81 FR 12903 - Agency Information Collection Activities: Submission for OMB Review; Comment Request
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services Federal Register Volume 81, Issue 48 (March 11, 2016)
Centers for Medicare & Medicaid Services
Federal Register Volume 81, Issue 48 (March 11, 2016)
| Page Range | 12903-12904 | |
| FR Document | 2016-05472 |
[Federal Register Volume 81, Number 48 (Friday, March 11, 2016)] [Notices] [Pages 12903-12904] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2016-05472] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [Document Identifiers: CMS-359/360, CMS-10003, and CMS-10280] 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: The necessity and utility of the proposed information collection for the proper performance of the agency's functions; the accuracy of the estimated burden; ways to enhance the quality, utility, and clarity of the information to be collected; and 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 11, 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: [email protected]. 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: 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: Extension of a currently approved information collection; Title of Information Collection: Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Supporting Regulations; Use: The form CMS-359 is used as the application for health care providers seeking to participate in the Medicare program as a Comprehensive Outpatient Rehabilitation Facility (CORF). This form initiates the process for facilities to become certified as a CORF and it provides the CMS Regional Office State Survey Agency staff identifying information regarding the applicant that is stored in the Automated Survey Processing Environment (ASPEN) system. The form CMS-360 is a survey tool used by the State Survey Agencies to record information in order to determine a provider's compliance with the CORF Conditions of Participation (CoPs) and to report this information to the Federal government. The form includes basic information on the CoP requirements, check boxes to indicate the level of compliance, and a section for recording notes. We have the responsibility and authority for certification decisions which are based on provider compliance with the CoPs and this form supports this process. Form Number: CMS-359/360 (OMB control number: 0938-0267); Frequency: Occasionally; Affected Public: Private Sector (Business or other for-profits); Number of Respondents: 50; Number of Responses: 50; Total Annual Hours: 123. (For questions regarding this collection contact James Cowher (410) 786-1948.) 2. 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 [[Page 12904]] 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. The PRA package has been revised subsequent to the publication of the 60-day Federal Register notice (October 16, 2015; 80 FR 62534). 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.) 3. Type of Information Collection Request: Extension of a currently approved collection; Title of Information Collection: Home Health Change of Care Notice (HHCCN); Use: The Home Health Change of Care Notice (HHCCN) is used to notify original Medicare beneficiaries receiving home health care benefits of plan of care changes. Home health agencies (HHAs) must provide the HHCCN whenever they reduce or terminate a beneficiary's home health services due to physician/ provider orders or limitation of the HHA in providing the specific service. Notification is required for covered and non-covered services listed in the plan of care. This iteration contains non-substantive changes which add language informing beneficiaries of their rights under Section 504 of the Rehabilitation Act of 1973 by alerting the beneficiary to CMS' nondiscrimination practices and the availability of alternate forms of this notice if needed. There are no substantive changes. Form Number: CMS-10280 (OMB control number: 0938-0829); Frequency: Occasionally; Affected Public: Private sector (Business or other for-profits and Not-for-profit institutions); Number of Respondents: 12,459; Total Annual Responses: 13,764,434; Total Annual Hours: 917,262. (For policy questions regarding this collection contact Evelyn Blaemire at 410-786-1803). Dated: March 7, 2016. William N. Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs. [FR Doc. 2016-05472 Filed 3-10-16; 8:45 am] BILLING CODE 4120-01-P
![Federal Register / Vol. 81, No. 48 / Friday, March 11, 2016 / Notices 12903
ESTIMATED ANNUALIZED BURDEN HOURS
Average
Number of
Number of burden per Total burden
Type of respondents Form name responses per
respondents response (in hrs.)
respondent (in hrs.)
Adult at least 18 years old using a Screening Form ................................ 2,500 1 6/60 250
private well for tap water. Questionnaire ................................... 2,000 1 35/60 1,167
Urine Specimen and Tap Water 2,000 1 20/60 667
Sample Collection.
Total ........................................... ........................................................... ........................ ........................ ........................ 2,084
Leroy A. Richardson, DATES: Comments on the collection(s) of comply with this requirement, CMS is
Chief, Information Collection Review Office, information must be received by the publishing this notice that summarizes
Office of Scientific Integrity, Office of the OMB desk officer by April 11, 2016. the following proposed collection(s) of
Associate Director for Science, Office of the ADDRESSES: When commenting on the information for public comment:
Director, Centers for Disease Control and proposed information collections, 1. Type of Information Collection
Prevention. Request: Extension of a currently
please reference the document identifier
[FR Doc. 2016–05519 Filed 3–10–16; 8:45 am] or OMB control number. To be assured approved information collection; Title
BILLING CODE 4163–18–P consideration, comments and of Information Collection:
recommendations must be received by Comprehensive Outpatient
the OMB desk officer via one of the Rehabilitation Facility (CORF)
DEPARTMENT OF HEALTH AND following transmissions: OMB, Office of Eligibility and Survey Forms and
HUMAN SERVICES Information and Regulatory Affairs, Supporting Regulations; Use: The form
Attention: CMS Desk Officer, Fax CMS–359 is used as the application for
Centers for Medicare & Medicaid Number: (202) 395–5806 OR Email: health care providers seeking to
Services OIRA_submission@omb.eop.gov. participate in the Medicare program as
To obtain copies of a supporting a Comprehensive Outpatient
[Document Identifiers: CMS–359/360, CMS– statement and any related forms for the Rehabilitation Facility (CORF). This
10003, and CMS–10280] proposed collection(s) summarized in form initiates the process for facilities to
this notice, you may make your request become certified as a CORF and it
Agency Information Collection using one of following: provides the CMS Regional Office State
Activities: Submission for OMB 1. Access CMS’ Web site address at Survey Agency staff identifying
Review; Comment Request http://www.cms.hhs.gov/Paperwork information regarding the applicant that
ReductionActof1995. is stored in the Automated Survey
ACTION: Notice. 2. Email your request, including your Processing Environment (ASPEN)
address, phone number, OMB number, system.
and CMS document identifier, to The form CMS–360 is a survey tool
SUMMARY: The Centers for Medicare & used by the State Survey Agencies to
Medicaid Services (CMS) is announcing Paperwork@cms.hhs.gov.
3. Call the Reports Clearance Office at record information in order to
an opportunity for the public to determine a provider’s compliance with
comment on CMS’ intention to collect (410) 786–1326.
FOR FURTHER INFORMATION CONTACT:
the CORF Conditions of Participation
information from the public. Under the (CoPs) and to report this information to
Paperwork Reduction Act of 1995 Reports Clearance Office at (410) 786–
the Federal government. The form
(PRA), federal agencies are required to 1326.
includes basic information on the CoP
publish notice in the Federal Register SUPPLEMENTARY INFORMATION: Under the requirements, check boxes to indicate
concerning each proposed collection of Paperwork Reduction Act of 1995 (PRA) the level of compliance, and a section
information, including each proposed (44 U.S.C. 3501–3520), federal agencies for recording notes. We have the
extension or reinstatement of an existing must obtain approval from the Office of responsibility and authority for
collection of information, and to allow Management and Budget (OMB) for each certification decisions which are based
a second opportunity for public collection of information they conduct on provider compliance with the CoPs
comment on the notice. Interested or sponsor. The term ‘‘collection of and this form supports this process.
persons are invited to send comments information’’ is defined in 44 U.S.C. Form Number: CMS–359/360 (OMB
regarding the burden estimate or any 3502(3) and 5 CFR 1320.3(c) and control number: 0938–0267); Frequency:
other aspect of this collection of includes agency requests or Occasionally; Affected Public: Private
information, including any of the requirements that members of the public Sector (Business or other for-profits);
following subjects: The necessity and submit reports, keep records, or provide Number of Respondents: 50; Number of
utility of the proposed information information to a third party. Section Responses: 50; Total Annual Hours:
collection for the proper performance of 3506(c)(2)(A) of the PRA (44 U.S.C. 123. (For questions regarding this
asabaliauskas on DSK3SPTVN1PROD with NOTICES
the agency’s functions; the accuracy of 3506(c)(2)(A)) requires federal agencies collection contact James Cowher (410)
the estimated burden; ways to enhance to publish a 30-day notice in the 786–1948.)
the quality, utility, and clarity of the Federal Register concerning each 2. Type of Information Collection
information to be collected; and the use proposed collection of information, Request: Revision of a currently
of automated collection techniques or including each proposed extension or approved collection; Title of
other forms of information technology to reinstatement of an existing collection Information Collection: Notice of Denial
minimize the information collection of information, before submitting the of Medical Coverage (or Payment); Use:
burden. collection to OMB for approval. To Medicare health plans, including
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![12904 Federal Register / Vol. 81, No. 48 / Friday, March 11, 2016 / Notices
Medicare Advantage plans, cost plans, Dated: March 7, 2016. 2. By regular mail. You may mail
and Health Care Prepayment Plans, are William N. Parham, III, written comments to the following
required to issue the CMS–10003 form Director, Paperwork Reduction Staff, Office address: CMS, Office of Strategic
when a request for either a medical of Strategic Operations and Regulatory Operations and Regulatory Affairs,
service or payment is denied in whole Affairs. Division of Regulations Development,
or in part. The notice explains why the [FR Doc. 2016–05472 Filed 3–10–16; 8:45 am] Attention: Document Identifier/OMB
plan denied the service or payment and BILLING CODE 4120–01–P Control Number lll, Room C4–26–
informs Medicare enrollees of their 05, 7500 Security Boulevard, Baltimore,
appeal rights. The notice is also used, as Maryland 21244–1850.
DEPARTMENT OF HEALTH AND To obtain copies of a supporting
appropriate, to explain Medicaid appeal
HUMAN SERVICES statement and any related forms for the
rights to full dual eligible individuals
proposed collection(s) summarized in
enrolled in a Medicare health plan that Centers for Medicare & Medicaid this notice, you may make your request
is also managing the individual’s Services using one of following:
Medicaid benefits. The PRA package has 1. Access CMS’ Web site address at
[Document Identifier: CMS–10146, CMS–
been revised subsequent to the 10377, CMS–10465 and CMS–10409] http://www.cms.hhs.gov/
publication of the 60-day Federal PaperworkReductionActof1995.
Register notice (October 16, 2015; 80 FR Agency Information Collection 2. Email your request, including your
62534). Form Number: CMS–10003 Activities: Proposed Collection; address, phone number, OMB number,
(OMB control number: 0938–0829). Comment Request and CMS document identifier, to
Frequency: Occasionally; Affected Paperwork@cms.hhs.gov.
AGENCY: Centers for Medicare & 3. Call the Reports Clearance Office at
Public: Private sector (Business or other
Medicaid Services, HHS. (410) 786–1326.
for-profit and Not-for-profit
ACTION: Notice.
institutions); Number of Respondents: FOR FURTHER INFORMATION CONTACT:
730; Total Annual Responses: SUMMARY: The Centers for Medicare & Reports Clearance Office at (410) 786–
33,574,293; Total Annual Hours: Medicaid Services (CMS) is announcing 1326.
5,593,477. (For policy questions an opportunity for the public to SUPPLEMENTARY INFORMATION:
regarding this collection contact Staci comment on CMS’ intention to collect
information from the public. Under the Contents
Paige at 410–786–2045.)
Paperwork Reduction Act of 1995 (the This notice sets out a summary of the
3. Type of Information Collection
PRA), federal agencies are required to use and burden associated with the
Request: Extension of a currently
publish notice in the Federal Register following information collections. More
approved collection; Title of
concerning each proposed collection of detailed information can be found in
Information Collection: Home Health each collection’s supporting statement
information (including each proposed
Change of Care Notice (HHCCN); Use: and associated materials (see
extension or reinstatement of an existing
The Home Health Change of Care Notice collection of information) and to allow ADDRESSES).
(HHCCN) is used to notify original 60 days for public comment on the CMS–10146 Notice of Denial of
Medicare beneficiaries receiving home proposed action. Interested persons are Medicare Prescription Drug Coverage
health care benefits of plan of care invited to send comments regarding our CMS–10377 Student Health Insurance
changes. Home health agencies (HHAs) burden estimates or any other aspect of Coverage
must provide the HHCCN whenever this collection of information, including CMS–10465 Minimum Essential
they reduce or terminate a beneficiary’s any of the following subjects: The Coverage
home health services due to physician/ necessity and utility of the proposed CMS–10409 Long Term Care Hospital
provider orders or limitation of the HHA information collection for the proper (LCTH) Continuity Assessment
in providing the specific service. performance of the agency’s functions; Record and Evaluation (CARE) Data
Notification is required for covered and the accuracy of the estimated burden; Set
non-covered services listed in the plan ways to enhance the quality, utility, and Under the PRA (44 U.S.C. 3501–
of care. This iteration contains non- clarity of the information to be 3520), federal agencies must obtain
substantive changes which add language collected; and the use of automated approval from the Office of Management
informing beneficiaries of their rights collection techniques or other forms of and Budget (OMB) for each collection of
under Section 504 of the Rehabilitation information technology to minimize the information they conduct or sponsor.
Act of 1973 by alerting the beneficiary information collection burden. The term ‘‘collection of information’’ is
to CMS’ nondiscrimination practices DATES: Comments must be received by defined in 44 U.S.C. 3502(3) and 5 CFR
and the availability of alternate forms of May 10, 2016. 1320.3(c) and includes agency requests
this notice if needed. There are no ADDRESSES: When commenting, please or requirements that members of the
substantive changes. Form Number: reference the document identifier or public submit reports, keep records, or
CMS–10280 (OMB control number: OMB control number. To be assured provide information to a third party.
0938–0829); Frequency: Occasionally; consideration, comments and Section 3506(c)(2)(A) of the PRA
Affected Public: Private sector (Business recommendations must be submitted in requires federal agencies to publish a
any one of the following ways: 60-day notice in the Federal Register
asabaliauskas on DSK3SPTVN1PROD with NOTICES
or other for-profits and Not-for-profit
institutions); Number of Respondents: 1. Electronically. You may send your concerning each proposed collection of
comments electronically to http:// information, including each proposed
12,459; Total Annual Responses:
www.regulations.gov. Follow the extension or reinstatement of an existing
13,764,434; Total Annual Hours:
instructions for ‘‘Comment or collection of information, before
917,262. (For policy questions regarding
Submission’’ or ‘‘More Search Options’’ submitting the collection to OMB for
this collection contact Evelyn Blaemire to find the information collection approval. To comply with this
at 410–786–1803). document(s) that are accepting requirement, CMS is publishing this
comments. notice.
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Document Created: 2016-03-11 01:51:33
Document Modified: 2016-03-11 01:51:33
| 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 on the collection(s) of information must be received by the OMB desk officer by April 11, 2016. | |
| Contact | Reports Clearance Office at (410) 786- 1326. | |
| FR Citation | 81 FR 12903 |
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