51462 Federal Register / Vol. 75, No. 161 / Friday, August 20, 2010 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10052, CMS–R– 

216, CMS–R–53, CMS–10215, CMS–724, 

CMS–116 and CMS–1500(08–05)] 

Agency Information Collection 

Activities: Proposed Collection; 

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) 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: Recognition of 

pass-through payment for additional 

(new) categories of devices under the 

Outpatient Prospective Payment System 

and Supporting Regulations in 42 CFR, 

Part 419; Use: Section 201(b) of the 

Balanced Budget Act of 1999 amended 

section 1833(t) of the Social Security 

Act (the Act) by adding new section 

1833(t)(6). This provision requires the 

Secretary to make additional payments 

to hospitals for a period of 2 to 3 years 

for certain drugs, radiopharmaceuticals, 

biological agents, medical devices and 

brachytherapy devices. Section 402 of 

the Benefits Improvement and 

Protection Act of 2000 made changes to 

the transitional pass-through provision 

for medical devices. The most 

significant change is the required use of 

categories as the basis for determining 

transitional pass-through eligibility for 

medical devices, through the addition of 

section 1833(t)(6)(B) of the Act. This 

information collection is necessary to 

determine eligibility of medical devices 

for establishment of additional device 

categories for payment under 

transitional pass-through payment 

provisions as required by section 

1833(t)(6) of the Act. Form Number: 

CMS–10052 (OMB#: 0938–0857); 

Frequency: Once; Affected Public: 

Private Sector: Business or other forprofits; Number of Respondents: 10; 

Total Annual Responses: 10; Total 

Annual Hours: 160. (For policy 

questions regarding this collection 

contact Christina S. Ritter at 410–786– 

4636. For all other issues call 410–786– 

1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Issuance of 

Advisory Opinions Concerning 

Physicians’ Referrals; Use: Section 

1877(g)(6) of the Social Security Act 

requires that the Department of Health 

and Human Services accept requests for 

advisory opinions made after November 

3, 1997 and before August 21, 2000. 

Section 543 of the Benefits 

Improvement and Protection Act of 

2001, Public Law 106–554, extended 

indefinitely the period during which the 

Department of Health and Human 

Services accepts requests for these 

advisory opinions. CMS promulgated 42 

CFR 411.370 through 411.389 to comply 

with this statutory mandate. The 

collection of information contained in 

42 CFR 411.372 and 411.373 is 

necessary to allow CMS to consider 

requests for advisory opinions and 

provide accurate and useful opinions. 

Form Number: CMS–R–216 (OMB#: 

0938–0714); Frequency: Occasionally; 

Affected Public: Private Sector: Business 

or other for-profits and not- for profit 

institutions; Number of Respondents: 

25; Total Annual Responses: 25; Total 

Annual Hours: 500. (For policy 

questions regarding this collection 

contact John Davis at 410–786–0008. 

For all other issues call 410–786–1326.) 

3. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Imposition of 

Cost Sharing Charges under Medicaid 

and Supporting Regulations in 42 CFR 

447.53; Use: The purpose of this 

collection is to ensure that States 

impose normal cost sharing charges 

upon categorically and medically needy 

individuals as allowed by law and 

implementing regulations. States must 

identify in their State plan the service 

for which the charge is made, the 

amount of the charge, the basis for 

determining the charge, the basis for 

determining whether an individual is 

unable to pay the charge and the way in 

which the individual will be identified 

to providers, and the procedures for 

implementing and enforcing the 

exclusions from cost sharing. Form 

Number: CMS–R–53 (OMB#: 0938– 

0429); Frequency: Occasionally; 

Affected Public: State, Local, or Tribal 

Governments; Number of Respondents: 

56; Total Annual Responses: 2; Total 

Annual Hours: 20. (For policy questions 

regarding this collection contact Barbara 

Washington at 410–786–9964. For all 

other issues call 410–786–1326.) 

4. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicaid 

Payment for Prescription Drugs— 

Physicians and Hospital Outpatient 

Departments Collecting and Submitting 

Drug Identifying Information to State 

Medicaid Programs; Use: Section 6002 

of the Deficit Reduction Act (DRA) of 

2005 added provisions under section 

1927 of the Social Security Act to 

require physicians in their offices and 

hospital outpatient settings or other 

entities (e.g., non-profit facilities) to 

collect and submit the drug National 

Drug Code (NDC) numbers on Medicaid 

claims to their State in order for Federal 

Financial Participation to be available 

for these drugs. Form Number: CMS– 

10215 (OMB#: 0938–1026); Frequency: 

Weekly; Affected Public: Private Sector: 

Business or other for-profits and Notfor-profit institutions; Number of 

Respondents: 20,000; Total Annual 

Responses: 3,910,000; Total Annual 

Hours: 15,836. (For policy questions 

regarding this collection contact 

Bernadette Leeds at 410–786–9463. For 

all other issues call 410–786–1326.) 

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare/ 

Medicaid Psychiatric Hospital Survey 

Data; Use: The CMS–724 form is used to 

collect data that is not collected 

elsewhere and assists CMS in program 

planning and evaluation and in 

maintaining an accurate database on 

providers participating in the 

psychiatric hospital program. Form 

Number: CMS–724 (OMB#: 0938–0378); 

Frequency: Annually; Affected Public: 

Private Sector: Business or other forprofits and Not-for-profit institutions; 

Number of Respondents: 500; Total 

Annual Responses: 150; Total Annual 

Hours: 75. (For policy questions 

regarding this collection contact Kelley 

Leonette at 410–786–6664. For all other 

issues call 410–786–1326.) 

6. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Clinical 

Laboratory Improvement Amendments 

(CLIA) Application Form and 

Supporting Regulations in 42 CFR 


sroberts on DSKD5P82C1PROD with NOTICES
Federal Register / Vol. 75, No. 161 / Friday, August 20, 2010 / Notices 51463 

493.1–.2001 Medicare/Medicaid 

Psychiatric Hospital Survey Data; Use: 

The application must be completed by 

entities performing laboratory’s testing 

specimens for diagnostic or treatment 

purposes. This information is vital to 

the certification process. Form Number: 

CMS–116 (OMB#: 0938–0581); 

Frequency: Biennially and Occasionally; 

Affected Public: Private Sector: Business 

or other for-profits and Not-for-profit 

institutions; Number of Respondents: 

219,000; Total Annual Responses: 

31,520; Total Annual Hours: 23,640. 

(For policy questions regarding this 

collection contact Sheila Ward at 410– 

786–3115. For all other issues call 410– 

786–1326.) 

7. Type of Information Collection 

Request: Extension of a currently 

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 thirdparty 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 

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-forprofit, Not-for-profit institutions; 

Number of Respondents: 1,048,243; 

Total Annual Responses: 991,160,925; 

Total Annual Hours: 23,815,541. 

To obtain copies of the supporting 

statement and any related forms for the 

proposed paperwork collections 

referenced above, access CMS’ Web Site 

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 October 19, 2010: 

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, Room C4–26–05, 7500 Security 

Boulevard, Baltimore, Maryland 21244– 

1850. 

Dated: August 13, 2010. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2010–20385 Filed 8–19–10; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–10314] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

AGENCY: Centers for Medicare & 

Medicaid Services. 

In compliance with the requirement 

of section 3506I(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: New collection; Title of 

Information Collection: Medicare 

Savings Program Protection from 

Medicaid Estate Recovery—State Plan 

Pre-print under Title XIX. Form No.: 

CMS–10314 (OMB# 0938–New); Use: 

Section 115 of the Medicare 

Improvements for Patients and 

Providers Act (MIPPA)—2008, provides 

new protections from Medicaid estate 

recovery for limited categories of dual 

eligibles age 55 and over. To offer these 

protections, States have to amend their 

Medicaid State plans to reflect these 

new limits on estate recovery. To reduce 

paperwork burden and expedite this 

process, CMS is providing States with a 

pre-printed document (i.e., a State plan 

preprint) which neither needs nor 

requires any insertion of language or 

even completion of a check-off box. As 

Section 115 simply mandates 

compliance (there is no option not to 

comply), States only need return the 

preprint page (as prepared by CMS) to 

CMS, as a requested amendment to their 

State Plan. This is a one-time only 

submission, with little burden 

imposition and complete electronic 

routing to and from States. 

Frequency: Reporting—Once; Affected 

Public: State, Local or Tribal 

Governments; Number of Respondents: 

51; Total Annual Responses: 51; Total 

Annual Hours: 102. (For policy 

questions regarding this collection 

contact Nancy Dieter at 410–786–7219. 

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. 


sroberts on DSKD5P82C1PROD with NOTICES