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OMB Control No: 0960-0803	ICR Reference No: 201904-0960-013
Status: Historical Active	Previous ICR Reference No: 201805-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Evidence From Excluded Medical Sources of Evidence
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/29/2020
	Date Received in OIRA: 08/16/2019
Terms of Clearance: Agency made minor clarifications regarding the operation of this information collection and its burden estimation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2023	36 Months From Approved	09/30/2020
Responses	3,000	0	3,000
Time Burden (Hours)	1,000	0	1,000
Cost Burden (Dollars)	0	0	0

Abstract: Section 812 of the Bipartisan Budget Act of 2015 (BBA 812) amends section 223(d)(5) of the Social Security Act (Act) by adding a subsection “C.” BBA 812 mandates that the Social Security Administration (SSA) implement the provisions of amended section 223(d)(5)(C)(i) by regulation by November 2, 2016. Section 223(d)(5)(C)(i) of the Act, as amended, requires SSA to exclude evidence (except for good cause) from medical sources: (1) convicted of a felony under sections 208 or 1632 of the Act; (2) excluded from participating in any Federal health care program under section 1128 of the Act; or (3) imposed with a civil monetary penalty (CMP), assessment, or both, for submitting false evidence, under section 1129 of the Act. These final, new regulations will require excluded medical sources to self-report their excluded status in writing each time they submit evidence related to a claim for benefits under Titles II or XVI of the Act. Excluded medical sources’ duty to self-report their excluded status will apply to evidence they submitted to SSA directly or through a representative, claimant, or other individual or entity. The self-report will include: (1) the heading "WRITTEN STATEMENT REGARDING SECTION 233(d)(5)(C) OF THE SOCIAL SECURITY ACT - DO NOT REMOVE[,]" (2) the name and title of the affected source; and (3) the applicable excluding event (i.e., felony conviction, section 1128 exclusion, or CMP or assessment under section 1129). Felons must also include their date of conviction, and those imposed with a CMP must provide the dates of imposition. Sources excluded under section 1128 must include: (1) the basis of their exclusion; (2) its effective date and anticipated length, and (3) whether the Department of Health and Human Services' Office of Inspector General waived it. The respondents for this collection are medical sources that (1) meet one of the exclusionary categories set forth in section 223(d)(5)(C)(i) of the Act, as amended, and (2) furnish evidence related to a claim for benefits under Titles II or XVI of the Act.

Authorizing Statute(s): US Code: 42 USC 423 Name of Law: Social Security Act
   US Code: 42 USC 405 Name of Law: Social Security Act
   PL: Pub.L. 114 - 74 812 Name of Law: Bipartisan Budget Act of 2015
   US Code: 42 USC 902 Name of Law: Social Security Act
   US Code: 42 USC 1383 Name of Law: Social Security Act

Citations for New Statutory Requirements: PL: Pub.L. 114 - 74 812 Name of Law: Bipartisan Budget Act of 2015

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:
	84 FR 25891	06/04/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 40121	08/13/2019
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
20 CFR 404.1503b(c) & 416.903b(c)

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	3,000	3,000
Annual Time Burden (Hours)	1,000	1,000
Annual Cost Burden (Dollars)	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:

Annual Cost to Federal Government: $47,679

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. Yes

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? No

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

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