Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 6277 

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. 

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: OIRA_submission@

omb.eop.gov. 

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 

Paperwork@cms.hhs.gov. 

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: 

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6278 Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 

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 nonparticipating 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-forprofit 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 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Health Resources and Services 

Administration 

National Vaccine Injury Compensation 

Program; List of Petitions Received 

AGENCY: Health Resources and Services 

Administration, HHS. 

ACTION: Notice. 

SUMMARY: The Health Resources and 

Services Administration (HRSA) is 

publishing this notice of petitions 

received under the National Vaccine 

Injury Compensation Program (the 

Program), as required by Section 

2112(b)(2) of the Public Health Service 

(PHS) Act, as amended. While the 

Secretary of Health and Human Services 

is named as the respondent in all 

proceedings brought by the filing of 

petitions for compensation under the 

Program, the United States Court of 

Federal Claims is charged by statute 

with responsibility for considering and 

acting upon the petitions. 

FOR FURTHER INFORMATION CONTACT: For 

information about requirements for 

filing petitions, and the Program in 

general, contact the Clerk, United States 

Court of Federal Claims, 717 Madison 

Place NW., Washington, DC 20005, 

(202) 357–6400. For information on 

HRSA’s role in the Program, contact the 

Director, National Vaccine Injury 

Compensation Program, 5600 Fishers 

Lane, Room 11C–26, Rockville, MD 

20857; (301) 443–6593, or visit our Web 

site at: http://www.hrsa.gov/

vaccinecompensation/index.html. 

SUPPLEMENTARY INFORMATION: The 

Program provides a system of no-fault 

compensation for certain individuals 

who have been injured by specified 

childhood vaccines. Subtitle 2 of Title 

XXI of the PHS Act, 42 U.S.C. 300aa– 

10 et seq., provides that those seeking 

compensation are to file a petition with 

the U.S. Court of Federal Claims and to 

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