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OMB Control No: 0938-1035	ICR Reference No: 201705-0938-010
Status: Historical Active	Previous ICR Reference No: 201311-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 20872
Title: Provider Enrollment Chain and Ownership System (PECOS) Web Security Consent Form (CMS-10220)
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 with change	Conclusion Date: 12/27/2017
	Date Received in OIRA: 05/24/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	02/28/2017
Responses	226,100	0	88,650
Time Burden (Hours)	226,100	0	22,163
Cost Burden (Dollars)	0	0	0

Abstract: The Security Consent and Surrogate Authorization form replicates business service agreements between Medicare providers/suppliers and Surrogates providing enrollment services. We are proposing one version of the Security Consent and Surrogate Authorization Form. The form, once signed, mailed and approved, grants a Surrogate access to all current and future enrollment data for the Individual or Organization Provider.

Authorizing Statute(s): US Code: 42 USC 1395l(e) Name of Law: PAYMENT OF BENEFITS
   US Code: 42 USC 1395m(j) Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395f(a) Name of Law: CONDITIONS OF AND LIMITATIONS ON PAYMENT FOR SERVICES
   US Code: 42 USC 1395g(a) Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1395u(u) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395u(r) Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395cc(j)(1)(C) Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 105 - 33 4313 Name of Law: The Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996

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:
	82 FR 11921	02/27/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23005	05/19/2017
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
PECOS Web Security Consent Form - Individuals	CMS-10220
PECOS Web Security Consent Form - Organizations	CMS-10220
Security Consent and Surrogate Authorization Form - Providers	CMS-10220

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	226,100	88,650	137,450
Annual Time Burden (Hours)	226,100	22,163	203,937
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: The burden has increased for three reasons. The first is we are using more accurate data from NPPES to estimate respondents who use the Security Consent and Surrogate Authorization Form to complete and submit the form to grant a surrogacy connection between two individuals or organizations or between an individual and an organization. By doing so, we have increased the number of respondents from 88,650 respondents to 226,100 respondents. This means our burden cost is now $42,981,610 for these respondents. The second is the previous estimate assumed that approximately 90 percent of individuals (i.e., physicians, non-physician practitioners) and 50 percent of organization providers and suppliers would use an entity other than themselves to complete their Medicare enrollment application and CMS therefore extended the assumption that approximately 90 percent of individuals and 50 percent of organization providers and suppliers would use an entity other than themselves to complete their Security Consent and Surrogate Authorization Form. This has been proven to be an incorrect assumption. NPPES currently reports providers are the respondents who complete and submit the Security Consent and Surrogate Authorization Form. In addition, it was previously estimated that the Security Consent and Surrogate Authorization Form took 15 minutes to complete. Using that figure, the previous burden hour estimate was approximately 22,162 hours. It is now estimated that completion and submission of this form takes approximately one hour. That increases the burden hour estimate by 203,938 hours (from 22,162 to 226,100 hours). Thirdly, the wage data used in the previous estimates are not the same wage data we currently use (now taken from the BLS wage tables). In the previous version, the wage estimate was $20.00 per hour (administrative wage) and $150.00 per hour (professional wage). Due to the incorrect assumption of who the respondents were for this form and the incorrect amount of time used to calculate the completion and submission of this form, it was calculated that the total cost for completing and submitting the Security Consent and Surrogate Authorization Form was $1,421,250. Using the correct wage data, number of respondents, and amount of time for completion and submission of the Security Consent and Surrogate Authorization Form, this increases the cost by $41,560,360 from $1,421,250 to $42,981,610. Combined, the increase in burden hours is 203,938 (from 22,162 to 226,100 hours) and the increase in cost is $41,560,360 (from $1,421,250 to $42,981,610). The combined increase in the number of respondents is 137,450 (from 88,650 to 226,100).

Annual Cost to Federal Government: $0

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

Agency Contact: Jamaa Hill 301 492-4190

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