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OMB Control No: 0938-0266	ICR Reference No: 202408-0938-021
Status: Active	Previous ICR Reference No: 202102-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report (CMS-377; CMS-370)
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 without change	Conclusion Date: 11/21/2024
	Date Received in OIRA: 08/29/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved
Responses	1,946	0	0
Time Burden (Hours)	1,559	0	0
Cost Burden (Dollars)	0	0	0

Abstract: The CMS-370 Health Insurance Benefits Agreement is utilized for the purpose of establishing eligibility for payment under Title XVIII of the Social Security Act. No edits were made to this agreement form. The CMS-377 ASC Request for Certification or Update of Certification Information in the Medicare Program form is utilized to collect facility-specific characteristics that facilitate CMS’ oversight of ASCs, for example, through the ability to track and trend survey results broken down by various facility characteristics. The data also enables CMS to respond to inquiries from the Congress, GAO, OIG concerning the characteristics of Medicare-participating ASCs. This form is submitted by ASCs when they request initial certification of compliance with the ASC CfCs or to update an ASC’s existing certification information. Minor edits to form were made for clarification of data being requested.

Authorizing Statute(s): US Code: 18 USC 1864 Name of Law: Social Security Act
US Code: 18 USC 1832 Name of Law: Social Security Act

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:
	89 FR 50589	06/14/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 68618	08/27/2024
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
Ambulatory Surgical Center (ASC) Health Insurance Benefits Agreement Form, Request for Certification, Survey Report	CMS-377, CMS-370	,

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,946	379	1,567
Annual Time Burden (Hours)	1,559	547	1,012
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The total annual number of responses for both the CMS-370 & CMS-377 forms has been increased from 1,567 in the previous PRA package to 1,946 in the current PRA package. This is an increase of 151 responses. The total burden hours increased from 1,012 to 1,559. The time burden estimate for completion of each CMS-370 form increased from five (5) minutes to 15 minutes. We made this change because the time estimate in the previous PRA package is too low. The CMS-370 form is a Health Insurance Benefits Agreement, in which the ASC facility agrees to comply with six (6) specifically enumerated requirements which are set forth on the form. The CMS-370 form also contains four (4) additional paragraphs regarding the terms for acceptance and effective date of the agreement. Also, there is a warning about proving false or misleading statements. We have increased the time burden for the CMS-377 form from 15 minutes to 30 minutes. We have made this change the CMS-377 form requires the ASC staff to provide information about the ASC and the type of services it provides. It may not be possible for the ASC staff member completing the form to obtain all necessary information required to complete the CMS-377 form in 15 minutes.

Annual Cost to Federal Government: $71,219

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? No

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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