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###### Department of Health and Human Services

###### Centers for Medicare & Medicaid Services 

          - [Document Identifier: CMS-1500 (12-90), CMS-1490-U, CMS-1490-S, CMS-1500 (08-05)] 

# AGENCY:

Centers for Medicare & Medicaid Services.

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:*                     Extension of a currently 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 (12-90), CMS-1490-U, CMS-1490-S (OMB#: 0938-0008);                     *Use:*                     The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare program and is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act (ASCA) Pub. L. 107-105 and the implementing regulation at 42 CFR 424.32. The Medicaid State Agencies, CHAMPUS/TriCare, Office of Workers’ Compensation Programs (OWCP), U.S. Railroad Retirement Board (RRB), 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. CMS is seeking re-approval of the CMS-1500 (12/90), CMS-1490-U, and the CMS-1490-S forms.;                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     State, Local, or Tribal Government, Business or other-for-profit, Not-for-profit institutions;                     *Number of Respondents:*                     902,378;                     *Total Annual Responses:*                     957,204,707;                     *Total Annual Hours:*                     46,383,364.                 

                    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;                     *Form Number:*                     CMS-1500 (08-05), CMS-1490-S (OMB#: 0938-NEW);                     *Use:*                     CMS is simultaneously seeking approval for form CMS-1500 (08-05) and the CMS-1500 (12-90). A concurrent approval for the two forms is needed to allow the industry to prepare for the conversion,                     *i.e.*                     computer system conversions and mass printing of the form CMS-1500 (08-05). The CMS-1500 (08-05) will be accepted beginning in October, 2006. Its use will be mandatory in 2007. In 2007, the CMS-1500 (12-90) and the corresponding OMB control number will be discontinued. The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare program and is only accepted from physicians and suppliers that are excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act (ASCA) Pub. L. 107-105 and the implementing regulation at 42 CFR 424.32. The Medicaid State Agencies, CHAMPUS/TriCare, Office of Workers’ Compensation Programs (OWCP), U.S. Railroad Retirement Board (RRB), 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.;                     *Frequency:*                     Reporting—On occasion;                     *Affected Public:*                     State, Local, or Tribal Government, Business or other-for-profit, Not-for-profit institutions;                     *Number of Respondents:*                     902,378;                     *Total Annual Responses:*                     957,204,707;                     *Total Annual Hours:*                     46,383,364.                 

                    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/​regulations/​pra/​*, 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 on (410) 786-1326.                 

To be assured consideration, comments and recommendations for the proposed information collections must be received at the address below, no later than 5 p.m. on January 31, 2006. 

CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development—B, Attention: William N. Parham, III, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 

Dated: November 23, 2005. 

Michelle Shortt, 

Director, Regulations Development Group, Office of Strategic Operations and Regulatory Affairs. 

[FR Doc. 05-23596 Filed 12-1-05; 8:45 am] 

BILLING CODE 4120-01-P