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

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

          - [Document Identifier: CMS-304/304a, CMS-10288, CMS-10289 and CMS-1450 (UB-04)]

# 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) 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 without change of a currently approved collection;                         *Title of Information Collection:*                         Reconciliation of State Invoice and Prior Quarter Adjustment Statement;                         *Use:*                         Section 1927 of the Social Security Act requires drug manufacturers to enter into and have in effect a rebate agreement with CMS in order for States to receive funding for drugs dispensed to Medicaid recipients. Drug manufacturers must complete and submit to States the 304 form (the Reconciliation of State Invoice Form) to explain any rebate payment adjustments for the current quarter, and complete and submit the 304A form (the Prior Quarter Adjustment Statement Form) to States to explain rebate payment adjustments to any prior quarters. Both forms are used to reconcile drug rebate payments made by manufacturers with the State invoices of rebates due.                         *Form Number:*                         CMS-304/304a (OMB#: 0938-0676);                         *Frequency:*                         Reporting—Quarterly;                         *Affected Public:*                         Private Sector: Business or other for profits;                         *Number of Respondents:*                         570;                         *Total Annual Responses:*                         3820;                         *Total Annual Hours:*                         141,080. (For policy questions regarding this collection contact Cindy Bergin at 410-786-1176. For all other issues call 410-786-1326.)                    

                        2.                         *Type of Information Collection Request:*                         New Collection;                         *Title of Information Collection:*                         State Plan Pre-Print to Implement Required Dental Benefits Pursuant of Children's Health Insurance Program Reauthorizing Act (CHIPRA) 2009;                         *Use:*                         Section 501 of CHIPRA 2009 amends XXI and requires that “child health assistance provide to a targeted low-income child shall include coverage of dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” States that provide coverage in a separate Children's Health Insurance Program may choose between two methods of providing the dental services required in Section 501. The State may define the                               ( print page 28250)                            services in the dental benefit package and demonstrate that it includes all the required services. Alternatively, the State may provide a dental benefit package that is equivalent to one of the three benchmark packages described in the statute. In order to implement one of these options and comply with the statute, States must amend their State Plan using the State Plan pre-print.                         *Form Number:*                         CMS-10288 (OMB #: 0938—NEW);                         *Frequency:*                         Reporting One-time;                         *Affected Public:*                         State, Local, or Tribal Governments;                         *Number of Respondents:*                         51;                         *Total Annual Responses:*                         51;                         *Total Annual Hours:*                         1530. (For policy questions regarding this collection contact Nancy Goetschius at 410-786-0707. For all other issues call 410-786-1326.)                    

                        3.                         *Type of Information Collection Request:*                         New Collection;                         *Title of Information Collection:*                         Optional Dental-only Supplemental Coverage State Plan Amendment Template;                         *Use:*                         CHIPRA 2009 provides States with an option to provide supplemental dental-only coverage to children who would be eligible to enroll in the State's Children's Health Insurance Program (CHIP), except that they already have health insurance coverage, either through a group health plan or employer sponsored insurance. If the health insurance plan the child is enrolled in does not provide dental benefits, the State may provide the child with the same State-defined dental package or benchmark benefit plan provided to children who are eligible for the entire CHIP benefit package. The child will only be entitled to the dental services provided to other CHIP children.                    

                        In order to choose this option, State must comply with all other requirements of the statute regarding cost sharing, income eligibility level, absence of a waiting list for their entire CHIP program (not just for dental coverage), and not providing more favorable treatment to children eligible for the supplemental dental benefit under this option. In order to implement this option States must amend their State Plan using the Supplemental Dental Benefits State Plan Amendment Template.                         *Form Number:*                         CMS-10289 (OMB#: 0938—NEW);                         *Frequency:*                         Reporting One-time;                         *Affected Public:*                         State, local, or Tribal Governments;                         *Number of Respondents:*                         51;                         *Total Annual Responses:*                         51;                         *Total Annual Hours:*                         1020. (For policy questions regarding this collection contact Nancy Goetschius at 410-786-0707. For all other issues call 410-786-1326.)                    

                        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#: 0938-0997);                         *Frequency:*                         Reporting—On occasion;                         *Affected Public:*                         Not-for-profit institutions, Business or other for-profit;                         *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. 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 at                         *http://www.cms.hhs.gov/​PaperworkReductionActof1995*, 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.                    

                        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                         *August 14, 2009:*

                        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 (CMS-10078), Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.                    

Dated: June 5, 2009.

Michelle Shortt,

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

[FR Doc. E9-13944 Filed 6-12-09; 8:45 am]

BILLING CODE 4120-01-P