81 FR 6277 - 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 24 (February 5, 2016)
Centers for Medicare & Medicaid Services
Federal Register Volume 81, Issue 24 (February 5, 2016)
| Page Range | 6277-6278 | |
| FR Document | 2016-02278 |
[Federal Register Volume 81, Number 24 (Friday, February 5, 2016)] [Notices] [Pages 6277-6278] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2016-02278] [[Page 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: [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: 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
![Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices 6277
DEPARTMENT OF HEALTH AND 2. Email your request, including your Qualified Entity Certification Program
HUMAN SERVICES address, phone number, OMB number, (QECP). The Qualified Entity
and CMS document identifier, to Certification Program (QECP) was
Centers for Medicare & Medicaid Paperwork@cms.hhs.gov. established to implement the Final Rule.
Services 3. Call the Reports Clearance Office at One of the requirements in the Final
(410) 786–1326. Rule is that QEs must reapply for
[Document Identifiers: CMS–10596, CMS– FOR FURTHER INFORMATION CONTACT: certification six months prior to the end
906, CMS–1771, CMS–1450, CMS–1500 (02– of their 3-year certification period to
Reports Clearance Office at (410) 786–
12)]
1326. remain in good standing. This form is
Agency Information Collection SUPPLEMENTARY INFORMATION: Under the
the official reapplication that QEs must
Activities: Submission for OMB Paperwork Reduction Act of 1995 (PRA) complete to reapply to the QECP. Form
Review; Comment Request (44 U.S.C. 3501–3520), federal agencies Number: CMS–10596 (OMB Control
must obtain approval from the Office of Number: 0938—New); Frequency:
ACTION: Notice. Management and Budget (OMB) for each Occasionally; Affected Public: Private
collection of information they conduct sector (Business or other for-profit and
SUMMARY: The Centers for Medicare & Not-for-profit institutions); Number of
or sponsor. The term ‘‘collection of
Medicaid Services (CMS) is announcing Respondents: 10; Total Annual
information’’ is defined in 44 U.S.C.
an opportunity for the public to Responses: 10; Total Annual Hours:
3502(3) and 5 CFR 1320.3(c) and
comment on CMS’ intention to collect 1,200. (For policy questions regarding
includes agency requests or
information from the public. Under the this collection contact Kari Gaare at
requirements that members of the public
Paperwork Reduction Act of 1995 410–786–8612.)
submit reports, keep records, or provide 2. Type of Information Collection
(PRA), federal agencies are required to
information to a third party. Section Request: Extension of a currently
publish notice in the Federal Register
3506(c)(2)(A) of the PRA (44 U.S.C. approved collection; Title of
concerning each proposed collection of
3506(c)(2)(A)) requires federal agencies Information Collection: The Fiscal
information, including each proposed
to publish a 30-day notice in the Soundness Reporting Requirements;
extension or reinstatement of an existing
Federal Register concerning each Use: The CMS is assigned responsibility
collection of information, and to allow
proposed collection of information, for overseeing all Medicare Advantage
a second opportunity for public
including each proposed extension or Organizations (MAOs), Prescription
comment on the notice. Interested
reinstatement of an existing collection Drug Plan (PDP) sponsors and PACE
persons are invited to send comments
of information, before submitting the organizations on-going financial
regarding the burden estimate or any
collection to OMB for approval. To performance. Specifically, CMS needs
other aspect of this collection of
comply with this requirement, CMS is the requested collection of information
information, including any of the
publishing this notice that summarizes to establish that contracting entities
following subjects: (1) The necessity and
the following proposed collection(s) of within those programs maintain fiscally
utility of the proposed information
information for public comment: sound organizations and thereby remain
collection for the proper performance of 1. Type of Information Collection
the agency’s functions; (2) the accuracy a going concern. All contracting
Request: New collection (Request for a organizations must submit annual
of the estimated burden; (3) ways to new OMB control number); Title of
enhance the quality, utility, and clarity independently audited financial
Information Collection: Reapplication statements one time per year. The
of the information to be collected; and Submission Requirement for Qualified
(4) the use of automated collection MAOs with a negative net worth and/or
Entities under ACA Section 10332; Use: a net loss and the amount of that loss
techniques or other forms of information Section 10332 of the Patient Protection
technology to minimize the information is greater than one-half of the
and Affordable Care Act (ACA) requires organization’s total net worth must file
collection burden. the Secretary to make standardized three quarterly financial statements.
DATES: Comments on the collection(s) of extracts of Medicare claims data under Currently, there are approximately 71
information must be received by the Parts A, B, and D available to ‘‘qualified MAOs filing quarterly financial
OMB desk officer by April 5, 2016. entities’’ for the evaluation of the statements. Part D organizations must
ADDRESSES: When commenting on the performance of providers of services also 3 quarterly financial statements.
proposed information collections, and suppliers. The statute provides the The PACE organizations are required to
please reference the document identifier Secretary with discretion to establish file 4 quarterly financial statements for
or OMB control number. To be assured criteria to determine whether an entity the first three years in the program as
consideration, comments and is qualified to use claims data to well as PACE organizations with a
recommendations must be received by evaluate the performance of providers of negative net worth and/or a net loss and
the OMB desk officer via one of the services and suppliers. After the amount of that loss is greater than
following transmissions: consideration of comments from a wide one-half of the organization’s total net
OMB, Office of Information and variety of stakeholders during the public worth. Form Number: CMS–906 (OMB
Regulatory Affairs, Attention: CMS Desk comment period, CMS established control number: 0938–0469); Frequency:
Officer, Fax Number: (202) 395–5806 ‘‘Medicare Program; Availability of Annually; Affected Public: Business or
OR, Email: OIRA_submission@ Medicare Data for Performance other for-profits; Number of
omb.eop.gov. Measurement’’ (hereinafter called the Respondents: 815; Total Annual
mstockstill on DSK4VPTVN1PROD with NOTICES
To obtain copies of a supporting Final Rule and referred to as the Responses: 1,518; Total Annual Hours:
statement and any related forms for the Medicare Data Sharing Program). It was 506. (For policy questions regarding this
proposed collection(s) summarized in published in the Federal Register on collection contact Geralyn Glenn at
this notice, you may make your request December 7, 2011 (42 CFR, Part 401, 410–786–0973.)
using one of following: Subpart G). To implement the 3. Type of Information Collection
1. Access CMS’ Web site address at requirements outlined in the legislation, Request: Reinstatement without change
http://www.cms.hhs.gov/ the Centers for Medicare and Medicaid of a previously approved collection;
PaperworkReductionActof1995. Services (CMS) established the Title of Information Collection:
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![6278 Federal Register / Vol. 81, No. 24 / Friday, February 5, 2016 / Notices
Emergency and Foreign Hospital ICD–9–CM codes, and outpatient or Tribal Governments, Private sector
Services; Use: Section 1866 of the Social procedures are described using the CMS (Business or other-for-profit and Not-for-
Security Act states that any provider of Common Procedure Coding System profit institutions); Number of
services shall be qualified to participate (HCPCS). These are standard systems of Respondents: 1,448,346; Total Annual
in the Medicare program and shall be identification for all major health Responses: 988,005,045; Total Annual
eligible for payments under Medicare if insurance claims payers. Submission of Hours: 21,418,336. (For policy questions
it files an agreement with the Secretary information on the CMS–1450 permits regarding this collection contact
to meet the conditions outlined in this Medicare intermediaries to receive Shannon Seales at 410–786–4089.)
section of the Act. Section 1814 (d)(1) of consistent data for proper payment. Dated: February 2, 2016.
the Social Security Act and 42 CFR Form Numbers: CMS–1450 (UB–04) William N. Parham, III,
424.100, allows payment of Medicare (OMB control number: 0938–0997); Director, Paperwork Reduction Staff, Office
benefits for a Medicare beneficiary to a Frequency: On occasion; Affected of Strategic Operations and Regulatory
nonparticipating hospital that does not Public: Private sector (Business or other Affairs.
have an agreement in effect with the for-profit and Not-for-profit [FR Doc. 2016–02278 Filed 2–4–16; 8:45 am]
Centers for Medicare and Medicaid institutions); Number of Respondents: BILLING CODE 4120–01–P
Services. These payments can be made 53,111; Total Annual Responses:
if such services were emergency 181,909,654; Total Annual Hours:
services and if CMS would be required 1,567,455. (For policy questions DEPARTMENT OF HEALTH AND
to make the payment if the hospital had regarding this collection contact Matt HUMAN SERVICES
an agreement in effect and met the Klischer at 410–786–7488.)
conditions of payment. This form is 5. Type of Information Collection Health Resources and Services
used in connection with claims for Request: Extension of a currently Administration
emergency hospital services provided approved collection; Title of
by hospitals that do not have an National Vaccine Injury Compensation
Information Collection: Health
agreement in effect under Section 1866 Program; List of Petitions Received
Insurance Common Claims Form and
of the Social Security Act. As specified Supporting Regulations at 42 CFR part AGENCY: Health Resources and Services
in 42 CFR 424.103(b), before a non- 424, subpart C; Use: The Form CMS– Administration, HHS.
participating hospital may be paid for 1500 answers the needs of many health ACTION: Notice.
emergency services rendered to a insurers. It is the basic form prescribed
Medicare beneficiary, a statement must by CMS for the Medicare program for SUMMARY: The Health Resources and
be submitted that is sufficiently claims from physicians and suppliers. Services Administration (HRSA) is
comprehensive to support that an The Medicaid State Agencies, publishing this notice of petitions
emergency existed. Form CMS–1771 CHAMPUS/TriCare, Blue Cross/Blue received under the National Vaccine
contains a series of questions relating to Shield Plans, the Federal Employees Injury Compensation Program (the
the medical necessity of the emergency. Health Benefit Plan, and several private Program), as required by Section
The attending physician must attest that health plans also use it; it is the de facto 2112(b)(2) of the Public Health Service
the hospitalization was required under standard ‘‘professional’’ claim form. (PHS) Act, as amended. While the
the regulatory emergency definition and Medicare carriers use the data collected Secretary of Health and Human Services
give clinical documentation to support on the CMS–1500 and the CMS–1490S is named as the respondent in all
the claim. A photocopy of the to determine the proper amount of proceedings brought by the filing of
beneficiary’s hospital records may be reimbursement for Part B medical and petitions for compensation under the
used in lieu of the CMS–1771 if the other health services (as listed in section Program, the United States Court of
records contain all the information 1861(s) of the Social Security Act) Federal Claims is charged by statute
required by the form. Form Number: provided by physicians and suppliers to with responsibility for considering and
CMS–1771 (OMB control number: beneficiaries. The CMS–1500 is acting upon the petitions.
0938–0023); Frequency: Annually; submitted by physicians/suppliers for FOR FURTHER INFORMATION CONTACT: For
Affected Public: Private sector (Business all Part B Medicare. Serving as a information about requirements for
or other for-profits and Not-for-profit common claim form, the CMS–1500 can filing petitions, and the Program in
institutions); Number of Respondents: be used by other third-party payers general, contact the Clerk, United States
100; Total Annual Responses: 200; Total (commercial and nonprofit health Court of Federal Claims, 717 Madison
Annual Hours: 50. (For policy questions insurers) and other Federal programs Place NW., Washington, DC 20005,
regarding this collection contact (e.g., CHAMPUS/TriCare, Railroad (202) 357–6400. For information on
Shauntari Cheely at 410–786–1818.) Retirement Board (RRB), and Medicaid). HRSA’s role in the Program, contact the
4. Type of Information Collection However, as the CMS–1500 displays Director, National Vaccine Injury
Request: Extension of a currently data items required for other third-party Compensation Program, 5600 Fishers
approved collection; Title of payers in addition to Medicare, the form Lane, Room 11C–26, Rockville, MD
Information Collection: Medicare is considered too complex for use by 20857; (301) 443–6593, or visit our Web
Uniform Institutional Provider Bill and beneficiaries when they file their own site at: http://www.hrsa.gov/
Supporting Regulations in 42 CFR claims. Therefore, the CMS–1490S vaccinecompensation/index.html.
424.5; Use: Section 42 CFR 424.5(a)(5) (Patient’s Request for Medicare SUPPLEMENTARY INFORMATION: The
mstockstill on DSK4VPTVN1PROD with NOTICES
requires providers of services to submit Payment) was explicitly developed for Program provides a system of no-fault
a claim for payment prior to any easy use by beneficiaries who file their compensation for certain individuals
Medicare reimbursement. Charges billed own claims. The form can be obtained who have been injured by specified
are coded by revenue codes. The bill from any Social Security office or childhood vaccines. Subtitle 2 of Title
specifies diagnoses according to the Medicare carrier. Form Number: CMS– XXI of the PHS Act, 42 U.S.C. 300aa–
International Classification of Diseases, 1500(02–12), CMS–1490S (OMB control 10 et seq., provides that those seeking
Ninth Edition (ICD–9–CM) code. number: 0938–1197) Frequency: On compensation are to file a petition with
Inpatient procedures are identified by occasion; Affected Public: State, Local, the U.S. Court of Federal Claims and to
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Document Created: 2016-02-05 00:17:11
Document Modified: 2016-02-05 00:17:11
| 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 5, 2016. | |
| Contact | Reports Clearance Office at (410) 786- 1326. | |
| FR Citation | 81 FR 6277 |
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