Federal Register / Vol. 77, No. 65 / Wednesday, April 4, 2012 / Notices 20403 

Information Collection: Medicare 

Enrollment Application; Use: The 

primary function of the CMS–855 

Medicare enrollment application is to 

gather information from a provider or 

supplier that tells us who it is, whether 

it meets certain qualifications to be a 

health care provider or supplier, where 

it practices or renders its services, the 

identity of the owners of the enrolling 

entity, and other information necessary 

to establish correct claims payments. 

Form Number: CMS–855(A, B, I, R) 

(OCN: 0938–0685); Frequency: Yearly; 

Affected Public: Private Sector; Business 

or other for-profit and not-for-profit 

institutions; Number of Respondents: 

440,450; Total Annual Responses: 

440,450; Total Annual Hours: 856,395. 

(For policy questions regarding this 

contact Kim McPhillips at 410–786– 

5374. 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. 

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 May 4, 2012. 

OMB, Office of Information and 

Regulatory Affairs, Attention: CMS 

Desk Officer, Fax Number: (202) 

395–6974, Email: 

OIRA_submission@omb.eop.gov. 

Dated: March 28, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–8010 Filed 4–3–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–855(S) and 

CMS–855(A,B,I,R); and CMS–10427] 

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: Revision of a currently 

approved collection; 

Title of Information Collection: 

Medicare Enrollment Application— 

Durable Medical Equipment, 

Prosthetics, Orthotics and Supplies 

(DMEPOS) Suppliers Use: The primary 

function of the CMS 855S Durable 

Medical Equipment, Prosthetics, 

Orthotics and Supplies (DMEPOS) 

supplier enrollment application is to 

gather information from a supplier that 

tells us who it is, whether it meets 

certain qualifications to be a health care 

supplier, where it renders its services or 

supplies, the identity of the owners of 

the enrolling entity, and information 

necessary to establish the correct claims 

payment. The goal of evaluating and 

revising the CMS 855S DMEPOS 

supplier enrollment application is to 

simplify and clarify the information 

collection without jeopardizing our 

need to collect specific information. The 

majority of the revisions contained in 

this submission are non-substantive in 

nature such as spelling and formatting 

corrections; however, we also removed 

duplicate fields and obsolete questions 

and provided clarification and 

simplified the instructions for the 

completing the application. Form 

Number: CMS–855(S) (OCN: 0938– 

1056); Frequency: Yearly; Affected 

Public: Private Sector; Business or other 

for-profit and not-for-profit institutions; 

Number of Respondents: 43,350; Total 

Annual Responses: 43,350; Total 

Annual Hours: 113,550 (For policy 

questions regarding this contact Kim 

McPhillips at 410–786–5374. For all 

other issues call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare 

Enrollment Application Use: The 

primary function of the CMS–855 

Medicare enrollment application is to 

gather information from a provider or 

supplier that tells us who it is, whether 

it meets certain qualifications to be a 

health care provider or supplier, where 

it practices or renders its services, the 

identity of the owners of the enrolling 

entity, and other information necessary 

to establish correct claims payments. 

Form Number: CMS–855(A, B, I, R) 

(OCN: 0938–0685); Frequency: Yearly; 

Affected Public: Private Sector; Business 

or other for-profit and not-for-profit 

institutions; Number of Respondents: 

440,450; Total Annual Responses: 

440,450; Total Annual Hours: 856,395 

(For policy questions regarding this 

contact Kim McPhillips at 410–786– 

5374. For all other issues call 410–786– 

1326.) 

3. Type of Information Collection 

Request: New collection; Title of 

Information Collection: For-Profit PACE 

Study; Use: The Program of All 

Inclusive Care of the Elderly (PACE) 

aims to provide integrated care and 

services to the frail elderly at risk of 

institutionalization to enable them to 

remain in the community. Under the 

Balanced Budget Act of 1997 (BBA), the 

not-for-profit PACE plans were 

established as permanent providers 

under the Medicare and Medicaid 

programs. The BBA also mandated a 

demonstration of for-profit PACE plans. 

This study will estimate the differences 

in quality and access to care between 

the for-profit and not-for-profit PACE 

plans. The data collected in the survey 

will be used to measure the outcomes of 

interest-differences in access to and 

quality of care delivered to PACE 

enrollees. To measure these key 

outcomes, the survey will collect data 

on access to and satisfaction with 

healthcare, personal care, and 

transportation assistance provided by 

the plans. Form Number: CMS–10427 

(OCN: 0938–New); Frequency: Yearly; 

Affected Public: Individuals. Number of 

Respondents: 813. Number of 

Responses: 813. Total Annual Hours: 

447. (For policy questions regarding this 

collection contact Julia Zucco at 410– 

786–6670. 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 


emcdonald on DSK29S0YB1PROD with NOTICES
20404 Federal Register / Vol. 77, No. 65 / Wednesday, April 4, 2012 / Notices 

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 June 4, 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: March 28, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–8009 Filed 4–3–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–437A and CMS– 

437B] 

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: Revision of a currently 

approved collection. Title of 

Information Collection: State Agency 

Sheets for Verifying Exclusions from the 

Inpatient Prospective Payment System 

and Supporting Regulations in 42 CFR 

Parts 412.20–412.29. Use: For first time 

verification requests for exclusion from 

the Inpatient Prospective Payment 

System (IPPS), a hospital/unit must 

notify the Regional Office (RO) servicing 

the State in which it is located that it 

believes it meets the criteria for 

exclusion from the IPPS. Currently, all 

new inpatient rehabilitation facilities 

(IRFs) must provide written certification 

that the inpatient population it intends 

to serve will meet the requirements of 

the IPPS exclusion criteria for IRFs. 

They must also complete the Form 

CMS–437A if they are a rehabilitation 

unit or complete Form CMS–437B if 

they are a rehabilitation hospital. This 

information is submitted to the State 

Agency (SA) no later than 5 months 

before the date the hospital/unit would 

become subject to IRF–PPS. 

CMS proposes to continue to use the 

Criteria Worksheets (Forms CMS–437A 

and CMS–437B) for verifying first-time 

exclusions from the IPPS, for complaint 

surveys, for its annual 5 percent 

validation sample, and for facility selfattestation. These forms are related to 

the survey and certification and 

Medicare approval of the IPPS-excluded 

rehabilitation units and rehabilitation 

hospitals. 

For rehabilitation hospitals and 

rehabilitation units already excluded 

from the IPPS, annual onsite reverification surveys by the SA are not 

required. These hospitals and units will 

be provided with a copy of the 

appropriate CMS–437 Worksheet at 

least 120 days prior to the beginning of 

its cost reporting period, so that the 

hospital/unit official may complete and 

sign an attestation statement and 

complete and return the appropriate 

CMS–437A or CMS–437B at least 120 

days prior to the beginning of its cost 

reporting period. Fiscal Intermediaries 

(FIs) will continue to verify, on an 

annual basis, compliance with the 60 

percent rule (42 CFR 412.29(b)(2)) for 

rehabilitation hospitals and 

rehabilitation units through a sample of 

medical records and the SA will verify 

the medical director requirement. 

The SA will maintain the documents 

unless instructed otherwise by the RO. 

The SA will notify the RO at least 60 

days prior to the end of the 

rehabilitation hospital’s/unit’s cost 

reporting period of the IRF’s compliance 

or non-compliance with the payment 

requirements. The information collected 

on these forms, along with other 

information submitted by the IRF is 

necessary for determining exclusion 

from the IPPS. Hospitals and units that 

have already been excluded need not 

reapply for exclusion. These facilities 

will automatically be reevaluated yearly 

to determine whether they continue to 

meet the exclusion criteria. 

In this PRA package, both forms have 

been revised. Form Number: CMS–437A 

and CMS–437B (OCN 0938–0986). 

Frequency: Yearly. Affected Public: 

Private Sector (Business or other forprofits). Number of Respondents: 1,164. 

Total Annual Responses: 1,164. Total 

Annual Hours: 291. (For policy 

questions regarding this collection 

contact Georgia Johnson at 410–786– 

6859. 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 June 4, 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 CMS–437A and CMS– 

437B (OCN 0938–0986), Room C4–26– 

05, 7500 Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Dated: March 28, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–8013 Filed 4–3–12; 8:45 am] 

BILLING CODE 4120–01–P 


emcdonald on DSK29S0YB1PROD with NOTICES