30944 Federal Register / Vol. 76, No. 103 / Friday, May 27, 2011 / Notices 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–222, CMS–287– 

05, CMS–1771, and CMS–10008] 

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: 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: 5,812; Total Annual 

Responses: 5,812; Total Annual Hours: 

290,600. (For policy questions regarding 

this collection contact Steve A. Raitzyk 

at 410–786–4599. For all other issues 

call 410–786–1326.) 

2. Type of Information Collection 

Request: Extension without change of a 

currently approved collection; Title of 

Information Collection: Chain Home 

Office Cost Statement and supporting 

Regulations in 42 CFR 413.17 and 

413.20; Use: The Form CMS–287–05 is 

filed annually by Chain Home Offices to 

report the information necessary for the 

determination of Medicare 

reimbursement to components of chain 

organizations. However, where 

providers are components of chain 

organizations, information included in 

the chain home office cost statement is 

in addition to that included in the 

provider cost report and is needed to 

determine whether payments are 

appropriate. Form Number: CMS–287– 

05 (OMB# 0938–0202); Frequency: 

Yearly; Affected Public: Business or 

other for-profit and not-for-profit 

institutions; Number of Respondents: 

1,541; Total Annual Responses: 1,541; 

Total Annual Hours: 718,106. (For 

policy questions regarding this 

collection contact Nadia Massuda at 

410–786–5834. For all other issues call 

410–786–1326.) 

3. 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 

Section 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. (For policy questions 

regarding this collection contact 

Shauntari Cheely at 410–786–1818. For 

all other issues call 410–786–1326.) 

4. 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. (For policy 

questions regarding this collection 

contact Christina Ritter Ph.D. at 410– 

786–4636. For all other issues call 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 June 27, 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: May 20, 2011. 

Michelle Shortt, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2011–13039 Filed 5–26–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Children and 

Families 

Proposed Information Collection 

Activity; Comment Request 

Title: ACF–535 LIHEAP Quarterly 

Allocation Estimates. 

OMB No. 0970–0037. 

Description: The LIHEAP Quarterly 

Allocation Estimates, ACF Form-535 is 

a one-page form that is sent to 50 State 

grantees and to the District of Columbia. 

It is also sent to Tribal Government 

grantees that receive over $1 million 

annually for the Low Income Home 

Energy Assistance Program (LIHEAP). 

Grantees are asked to complete and 

submit the form in the 4th quarter of 

each year. The data collected on the 

form are grantees estimates of 

obligations they expect to make each 


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