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[Federal Register Volume 77, Number 103 (Tuesday, May 29, 2012)]
[Notices]
[Pages 31615-31616]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-12810]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier CMS-1500 (08/05) and CMS-1500 (2/12)]

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: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Health Insurance Common Claims Form and Supporting 
Regulations at 42 CFR part 424, Subpart C; 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

[[Page 31616]]

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 easy use by beneficiaries who file their own 
claims. The form can be obtained from any Social Security office or 
Medicare carrier. Form Number: CMS-1500(08/05), CMS-1490-S 
(OMB: 0938-0999); Frequency: Reporting--On occasion; Affected 
Public: State, Local, or Tribal Government, Business or other-for-
profit, Not-for-profit institutions; Number of Respondents: 1,448,346; 
Total Annual Responses: 988,005,045; Total Annual Hours: 21,418,336. 
(For policy questions regarding this collection contact Brian Reitz at 
410-786-5001. For all other issues call 410-786-1326.)
    2. Type of Information Collection Request: New collection; Title of 
Information Collection: Health Insurance Common Claims Form and 
Supporting Regulations at 42 CFR part 424, Subpart C; 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 easy use by beneficiaries who file their own 
claims. The form can be obtained from any Social Security office or 
Medicare carrier.
    Most recently, the National Uniform Claim Committee (NUCC) has 
revised the CMS-1500. The NUCC began revision work on the 1500 Claim 
Form, version 02/12 in 2009. The goal of this work was to align the 
paper form with some of the changes in the electronic Health Care 
Claim: Professional (837), 005010X222 Technical Report Type 3 (5010) 
and 005010X222A1 Technical Report Type 3 (5010A1). During the revision 
work, consideration was given to different approaches to revising the 
form. The NUCC decided to proceed with making ``minor changes'' to the 
current form, which was defined as no physical changes to the existing 
form lines or underlying layout of the form. Once the CMS-1500 (02/12) 
has been approved, the CMS-1500 (08/05) will be discontinued after a 
form runoff period during which both the CMS-1500 (08/05) and the CMS-
1500 (02/12) can be used. Form Number: CMS-1500(02/12), CMS-1490-S 
(OMB: 0938-New); Frequency: Reporting--On occasion; Affected 
Public: State, Local, or Tribal Government, Business or other-for-
profit, Not-for-profit institutions; Number of Respondents: 1,448,346; 
Total Annual Responses: 988,005,045; Total Annual Hours: 21,418,336. 
(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 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 July 30, 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 --------, Room C4-26-05, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850.

    Dated: May 22, 2012.
Martique Jones,
Director, Regulations Development Group, Division B, Office of 
Strategic Operations and Regulatory Affairs.
[FR Doc. 2012-12810 Filed 5-25-12; 8:45 am]
BILLING CODE 4120-01-P
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