65658 Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifiers: CMS–10305, CMS– 

10488, CMS–R–71, CMS–R–10, CMS–10220 

and CMS–855C] 

Agency Information Collection 

Activities: Submission for OMB 

Review; Comment Request 

ACTION: Notice. 

SUMMARY: The Centers for Medicare & 

Medicaid Services (CMS) is announcing 

an opportunity for the public to 

comment on CMS’ intention to collect 

information from the public. Under the 

Paperwork Reduction Act of 1995 

(PRA), federal agencies are required to 

publish notice in the Federal Register 

concerning each proposed collection of 

information, including each proposed 

extension or reinstatement of an existing 

collection of information, and to allow 

a second opportunity for public 

comment on the notice. Interested 

persons are invited to send comments 

regarding the 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. 

DATES: Comments on the collection(s) of 

information must be received by the 

OMB desk officer by December 2, 2013: 

ADDRESSES: When commenting on the 

proposed information collections, 

please reference the document identifier 

or OMB control number. To be assured 

consideration, comments and 

recommendations must be received by 

the OMB desk officer via one of the 

following transmissions: OMB, Office of 

Information and Regulatory Affairs, 

Attention: CMS Desk Officer, Fax 

Number: (202) 395–6974 OR Email: 

OIRA_submission@omb.eop.gov. 

To obtain copies of a supporting 

statement and any related forms for the 

proposed collection(s) summarized in 

this notice, you may make your request 

using one of following: 

1. Access CMS’ Web site address at 

http://www.cms.hhs.gov/

PaperworkReductionActof1995. 

2. Email your request, including your 

address, phone number, OMB number, 

and CMS document identifier, to 

Paperwork@cms.hhs.gov. 

3. Call the Reports Clearance Office at 

(410) 786–1326. 

FOR FURTHER INFORMATION CONTACT: 

Reports Clearance Office at (410) 786– 

1326 

SUPPLEMENTARY INFORMATION: Under the 

Paperwork Reduction Act of 1995 (PRA) 

(44 U.S.C. 3501–3520), federal Agencies 

must obtain approval from the Office of 

Management and Budget (OMB) for each 

collection of information they conduct 

or sponsor. The term ‘‘collection of 

information’’ is defined in 44 U.S.C. 

3502(3) and 5 CFR 1320.3(c) and 

includes agency requests or 

requirements that members of the public 

submit reports, keep records, or provide 

information to a third party. Section 

3506(c)(2)(A) of the PRA (44 U.S.C. 

3506(c)(2)(A)) requires federal agencies 

to publish a 30-day notice in the 

Federal Register concerning each 

proposed collection of information, 

including each proposed extension or 

reinstatement of an existing collection 

of information, before submitting the 

collection to OMB for approval. To 

comply with this requirement, CMS is 

publishing this notice that summarizes 

the following proposed collection(s) of 

information for public comment: 

1. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title: Medicare 

Part C and Part D Data Validation (42 

CFR 422.516(g) and 423.514(g)); Use: 

Data collected via the Medicare Part C 

and Part D Reporting Requirements 

Technical Specifications is an integral 

resource for oversight, monitoring, 

compliance and auditing activities 

necessary to ensure quality provision of 

the Medicare benefits to beneficiaries. 

We use the data collected through the 

Medicare Data Validation Program to 

substantiate the data collected via 

Medicare Part C and Part D Reporting 

Requirements Technical Specifications. 

If we detect data anomalies, the CMS 

division with primary responsibility for 

the applicable reporting requirement 

assists with determining a resolution. 

Form Number: CMS–10305 (OCN: 

0938–1115); Frequency: Yearly; Affected 

Public: Private sector—Business or other 

for-profit or Not-for-profit organizations; 

Number of Respondents: 208; Total 

Annual Responses: 657; Total Annual 

Hours: 179,301. (For policy questions 

regarding this collection contact Terry 

Lied at 410–786–8973.) 

2. Type of Information Collection 

Request: New collection (Request for a 

new OMB control number); Title of 

Information Collection: Health 

Insurance Marketplace Consumer 

Experience Surveys: Enrollee 

Satisfaction Survey and Marketplace 

Survey Data Collection; Use: Section 

1311(c)(4) of the Affordable Care Act 

(ACA) requires the Department of 

Health and Human Services (HHS) to 

develop an enrollee satisfaction survey 

system that assesses consumer 

experience with qualified health plans 

(QHPs) offered through an Exchange. It 

also requires public display of enrollee 

satisfaction information by the 

Exchange to allow individuals to easily 

compare enrollee satisfaction levels 

between comparable plans. The HHS 

intends to establish two surveys that 

assess consumer experience with the 

Marketplaces and the QHPs offered 

through the Marketplaces. The surveys 

will include topics to assess consumer 

experience with the Marketplace such 

as enrollment and customer service, as 

well as experience with the health care 

system such as communication skills of 

providers and ease of access to health 

care services. We are considering using 

the Consumer Assessment of Health 

Providers and Systems (CAHPS®) 

principles (http://www.cahps.ahrq.gov/

about.htm) for developing the surveys. 

We have proposed an application and 

approval process for enrollee 

satisfaction survey vendors who want to 

participate in collecting ESS data. The 

application form for survey vendors 

includes information regarding 

organization name and contact(s) as 

well as minimum business requirements 

such as relevant survey experience, 

organizational survey capacity, and 

quality control procedures. 

The Marketplace Survey will provide 

(1) Actionable information that the 

Marketplaces can use to improve 

performance, (2) information that CMS 

and state regulatory organizations can 

use for general oversight, and (3) a 

longitudinal database for future 

Marketplace research. The CAHPS®

family of instruments does not have a 

survey that assesses entities similar to 

Marketplaces, so the Marketplace survey 

items were generated by the project 

team. The QHP Enrollee Experience 

survey will (1) help consumers choose 

among competing health plans, (2) 

provide actionable information that the 

QHPs can use to improve performance, 

(3) provide information that regulatory 

and accreditation organizations can use 

to regulate and accredit plans, and (4) 

provide a longitudinal database for 

consumer research. We plan to base the 

QHP survey on the CAHPS® Health Plan 

Survey. 

We are planning for two rounds of 

developmental testing for the 

Marketplace and QHP surveys. The 

2014 survey field tests will help 


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Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices 65659 

determine psychometric properties and 

provide an initial measure of 

performance for Marketplaces and QHPs 

to use for quality improvement. Based 

on field test results, there will be further 

refinement of the questionnaires and 

sampling designs to conduct the 2015 

beta test of each survey. We plan to 

request clearance for two additional 

rounds of national implementation with 

reporting of scores for each survey in 

the future. A summary of findings from 

the testing rounds will be included 

when requesting clearance for the 

additional two rounds of national 

implementation in 2016 and 2017. In 

2014, the total annual burden hours for 

the Marketplace and QHP Survey field 

tests are 34,668 hours with 93,802 

responses. In 2015, the total annual 

burden hours for the Marketplace and 

QHP Survey beta tests are 267,460 hours 

with 661,241 responses. The total 

average annualized burden over three 

years for this requested information 

collection is 100,709 hours and the total 

average annualized number of responses 

is 251,681 responses. Form Number: 

CMS–10488 (OCN: 0938–NEW); 

Frequency: Annually; Affected Public: 

Public sector—Individuals and 

Households and Private sector— 

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

Respondents: 251,681; Total Annual 

Responses: 251,681; Total Annual 

Hours: 100,709. (For policy questions 

regarding this collection contact 

Kathleen Jack at 410–786–7214.) 

3. Type of Information Collection 

Request: Reinstatement with change of a 

previously approved collection; Title of 

Information Collection: Quality 

Improvement Organization (QIO) 

Assumption of Responsibilities and 

Supporting Regulations; Use: The Peer 

Review Improvement Act of 1982 

amended Title XI of the Social Security 

Act to create the Utilization and Quality 

Control Peer Review Organization (PRO) 

program which replaces the Professional 

Standards Review Organization (PSRO) 

program and streamlines peer review 

activities. The term PRO has been 

renamed Quality Improvement 

Organization (QIO). This information 

collection describes the review 

functions to be performed by the QIO. 

It outlines relationships among QIOs, 

providers, practitioners, beneficiaries, 

intermediaries, and carriers. Form 

Number: CMS–R–71 (OCN: 0938–0445); 

Frequency: Yearly; Affected Public: 

Private sector—Business or other forprofit and Not-for-profit institutions; 

Number of Respondents: 6,939; Total 

Annual Responses: 50,377; Total 

Annual Hours: 158,993. (For policy 

questions regarding this collection 

contact Coles Mercier at 410–786–2112.) 

4. Type of Information Collection 

Request: Reinstatement with change of a 

previously approved collection; Title of 

Information Collection: Advance 

Directives (Medicare and Medicaid) and 

Supporting Regulations; Use: The 

advance directives requirement was 

enacted because Congress wanted 

individuals to know that they have a 

right to make health care decisions and 

to refuse treatment even when they are 

unable to communicate. Steps have 

been taken at both the federal and state 

level, to afford greater opportunity for 

the individual to participate in 

decisions made concerning the medical 

treatment to be received by an adult 

patient in the event that the patient is 

unable to communicate to others, a 

preference about medical treatment. The 

individual may make his preference 

known through the use of an advance 

directive, which is a written instruction 

prepared in advance, such as a living 

will or durable power of attorney. This 

information is documented in a 

prominent part of the individual’s 

medical record. Advance directives as 

described in the Patient SelfDetermination Act have increased the 

individual’s control over decisions 

concerning medical treatment. Sections 

4206 of the Omnibus Budget 

Reconciliation Act of 1990 defined an 

advance directive as a written 

instruction recognized under State law 

relating to the provision of health care 

when an individual is incapacitated 

(those persons unable to communicate 

their wishes regarding medical 

treatment). 

All states have enacted legislation 

defining a patient’s right to make 

decisions regarding medical care, 

including the right to accept or refuse 

medical or surgical treatment and the 

right to formulate advance directives. 

Participating hospitals, skilled nursing 

facilities, nursing facilities, home health 

agencies, providers of home health care, 

hospices, religious nonmedical health 

care institutions, and prepaid or eligible 

organizations (including Health Care 

Prepayment Plans (HCPPs) and 

Medicare Advantage Organizations 

(MAOs) such as Coordinated Care Plans, 

Demonstration Projects, Chronic Care 

Demonstration Projects, Program of All 

Inclusive Care for the Elderly, Private 

Fee for Service, and Medical Savings 

Accounts must provide written 

information, at explicit time frames, to 

all adult individuals about: (a) The right 

to accept or refuse medical or surgical 

treatments; (b) the right to formulate an 

advance directive; (c) a description of 

applicable State law (provided by the 

State); and (d) the provider’s or 

organization’s policies and procedures 

for implementing an advance directive. 

Form Number: CMS–R–10 (OCN: 0938– 

0610); Frequency: Yearly; Affected 

Public: Private sector—Business or other 

for-profits; Number of Respondents: 

39,575; Total Annual Responses: 

39,575; Total Annual Hours: 2,836,441. 

(For policy questions regarding this 

collection contact Sonia Swancy at 410– 

786–8445.) 

5. Type of Information Collection 

Request: Reinstatement with change of a 

previously approved collection; Title of 

Information Collection: Security 

Consent and Surrogate Authorization 

Form; Use: The primary function of the 

Medicare enrollment application is to 

obtain information about the Provider or 

supplier and whether they meet the 

Federal and/or State qualifications to 

participate in the Medicare program. In 

addition, the Medicare enrollment 

application gathers information 

regarding the provider or supplier’s 

practice location, the identity of the 

owners of the enrolling organization, 

and information necessary to establish 

the correct claims payment. 

Enrollees have the option of 

submitting either a CMS 855 form, or 

submitting information via a web based 

process. In establishing a web based 

application process, we allow providers 

and suppliers the ability to enroll in the 

Medicare program, revalidate their 

enrollment and make changes to their 

enrollment information via Internetbased Provider Enrollment, Chain and 

Ownership System (PECOS). Individual 

providers/suppliers (hereinafter referred 

to as ‘‘Individual Providers’’) log into 

Internet-based PECOS using their User 

IDs and passwords established when 

they applied on-line to the National 

Plan and Provider Enumeration System 

(NPPES) for their National Provider 

Identifiers (NPIs). Authorized Officials 

(AOs) of the provider or supplier 

organizations (hereinafter referred to as 

‘‘Organizational Providers’’) must 

register for a user account and 

authenticate their identity and 

connection to the organization they 

represent before being able to log into 

Internet-based PECOS. Once 

authenticated, AOs for Organizational 

Providers, receive complete access to 

their enrollment information via 

Internet-based PECOS. Individuals and 

AOs of Organizational Providers are not 

required to submit a Security Consent 

and Surrogate Authorization Form to 

enroll, revalidate or make changes to 

their Medicare enrollment information. 

Individual and Organizational 

Providers may complete their Medicare 

enrollment responsibilities on their own 


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65660 Federal Register / Vol. 78, No. 212 / Friday, November 1, 2013 / Notices 

or elect to delegate this task to a 

Surrogate. A Surrogate is an individual 

or organization identified by an 

Individual or Organizational Provider as 

someone authorized to access CMS 

computer systems, such as Internetbased PECOS, National Provider Plan 

and Enumeration System (NPPES) and 

the Medicare and Medicaid Electronic 

Health Records (EHR) Incentive Program 

Registration and Attestation System 

(HITECH), on their behalf and to modify 

or view any information contained 

therein that the Individual or 

Organizational Provider may have 

permission or right to access in 

accordance with Medicare statutes, 

regulations, policies, and usage 

guidelines for any CMS system. 

Surrogates may consist of administrative 

staff, independent contractors, 3rd party 

consulting companies or credentialing 

departments. In order for an Individual 

or Organizational Provider to delegate 

the Medicare credentialing process to a 

Surrogate to access and update their 

enrollment information in the above 

mentioned CMS systems on their behalf, 

it is required that a Security Consent 

and Surrogate Authorization Form be 

completed, or Individual and 

Organizational Providers use an 

equivalent online process via the 

PECOS Identity and Access 

Management (I&A) system. The Security 

Consent and Surrogate Authorization 

form replicates business service 

agreements between Medicare 

providers, suppliers or both and 

Surrogates providing enrollment 

services. 

We are proposing one version of the 

Security Consent and Surrogate 

Authorization Form. The form, once 

signed, mailed and approved, grants a 

Surrogate access to all current and 

future enrollment data for the 

Individual or Organization Provider. 

Form Number: CMS–10220 (OCN: 

0938–1035); Frequency: Occasionally; 

Affected Public: Individuals and Private 

Sector—Business or other for-profits 

and Not-for-profit institutions; Number 

of Respondents: 88,650; Total Annual 

Responses: 88,650; Total Annual Hours: 

22,162. (For policy questions regarding 

this collection contact Alisha Banks at 

410–786–0671.) 

6. Type of Information Collection 

Request: New collection (Request for a 

new OMB control number); Title of 

Information Collection: Medicare 

Enrollment Application for Registration 

of Eligible Entities That Provide Health 

Insurance Coverage Complementary to 

Medicare Part B; Use: The primary 

function of a Medicare enrollment 

application is to gather information 

from a provider, supplier or other entity 

that tells us who it is, whether it meets 

certain qualifications to be a health care 

provider, supplier or entity, where it 

practices or renders its services, the 

identity of the owners of the enrolling 

entity, and information necessary to 

establish correct claims payments. We 

are adding a new CMS–855 Medicare 

Registration Application, the CMS– 

855C: Medicare Enrollment Application 

for Registration of Eligible Entities That 

Provide Health Insurance Coverage 

Complementary to Medicare Part B. 

This Medicare registration application is 

to be completed by all entities that 

provide a complimentary health benefit 

plan and intend to bill Medicare as an 

indirect payment procedure (IPP) biller 

and the entity or health plan meets all 

Medicare requirements to submit claims 

for indirect payments. The entity must 

furnish the name of at least one 

authorized official, preferably the 

administrator of the health plan, who 

must sign this registration application 

attesting that the registering entity meets 

the requirements to register as an 

indirect payment procedure biller and 

will also abide by the requirements 

stated in the Certification & Attestation 

Statement in Section 10 of the 

application. 

The CMS–855C will be submitted at 

the time the applicant first requests a 

Medicare identification number for the 

sole purpose of submitting claims under 

the ‘‘Indirect Payment Procedure (IPP)’’ 

for reimbursement, and when necessary 

to report any changes to information 

previously submitted. The application 

will be used by Medicare contractors to 

collect data to ensure the applicant has 

the necessary credentials to submit 

Medicare claims for reimbursement, 

including information that allows 

Medicare contractors to ensure that the 

entity and its owners and administrators 

are not sanctioned from the Medicare 

program, or debarred, suspended or 

excluded from any other Federal agency 

or program. Form Number: CMS–855C 

(OCN: 0938—New); Frequency: 

Occasionally; Affected Public: Private 

sector—Business or other for-profits and 

Not-for-profit institutions; Number of 

Respondents: 440; Total Annual 

Responses: 440; Total Annual Hours: 

500. (For policy questions regarding this 

collection contact Kim McPhillips at 

410–786–5374.) 

Dated: October 29, 2013. 

Martique Jones, 

Deputy Director, Regulations Development 

Group, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2013–26107 Filed 10–31–13; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–1462–N] 

Medicare Program; Solicitation of Five 

Nominations to the Advisory Panel on 

Hospital Outpatient Payment (HOP, the 

Panel) 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: This notice solicits 

nominations for five new members to 

the Advisory Panel on Hospital 

Outpatient Payment (HOP, the Panel). 

There are five vacancies on the Panel 

effective September 30, 2013. 

The purpose of the Panel is to advise 

the Secretary of the Department of 

Health and Human Services and the 

Administrator of the Centers for 

Medicare & Medicaid Services on the 

clinical integrity of the Ambulatory 

Payment Classification (APC) groups 

and their associated weights, and 

supervision of hospital outpatient 

services. 

The Secretary rechartered the Panel in 

2012 for a 2-year period effective 

through November 19, 2014. 

DATES: Submission of Nominations: We 

will consider nominations if they are 

received no later than 5 p.m. (e.s.t.) 

December 31, 2013. 

ADDRESSES: Please mail or hand deliver 

nominations to the following address: 

Centers for Medicare & Medicaid 

Services; Attn: Chuck Braver, Advisory 

Panel on HOP; Center for Medicare, 

Hospital & Ambulatory Policy Group, 

Division of Outpatient Care; 7500 

Security Boulevard; Mail Stop C4–05– 

17 Baltimore, MD 21244–1850. 

Web site: For additional information 

on the Panel and updates to the Panel’s 

activities, we refer readers to our Web 

site at the following address: http:// 

www.cms.gov/Regulations-andGuidance/Guidance/FACA/ 

AdvisoryPanelonAmbulatory

PaymentClassificationGroups.html. 

FOR FURTHER INFORMATION CONTACT: 

Persons wishing to nominate 

individuals to serve on the Panel or to 

obtain further information may contact 

Chuck Braver at the following email 

address: APCPanel@cms.hhs.gov or call 

(410) 786–3985. 

News Media: Representatives should 

contact the CMS Press Office at (202) 

690–6145. 

SUPPLEMENTARY INFORMATION: 


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