View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-1029	ICR Reference No: 202306-0938-004
Status: Active	Previous ICR Reference No: 202001-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10221
Title: Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs) (CMS-10221)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2024
	Date Received in OIRA: 06/07/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	36 Months From Approved
Responses	652	0	0
Time Burden (Hours)	1,304	0	0
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): US Code: 42 USC 1395f Name of Law: Requirement of Requests and Certifications
   PL: Pub.L. 105 - 33 4313 Name of Law: BBA of 1997
   PL: Pub.L. 104 - 134 31001 Name of Law: The Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395g Name of Law: PAYMENT TO PROVIDERS OF SERVICES
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	652	-75	727
Annual Time Burden (Hours)	1,304	-150	1,454
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 currently approved burden estimate was based on 727 respondents annually with an annual total burden hours of 1,454. This was calculated at an hour amount per application (two hours per application). Based on these numbers, there is an annual decrease in respondents of 75(from 727 to 652). CMS believes this decrease is due to less IDTFs entering the Medicare program. Over a three-year period, the hour burden has decreased by 450 hours (from 4,362 to 3,912 hours).

Annual Cost to Federal Government: $130,400

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: Jamaa Hill 301 492-4190

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.