80 FR 62534 - Agency Information Collection Activities: Proposed Collection; Comment Request
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Federal Register Volume 80, Issue 200 (October 16, 2015)
Centers for Medicare & Medicaid Services
Federal Register Volume 80, Issue 200 (October 16, 2015)
| Page Range | 62534-62536 | |
| FR Document | 2015-26390 |
[Federal Register Volume 80, Number 200 (Friday, October 16, 2015)] [Notices] [Pages 62534-62536] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2015-26390] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document Identifier: CMS-10003, CMS-10467, CMS-1450(UB-04), CMS- 1500(08-05)] Agency Information Collection Activities: Proposed Collection; Comment Request AGENCY: Centers for Medicare & Medicaid Services, HHS. 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 (the 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 60 days for public comment on the proposed action. Interested persons are invited to send comments regarding our burden estimates 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 must be received by December 15, 2015. ADDRESSES: When commenting, please reference the document identifier or OMB control number. To be assured consideration, comments and recommendations must be submitted in any one of the following ways: 1. Electronically. You may send your comments electronically to http://www.regulations.gov. Follow the [[Page 62535]] instructions for ``Comment or Submission'' or ``More Search Options'' to find the information collection document(s) that are 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 __, Room C4-26-05, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. 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 [email protected]. 3. Call the Reports Clearance Office at (410) 786-1326. FOR FURTHER INFORMATION CONTACT: Reports Clearance Office at (410) 786- 1326. SUPPLEMENTARY INFORMATION: Contents This notice sets out a summary of the use and burden associated with the following information collections. More detailed information can be found in each collection's supporting statement and associated materials (see ADDRESSES). CMS-10003 Notice of Denial of Medical Coverage (or Payment) CMS-10467 Evaluation of the Graduate Nurse Education Demonstration Program CMS-1450(UB-04) Medicare Uniform Institutional Provider Bill and Supporting Regulations CMS-1500(08-05) Health Insurance Common Claims Form and Supporting Regulations Under the 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 requires federal agencies to publish a 60-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. Information Collection 1. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Notice of Denial of Medical Coverage (or Payment); Use: Medicare health plans, including Medicare Advantage plans, cost plans, and Health Care Prepayment Plans, are required to issue the CMS-10003 form when a request for either a medical service or payment is denied in whole or in part. The notice explains why the plan denied the service or payment and informs Medicare enrollees of their appeal rights. The notice is also used, as appropriate, to explain Medicaid appeal rights to full dual eligible individuals enrolled in a Medicare health plan that is also managing the individual's Medicaid benefits. To that end, the revised notice contains bracketed text the plan will insert if the denial notice is being delivered to an enrollee who is a full dual eligible. The text in square brackets ``[ ]'' reflects the Federal protections for Medicaid managed care enrollees. Since a State may offer additional protections, there is also free-text space for inclusion of any State-specific protections that exceed the Federal protections. Form Number: CMS-10003 (OMB control number: 0938-0829). Frequency: Occasionally; Affected Public: Private sector (Business or other for-profit and Not-for-profit institutions); Number of Respondents: 730; Total Annual Responses: 33,574,293; Total Annual Hours: 5,593,477. (For policy questions regarding this collection contact Staci Paige at 410-786-2045. For all other issues call 410-786-1326.) 2. Type of Information Collection Request: Revision of a currently approved information collection; Title of Information Collection: Evaluation of the Graduate Nurse Education Demonstration Program; Use: The Graduate Nurse Education (GNE) Demonstration is mandated under Section 5509 of the Affordable Care Act (ACA) under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). According to Section 5509 of the ACA, the five selected demonstration sites receive ``payment for the hospital's reasonable costs for the provision of qualified clinical training to advance practice registered nurses.'' Section 5509 of the ACA also states that an evaluation of the graduate nurse education demonstration must be completed no later than October 17, 2017. This evaluation includes analysis of the following: (1) Growth in the number of advanced practice registered nurses (APRNs) with respect to a specific base year as a result of the demonstration; (2) growth for each of the following specialties: clinical nurse specialist, nurse practitioner, certified nurse anesthetist, certified nurse-midwife; and (3) costs to the Medicare program as result of the demonstration. All information collected through the Evaluation of the GNE project will be used to meet the requirements specified under the ACA Section 5509. We will also use the information to determine the overall effectiveness of the GNE project. The process evaluation seeks to understand how the demonstration is implemented overall, how that implementation has changed over time, which aspects of the demonstration have been successful or unsuccessful, and what plans the sites have for the remainder of the implementation and after the demonstration formally ends. The process evaluation will answer both quantitative and qualitative questions. Form Number: CMS-10467 (OMB control number: 0938-1212); Frequency: Annually; Affected Public: State, Local, or Tribal Governments; Private sector (Business and other for-profit and Not-for-profit institutions); Number of Respondents: 104; Total Annual Responses: 104; Total Annual Hours: 802. (For policy questions regarding this collection contact Pauline Karikari-Martin at 410-786-1040.) 3. 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) [[Page 62536]] (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.) 4. 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(08/05), CMS-1490-S (OMB control number: 0938-0999) 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: October 13, 2015. William N. Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs. [FR Doc. 2015-26390 Filed 10-15-15; 8:45 am] BILLING CODE 4120-01-P
![62534 Federal Register / Vol. 80, No. 200 / Friday, October 16, 2015 / Notices
the Superfund Amendments and most commonly found at facilities on www.regulations.gov, Docket No.
Reauthorization Act of 1986 (SARA), the CERCLA National Priorities List ATSDR–2015–0002.
§ 104(i)(3), (42 U.S.C. 9604(i)(3)), directs (NPL). As part of these responsibilities, Donna B. Knutson,
the ATSDR Administrator to prepare the ATSDR Administrator must prepare
Toxicological Profiles of Priority Acting Director, Office of Policy, Planning
Toxicological Profiles for substances and Evaluation, National Center for
hazardous substances and, as necessary, enumerated on the priority list of Environmental Health and Agency for Toxic
to revise and publish each updated hazardous substances. This list Substances and Disease Registry.
toxicological profile. identifies 275 hazardous substances [FR Doc. 2015–26321 Filed 10–15–15; 8:45 am]
Comments can include additional which, according to ATSDR and U.S. BILLING CODE 4163–18–P
information or reports on studies about EPA, pose the most significant potential
the health effects of Set 27 substances.
threat to human health. The availability
Although ATSDR considered key DEPARTMENT OF HEALTH AND
of the revised priority list of 275
studies for each of these substances HUMAN SERVICES
during the profile development process, hazardous substances was announced in
the Federal Register notice solicits any the Federal Register on May 28, 2014
(79 FR 30613). In addition, ATSDR has Centers for Medicare & Medicaid
relevant, additional studies, particularly Services
unpublished data. ATSDR will evaluate the authority to prepare Toxicological
the quality and relevance of such data Profiles for substances not found at sites [Document Identifier: CMS–10003, CMS–
on the National Priorities List, in an 10467, CMS–1450(UB–04), CMS–1500(08–
or studies for possible inclusion into the
effort to ‘‘. . . establish and maintain 05)]
profile. ATSDR remains committed to
providing a public comment period for inventory of literature, research, and Agency Information Collection
this document as a means to best serve studies on the health effects of toxic Activities: Proposed Collection;
public health and our clients. substances’’ under CERCLA Section Comment Request
DATES: Written comments on this draft 104(i)(1)(B). ATSDR also prepares
Toxicological Profile must be received Toxicological Profiles in response to AGENCY: Centers for Medicare &
on or before January 14, 2016. requests for consultation under section Medicaid Services, HHS.
ADDRESSES: You may submit comments, 104(i)(4), and as otherwise necessary to ACTION: Notice.
identified by docket number ATSDR– support the site-specific response
actions conducted by ATSDR. SUMMARY: The Centers for Medicare &
2015–0002, by any of the following
Medicaid Services (CMS) is announcing
methods: Each profile will include an
• Federal eRulemaking Portal: an opportunity for the public to
examination, a summary, and an comment on CMS’ intention to collect
www.regulations.gov. Follow the interpretation of available toxicological
instructions for submitting comments. information from the public. Under the
information and epidemiological Paperwork Reduction Act of 1995 (the
• Mail: Division of Toxicology and
Human Health Sciences, Agency for evaluations. This information and these PRA), federal agencies are required to
Toxic Substances and Disease Registry, data identify the levels of significant publish notice in the Federal Register
1600 Clifton Rd. NE., MS F–57, Atlanta, human exposure for the substance and concerning each proposed collection of
GA 30329. Attn: Docket No. ATSDR– for the associated health effects. The information (including each proposed
2015–0002. profiles must also include a extension or reinstatement of an existing
Instructions: All submissions received determination of whether adequate collection of information) and to allow
must include the agency name and information on the health effects of each 60 days for public comment on the
docket number for this notice. All substance is available (or in the process proposed action. Interested persons are
relevant comments will be posted of development) in order to identify invited to send comments regarding our
without change. Because all public levels of significant human exposure. If burden estimates or any other aspect of
comments regarding ATSDR adequate information is not available, this collection of information, including
Toxicological Profiles are available for ATSDR, in cooperation with the any of the following subjects: (1) The
public inspection, no confidential National Toxicology Program (NTP), is necessity and utility of the proposed
business information or other information collection for the proper
required to ensure the initiation of a
confidential information should be performance of the agency’s functions;
program of research to provide such
submitted in response to this notice. (2) the accuracy of the estimated
information.
FOR FURTHER INFORMATION CONTACT: Ms.
burden; (3) ways to enhance the quality,
Delores Grant, Division of Toxicology utility, and clarity of the information to
SET 27 TOXICOLOGICAL PROFILES be collected; and (4) the use of
and Human Health Sciences, Agency for
Toxic Substances and Disease Registry, automated collection techniques or
Name
1600 Clifton Rd. NE., MS F–57, Atlanta, other forms of information technology to
GA 30329. Phone: (800) 232–4636 or 1 .. Polybrominated Biphenyl Ethers minimize the information collection
770–488–3351. (PBDEs) UPDATE. burden.
SUPPLEMENTARY INFORMATION: The 2 .. N,N-Diethyl-meta-toluamide (DEET). DATES: Comments must be received by
Superfund Amendments and 3 .. Toluene Diisocyanates (mixture). December 15, 2015.
Reauthorization Act (SARA) (Pub. L. Methylenediphenyl Diisocyanates ADDRESSES: When commenting, please
(NEW).
99–499) amends the Comprehensive reference the document identifier or
srobinson on DSK5SPTVN1PROD with NOTICES
4 .. Nitrates/Nitrites (NEW).
Environmental Response, OMB control number. To be assured
5 .. Toluene (UPDATE).
Compensation, and Liability Act consideration, comments and
(CERCLA or Superfund) (42 U.S.C. 9601 recommendations must be submitted in
et seq.) by establishing certain The Set 27 Toxicological Profiles are any one of the following ways:
responsibilities for ATSDR and the U.S. available online at http:// 1. Electronically. You may send your
Environmental Protection Agency (U.S. www.atsdr.cdc.gov/toxprofiles/ comments electronically to http://
EPA) regarding hazardous substances index.asp and http:// www.regulations.gov. Follow the
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![Federal Register / Vol. 80, No. 200 / Friday, October 16, 2015 / Notices 62535
instructions for ‘‘Comment or 60-day notice in the Federal Register practice registered nurses.’’ Section
Submission’’ or ‘‘More Search Options’’ concerning each proposed collection of 5509 of the ACA also states that an
to find the information collection information, including each proposed evaluation of the graduate nurse
document(s) that are accepting extension or reinstatement of an existing education demonstration must be
comments. collection of information, before completed no later than October 17,
2. By regular mail. You may mail submitting the collection to OMB for 2017. This evaluation includes analysis
written comments to the following approval. To comply with this of the following: (1) Growth in the
address: requirement, CMS is publishing this number of advanced practice registered
CMS, Office of Strategic Operations and notice. nurses (APRNs) with respect to a
Regulatory Affairs, specific base year as a result of the
Information Collection
Division of Regulations Development, demonstration; (2) growth for each of
Attention: Document Identifier/OMB 1. Type of Information Collection the following specialties: clinical nurse
Request: Revision of a currently specialist, nurse practitioner, certified
Control Number ll,
approved collection; Title of nurse anesthetist, certified nurse-
Room C4–26–05,
Information Collection: Notice of Denial midwife; and (3) costs to the Medicare
7500 Security Boulevard,
of Medical Coverage (or Payment); Use: program as result of the demonstration.
Baltimore, Maryland 21244–1850.
Medicare health plans, including All information collected through the
To obtain copies of a supporting Medicare Advantage plans, cost plans, Evaluation of the GNE project will be
statement and any related forms for the and Health Care Prepayment Plans, are used to meet the requirements specified
proposed collection(s) summarized in required to issue the CMS–10003 form under the ACA Section 5509. We will
this notice, you may make your request when a request for either a medical also use the information to determine
using one of following: service or payment is denied in whole the overall effectiveness of the GNE
1. Access CMS’ Web site address at or in part. The notice explains why the project. The process evaluation seeks to
http://www.cms.hhs.gov/ plan denied the service or payment and understand how the demonstration is
PaperworkReductionActof1995. informs Medicare enrollees of their implemented overall, how that
2. Email your request, including your appeal rights. The notice is also used, as implementation has changed over time,
address, phone number, OMB number, appropriate, to explain Medicaid appeal which aspects of the demonstration
and CMS document identifier, to rights to full dual eligible individuals have been successful or unsuccessful,
Paperwork@cms.hhs.gov. enrolled in a Medicare health plan that and what plans the sites have for the
3. Call the Reports Clearance Office at is also managing the individual’s remainder of the implementation and
(410) 786–1326. Medicaid benefits. To that end, the after the demonstration formally ends.
FOR FURTHER INFORMATION CONTACT: revised notice contains bracketed text The process evaluation will answer both
Reports Clearance Office at (410) 786– the plan will insert if the denial notice quantitative and qualitative questions.
1326. is being delivered to an enrollee who is Form Number: CMS–10467 (OMB
SUPPLEMENTARY INFORMATION:
a full dual eligible. The text in square control number: 0938–1212); Frequency:
brackets ‘‘[ ]’’ reflects the Federal Annually; Affected Public: State, Local,
Contents protections for Medicaid managed care or Tribal Governments; Private sector
This notice sets out a summary of the enrollees. Since a State may offer (Business and other for-profit and Not-
use and burden associated with the additional protections, there is also free- for-profit institutions); Number of
following information collections. More text space for inclusion of any State- Respondents: 104; Total Annual
detailed information can be found in specific protections that exceed the Responses: 104; Total Annual Hours:
each collection’s supporting statement Federal protections. Form Number: 802. (For policy questions regarding this
and associated materials (see CMS–10003 (OMB control number: collection contact Pauline Karikari-
ADDRESSES).
0938–0829). Frequency: Occasionally; Martin at 410–786–1040.)
Affected Public: Private sector (Business 3. Type of Information Collection
CMS–10003 Notice of Denial of Medical or other for-profit and Not-for-profit Request: Extension of a currently
Coverage (or Payment) institutions); Number of Respondents: approved collection; Title of
CMS–10467 Evaluation of the Graduate 730; Total Annual Responses: Information Collection: Medicare
Nurse Education Demonstration 33,574,293; Total Annual Hours: Uniform Institutional Provider Bill and
Program 5,593,477. (For policy questions Supporting Regulations in 42 CFR
CMS–1450(UB–04) Medicare Uniform regarding this collection contact Staci 424.5; Use: Section 42 CFR 424.5(a)(5)
Institutional Provider Bill and Paige at 410–786–2045. For all other requires providers of services to submit
Supporting Regulations CMS– issues call 410–786–1326.) a claim for payment prior to any
1500(08–05) Health Insurance 2. Type of Information Collection Medicare reimbursement. Charges billed
Common Claims Form and Request: Revision of a currently are coded by revenue codes. The bill
Supporting Regulations approved information collection; Title specifies diagnoses according to the
Under the PRA (44 U.S.C. 3501– of Information Collection: Evaluation of International Classification of Diseases,
3520), federal agencies must obtain the Graduate Nurse Education Ninth Edition (ICD–9–CM) code.
approval from the Office of Management Demonstration Program; Use: The Inpatient procedures are identified by
and Budget (OMB) for each collection of Graduate Nurse Education (GNE) ICD–9–CM codes, and outpatient
information they conduct or sponsor. Demonstration is mandated under procedures are described using the CMS
The term ‘‘collection of information’’ is Section 5509 of the Affordable Care Act Common Procedure Coding System
srobinson on DSK5SPTVN1PROD with NOTICES
defined in 44 U.S.C. 3502(3) and 5 CFR (ACA) under title XVIII of the Social (HCPCS). These are standard systems of
1320.3(c) and includes agency requests Security Act (42 U.S.C. 1395 et seq.). identification for all major health
or requirements that members of the According to Section 5509 of the ACA, insurance claims payers. Submission of
public submit reports, keep records, or the five selected demonstration sites information on the CMS–1450 permits
provide information to a third party. receive ‘‘payment for the hospital’s Medicare intermediaries to receive
Section 3506(c)(2)(A) of the PRA reasonable costs for the provision of consistent data for proper payment.
requires federal agencies to publish a qualified clinical training to advance Form Numbers: CMS–1450 (UB–04)
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![62536 Federal Register / Vol. 80, No. 200 / Friday, October 16, 2015 / Notices
(OMB control number: 0938–0997); the CMS–1490S (Patient’s Request for formatted electronic application form
Frequency: On occasion; Affected Medicare Payment) was explicitly that is user-friendly and has an
Public: Private sector (Business or other developed for easy use by beneficiaries interactive interface providing structure
for-profit and Not-for-profit who file their own claims. The form can and clarity for applicants. The proposed
institutions); Number of Respondents: be obtained from any Social Security F.A.S.T. form is not intended to replace
53,111; Total Annual Responses: office or Medicare carrier. Form the Funding Opportunity
181,909,654; Total Annual Hours: Number: CMS–1500(08/05), CMS–1490– Announcement (FOAs) which will still
1,567,455. (For policy questions S (OMB control number: 0938–0999) function as the full text of all funding
regarding this collection contact Matt Frequency: On occasion; Affected opportunities for which applications are
Klischer at 410–786–7488.) Public: State, Local, or Tribal sought and considered by the
4. Type of Information Collection Governments, Private sector (Business Administration for Native Americans.
Request: Extension of a currently or other-for-profit and Not-for-profit The proposed F.A.S.T. form will be
approved collection; Title of institutions); Number of Respondents: used in a pilot capacity in just one
Information Collection: Health 1,448,346; Total Annual Responses: Administration for Native Americans’
Insurance Common Claims Form and 988,005,045; Total Annual Hours: discretionary program areas: Native
Supporting Regulations at 42 CFR part 21,418,336. (For policy questions American Language Preservation and
424, Subpart C; Use: The Form CMS– regarding this collection contact Maintenance. All applicants applying
1500 answers the needs of many health Shannon Seales at 410–786–4089.) for funding in that program area will be
insurers. It is the basic form prescribed required to use the F.A.S.T. form during
Dated: October 13, 2015.
by CMS for the Medicare program for the pilot competition proposed for FY16
claims from physicians and suppliers. William N. Parham, III,
Director, Paperwork Reduction Staff, Office unless they request and receive
The Medicaid State Agencies, approval to submit a paper application.
CHAMPUS/TriCare, Blue Cross/Blue of Strategic Operations and Regulatory
Affairs. By using the F.A.S.T. form no applicant
Shield Plans, the Federal Employees
[FR Doc. 2015–26390 Filed 10–15–15; 8:45 am] will be required to provide any
Health Benefit Plan, and several private
information beyond what is already
health plans also use it; it is the de facto BILLING CODE 4120–01–P
required by the FOA. Additionally, free
standard ‘‘professional’’ claim form.
Medicare carriers use the data training and technical assistance will be
collected on the CMS–1500 and the DEPARTMENT OF HEALTH AND available to all applicants on use of the
CMS–1490S to determine the proper HUMAN SERVICES F.A.S.T. form.
amount of reimbursement for Part B ANA intends to use the project
medical and other health services (as Administration for Children and proposals submitted via the F.A.S.T.
listed in section 1861(s) of the Social Families form to make funding decisions for
Security Act) provided by physicians Native American Language Preservation
Submission for OMB Review; and Maintenance grant awards made in
and suppliers to beneficiaries. The Comment Request
CMS–1500 is submitted by physicians/ the FY 2016 pilot year. In addition,
suppliers for all Part B Medicare. Title: Native Language Preservation ANA will solicit feedback from
Serving as a common claim form, the and Maintenance Grant Application applicants and panel reviewers to obtain
CMS–1500 can be used by other third- Template Pilot (Funding Application feedback on the results, outcomes, and
party payers (commercial and nonprofit Submission Tool (F.A.S.T. form)) their recommendations regarding the
health insurers) and other Federal OMB No.: F.A.S.T. form as a user friendly method
programs (e.g., CHAMPUS/TriCare, Description: The proposed F.A.S.T. of applying for funding opportunities. If
Railroad Retirement Board (RRB), and form is intended to be used by the pilot is successful in making it
Medicaid). However, as the CMS–1500 applicants in the Administration for easier for applicants to apply, ANA will
displays data items required for other Native Americans’ Native American consider potentially expanding use of
third-party payers in addition to Language Preservation and Maintenance the F.A.S.T. form to all Administration
Medicare, the form is considered too grant competition in FY 2016. The for Native Americans’ discretionary
complex for use by beneficiaries when F.A.S.T. form is proposed to be piloted funding areas in subsequent years.
they file their own claims. Therefore, as a consolidated and streamlined pre- Respondents: 40.
ANNUAL BURDEN ESTIMATES
Number of Average
Number of Total burden
Instrument responses per burden hours
respondents hours
respondent per response
F.A.S.T. form ................................................................................................... 40 28 .50 14
Estimated Total Annual Burden Attn: ACF Reports Clearance Officer. All Federal Register. Therefore, a comment
Hours: 560. requests should be identified by the title is best assured of having its full effect
of the information collection. Email if OMB receives it within 30 days of
srobinson on DSK5SPTVN1PROD with NOTICES
Additional Information
address: infocollection@acf.hhs.gov. publication. Written comments and
Copies of the proposed collection may recommendations for the proposed
OMB Comment
be obtained by writing to the information collection should be sent
Administration for Children and OMB is required to make a decision directly to the following: Office of
Families, Office of Planning, Research concerning the collection of information Management and Budget, Paperwork
and Evaluation, 370 L’Enfant between 30 and 60 days after Reduction Project, Email:
Promenade SW., Washington, DC 20447, publication of this document in the OIRA_SUBMISSION@OMB.EOP.GOV,
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Document Created: 2015-12-14 15:23:14
Document Modified: 2015-12-14 15:23:14
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice. | |
| Dates | Comments must be received by December 15, 2015. | |
| Contact | Reports Clearance Office at (410) 786- 1326. | |
| FR Citation | 80 FR 62534 |
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