[Federal Register Volume 81, Number 24 (Friday, February 5, 2016)]
[Notices]
[Pages 6277-6278]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-02278]



[[Page 6277]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifiers: CMS-10596, CMS-906, CMS-1771, CMS-1450, CMS-1500 
(02-12)]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

ACTION: Notice.

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SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is 
announcing an opportunity for the public to comment on CMS' intention 
to collect information from the public. Under the Paperwork Reduction 
Act of 1995 (PRA), federal agencies are required to publish notice in 
the Federal Register concerning each proposed collection of 
information, including each proposed extension or reinstatement of an 
existing collection of information, and to allow a second opportunity 
for public comment on the notice. Interested persons are invited to 
send comments regarding the 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.

DATES: Comments on the collection(s) of information must be received by 
the OMB desk officer by April 5, 2016.

ADDRESSES: When commenting on the proposed information collections, 
please reference the document identifier or OMB control number. To be 
assured consideration, comments and recommendations must be received by 
the OMB desk officer via one of the following transmissions:
    OMB, Office of Information and Regulatory Affairs, Attention: CMS 
Desk Officer, Fax Number: (202) 395-5806 OR, Email: 
<a href="/cdn-cgi/l/email-protection#622d2b30233d1117000f0b11110b0d0c220d0f004c070d124c050d14"><span class="__cf_email__" data-cfemail="06494f5447597573646b6f75756f696846696b642863697628616970">[email protected]</span></a>.
    To obtain copies of a supporting statement and any related forms 
for the proposed collection(s) summarized in this notice, you may make 
your request using one of following:
    1. Access CMS' Web site address at http://www.cms.hhs.gov/PaperworkReductionActof1995.
    2. Email your request, including your address, phone number, OMB 
number, and CMS document identifier, to <a href="/cdn-cgi/l/email-protection#8fdfeeffeafdf8e0fde4cfece2fca1e7e7fca1e8e0f9"><span class="__cf_email__" data-cfemail="401021302532372f322b00232d336e2828336e272f36">[email protected]</span></a>.
    3. Call the Reports Clearance Office at (410) 786-1326.

FOR FURTHER INFORMATION CONTACT: Reports Clearance Office at (410) 786-
1326.

SUPPLEMENTARY INFORMATION: Under the Paperwork Reduction Act of 1995 
(PRA) (44 U.S.C. 3501-3520), federal agencies must obtain approval from 
the Office of Management and Budget (OMB) for each collection of 
information they conduct or sponsor. The term ``collection of 
information'' is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and 
includes agency requests or requirements that members of the public 
submit reports, keep records, or provide information to a third party. 
Section 3506(c)(2)(A) of the PRA (44 U.S.C. 3506(c)(2)(A)) requires 
federal agencies to publish a 30-day notice in the Federal Register 
concerning each proposed collection of information, including each 
proposed extension or reinstatement of an existing collection of 
information, before submitting the collection to OMB for approval. To 
comply with this requirement, CMS is publishing this notice that 
summarizes the following proposed collection(s) of information for 
public comment:
    1. Type of Information Collection Request: New collection (Request 
for a new OMB control number); Title of Information Collection: 
Reapplication Submission Requirement for Qualified Entities under ACA 
Section 10332; Use: Section 10332 of the Patient Protection and 
Affordable Care Act (ACA) requires the Secretary to make standardized 
extracts of Medicare claims data under Parts A, B, and D available to 
``qualified entities'' for the evaluation of the performance of 
providers of services and suppliers. The statute provides the Secretary 
with discretion to establish criteria to determine whether an entity is 
qualified to use claims data to evaluate the performance of providers 
of services and suppliers. After consideration of comments from a wide 
variety of stakeholders during the public comment period, CMS 
established ``Medicare Program; Availability of Medicare Data for 
Performance Measurement'' (hereinafter called the Final Rule and 
referred to as the Medicare Data Sharing Program). It was published in 
the Federal Register on December 7, 2011 (42 CFR, Part 401, Subpart G). 
To implement the requirements outlined in the legislation, the Centers 
for Medicare and Medicaid Services (CMS) established the Qualified 
Entity Certification Program (QECP). The Qualified Entity Certification 
Program (QECP) was established to implement the Final Rule. One of the 
requirements in the Final Rule is that QEs must reapply for 
certification six months prior to the end of their 3-year certification 
period to remain in good standing. This form is the official 
reapplication that QEs must complete to reapply to the QECP. Form 
Number: CMS-10596 (OMB Control Number: 0938--New); Frequency: 
Occasionally; Affected Public: Private sector (Business or other for-
profit and Not-for-profit institutions); Number of Respondents: 10; 
Total Annual Responses: 10; Total Annual Hours: 1,200. (For policy 
questions regarding this collection contact Kari Gaare at 410-786-
8612.)
    2. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: The Fiscal 
Soundness Reporting Requirements; Use: The CMS is assigned 
responsibility for overseeing all Medicare Advantage Organizations 
(MAOs), Prescription Drug Plan (PDP) sponsors and PACE organizations 
on-going financial performance. Specifically, CMS needs the requested 
collection of information to establish that contracting entities within 
those programs maintain fiscally sound organizations and thereby remain 
a going concern. All contracting organizations must submit annual 
independently audited financial statements one time per year. The MAOs 
with a negative net worth and/or a net loss and the amount of that loss 
is greater than one-half of the organization's total net worth must 
file three quarterly financial statements. Currently, there are 
approximately 71 MAOs filing quarterly financial statements. Part D 
organizations must also 3 quarterly financial statements. The PACE 
organizations are required to file 4 quarterly financial statements for 
the first three years in the program as well as PACE organizations with 
a negative net worth and/or a net loss and the amount of that loss is 
greater than one-half of the organization's total net worth. Form 
Number: CMS-906 (OMB control number: 0938-0469); Frequency: Annually; 
Affected Public: Business or other for-profits; Number of Respondents: 
815; Total Annual Responses: 1,518; Total Annual Hours: 506. (For 
policy questions regarding this collection contact Geralyn Glenn at 
410-786-0973.)
    3. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection:

[[Page 6278]]

Emergency and Foreign Hospital Services; Use: Section 1866 of the 
Social Security Act states that any provider of services shall be 
qualified to participate in the Medicare program and shall be eligible 
for payments under Medicare if it files an agreement with the Secretary 
to meet the conditions outlined in this section of the Act. Section 
1814 (d)(1) of the Social Security Act and 42 CFR 424.100, allows 
payment of Medicare benefits for a Medicare beneficiary to a 
nonparticipating hospital that does not have an agreement in effect 
with the Centers for Medicare and Medicaid Services. These payments can 
be made if such services were emergency services and if CMS would be 
required to make the payment if the hospital had an agreement in effect 
and met the conditions of payment. This form is used in connection with 
claims for emergency hospital services provided by hospitals that do 
not have an agreement in effect under Section 1866 of the Social 
Security Act. As specified in 42 CFR 424.103(b), before a non-
participating 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 and give clinical documentation to support the claim. A 
photocopy of the beneficiary's hospital records may be used in lieu of 
the CMS-1771 if the records contain all the information required by the 
form. Form Number: CMS-1771 (OMB control number: 0938-0023); Frequency: 
Annually; Affected Public: Private sector (Business or other for-
profits 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.)
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicare Uniform 
Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5; 
Use: Section 42 CFR 424.5(a)(5) requires providers of services to 
submit a claim for payment prior to any Medicare reimbursement. Charges 
billed are coded by revenue codes. The bill specifies diagnoses 
according to the International Classification of Diseases, Ninth 
Edition (ICD-9-CM) code. Inpatient procedures are identified by ICD-9-
CM codes, and outpatient procedures are described using the CMS Common 
Procedure Coding System (HCPCS). These are standard systems of 
identification for all major health insurance claims payers. Submission 
of information on the CMS-1450 permits Medicare intermediaries to 
receive consistent data for proper payment. Form Numbers: CMS-1450 (UB-
04) (OMB control number: 0938-0997); Frequency: On occasion; Affected 
Public: Private sector (Business or other for-profit and Not-for-profit 
institutions); Number of Respondents: 53,111; Total Annual Responses: 
181,909,654; Total Annual Hours: 1,567,455. (For policy questions 
regarding this collection contact Matt Klischer at 410-786-7488.)
    5. 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; 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 third-party 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(02-12), CMS-1490S (OMB control number: 0938-1197) 
Frequency: On occasion; Affected Public: State, Local, or Tribal 
Governments, Private sector (Business or other-for-profit and 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 Shannon Seales at 410-786-
4089.)

    Dated: February 2, 2016.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2016-02278 Filed 2-4-16; 8:45 am]
 BILLING CODE 4120-01-P


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