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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services

          - [Document Identifier: CMS-1500(08-05)]

# 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:*                     Reinstatement of a previously approved collection;                     *Title of Information Collection:*                     Health Insurance Common Claims Form and Supporting Regulations at 42 CFR part 424, Subpart C;                     *Form Number:*                     CMS-1500(08-05), CMS-1490-S (OMB#: 0938-0999);                     *Use:*                     The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare program for claims from physicians and suppliers. The Medicaid State Agencies, CHAMPUS/TriCare, Blue Cross/Blue Shield Plans, the Federal Employees Health Benefit Plan, and several private health plans also use it; it is the de facto standard “professional” claim form.                

                    Medicare carriers use the data collected on the CMS-1500 and the CMS-1490S to determine the proper amount of reimbursement for Part B medical and other health services (as listed in section 1861(s) of the Social Security Act) provided by physicians and suppliers to beneficiaries. The CMS-1500 is submitted by physicians/suppliers for all Part B Medicare. Serving as a common claim form, the CMS-1500 can be used by other third-party payers (commercial and nonprofit health insurers) and other Federal programs (                    *e.g.,*                     CHAMPUS/TriCare, Railroad Retirement Board (RRB), and Medicaid).                

                    However, as the CMS-1500 displays data items required for other third-party payers in addition to Medicare, the form is considered too complex for use by beneficiaries when they file their own claims. Therefore, the CMS-1490S (Patient's Request for Medicare Payment) was explicitly developed for                           ( print page 76988)                        easy use by beneficiaries who file their own claims. The form can be obtained from any Social Security office or Medicare carrier.                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     State, Local, or Tribal Government, Business or other-for-profit, Not-for-profit institutions;                     *Number of Respondents:*                     1,048,243;                     *Total Annual Responses:*                     991,160,925;                     *Total Annual Hours:*                     23,815,541. (For policy questions regarding this collection contact Brian Reitz at 410-786-5001. 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 e-mail 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                    *January 10, 2011.*

OMB, Office of Information and Regulatory Affairs.

Attention: CMS Desk Officer.

Fax Number: (202) 395-6974.

                    E-mail:                     *OIRA_submission@omb.eop.gov.*

Dated: December 6, 2010.

Michelle Shortt,

Director, Regulations Development Group Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2010-31075 Filed 12-9-10; 8:45 am]

BILLING CODE 4120-01-P