58558 Federal Register / Vol. 77, No. 184 / Friday, September 21, 2012 / Notices 

Health Services and the U.S. Environmental 

Protection Agency. 

Agenda items are subject to change as 

priorities dictate. 

Supplementary Information: The public 

comment period is scheduled on Tuesday, 

October 16, 2012, from 3:15 p.m. until 3:30 

p.m., and on Wednesday, October 17, 2012, 

from 10 a.m. until 10:15 a.m. 

Contact Person for More Information: 

Sandra Malcom, Committee Management 

Specialist, NCEH/ATSDR, CDC, 4770 Buford 

Highway, Mail Stop F–61, Chamblee, Georgia 

30345; telephone 770/488–0575, Fax: 770/ 

488–3377; Email: smalcom@cdc.gov. The 

deadline for notification of attendance is 

October 12, 2012. 

The Director, Management Analysis and 

Services Office, has been delegated the 

authority to sign Federal Register notices 

pertaining to announcements of meetings and 

other committee management activities for 

both the Centers for Disease Control and 

Prevention and the Agency for Toxic 

Substances and Disease Registry. 

Dated: September 17, 2012. 

Elaine L. Baker, 

Director, Management Analysis and Services 

Office, Centers for Disease Control and 

Prevention (CDC). 

[FR Doc. 2012–23392 Filed 9–20–12; 8:45 am] 

BILLING CODE 4163–18–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[Document Identifier CMS–2567, CMS– 

10425, CMS–10417, CMS–10428, CMS–1500 

(02/12), and CMS–1500 (08/05)] 

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 without change of a 

currently approved collection. Title of 

Information Collection: Deficiencies and 

Plan of Correction (CMS–2567) and 

Supporting Regulations contained in 42 

CFR 488.18, 488.26, and 488.28. Use: 

Section 1864(a) of the Social Security 

Act requires that the Secretary use state 

survey agencies to conduct surveys to 

determine whether health care facilities 

meet Medicare and Clinical Laboratory 

Improvement Amendments 

participation requirements. The CMS– 

2567 form is the means by which the 

survey findings are documented. This 

section of the law further requires that 

compliance findings resulting from 

these surveys be made available to the 

public within 90 days of such surveys. 

The CMS–2567 form is the vehicle for 

this disclosure. The regulations at 42 

CFR 488.18 require that state survey 

agencies document all deficiency 

findings on a statement of deficiencies 

and plan of correction, which is the 

CMS–2567. 42 CFR 488.26 and 488.28 

further delineate how compliance 

findings must be recorded and that CMS 

prescribed forms must be used. 

The form is also used by health care 

facilities to document their plan of 

correction and by CMS, the states, 

facilities, purchasers, consumers, 

advocacy groups, and the public as a 

source of information about quality of 

care and facility compliance. 

Form Number: CMS–2567 (OCN 

0938–0391). Frequency: Yearly and 

occasionally. Affected Public: Private 

Sector (Business or other for-profit and 

not-for-profit institutions). Number of 

Respondents: 62,000. Total Annual 

Responses: 62,000. Total Annual Hours: 

134,540. (For policy questions regarding 

this collection contact Angela MasonElbert at 410–786–8279. For all other 

issues call 410–786–1326.) 

2. Type of Information Collection 

Request: New collection; Title of 

Information Collection: Evaluation of 

Patient Satisfaction and Experience of 

Care for Medicare Beneficiaries with 

End-Stage Renal Disease (ESRD): Impact 

of the ESRD Prospective Payment 

System (PPS) and ESRD Quality 

Incentive Program (QIP) ; Use: The 

Medicare Prescription Drug 

Improvement, and Modernization Act of 

2003 (MMA) required the Secretary of 

Health and Human Services (HHS) to 

submit to Congress a report detailing the 

elements and features for the design and 

implementation of a bundled End-Stage 

Renal Disease Prospective Payment 

System, specifying that such a system 

should include the bundling of 

separately billed drugs, clinical 

laboratory tests, and other items ‘‘to 

maximum extent feasible’’. The 

Medicare Improvements for Patients and 

Providers Act of 2008 (MIPPA) directed 

the Secretary of HHS to implement a 

payment system under which a single 

payment is made to a provider of 

services or a renal dialysis facility for 

renal dialysis services in lieu of any 

other payment. The ESRD PPS combines 

composite rate dialysis services with 

separately billable services under a 

single payment adjusted to reflect 

patient differences in resource needs or 

case-mix. The MIPPA also stipulated the 

development of quality incentives for 

the ESRD program. CMS has established 

the End-Stage Renal Disease Quality 

Incentive Program (ESRD QIP) to 

address this provision of the legislation. 

In order to assess the impact of the 

final rule (76 FR 627) on ESRD 

beneficiary experiences, satisfaction, 

and health outcomes, CMS is requesting 

OMB approval to obtain input on the 

effect of the final rule on our ESRD 

beneficiaries. The purpose of this data 

collection effort is to assess beneficiary 

satisfaction and experience of care in 

terms of access to services, quality of 

care, outcomes, and cost. This will be 

measured through telephone surveys 

with ESRD beneficiaries and through 

interviews with key stakeholders in the 

renal health care community. The 

information obtained from both the 

beneficiary respondents and key 

stakeholders will be used to provide an 

initial reporting of the ESRD PPS/QIP’s 

effects on beneficiary satisfaction and 

experience of care and to inform the 

Centers for Medicare & Medicaid 

Services (CMS) of the impact of the 

ESRD PPS/QIP on patient satisfaction 

and experience of care, including 

unintended consequences, for 

consideration of future modification of 

the programs. 

Subsequent to the publication of the 

60-day Federal Register notice (77 FR 

27777), the annual burden hours have 

decreased from 1,287 to 662. Early 

cognitive interview findings of the 

ESRD Beneficiary Survey submitted 

during the 60 day notice exhibited 

respondent complaints that the survey 

was too long and some participants had 

to hang up early because they were 

feeling sick. Medicare beneficiaries with 

end stage renal disease (ESRD) are very 

sick and unable to remain cognitively 

aware for 30 minutes. The ESRD 

Beneficiary Survey was significantly 

shortened so that the time necessary to 

interview a single participant was 

reduced from 30 to 15 minutes. Form 

Number: CMS–10425 (OCN: 0938– 

New); Frequency: Yearly; Affected 


pmangrum on DSK3VPTVN1PROD with NOTICES
Federal Register / Vol. 77, No. 184 / Friday, September 21, 2012 / Notices 58559 

Public: Individuals. Number of 

Respondents: 2,540. Number of 

Responses: 2,540. Total Annual Hours: 

662. (For policy questions regarding this 

collection contact Steve Blackwell at 

410–786–6852. For all other issues call 

410–786–1326.) 

3. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title of 

Information Collection: Medicare Feefor-Service Prepayment Medical 

Review; Use: The information required 

under this collection is requested by 

Medicare contractors to determine 

proper payment or if there is a suspicion 

of fraud. Medicare contractors 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. In addition, we are 

specifically soliciting public comments 

on the information collection burden 

that is associated with the currently 

approved information collection 

request. Form Number: CMS–10417 

(OMB 0938–0969); Frequency: 

Occasionally; Affected Public: Private 

Sector (Business or other for-profit and 

Not-for-profit institutions); Number of 

Respondents: 2,220,434; Total Annual 

Responses: 2,220,434; Total Annual 

Hours: 1,105,560. (For policy questions 

regarding this collection contact Debbie 

Skinner at 410–786–7480. For all other 

issues call 410–786–1326.) 

4. Type of Information Collection 

Request: Extension of a currently 

approved collection; Title: Pre-Existing 

Condition Insurance Plan (PCIP) 

Authorization to Share Personal Health 

Information; Use: On March 23, 2010, 

the President signed into law H.R. 3590, 

the Patient Protection and Affordable 

Care Act (Affordable Care Act), Public 

Law 111–148. Section 1101 of the law 

establishes a ‘‘temporary high risk 

health insurance pool program’’ (which 

has been named the Pre-Existing 

Condition Insurance Plan, or PCIP) to 

provide health insurance coverage to 

currently uninsured individuals with 

pre-existing conditions. The law 

authorizes HHS to carry out the program 

directly or through contracts with states 

or private, non-profit entities. 

Reapproval of this package is being 

requested as a result of CMS, in its 

administration of the PCIP program, 

serving as a covered entity under the 

Health Insurance Portability and 

Accountability Act (HIPAA). Without a 

valid authorization, the PCIP program is 

unable to disclose information, with 

respect to an applicant or enrollee, 

about the status of an application, 

enrollment, premium billing or claim, to 

individuals of the applicant’s or 

enrollee’s choosing. The HIPAA 

Authorization Form has been modeled 

after CMS’ Medicare HIPAA 

Authorization Form (OMB control 

number 0938–0930) and is used by 

applicants or enrollees to designate 

someone else to communicate with PCIP 

about their protected health information 

(PHI). 

Unless permitted or required by law, 

the Health Insurance Portability and 

Accountability Act (HIPAA) Privacy 

Rule (§ 164.508) prohibits CMS’ PCIP 

program (a HIPAA covered entity) from 

disclosing an individual’s protected 

health information without a valid 

authorization. In order to be valid, an 

authorization must include specified 

core elements and statements. 

CMS will make available to PCIP 

applicants and enrollees a standard, 

valid authorization to enable 

beneficiaries to communicate with PCIP 

about their personal health information. 

This is a critical tool because the 

population the PCIP program serves is 

comprised of individuals with preexisting conditions who may be 

incapacitated and need an advocate to 

help them apply for or receive benefits 

from the program. This standard 

authorization will simplify the process 

of requesting information disclosure for 

beneficiaries and minimize the response 

time for the PCIP program. 

Each individual will be asked to 

complete the form which will include 

providing the individual’s name, PCIP 

account number (if known), date of 

birth, what personal health information 

they agree to share, the length of time 

the individual agrees their personal 

health information can be shared, the 

names and addresses of the third party 

the individual wants PCIP to share their 

personal health information with, and 

an attestation that the individual is 

giving PCIP permission to share their 

personal health information with the 

third party listed in the form. This 

completed form will be submitted to the 

PCIP benefits administrator, GEHA, 

which contracts with CMS. 

We estimate that it will take 

approximately 15 minutes per applicant 

to complete and submit a HIPAA 

Authorization Form to the PCIP 

program. 

The federally-run PCIP program 

operates in 23 states plus the District of 

Columbia and receives an average of 

35,000 enrollment applications per year. 

To estimate the number of PCIP 

applicants and enrollees who may 

complete an authorization, we looked at 

the percentage of individuals who 

request an authorization in Medicare as 

a baseline. Medicare estimates 3% of its 

population will submit an authorization 

per year. However, since the PCIP 

program caters to an exclusive 

population comprised of individuals 

who have one or more pre-existing 

conditions, we believe it is likely we 

could receive double the percentage 

estimated by Medicare. Accordingly, 

PCIP estimates 6% (or 2,100) of its 

applicants and enrollees may submit an 

authorization per year. 

It is estimated that up to 2,100 

applicants and enrollees may submit an 

authorization annually. There is no cost 

to PCIP beneficiaries to request, 

complete, submit, or have the 

authorization form processed by PCIP. It 

should take approximately 15 minutes 

for a beneficiary to complete the 

authorization form. 15 minutes 

multiplied by 2,100 beneficiaries equals 

525 hours. Form Number: CMS–10428 

(OCN#: 0938–1161); Frequency: 

Reporting—Once; Affected Public: 

individuals or households; Number of 

Respondents: 2,100; Total Annual 

Responses: 2,100; Total Annual Hours: 

525. (For policy questions regarding this 

collection contact Laura Dash at 410– 

786–8623. For all other issues call 410– 

786–1326.) 

5. 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 


pmangrum on DSK3VPTVN1PROD with NOTICES
58560 Federal Register / Vol. 77, No. 184 / Friday, September 21, 2012 / Notices 

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 Claudette Sikora at 

410–786–5618. For all other issues call 

410–786–1326.) 

6. Type of Information Collection 

Request: Reinstatement without change 

of a previously approved collection; 

Title of Information Collection: Health 

Insurance Common Claims Form and 

Supporting Regulations at 42 CFR Part 

424, Subpart C; Form Number: CMS– 

1500(08/05), CMS–1490–S (OMB#: 

0938–0999); 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. 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 Claudette Sikora at 

410–786–5618. 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 October 22, 2012. OMB, Office of 

Information and Regulatory Affairs, 

Attention: CMS Desk Officer, Fax 

Number: (202) 395–6974, Email: 

OIRA_submission@omb.eop.gov. 

Dated: September 18, 2012. 

Martique Jones, 

Director, Regulations Development Group, 

Division B, Office of Strategic Operations and 

Regulatory Affairs. 

[FR Doc. 2012–23365 Filed 9–20–12; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Federal Emergency Management 

Agency 

[Docket ID FEMA–2012–0003; Internal 

Agency Docket No. FEMA–B–1270] 

Proposed Flood Hazard 

Determinations 

AGENCY: Federal Emergency 

Management Agency, DHS. 

ACTION: Notice. 

SUMMARY: Comments are requested on 

proposed flood hazard determinations, 

which may include additions or 

modifications of any Base Flood 

Elevation (BFE), base flood depth, 

Special Flood Hazard Area (SFHA) 

boundary or zone designation, or 

regulatory floodway on the Flood 

Insurance Rate Maps (FIRMs), and 

where applicable, in the supporting 

Flood Insurance Study (FIS) reports for 

the communities listed in the table 

below. The purpose of this notice is to 

seek general information and comment 

regarding the preliminary FIRM, and 

where applicable, the FIS report that the 

Federal Emergency Management Agency 

(FEMA) has provided to the affected 

communities. The FIRM and FIS report 

are the basis of the floodplain 

management measures that the 

community is required either to adopt 

or to show evidence of having in effect 

in order to qualify or remain qualified 

for participation in the National Flood 

Insurance Program (NFIP). In addition, 

the FIRM and FIS report, once effective, 

will be used by insurance agents and 

others to calculate appropriate flood 

insurance premium rates for new 

buildings and the contents of those 

buildings. 

DATES: Comments are to be submitted 

on or before December 20, 2012. 

ADDRESSES: The Preliminary FIRM, and 

where applicable, the FIS report for 

each community are available for 

inspection at both the online location 

and the respective Community Map 

Repository address listed in the tables 

below. Additionally, the current 

effective FIRM and FIS report for each 

community are accessible online 

through the FEMA Map Service Center 

at www.msc.fema.gov for comparison. 

You may submit comments, identified 

by Docket No. FEMA–B–1270, to Luis 

Rodriguez, Chief, Engineering 

Management Branch, Federal Insurance 

and Mitigation Administration, FEMA, 

500 C Street SW., Washington, DC 

20472, (202) 646–4064, or (email) 

Luis.Rodriguez3@fema.dhs.gov. 


pmangrum on DSK3VPTVN1PROD with NOTICES