31616 Federal Register / Vol. 77, No. 103 / Tuesday, May 29, 2012 / Notices 

claims from physicians and suppliers. 

The Medicaid State Agencies, 

CHAMPUS/TriCare, Blue Cross/Blue 

Shield Plans, the Federal Employees 

Health Benefit Plan, and several private 

health plans also use it; it is the de facto 

standard ‘‘professional’’ claim form. 

Medicare carriers use the data 

collected on the CMS–1500 and the 

CMS–1490S to determine the proper 

amount of reimbursement for Part B 

medical and other health services (as 

listed in section 1861(s) of the Social 

Security Act) provided by physicians 

and suppliers to beneficiaries. The 

CMS–1500 is submitted by physicians/ 

suppliers for all Part B Medicare. 

Serving as a common claim form, the 

CMS–1500 can be used by other thirdparty payers (commercial and nonprofit 

health insurers) and other Federal 

programs (e.g., CHAMPUS/TriCare, 

Railroad Retirement Board (RRB), and 

Medicaid). 

However, as the CMS–1500 displays 

data items required for other third-party 

payers in addition to Medicare, the form 

is considered too complex for use by 

beneficiaries when they file their own 

claims. Therefore, the CMS–1490S 

(Patient’s Request for Medicare 

Payment) was explicitly developed for 

easy use by beneficiaries who file their 

own claims. The form can be obtained 

from any Social Security office or 

Medicare carrier. Form Number: CMS– 

1500(08/05), CMS–1490–S (OMB#: 

0938–0999); Frequency: Reporting—On 

occasion; Affected Public: State, Local, 

or Tribal Government, Business or 

other-for-profit, Not-for-profit 

institutions; Number of Respondents: 

1,448,346; Total Annual Responses: 

988,005,045; Total Annual Hours: 

21,418,336. (For policy questions 

regarding this collection contact Brian 

Reitz at 410–786–5001. For all other 

issues call 410–786–1326.) 

2. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Health 

Insurance Common Claims Form and 

Supporting Regulations at 42 CFR part 

424, Subpart C; Use: The Form CMS– 

1500 answers the needs of many health 

insurers. It is the basic form prescribed 

by CMS for the Medicare program for 

claims from physicians and suppliers. 

The Medicaid State Agencies, 

CHAMPUS/TriCare, Blue Cross/Blue 

Shield Plans, the Federal Employees 

Health Benefit Plan, and several private 

health plans also use it; it is the de facto 

standard ‘‘professional’’ claim form. 

Medicare carriers use the data 

collected on the CMS–1500 and the 

CMS–1490S to determine the proper 

amount of reimbursement for Part B 

medical and other health services (as 

listed in section 1861(s) of the Social 

Security Act) provided by physicians 

and suppliers to beneficiaries. The 

CMS–1500 is submitted by physicians/ 

suppliers for all Part B Medicare. 

Serving as a common claim form, the 

CMS–1500 can be used by other thirdparty payers (commercial and nonprofit 

health insurers) and other Federal 

programs (e.g., CHAMPUS/TriCare, 

Railroad Retirement Board (RRB), and 

Medicaid). 

However, as the CMS–1500 displays 

data items required for other third-party 

payers in addition to Medicare, the form 

is considered too complex for use by 

beneficiaries when they file their own 

claims. Therefore, the CMS–1490S 

(Patient’s Request for Medicare 

Payment) was explicitly developed for 

easy use by beneficiaries who file their 

own claims. The form can be obtained 

from any Social Security office or 

Medicare carrier. 

Most recently, the National Uniform 

Claim Committee (NUCC) has revised 

the CMS–1500. The NUCC began 

revision work on the 1500 Claim Form, 

version 02/12 in 2009. The goal of this 

work was to align the paper form with 

some of the changes in the electronic 

Health Care Claim: Professional (837), 

005010X222 Technical Report Type 3 

(5010) and 005010X222A1 Technical 

Report Type 3 (5010A1). During the 

revision work, consideration was given 

to different approaches to revising the 

form. The NUCC decided to proceed 

with making ‘‘minor changes’’ to the 

current form, which was defined as no 

physical changes to the existing form 

lines or underlying layout of the form. 

Once the CMS–1500 (02/12) has been 

approved, the CMS–1500 (08/05) will be 

discontinued after a form runoff period 

during which both the CMS–1500 (08/ 

05) and the CMS–1500 (02/12) can be 

used. Form Number: CMS–1500(02/12), 

CMS–1490–S (OMB#: 0938–New); 

Frequency: Reporting—On occasion; 

Affected Public: State, Local, or Tribal 

Government, Business or other-forprofit, Not-for-profit institutions; 

Number of Respondents: 1,448,346; 

Total Annual Responses: 988,005,045; 

Total Annual Hours: 21,418,336. (For 

policy questions regarding this 

collection contact Brian Reitz at 410– 

786–5001. 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 July 30, 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 llll, Room C4–26– 

05, 7500 Security Boulevard, Baltimore, 

Maryland 21244–1850. 

Dated: May 22, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–12810 Filed 5–25–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier CMS–10426, CMS– 

10421 and CMS–10415] 

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 


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Federal Register / Vol. 77, No. 103 / Tuesday, May 29, 2012 / Notices 31617 

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: End Stage Renal 

Disease (ESRD) System Access Request 

Form; Use: Within CMS, the Office of 

Clinical Standards and Quality is 

developing a new suite of systems to 

support the End Stage Renal Disease 

(ESRD) program. Due to the sensitivity 

of the data being collected and reported, 

CMS must ensure that only authorized 

personnel have access to data. Personnel 

are given access to the ESRD systems 

through the creation of user IDs and 

passwords within the QualityNet 

Identity Management System (QIMS); 

however, once within the system, the 

system determines the rights and 

privileges the personnel has over the 

data within the system. 

The sole purpose the End Stage Renal 

Disease System (ESRD) System Access 

Request Form is to identify the 

individual’s data access rights once 

within the ESRD system. This function 

and the associated data collection is 

currently being accomplished under 

‘‘Part B’’ of the QualityNet Identity 

Management System Account Form 

(CMS–10267; OCN: 0938–1050). Once 

the ESRD System Access Form is 

approved, the QualityNet Identity 

Management System (QIMS) Account 

Form will be revised to remove Part B 

from the QIMS data collection. Form 

Number: CMS–10426 (OCN: 0938– 

New); Frequency: Yearly; Affected 

Public: Private Sector—Business or 

other for-profits. Number of 

Respondents: 25,000. Number of 

Responses: 25,000. Total Annual Hours: 

6,250. (For policy questions regarding 

this collection contact Michelle Tucker 

at 410–786–0736. For all other issues 

call 410–786–1326.) 

2. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Fee-for-Service 

Recovery Audit Prepayment Review 

Demonstration and Prior Authorization 

Demonstration; Use: The Centers for 

Medicare & Medicaid Services (CMS) is 

requesting the Office of Management 

and Budget (OMB) approval of the 

collections required for two 

demonstrations of prepayment review 

and prior authorization. The first 

demonstration would allow Medicare 

Recovery Auditors to review claims on 

a pre-payment basis in certain States. 

The second demonstration would 

establish a prior authorization program 

for Power Mobility Device claims in 

certain States. 

For the Recovery Audit Prepayment 

Review Demonstration, CMS and its 

agents will request additional 

documentation, including medical 

records, to support submitted claims. As 

discussed in more detail in Chapter 3 of 

the Program Integrity Manual, 

additional documentation includes any 

medical documentation, beyond what is 

included on the face of the claim that 

supports the item or service that is 

billed. For Medicare to consider 

coverage and payment for any item or 

service, the information submitted by 

the provider or supplier (e.g., claims) 

must be supported by the 

documentation in the patient’s medical 

records. When conducting complex 

medical review, the contractor specifies 

documentation they require in 

accordance with Medicare’s rules and 

policies. In addition, providers and 

suppliers may supply additional 

documentation not explicitly listed by 

the contractor. This supporting 

information may be requested by CMS 

and its agents on a routine basis in 

instances where diagnoses on a claim do 

not clearly indicate medical necessity, 

or if there is a suspicion of fraud. 

For the Prior Authorization of Power 

Mobility Devices (PMDs) 

Demonstration, CMS will pilot prior 

authorization for Power Mobility 

Devices. Prior authorization will allow 

the applicable documentation that 

supports a claim to be submitted before 

the item is delivered. For prior 

authorization, relevant documentation 

for review is submitted before the item 

is delivered or the service is rendered. 

CMS will conduct this demonstration in 

California, Florida, Illinois, Michigan, 

New York, North Carolina and Texas 

based on beneficiary address as reported 

to the Social Security Administration 

and recorded in the Common Working 

File (CWF). For the demonstration, a 

prior authorization request can be 

completed by the (ordering) physician 

or treating practitioner and submitted to 

the appropriate DME MAC for an initial 

decision. The supplier may also submit 

the request on behalf of the physician or 

treating practitioner. The physician, 

treating practitioner or supplier who 

submits the request on behalf of the 

physician or treating practitioner, is 

referred to as the ‘‘submitter.’’ Under 

this demonstration, the submitter will 

submit to the DME MAC a request for 

prior authorization and all relevant 

documentation to support Medicare 

coverage of the PMD item. 

CMS has decided to amend the 

requirement when subsequent prior 

authorization requests are submitted. 

Currently, CMS or its agents have up to 

30 business days in which to conduct a 

review and communicate a decision. 

CMS now proposes to allow up to 20 

business days to provide suppliers and 

the Medicare beneficiaries’ quality 

services within reasonable time period 

to facilitate the delivery of necessary 

equipment which enhances mobility 

related activities of daily living and 

supports independence. 

These demonstrations have been 

designed to develop and demonstrate 

improved methods for the investigation 

and prosecution of fraud in the 

provision of care or services under the 

health programs established by the 

Social Security Act. The information 

required under this information 

collection request is requested by 

Medicare contractors to determine 

proper payment or if there is a suspicion 

of fraud. For the RAC demonstration, 

Medicare contractors may request the 

information from providers or suppliers 

submitting claims for payment from the 

Medicare program when data analysis 

indicates aberrant billing patterns or 

other information which may present a 

vulnerability to the Medicare program. 

Under the prior authorization 

demonstration, for certain PMDs, with a 

history of aberrant billing patterns, this 

information is requested in advance to 

determine appropriate payment or if 

there is a suspicion of fraud. Form 

Number: CMS–10421 (OCN 0938— 

New); Frequency: Occasionally; 

Affected Public: State, Local or Tribal 

Governments; Number of Respondents: 

479,750; Total Annual Responses: 

479,750; Total Annual Hours: 243,060. 

(For policy questions regarding this 

collection contact Debbie Skinner at 

410–786–7480. For all other issues call 

410–786–1326.) 

3. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Generic 

Clearance for the Collection Customer 

Satisfaction Surveys; Use: This 

collection of information is necessary to 

enable the Agency to garner customer 

and stakeholder feedback in an efficient, 

timely manner, in accordance with our 

commitment to improving service 

delivery. The information collected 

from our customers and stakeholders 

will help ensure that users have an 

effective, efficient, and satisfying 

experience with the Agency’s programs. 

This feedback will provide insights into 

customer or stakeholder perceptions, 

experiences and expectations, provide 

an early warning of issues with service, 

or focus attention on areas where 

communication, training or changes in 

operations might improve delivery of 

products or services. These collections 

will allow for ongoing, collaborative and 

actionable communications between the 


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31618 Federal Register / Vol. 77, No. 103 / Tuesday, May 29, 2012 / Notices 

Agency and its customers and 

stakeholders. It will also allow feedback 

to contribute directly to the 

improvement of program management. 

Collecting voluntary customer 

feedback is the least burdensome, most 

effective way for the Agency to 

determine whether or not its public Web 

sites are useful to and used by its 

customers. Generic clearance is needed 

to ensure that the Agency can 

continuously improve its Web sites 

though regular surveys developed from 

these pre-defined questions. Surveying 

the Agency Web sites on a regular, 

ongoing basis will help ensure that 

users have an effective, efficient, and 

satisfying experience on any of the Web 

sites, maximizing the impact of the 

information and resulting in optimum 

benefit for the public. The surveys will 

ensure that this communication channel 

meets customer and partner priorities, 

builds the Agency’s brands, and 

contributes to the Agency’s health and 

human services impact goals. Form 

Number: CMS–10415 (OCN 0938— 

New); Frequency: Occasionally; 

Affected Public: Individuals and 

Households, Business or other forprofits and Not-for-profit institutions, 

State, Local or Tribal Governments; 

Number of Respondents: 1,000,000; 

Total Annual Responses: 1,000,000; 

Total Annual Hours: 67,000. (For policy 

questions regarding this collection 

contact John Booth at 410–786–6577. 

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 June 28, 2012. OMB, Office of 

Information and Regulatory Affairs, 

Attention: CMS Desk Officer, Fax 

Number: (202) 395–6974, Email: 

OIRA_submission@omb.eop.gov. 

Dated: May 22, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–12811 Filed 5–25–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services (CMS) 

[CMS–2382–N] 

Medicaid Program; Announcement of 

Requirements and Registration for 

CMS Provider Screening Innovator 

Challenge 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Notice. 

SUMMARY: The Centers for Medicare & 

Medicaid Services (CMS), is announcing 

the launch of the ‘‘CMS Provider 

Screening Innovator Challenge.’’ This 

Challenge is sponsored by CMS and is 

presented as part of the Partnership for 

Program Integrity Innovation program, 

and will be administered by the 

National Aeronautic and Space 

Administration’s (NASA) Federal Center 

of Excellence for Collaborative 

Innovation. This Challenge addresses 

our goals of improving our abilities to 

streamline operations, screen providers, 

and reduce fraud and abuse. 

Specifically, the challenge is an 

innovation competition to develop a 

multi-State, multi-program provider 

screening software application which 

would be capable of risk scoring, 

credentialing validation, identity 

authentication, and sanction checks, 

while lowering burden on providers and 

reducing administrative and 

infrastructure expenses for States and 

Federal programs. More information 

pertaining to the Medicaid and CHIP 

programs can be found at 

www.medicaid.gov. 

DATES: Important dates concerning the 

Challenge include the following: 

Challenge Competition Begin: 6:00 

p.m., e.d.t., May 30, 2012. 

Challenge Competition End: To be 

determined, but expected to be 

completed by October/November 2012 

timeframe. 

FOR FURTHER INFORMATION CONTACT: John 

‘‘Chip’’ Garner, 410–786–3012. 

SUPPLEMENTARY INFORMATION: 

Subject of Challenge Competition 

Entrants are asked to develop artifacts 

and components of software 

applications that can be integrated into 

an open source solution that can deliver 

a reliable, scalable, and cost-effective 

provider-screening capability for 

multiple States (or for the nation). 

We expect the winning entry to 

exhibit the following characteristics: 

1. Reduced processing and transaction 

time for submitting and receiving 

queries to authoritative data sources 

regarding provider credentials and 

sanctions. 

2. Reductions in time needed by 

providers to submit information and 

resolve discrepancies. 

3. Administrative/infrastructure 

savings from a multi-tenant provider 

screening solution. 

4. Improved availability of key 

provider data relevant for program 

participation and oversight. 

5. Improved timeliness and accuracy 

in provider participation, oversight, and 

enrollment decisions. 

6. Improved ability to implement 

sections 1902(a)(39) and 1902(a)(77) of 

the Social Security Act, as amended by 

the Patient Protection and Affordable 

Care Act (Pub. L. 111–148 and 111–152) 

subsections 6401(b) and (c) (Provider 

Screening and Other Enrollment 

Requirements Under Medicare, 

Medicaid, and CHIP), and section 6501 

(Termination of Provider Participation 

Under Medicaid if Terminated by 

Medicare or Other State Plan). 

7. Assist in better driving alignment of 

the Medicaid Information Technology 

Architecture (MITA) 3.0 framework to 

the Information and Technology 

Architecture levels. More information 

pertaining to MITA can be found at the 

following Web site: www.medicaid.gov/ 

Medicaid-CHIP–Program-Information/ 

By-Topics/Data-and-Systems/MedicaidInformation-Technology-ArchitectureMITA.html. 

General Eligibility Rules for 

Participating in the Competition 

To be eligible to win a prize under 

this Challenge, an individual or entity 

must comply with all the requirements 

under this section. 

An individual or entity shall not be 

deemed ineligible solely because the 

individual or entity used Federal 

facilities or consulted with Federal 

employees during a competition if such 

facilities and employees are made 

available to all individuals and entities 

participating in the competition on an 

equitable basis. 

A Federal entity or Federal employee 

acting within the scope of his or her 

employment is not eligible to 

participate. A Federal employee seeking 

to participate in this competition 

outside the scope of his/her 

employment should consult his/her 

ethics official prior to developing the 

submission. Employees of CMS, the 

Challenge judges, and employees of any 

other company or individual involved 

with the design, production, execution, 

or distribution of the Challenge, along 

with such employees’ or judges’ 

immediate families (spouse, parents and 


srobinson on DSK4SPTVN1PROD with NOTICES