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View ICR - OIRA Conclusion

OMB Control No: 0938-1133	ICR Reference No: 202101-0938-009
Status: Historical Active	Previous ICR Reference No: 201709-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Disclosure Requirement for the In-Office Ancillary Services Exception (CMS-10332)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/10/2021
	Date Received in OIRA: 01/29/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2024	36 Months From Approved	08/31/2021
Responses	989,971	0	273,774
Time Burden (Hours)	18,701	0	17,881
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	989,971	273,774	716,197
Annual Time Burden (Hours)	18,701	17,881	820
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 total adjusted annual burden for this collection is 18,701 hours, an increase from the previous burden hours of 17,881 hours. increase in overall burden hours is due to an increase in the number of beneficiaries receiving imaging services. The currently approved response (273,774) was incorrectly reported and was actually 922,709. Thus the correct increase in responses is 67,262 and burden is an increase of 820.

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]? Yes

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: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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