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[Federal Register Volume 75, Number 237 (Friday, December 10, 2010)]
[Notices]
[Pages 76987-76988]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-31075]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

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

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: 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

[[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
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