number of claims, and the addition of 100% of the hourly wage for the cost calculations used to account for fringe and overhead. We have not changed the information collection requirements in any way. The number of Medicare-enrolled ambulance suppliers decreased from 11,564 to 10,402. The total estimated number of ambulance transports for Part B-paid claims in 2015 was 14,155,617. This number represents a 9.46% decrease in the number of Part B-paid ambulance transport claims from 2011. In light of these facts, we have adjusted the annual time and cost burden estimates accordingly. The total number of burden hours decreased from 1,303,857 to 1,180,578. The estimated average hourly wage for emergency medical technicians and paramedics increased from $16.53 to $34.08. The total estimated cost for obtaining the documentation requirements in 42 CFR 424.36(b) (6) increased from approximately $1,863.78 to $3867.92 per ambulance 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: Kayla Williams 410 786-5887 Kayla.Williams@cms.hhs.gov

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