6124 Federal Register / Vol. 77, No. 25 / Tuesday, February 7, 2012 / Notices 

or treating practitioner and submitted to 

the appropriate DME MAC for an initial 

decision. The supplier may also submit 

the request on behalf of the physician or 

treating practitioner. The physician, 

treating practitioner or supplier who 

submits the request on behalf of the 

physician or treating practitioner, is 

referred to as the ‘‘submitter.’’ Under 

this demonstration, the submitter will 

submit to the DME MAC a request for 

prior authorization and all relevant 

documentation to support Medicare 

coverage of the PMD item. 

These demonstrations have been 

designed to develop and demonstrate 

improved methods for the investigation 

and prosecution of fraud in the 

provision of care or services under the 

health programs established by the 

Social Security Act. The information 

required under this information 

collection request is requested by 

Medicare contractors to determine 

proper payment or if there is a suspicion 

of fraud. For the RAC demonstration, 

Medicare contractors may request the 

information from providers or suppliers 

submitting claims for payment from the 

Medicare program when data analysis 

indicates aberrant billing patterns or 

other information which may present a 

vulnerability to the Medicare program. 

Under the prior authorization 

demonstration, for certain PMDs, with a 

history of aberrant billing patterns, this 

information is requested in advance to 

determine appropriate payment or if 

there is a suspicion of fraud. Form 

Number: CMS–10421 (OCN 0938–New); 

Frequency: Occasionally; Affected 

Public: State, Local or Tribal 

Governments; Number of Respondents: 

479,750; Total Annual Responses: 

479,750; Total Annual Hours: 243,060. 

(For policy questions regarding this 

collection contact Debbie Skinner at 

(410) 786–7480. For all other issues call 

(410) 786–1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web Site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or 

Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 

Reports Clearance Office on (410) 786– 

1326. 

In commenting on the proposed 

information collections please reference 

the document identifier or OMB control 

number. To be assured consideration, 

comments and recommendations must 

be submitted in one of the following 

ways by April 9, 2012: 

1. Electronically. You may submit 

your comments electronically to http:// 

www.regulations.gov. Follow the 

instructions for ‘‘Comment or 

Submission’’ or ‘‘More Search Options’’ 

to find the information collection 

document(s) accepting comments. 

2. By regular mail. You may mail 

written comments to the following 

address: CMS, Office of Strategic 

Operations and Regulatory Affairs, 

Division of Regulations Development, 

Attention: Document Identifier/OMB 

Control Number CMS–10161 (OCN 

0938–0979), Room C4–26–05, 7500 

Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Dated: February 1, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–2821 Filed 2–3–12; 11:15 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier CMS–668B and CMS– 

1557] 

Agency Information Collection 

Activities: Proposed Collection; 

Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services. 

In compliance with the requirement 

of section 3506(c)(2)(A) of the 

Paperwork Reduction Act of 1995, the 

Centers for Medicare & Medicaid 

Services (CMS) is publishing the 

following summary of proposed 

collections for public comment. 

Interested persons are invited to send 

comments regarding this burden 

estimate or any other aspect of this 

collection of information, including any 

of the following subjects: (1) The 

necessity and utility of the proposed 

information collection for the proper 

performance of the agency’s functions; 

(2) the accuracy of the estimated 

burden; (3) ways to enhance the quality, 

utility, and clarity of the information to 

be collected; and (4) the use of 

automated collection techniques or 

other forms of information technology to 

minimize the information collection 

burden. 

1. Type of Information Collection 

Request: Extension of a currently 

approved collection. Title of 

Information Collection: Post Clinical 

Laboratory Survey Questionnaire and 

Supporting Regulations in 42 CFR 

493.1771, 493.1773, and 493.1777. Use: 

Form CMS–668B is used by a Clinical 

Laboratory Improvement Amendments 

(CLIA) laboratory to express its 

satisfaction with the survey process and 

to make recommendations for 

improvement. Surveyors furnish this 

form to all laboratories that receive 

either an onsite survey or the Alternate 

Quality Assessment Survey (i.e., paper 

survey of quality indicators). CMS 

Central Office performs an overview 

evaluation of the completed forms. Each 

calendar year, a summary of the 

information collected is sent to the State 

and CMS Regional Office. Form 

Number: CMS–668B (OCN 0938–0653). 

Frequency: Biennially; Affected Public: 

Business or other for-profits and not-forprofit institutions. State, Local, or Tribal 

Government, Federal Government. 

Number of Respondents: 21,000. Total 

Annual Responses: 10,500. Total 

Annual Hours: 2,625. (For policy 

questions regarding this collection 

contact Kathleen Todd at (410) 786– 

3385. For all other issues call (410) 786– 

1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection. Title of 

Information Collection: Survey Report 

Form for Clinical Laboratory 

Improvement Amendments (CLIA) and 

Supporting Regulations in 42 CFR 

493.1–493.2001. Use: CMS 1557 is used 

to report surveyor findings during a 

CLIA survey. For each type of survey 

conducted (i.e., initial certification, 

recertification, validation, complaint, 

addition/deletion of specialty/ 

subspecialty, transfusion fatality 

investigation, or revisit inspections) the 

Survey Report Form incorporates the 

requirements specified in the CLIA 

regulations. Form Number: CMS–1557 

(OCN 0938–0544). Frequency: 

Biennially. Affected Public: Business or 

other for-profit, Not-for-profit 

institutions, State, Local or Tribal 

Governments and Federal Government. 

Number of Respondents: 21,000. Total 

Annual Responses: 10,500. Total 

Annual Hours: 5,248. (For policy 

questions regarding this collection 

contact Kathleen Todd at (410) 786– 

3385. For all other issues call (410) 786– 

1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web Site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or 

Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 


tkelley on DSK3SPTVN1PROD with NOTICES
Federal Register / Vol. 77, No. 25 / Tuesday, February 7, 2012 / Notices 6125 

Reports Clearance Office on (410) 786– 

1326. 

In commenting on the proposed 

information collections please reference 

the document identifier or OMB control 

number. To be assured consideration, 

comments and recommendations must 

be submitted in one of the following 

ways by April 9, 2012: 

1. Electronically. You may submit 

your comments electronically to http:// 

www.regulations.gov. Follow the 

instructions for ‘‘Comment or 

Submission’’ or ‘‘More Search Options’’ 

to find the information collection 

document(s) accepting comments. 

2. By regular mail. You may mail 

written comments to the following 

address: CMS, Office of Strategic 

Operations and Regulatory Affairs, 

Division of Regulations Development, 

Attention: Document Identifier/OMB 

Control Number lllll, Room C4– 

26–05, 7500 Security Boulevard, 

Baltimore, Maryland 21244–1850. 

Dated: January 31, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–2774 Filed 2–6–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–29 and CMS– 

10366] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services, HHS. 

In compliance with the requirement 

of section 3506(c)(2)(A) of the 

Paperwork Reduction Act of 1995, the 

Centers for Medicare & Medicaid 

Services (CMS), Department of Health 

and Human Services, is publishing the 

following summary of proposed 

collections for public comment. 

Interested persons are invited to send 

comments regarding this burden 

estimate or any other aspect of this 

collection of information, including any 

of the following subjects: (1) The 

necessity and utility of the proposed 

information collection for the proper 

performance of the Agency’s function; 

(2) the accuracy of the estimated 

burden; (3) ways to enhance the quality, 

utility, and clarity of the information to 

be collected; and (4) the use of 

automated collection techniques or 

other forms of information technology to 

minimize the information collection 

burden. 

1. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Request for 

Certification as a Rural Health Clinic 

Form and Supporting Regulations in 42 

CFR 491.1–491.11; Use: The Form 

CMS–29, Request for Certification as a 

Supplier of Rural Health Clinic (RHC) 

Services under the Medicare/Medicaid 

Program, is utilized as an application to 

be completed by suppliers of RHC 

services requesting participation in the 

Medicare program. This form initiates 

the process of obtaining a decision as to 

whether the conditions for certification 

are met as a supplier of RHC services. 

It also promotes data reduction or 

introduction to and retrieval from the 

Automated Survey Process Environment 

(ASPEN) and related survey and 

certification databases by the CMS 

Regional Offices. Should any question 

arise regarding the structure of the 

organization, this information is readily 

available. With this renewal request, the 

title of the Form CMS–29 is being 

revised to better describe the purpose of 

the data being collected. Both new and 

existing clinics must provide and attest 

to the accuracy of specific clinic data as 

a part of the RHC certification process. 

Therefore, the revised title is ‘‘Form 

CMS–29/Verification of Clinic Data— 

Rural Health Clinic Program.’’ The Form 

CMS–29 is also being revised to remove 

Section V, Federal Support. The 

information captured under Section V is 

not a deciding factor as to whether or 

not a clinic meets RHC certification 

requirements. Therefore, it is 

unnecessary to require facilities to 

complete this section as a part of the 

certification process; Form Number: 

CMS–29 (OCN 0938–0074); Frequency: 

Occasionally (initially and then every 

six years); Affected Public: Private 

Sector (Business or other for-profit and 

Not-for-profit institutions); Number of 

Respondents: 3,981; Total Annual 

Responses: 830; Total Annual Hours: 

138. (For policy questions regarding this 

collection contact Shonte ́ Carter at (410) 

786–3532. For all other issues call (410) 

786–1326.) 

2. Type of Information Collection 

Request: New collection (request for 

new OMB control number); Title of 

Information Collection: Nursing Home 

Quality Improvement Questionnaire; 

Use: The information obtained via the 

Nursing Home Quality Improvement 

Questionnaire will be utilized by CMS 

staff in the Survey & Certification 

Group, Division of Nursing Homes, to 

identify areas for quality assurance and 

performance improvement (QAPI) 

technical assistance (TA) that will be 

useful to nursing facilities as they 

prepare to meet the new QAPI 

regulation that was mandated as part of 

the Affordable Care Act. Specifically, 

the information collected through the 

use of the questionnaire will be used to 

establish a baseline of QAPI practices in 

nursing homes, gather information on 

the challenges and barriers to 

implementing effective QAPI programs, 

assess the development of QAPI 

systems, determine what types of TA to 

make available to nursing homes, and 

assess the potential impact of TA in 

advancing QAPI in nursing homes; 

Form Number: CMS–10366 (OCN 0938– 

New); Frequency: Once; Affected Public: 

Private Sector (Business or other forprofits and Not-for-profit institutions) 

and State, Local or Tribal Governments; 

Number of Respondents: 4,200; Total 

Annual Responses: 4,200; Total Annual 

Hours: 1,386. (For policy questions 

regarding this collection contact Debra 

Lyons at (410) 786–6780. For all other 

issues call (410) 786–1326.) 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS Web Site 

address at http://www.cms.hhs.gov/ 

PaperworkReductionActof1995, or 

Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov, or call the 

Reports Clearance Office on (410) 786– 

1326. 

To be assured consideration, 

comments and recommendations for the 

proposed information collections must 

be received by the OMB desk officer at 

the address below, no later than 5 p.m. 

on March 8, 2012. OMB, Office of 

Information and Regulatory Affairs, 

Attention: CMS Desk Officer. Fax 

Number: (202) 395–6974. Email: 

OIRA_submission@omb.eop.gov. 

Dated: January 31, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division-B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–2762 Filed 2–6–12; 8:45 am] 

BILLING CODE 4120–01–P 


tkelley on DSK3SPTVN1PROD with NOTICES