Federal Register / Vol. 76, No. 29 / Friday, February 11, 2011 / Notices 7863 

public comments. If individuals in 

making a statement reveal personal 

information (e.g., medical information) 

about themselves, that information will 

not usually be redacted. The CDC 

Freedom of Information Act coordinator 

will, however, review such revelations 

in accordance with the Freedom of 

Information Act and if deemed 

appropriate, will redact such 

information. Disclosures of information 

concerning third parties will be 

redacted. 

The Director, Management Analysis 

and Services Office, has been delegated 

the authority to sign Federal Register 

Notices pertaining to announcements of 

meetings and other committee 

management activities, for both the 

Centers for Disease Control and 

Prevention and the Agency for Toxic 

Substances and Disease Registry. 

Dated: February 7, 2011. 

Elaine L. Baker, 

Director, Management Analysis and Services 

Office Centers for Disease Control and 

Prevention. 

[FR Doc. 2011–3089 Filed 2–10–11; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–222, CMS–1771, 

CMS–10008, CMS–10368, and CMS–R–21] 

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 currently 

approved collection; Title of 

Information Collection: Independent 

Rural Health Center/Freestanding 

Federally Qualified Health Center Cost 

Report and Supporting Regulations 42 

CFR 413.20 and 42 CFR 413.24; Use: 

Providers of service in the Medicare 

program are required to submit annual 

information to achieve reimbursement 

for health care services rendered to 

Medicare beneficiaries. The Form CMS– 

222 cost report is needed to determine 

the amount of reasonable cost due to the 

providers for furnishing medical 

services to Medicare beneficiaries; Form 

Number: CMS–222 (OMB# 0938–0107); 

Frequency: Yearly; Affected Public: 

Business or other for-profit and not-forprofit institutions; Number of 

Respondents: 5812; Total Annual 

Responses: 5812; Total Annual Hours: 

290,600. 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Attending 

Physicians Statement and 

Documentation of Medicare Emergency 

and Supporting Regulations in 42 CFR 

424.103; Use: 42 CFR 424.103(b) 

requires that before a nonparticipating 

hospital may be paid for emergency 

services rendered to a Medicare 

beneficiary, a statement must be 

submitted that is sufficiently 

comprehensive to support that an 

emergency existed. Form CMS–1771 

contains a series of questions relating to 

the medical necessity of the emergency. 

The attending physician must attest that 

the hospitalization was required under 

the regulatory emergency definition 

(42 CFR 424.101) and give clinical 

documentation to support the claim. 

Form Number: CMS–1771 (OMB# 0938– 

0023); Frequency: Yearly; Affected 

Public: Private sector—business or other 

for-profit and not-for-profit institutions; 

Number of Respondents: 100; Total 

Annual Responses: 200; Total Annual 

Hours: 50. 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Process and 

Information Required to Determine 

Eligibility of Drugs, Biologicals, and 

Radiopharmaceutical Agents for 

Transitional Pass-Through Status Under 

the Hospital Outpatient Prospective 

Payment System (OPPS); Use: Section 

1833(t)(6) of the Social Security Act 

provides for temporary additional 

payments or ‘‘transitional pass-through 

payments’’ for certain drugs and 

biological agents. Interested parties such 

as hospitals, pharmaceutical companies, 

and physicians can apply for 

transitional pass-through payment for 

drugs and biologicals used with services 

covered under the OPPS. CMS uses this 

information to determine if the criteria 

for making a transitional pass-through 

payment are met and if an interim 

Healthcare Common Procedure Coding 

System (HCPCS) code for a new drug or 

biological is necessary. Form Number: 

CMS–10008 (OMB#: 0938–0802); 

Frequency: Once; Affected Public: 

Private sector—business or other forprofit; Number of Respondents: 30; 

Total Annual Responses: 480; Total 

Annual Hours: 480. 

4. Type of Information Collection 

Request: New collection (request for a 

new OMB control number); Title of 

Information Collection: Dental Action 

Plan Template for Medicaid and CHIP 

Programs; Form No.: CMS–10368 

(OMB#: 0938–NEW); Use: CMS is 

responsible for administering the 

Federal Medicaid program and the 

Children’s Health Insurance Program 

(CHIP). As part of the Federal Medicaid 

program, CMS oversees the Early and 

Periodic Screening, Diagnostic, and 

Treatment (EPSDT) benefit to assure 

that all requirements are met. The 

provision of dental services to EPSDTeligible individuals is required under 

section 1905(r)(3) of the Social Security 

Act. In addition, section 

1902(a)(43)(D)(iii) requires that CMS 

collect information on dental services 

furnished to eligible individuals. 

Section 501(e) of CHIPRA imposed new 

data reporting requirements for the 

CHIP program by requiring certain 

dental data to be reported in 2011 on the 

CHIP annual report. Dental data for 

CHIP is unavailable as the requirement 

to report this data is new for CHIP 

programs. CMS intends to use the 

information provided in the template to 

help inform us of the States activities 

undertaken to achieve the national oral 

health goals for Medicaid and CHIP. 

CMS will use the information to 

routinely follow-up with States on the 

achievement of their goals and activities 

and will share that information with 

other States; Frequency: Once; Affected 

Public: State, Local, or Tribal 

Governments; Number of Respondents: 

69; Total Annual Responses: 69; Total 

Annual Hours: 4,485. (For policy 

questions regarding this collection 

contact Cindy Ruff at 410–786–5916. 

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

5. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Withholding 

Medicare Payments to Recover 

Medicaid Overpayments and 

Supporting Regulations in 42 CFR 


jlentini on DSKJ8SOYB1PROD with NOTICES
7864 Federal Register / Vol. 76, No. 29 / Friday, February 11, 2011 / Notices 

447.31; Form No.: CMS–R–21 (OMB#: 

0938–0287); Use: Section 2104 of the 

Omnibus Reconciliation Act of 1981 

(Pub. L. 97–35) provides CMS with the 

authority to withhold Federal Medicare 

payments to recover Medicaid 

overpayments that the Medicaid State 

Agency has been unable to recover. 

When the CMS Regional Office (RO) 

receives an overpayment case from a 

State Agency, the case file is examined 

to determine whether the conditions for 

withholding Medicare payments have 

been met. If the RO determines the case 

is appropriate for withholding Medicare 

payments, the RO will contact the 

institution’s intermediary or 

individual’s carrier to determine the 

amount of Medicare payments to which 

the entity would otherwise be entitled. 

The RO will then give notice to the 

intermediary/carrier to withhold the 

entity’s Medicare payment; Frequency: 

Occasionally; Affected Public: State, 

Local, or Tribal Governments; Number 

of Respondents: 54; Total Annual 

Responses: 27; Total Annual Hours: 81. 

(For policy questions regarding this 

collection contact Rory Howe at 410– 

786–4878. 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 

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 at 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 12, 2011: 

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. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–3057 Filed 2–10–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–437, CMS–10358 

and CMS–10360] 

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: Extension of currently 

approved collection; Title of 

Information Collection: Psychiatric Unit 

Criteria Work Sheet and Supporting 

Regulations 412.25 and 412.27; Use: A 

limited number of hospitals and special 

hospital units are excluded from the 

Medicare Prospective Payment System 

(PPS) which determines Medicare 

payment for operating costs and capitalrelated costs of inpatient hospital 

services. 42 CFR 412.25 and 42 CFR 

412.27 describes the criteria under 

which these facilities are excluded. 

Excluded units are paid on the basis of 

reasonable costs subject to target rate 

ceilings (provided for by Section 

1886(b) of the Social Security Act). State 

survey agencies (SAs) are required to 

conduct initial onsite surveys of these 

units to verify that they continue to 

meet PPS-exclusion criteria. CMS 

proposes to continue to use the Criteria 

Worksheet, Forms CMS–437 for 

verifying first-time exclusions from the 

PPS, for complaint surveys, for its 

annual 5 percent validation sample, and 

for facility self-attestation. These forms 

are related to the survey and 

certification and Medicare approval of 

the PPS-excluded units; Form Number: 

CMS–437 (OMB#: 0938–0358); 

Frequency: Annually; Affected Public: 

Private sector businesses or other forprofits; Number of Respondents: 1,333; 

Total Annual Responses: 1,333; Total 

Annual Hours: 333. (For policy 

questions regarding this collection 

contact Kelley Leonette at 410–786– 

6664. For all other issues call 410–786– 

1326.) 

2. Type of Information Collection 

Request: New Collection; Title of 

Information Collection: MMIS APD 

Template for Use by States When 

Implementing the Mandatory National 

Correct Coding Initiative in Medicaid, 

SMD Letter #10–017 dated September 1, 

2010. Use; The Patient Protection and 

Affordable Care Act (Affordable Care 

Act) requires implementation of Section 

6507, Mandatory State Use of National 

Correct Coding Initiative. A State 

Medicaid Director letter, #10–017 dated 

September 1, 2010 was published with 

implementation requirements for 

provision 6507. Within this SMD letter, 

CMS states that a Medicaid Management 

Information System (MMIS) Advanced 

Planning Document (APD) template is 

required for States to request Federal 

financial participation (FFP) funding for 

implementing the provision and is also 

the tool for requesting deactivation of 

edits, due to direct conflicts with State 

laws, regulations, administrative rules, 

or payment policies. CMS has 

developed an MMIS–APD template 

specific to NCCI for State convenience. 

The MMIS APD template supporting 

implementation of the National Correct 

Coding Initiative in Medicaid will be 

submitted by States to the Regional 

Offices for review and to CMS Central 

Office for review and approval. The 

information requested on the MMIS 

APD template for NCCI will be used to 

determine and approve FFP to States. 

Form Number: CMS–10358 (OMB#: 

0938–New); Frequency: Occasionally; 

Affected Public: State, Local, or Tribal 

Governments; Number of Respondents: 

55; Total Annual Responses: 56; Total 

Annual Hours: 56. (For policy questions 

regarding this collection contact Richard 

Friedman at 410–786–4451. For all 

other issues call 410–786–1326.) 

3. Type of Information Collection 

Request: New collection; Title of 


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