Federal Register / Vol. 76, No. 98 / Friday, May 20, 2011 / Notices 29247 

ESTIMATED ANNUALIZED BURDEN HOURS

Type of 

respondent 

Number of 

respondents 

Number of 

responses per 

respondent 

Average burden 

per response 

(in hours) 

Total burden 

hours 

Police & Sheriff’s Patrol Officers ..................................................... 2,467 1 20/60 822 

First-Line Supervisors/Managers of Police & Detectives ................ 162 1 1 162 

Dated: May 16, 2011. 

Daniel Holcomb, 

Acting Reports Clearance Officer, Centers for 

Disease Control and Prevention. 

[FR Doc. 2011–12467 Filed 5–19–11; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–855(O), CMS– 

855(S) and CMS–855(A, B, I, R)] 

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: New collection; Title of 

Information Collection: Medicare 

Enrollment Application for Eligible 

Ordering and Referring Physicians and 

Non-physician Practices Use: CMS is 

adding a new CMS–855 Medicare 

Enrollment Application (CMS 855O— 

Medicare Enrollment Application for 

Ordering and Referring Physicians 

only). CMS has found that many 

providers and suppliers who are not 

enrolled in Medicare are ordering and 

referring physicians for Medicare 

enrolled providers and suppliers. The 

ordering and referring data field on the 

CMS 1500 claims submission form 

requires an ordering or referring 

physician to have a Medicare 

identification number. Without an 

ordering or referring physician, specific 

types of claims submitted by Medicare 

approved providers and suppliers are 

rejected by Medicare Administrative 

Contractors (MAC) as required by 

Medicare regulation. Therefore, if an 

ordering or referring physician does not 

participate in the Medicare program, but 

orders or refers his/her patients to a 

Medicare provider or supplier, the claim 

submitted by the Medicare provider or 

supplier for the given ordered or 

referred service is automatically rejected 

by the MAC. The CMS 855O allows a 

physician to receive a Medicare 

identification number (without being 

approved for billing privileges) for the 

sole purpose of ordering and referring 

beneficiaries to Medicare approved 

providers and suppliers. This new 

Medicare application form allows 

physicians who do not provide services 

to Medicare beneficiaries to be given a 

Medicare identification number without 

having to supply all the data required 

for the submission of Medicare claims. 

It also allows the Medicare program to 

identify ordering and referring 

physicians without having to validate 

the amount of data necessary to 

determine claims payment eligibility 

(such as banking information), while 

continuing to identify the physician’s 

credentials as valid for ordering and 

referring purposes. Form Number: 

CMS–855(O) (OMB#: 0938–NEW0685); 

Frequency: Yearly; Affected Public: 

Private Sector; Business or other forprofit and not-for-profit institutions; 

Number of Respondents: 48,000; Total 

Annual Responses: 48,000; Total 

Annual Hours: 46,000. (For policy 

questions regarding this collection 

contact Kim McPhillips at 410–786– 

5374. For all other issues call 410–786– 

1326.) 

2. Type of Information Collection 

Request: Revision of a currently 

approved collection; Title of 

Information Collection: Medicare 

Durable Medical Equipment Supplier 

Enrollment Application; Use: The 

primary function of the CMS 855S 

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. Additionally, 

periodic revisions are necessary to 

incorporate new regulatory 

requirements. 

The goal of this revision of the CMS 

855S is to incorporate new regulatory 

provisions found at 42 CFR 424.57(c) (1 

through 30) and 42 CFR 424.58. These 

revisions will allow CMS to be in 

compliance with the above stated 

regulations implementing new quality 

standards for DMEPOS suppliers, 

including accreditation requirements. 

This revision will also incorporate new 

supplier standard regulations found in 

the final regulation that published on 

August 27, 2010 (75 FR 52629–52649). 

Form Number: CMS–855(S) (OMB#: 

0938–1056); Frequency: Yearly; Affected 

Public: Private Sector; Business or other 

for-profit and not-for-profit institutions; 

Number of Respondents: 140,290; Total 

Annual Responses: 140,290; Total 

Annual Hours: 331,619. (For policy 

questions regarding this collection 

contact Kim McPhillips at 410–786– 

5374. For all other issues call 410–786– 

1326.) 

3. Type of Information Collection 

Request: Revision 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. 

The goal of this submission is to address 


jlentini on DSK4TPTVN1PROD with NOTICES
29248 Federal Register / Vol. 76, No. 98 / Friday, May 20, 2011 / Notices 

the following issues. The CMS–855A 

enrollment form currently captures 

ownership/managerial information on 

providers. The data required under 

sections 6401 and 6001, however, is 

more specific than that currently 

obtained on the CMS–855A. CMS will 

therefore create four attachments to the 

CMS–855A—two for SNFs and the other 

two for physician-owned hospitals—to 

secure this information. In addition to 

the application changes triggered by 

ACA, CMS is making other revisions to 

the forms as well. 

This information collection request 

has been revised since the 60-day 

Federal Register notice published on 

March 22, 2011 (76 FR 13415). The 

group/clinic and individual burden has 

decreased due to the removal of a 

previously proposed supplier 

attachment. However, the overall 

burden hour estimate has increased 

slightly due to additional role-specific 

ownership and managerial control data 

collection for institutional providers. 

Form Number: CMS–855(A, B, I, R) 

(OMB#: 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 

collection contact Kim McPhillips at 

410–786–5374. 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 20, 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 17, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division-B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–12473 Filed 5–19–11; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier: CMS–R–235] 

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: Data Use 

Agreement (DUA) for Data Acquired 

from the Centers for Medicare & 

Medicaid Services (CMS); Use: The 

Privacy Act of 1976, § 552a requires the 

Centers for Medicare & Medicaid 

Services (CMS) to track all disclosures 

of the agency’s Personally Identifiable 

Information (PII) and the exceptions for 

these data releases. CMS is also required 

by the Health Insurance Portability and 

Accountability Act (HIPAA) of 1996 and 

the Federal Information Security 

Management Act (FISMA) of 2002 to 

properly protect all PII data maintained 

by the agency. When entities request 

CMS PII data, they enter into a Data Use 

Agreement (DUA) with CMS. The DUA 

stipulates that the recipient of CMS PII 

data must properly protect the data 

according to FISMA and also provide 

for its appropriate destruction at the 

completion of the project/study or the 

expiration date of the DUA. The DUA 

form enables the data recipient and 

CMS to document the request and 

approval for release of CMS PII data. 

The form requires the submitter to 

provide the Requestor’s organization; 

project/study name; CMS contract 

number (if applicable); data descriptions 

and the years of the data; retention date; 

attachments to the agreement; name, 

title, contact information to include 

address, city, state, zip code, phone, email, signature and date signed by the 

requester and custodian; disclosure 

provision; name of Federal Agency 

sponsor; Federal Representative name, 

title, contact information, signature, 

date; CMS representative name, title, 

contact information, signature and date; 

and concurrence/non-concurrence 

signatures and dates from 3 CMS 

System Manager or Business Owners. 

While the data elements collected are 

not subject to change, the 

individualized clauses that are 

incorporated into any specific DUA are 

subject to change based on a specific 

case or situation such as disclosures to 

states, oversight agencies or DUAs for 

disproportionate share hospital (DSH) 

data requests as well as updates to 

DUAs with additional data descriptions, 

changes to the requestor or adding 

custodians to current DUAs. Form 

Number: CMS–R–235 (OCN: 0938–0734) 

Frequency: Once; Affected Public: 

Private Sector—Business or other Forprofits and Not-for-profit Institutions; 

Number of Respondents: 2,200; Number 

of Responses: 2,200; Total Annual 

Hours: 916. (For policy questions 

regarding this collection, contact Sharon 

Kavanagh at 410–786–5441. 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.gov/Paperwork

ReductionActof1995/PRAL/

list.asp#TopOfPage 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 July 19, 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. 

Dated: May 17, 2011. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2011–12472 Filed 5–19–11; 8:45 am] 

BILLING CODE 4120–01–P 


jlentini on DSK4TPTVN1PROD with NOTICES