Agency Information Collection Activities: Submission for OMB Review; Comment Request, 58558-58560 [2012-23365]
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58558
Federal Register / Vol. 77, No. 184 / Friday, September 21, 2012 / Notices
Health Services and the U.S. Environmental
Protection Agency.
Agenda items are subject to change as
priorities dictate.
Supplementary Information: The public
comment period is scheduled on Tuesday,
October 16, 2012, from 3:15 p.m. until 3:30
p.m., and on Wednesday, October 17, 2012,
from 10 a.m. until 10:15 a.m.
Contact Person for More Information:
Sandra Malcom, Committee Management
Specialist, NCEH/ATSDR, CDC, 4770 Buford
Highway, Mail Stop F–61, Chamblee, Georgia
30345; telephone 770/488–0575, Fax: 770/
488–3377; Email: smalcom@cdc.gov. The
deadline for notification of attendance is
October 12, 2012.
The Director, Management Analysis and
Services Office, has been delegated the
authority to sign Federal Register notices
pertaining to announcements of meetings and
other committee management activities for
both the Centers for Disease Control and
Prevention and the Agency for Toxic
Substances and Disease Registry.
Dated: September 17, 2012.
Elaine L. Baker,
Director, Management Analysis and Services
Office, Centers for Disease Control and
Prevention (CDC).
[FR Doc. 2012–23392 Filed 9–20–12; 8:45 am]
BILLING CODE 4163–18–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier CMS–2567, CMS–
10425, CMS–10417, CMS–10428, CMS–1500
(02/12), and CMS–1500 (08/05)]
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
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), Department of Health
and Human Services, 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 function;
(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
pmangrum on DSK3VPTVN1PROD with NOTICES
AGENCY:
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minimize the information collection
burden.
1. Type of Information Collection
Request: Extension without change of a
currently approved collection. Title of
Information Collection: Deficiencies and
Plan of Correction (CMS–2567) and
Supporting Regulations contained in 42
CFR 488.18, 488.26, and 488.28. Use:
Section 1864(a) of the Social Security
Act requires that the Secretary use state
survey agencies to conduct surveys to
determine whether health care facilities
meet Medicare and Clinical Laboratory
Improvement Amendments
participation requirements. The CMS–
2567 form is the means by which the
survey findings are documented. This
section of the law further requires that
compliance findings resulting from
these surveys be made available to the
public within 90 days of such surveys.
The CMS–2567 form is the vehicle for
this disclosure. The regulations at 42
CFR 488.18 require that state survey
agencies document all deficiency
findings on a statement of deficiencies
and plan of correction, which is the
CMS–2567. 42 CFR 488.26 and 488.28
further delineate how compliance
findings must be recorded and that CMS
prescribed forms must be used.
The form is also used by health care
facilities to document their plan of
correction and by CMS, the states,
facilities, purchasers, consumers,
advocacy groups, and the public as a
source of information about quality of
care and facility compliance.
Form Number: CMS–2567 (OCN
0938–0391). Frequency: Yearly and
occasionally. Affected Public: Private
Sector (Business or other for-profit and
not-for-profit institutions). Number of
Respondents: 62,000. Total Annual
Responses: 62,000. Total Annual Hours:
134,540. (For policy questions regarding
this collection contact Angela MasonElbert at 410–786–8279. For all other
issues call 410–786–1326.)
2. Type of Information Collection
Request: New collection; Title of
Information Collection: Evaluation of
Patient Satisfaction and Experience of
Care for Medicare Beneficiaries with
End-Stage Renal Disease (ESRD): Impact
of the ESRD Prospective Payment
System (PPS) and ESRD Quality
Incentive Program (QIP) ; Use: The
Medicare Prescription Drug
Improvement, and Modernization Act of
2003 (MMA) required the Secretary of
Health and Human Services (HHS) to
submit to Congress a report detailing the
elements and features for the design and
implementation of a bundled End-Stage
Renal Disease Prospective Payment
System, specifying that such a system
should include the bundling of
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separately billed drugs, clinical
laboratory tests, and other items ‘‘to
maximum extent feasible’’. The
Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) directed
the Secretary of HHS to implement a
payment system under which a single
payment is made to a provider of
services or a renal dialysis facility for
renal dialysis services in lieu of any
other payment. The ESRD PPS combines
composite rate dialysis services with
separately billable services under a
single payment adjusted to reflect
patient differences in resource needs or
case-mix. The MIPPA also stipulated the
development of quality incentives for
the ESRD program. CMS has established
the End-Stage Renal Disease Quality
Incentive Program (ESRD QIP) to
address this provision of the legislation.
In order to assess the impact of the
final rule (76 FR 627) on ESRD
beneficiary experiences, satisfaction,
and health outcomes, CMS is requesting
OMB approval to obtain input on the
effect of the final rule on our ESRD
beneficiaries. The purpose of this data
collection effort is to assess beneficiary
satisfaction and experience of care in
terms of access to services, quality of
care, outcomes, and cost. This will be
measured through telephone surveys
with ESRD beneficiaries and through
interviews with key stakeholders in the
renal health care community. The
information obtained from both the
beneficiary respondents and key
stakeholders will be used to provide an
initial reporting of the ESRD PPS/QIP’s
effects on beneficiary satisfaction and
experience of care and to inform the
Centers for Medicare & Medicaid
Services (CMS) of the impact of the
ESRD PPS/QIP on patient satisfaction
and experience of care, including
unintended consequences, for
consideration of future modification of
the programs.
Subsequent to the publication of the
60-day Federal Register notice (77 FR
27777), the annual burden hours have
decreased from 1,287 to 662. Early
cognitive interview findings of the
ESRD Beneficiary Survey submitted
during the 60 day notice exhibited
respondent complaints that the survey
was too long and some participants had
to hang up early because they were
feeling sick. Medicare beneficiaries with
end stage renal disease (ESRD) are very
sick and unable to remain cognitively
aware for 30 minutes. The ESRD
Beneficiary Survey was significantly
shortened so that the time necessary to
interview a single participant was
reduced from 30 to 15 minutes. Form
Number: CMS–10425 (OCN: 0938–
New); Frequency: Yearly; Affected
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Public: Individuals. Number of
Respondents: 2,540. Number of
Responses: 2,540. Total Annual Hours:
662. (For policy questions regarding this
collection contact Steve Blackwell at
410–786–6852. For all other issues call
410–786–1326.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Medicare Feefor-Service Prepayment Medical
Review; Use: The information required
under this collection is requested by
Medicare contractors to determine
proper payment or if there is a suspicion
of fraud. Medicare contractors request
the information from providers or
suppliers submitting claims for payment
from the Medicare program when data
analysis indicates aberrant billing
patterns or other information which
may present a vulnerability to the
Medicare program. In addition, we are
specifically soliciting public comments
on the information collection burden
that is associated with the currently
approved information collection
request. Form Number: CMS–10417
(OMB 0938–0969); Frequency:
Occasionally; Affected Public: Private
Sector (Business or other for-profit and
Not-for-profit institutions); Number of
Respondents: 2,220,434; Total Annual
Responses: 2,220,434; Total Annual
Hours: 1,105,560. (For policy questions
regarding this collection contact Debbie
Skinner at 410–786–7480. For all other
issues call 410–786–1326.)
4. Type of Information Collection
Request: Extension of a currently
approved collection; Title: Pre-Existing
Condition Insurance Plan (PCIP)
Authorization to Share Personal Health
Information; Use: On March 23, 2010,
the President signed into law H.R. 3590,
the Patient Protection and Affordable
Care Act (Affordable Care Act), Public
Law 111–148. Section 1101 of the law
establishes a ‘‘temporary high risk
health insurance pool program’’ (which
has been named the Pre-Existing
Condition Insurance Plan, or PCIP) to
provide health insurance coverage to
currently uninsured individuals with
pre-existing conditions. The law
authorizes HHS to carry out the program
directly or through contracts with states
or private, non-profit entities.
Reapproval of this package is being
requested as a result of CMS, in its
administration of the PCIP program,
serving as a covered entity under the
Health Insurance Portability and
Accountability Act (HIPAA). Without a
valid authorization, the PCIP program is
unable to disclose information, with
respect to an applicant or enrollee,
about the status of an application,
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enrollment, premium billing or claim, to
individuals of the applicant’s or
enrollee’s choosing. The HIPAA
Authorization Form has been modeled
after CMS’ Medicare HIPAA
Authorization Form (OMB control
number 0938–0930) and is used by
applicants or enrollees to designate
someone else to communicate with PCIP
about their protected health information
(PHI).
Unless permitted or required by law,
the Health Insurance Portability and
Accountability Act (HIPAA) Privacy
Rule (§ 164.508) prohibits CMS’ PCIP
program (a HIPAA covered entity) from
disclosing an individual’s protected
health information without a valid
authorization. In order to be valid, an
authorization must include specified
core elements and statements.
CMS will make available to PCIP
applicants and enrollees a standard,
valid authorization to enable
beneficiaries to communicate with PCIP
about their personal health information.
This is a critical tool because the
population the PCIP program serves is
comprised of individuals with preexisting conditions who may be
incapacitated and need an advocate to
help them apply for or receive benefits
from the program. This standard
authorization will simplify the process
of requesting information disclosure for
beneficiaries and minimize the response
time for the PCIP program.
Each individual will be asked to
complete the form which will include
providing the individual’s name, PCIP
account number (if known), date of
birth, what personal health information
they agree to share, the length of time
the individual agrees their personal
health information can be shared, the
names and addresses of the third party
the individual wants PCIP to share their
personal health information with, and
an attestation that the individual is
giving PCIP permission to share their
personal health information with the
third party listed in the form. This
completed form will be submitted to the
PCIP benefits administrator, GEHA,
which contracts with CMS.
We estimate that it will take
approximately 15 minutes per applicant
to complete and submit a HIPAA
Authorization Form to the PCIP
program.
The federally-run PCIP program
operates in 23 states plus the District of
Columbia and receives an average of
35,000 enrollment applications per year.
To estimate the number of PCIP
applicants and enrollees who may
complete an authorization, we looked at
the percentage of individuals who
request an authorization in Medicare as
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58559
a baseline. Medicare estimates 3% of its
population will submit an authorization
per year. However, since the PCIP
program caters to an exclusive
population comprised of individuals
who have one or more pre-existing
conditions, we believe it is likely we
could receive double the percentage
estimated by Medicare. Accordingly,
PCIP estimates 6% (or 2,100) of its
applicants and enrollees may submit an
authorization per year.
It is estimated that up to 2,100
applicants and enrollees may submit an
authorization annually. There is no cost
to PCIP beneficiaries to request,
complete, submit, or have the
authorization form processed by PCIP. It
should take approximately 15 minutes
for a beneficiary to complete the
authorization form. 15 minutes
multiplied by 2,100 beneficiaries equals
525 hours. Form Number: CMS–10428
(OCN#: 0938–1161); Frequency:
Reporting—Once; Affected Public:
individuals or households; Number of
Respondents: 2,100; Total Annual
Responses: 2,100; Total Annual Hours:
525. (For policy questions regarding this
collection contact Laura Dash at 410–
786–8623. For all other issues call 410–
786–1326.)
5. Type of Information Collection
Request: New 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 thirdparty 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
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Federal Register / Vol. 77, No. 184 / Friday, September 21, 2012 / Notices
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.
Most recently, the National Uniform
Claim Committee (NUCC) has revised
the CMS–1500. The NUCC began
revision work on the 1500 Claim Form,
version 02/12 in 2009. The goal of this
work was to align the paper form with
some of the changes in the electronic
Health Care Claim: Professional (837),
005010X222 Technical Report Type 3
(5010) and 005010X222A1 Technical
Report Type 3 (5010A1). During the
revision work, consideration was given
to different approaches to revising the
form. The NUCC decided to proceed
with making ‘‘minor changes’’ to the
current form, which was defined as no
physical changes to the existing form
lines or underlying layout of the form.
Once the CMS–1500 (02/12) has been
approved, the CMS–1500 (08/05) will be
discontinued after a form runoff period
during which both the CMS–1500 (08/
05) and the CMS–1500 (02/12) can be
used. Form Number: CMS–1500(02/12),
CMS–1490–S (OMB#: 0938-New);
Frequency: Reporting—On occasion;
Affected Public: State, Local, or Tribal
Government, Business or other-forprofit, 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 Claudette Sikora at
410–786–5618. For all other issues call
410–786–1326.)
6. Type of Information Collection
Request: Reinstatement without change
of a previously approved collection;
Title of Information Collection: Health
Insurance Common Claims Form and
Supporting Regulations at 42 CFR Part
424, Subpart C; Form Number: CMS–
1500(08/05), CMS–1490–S (OMB#:
0938–0999); 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
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15:05 Sep 20, 2012
Jkt 226001
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 thirdparty 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. Frequency:
Reporting—On occasion; Affected
Public: State, Local, or Tribal
Government, Business or other-forprofit, 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 Claudette Sikora at
410–786–5618. 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
address at https://www.cms.hhs.gov/
PaperworkReductionActof1995, or
Email 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.
To be assured consideration,
comments and recommendations for the
proposed information collections must
be received by the OMB desk officer at
the address below, no later than 5 p.m.
on October 22, 2012. OMB, Office of
Information and Regulatory Affairs,
Attention: CMS Desk Officer, Fax
Number: (202) 395–6974, Email:
OIRA_submission@omb.eop.gov.
Dated: September 18, 2012.
Martique Jones,
Director, Regulations Development Group,
Division B, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2012–23365 Filed 9–20–12; 8:45 am]
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DEPARTMENT OF HOMELAND
SECURITY
Federal Emergency Management
Agency
[Docket ID FEMA–2012–0003; Internal
Agency Docket No. FEMA–B–1270]
Proposed Flood Hazard
Determinations
Federal Emergency
Management Agency, DHS.
ACTION: Notice.
AGENCY:
Comments are requested on
proposed flood hazard determinations,
which may include additions or
modifications of any Base Flood
Elevation (BFE), base flood depth,
Special Flood Hazard Area (SFHA)
boundary or zone designation, or
regulatory floodway on the Flood
Insurance Rate Maps (FIRMs), and
where applicable, in the supporting
Flood Insurance Study (FIS) reports for
the communities listed in the table
below. The purpose of this notice is to
seek general information and comment
regarding the preliminary FIRM, and
where applicable, the FIS report that the
Federal Emergency Management Agency
(FEMA) has provided to the affected
communities. The FIRM and FIS report
are the basis of the floodplain
management measures that the
community is required either to adopt
or to show evidence of having in effect
in order to qualify or remain qualified
for participation in the National Flood
Insurance Program (NFIP). In addition,
the FIRM and FIS report, once effective,
will be used by insurance agents and
others to calculate appropriate flood
insurance premium rates for new
buildings and the contents of those
buildings.
SUMMARY:
Comments are to be submitted
on or before December 20, 2012.
ADDRESSES: The Preliminary FIRM, and
where applicable, the FIS report for
each community are available for
inspection at both the online location
and the respective Community Map
Repository address listed in the tables
below. Additionally, the current
effective FIRM and FIS report for each
community are accessible online
through the FEMA Map Service Center
at www.msc.fema.gov for comparison.
You may submit comments, identified
by Docket No. FEMA–B–1270, to Luis
Rodriguez, Chief, Engineering
Management Branch, Federal Insurance
and Mitigation Administration, FEMA,
500 C Street SW., Washington, DC
20472, (202) 646–4064, or (email)
Luis.Rodriguez3@fema.dhs.gov.
DATES:
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]]>Agencies
[Federal Register Volume 77, Number 184 (Friday, September 21, 2012)]
[Notices]
[Pages 58558-58560]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-23365]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier CMS-2567, CMS-10425, CMS-10417, CMS-10428, CMS-
1500 (02/12), and CMS-1500 (08/05)]
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
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), Department of Health and Human Services, 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 function; (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:
Deficiencies and Plan of Correction (CMS-2567) and Supporting
Regulations contained in 42 CFR 488.18, 488.26, and 488.28. Use:
Section 1864(a) of the Social Security Act requires that the Secretary
use state survey agencies to conduct surveys to determine whether
health care facilities meet Medicare and Clinical Laboratory
Improvement Amendments participation requirements. The CMS-2567 form is
the means by which the survey findings are documented. This section of
the law further requires that compliance findings resulting from these
surveys be made available to the public within 90 days of such surveys.
The CMS-2567 form is the vehicle for this disclosure. The regulations
at 42 CFR 488.18 require that state survey agencies document all
deficiency findings on a statement of deficiencies and plan of
correction, which is the CMS-2567. 42 CFR 488.26 and 488.28 further
delineate how compliance findings must be recorded and that CMS
prescribed forms must be used.
The form is also used by health care facilities to document their
plan of correction and by CMS, the states, facilities, purchasers,
consumers, advocacy groups, and the public as a source of information
about quality of care and facility compliance.
Form Number: CMS-2567 (OCN 0938-0391). Frequency: Yearly and
occasionally. Affected Public: Private Sector (Business or other for-
profit and not-for-profit institutions). Number of Respondents: 62,000.
Total Annual Responses: 62,000. Total Annual Hours: 134,540. (For
policy questions regarding this collection contact Angela Mason-Elbert
at 410-786-8279. For all other issues call 410-786-1326.)
2. Type of Information Collection Request: New collection; Title of
Information Collection: Evaluation of Patient Satisfaction and
Experience of Care for Medicare Beneficiaries with End-Stage Renal
Disease (ESRD): Impact of the ESRD Prospective Payment System (PPS) and
ESRD Quality Incentive Program (QIP) ; Use: The Medicare Prescription
Drug Improvement, and Modernization Act of 2003 (MMA) required the
Secretary of Health and Human Services (HHS) to submit to Congress a
report detailing the elements and features for the design and
implementation of a bundled End-Stage Renal Disease Prospective Payment
System, specifying that such a system should include the bundling of
separately billed drugs, clinical laboratory tests, and other items
``to maximum extent feasible''. The Medicare Improvements for Patients
and Providers Act of 2008 (MIPPA) directed the Secretary of HHS to
implement a payment system under which a single payment is made to a
provider of services or a renal dialysis facility for renal dialysis
services in lieu of any other payment. The ESRD PPS combines composite
rate dialysis services with separately billable services under a single
payment adjusted to reflect patient differences in resource needs or
case-mix. The MIPPA also stipulated the development of quality
incentives for the ESRD program. CMS has established the End-Stage
Renal Disease Quality Incentive Program (ESRD QIP) to address this
provision of the legislation.
In order to assess the impact of the final rule (76 FR 627) on ESRD
beneficiary experiences, satisfaction, and health outcomes, CMS is
requesting OMB approval to obtain input on the effect of the final rule
on our ESRD beneficiaries. The purpose of this data collection effort
is to assess beneficiary satisfaction and experience of care in terms
of access to services, quality of care, outcomes, and cost. This will
be measured through telephone surveys with ESRD beneficiaries and
through interviews with key stakeholders in the renal health care
community. The information obtained from both the beneficiary
respondents and key stakeholders will be used to provide an initial
reporting of the ESRD PPS/QIP's effects on beneficiary satisfaction and
experience of care and to inform the Centers for Medicare & Medicaid
Services (CMS) of the impact of the ESRD PPS/QIP on patient
satisfaction and experience of care, including unintended consequences,
for consideration of future modification of the programs.
Subsequent to the publication of the 60-day Federal Register notice
(77 FR 27777), the annual burden hours have decreased from 1,287 to
662. Early cognitive interview findings of the ESRD Beneficiary Survey
submitted during the 60 day notice exhibited respondent complaints that
the survey was too long and some participants had to hang up early
because they were feeling sick. Medicare beneficiaries with end stage
renal disease (ESRD) are very sick and unable to remain cognitively
aware for 30 minutes. The ESRD Beneficiary Survey was significantly
shortened so that the time necessary to interview a single participant
was reduced from 30 to 15 minutes. Form Number: CMS-10425 (OCN: 0938-
New); Frequency: Yearly; Affected
[[Page 58559]]
Public: Individuals. Number of Respondents: 2,540. Number of Responses:
2,540. Total Annual Hours: 662. (For policy questions regarding this
collection contact Steve Blackwell at 410-786-6852. For all other
issues call 410-786-1326.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Medicare Fee-for-
Service Prepayment Medical Review; Use: The information required under
this collection is requested by Medicare contractors to determine
proper payment or if there is a suspicion of fraud. Medicare
contractors request the information from providers or suppliers
submitting claims for payment from the Medicare program when data
analysis indicates aberrant billing patterns or other information which
may present a vulnerability to the Medicare program. In addition, we
are specifically soliciting public comments on the information
collection burden that is associated with the currently approved
information collection request. Form Number: CMS-10417 (OMB 0938-0969);
Frequency: Occasionally; Affected Public: Private Sector (Business or
other for-profit and Not-for-profit institutions); Number of
Respondents: 2,220,434; Total Annual Responses: 2,220,434; Total Annual
Hours: 1,105,560. (For policy questions regarding this collection
contact Debbie Skinner at 410-786-7480. For all other issues call 410-
786-1326.)
4. Type of Information Collection Request: Extension of a currently
approved collection; Title: Pre-Existing Condition Insurance Plan
(PCIP) Authorization to Share Personal Health Information; Use: On
March 23, 2010, the President signed into law H.R. 3590, the Patient
Protection and Affordable Care Act (Affordable Care Act), Public Law
111-148. Section 1101 of the law establishes a ``temporary high risk
health insurance pool program'' (which has been named the Pre-Existing
Condition Insurance Plan, or PCIP) to provide health insurance coverage
to currently uninsured individuals with pre-existing conditions. The
law authorizes HHS to carry out the program directly or through
contracts with states or private, non-profit entities.
Reapproval of this package is being requested as a result of CMS,
in its administration of the PCIP program, serving as a covered entity
under the Health Insurance Portability and Accountability Act (HIPAA).
Without a valid authorization, the PCIP program is unable to disclose
information, with respect to an applicant or enrollee, about the status
of an application, enrollment, premium billing or claim, to individuals
of the applicant's or enrollee's choosing. The HIPAA Authorization Form
has been modeled after CMS' Medicare HIPAA Authorization Form (OMB
control number 0938-0930) and is used by applicants or enrollees to
designate someone else to communicate with PCIP about their protected
health information (PHI).
Unless permitted or required by law, the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule (Sec. 164.508)
prohibits CMS' PCIP program (a HIPAA covered entity) from disclosing an
individual's protected health information without a valid
authorization. In order to be valid, an authorization must include
specified core elements and statements.
CMS will make available to PCIP applicants and enrollees a
standard, valid authorization to enable beneficiaries to communicate
with PCIP about their personal health information. This is a critical
tool because the population the PCIP program serves is comprised of
individuals with pre-existing conditions who may be incapacitated and
need an advocate to help them apply for or receive benefits from the
program. This standard authorization will simplify the process of
requesting information disclosure for beneficiaries and minimize the
response time for the PCIP program.
Each individual will be asked to complete the form which will
include providing the individual's name, PCIP account number (if
known), date of birth, what personal health information they agree to
share, the length of time the individual agrees their personal health
information can be shared, the names and addresses of the third party
the individual wants PCIP to share their personal health information
with, and an attestation that the individual is giving PCIP permission
to share their personal health information with the third party listed
in the form. This completed form will be submitted to the PCIP benefits
administrator, GEHA, which contracts with CMS.
We estimate that it will take approximately 15 minutes per
applicant to complete and submit a HIPAA Authorization Form to the PCIP
program.
The federally-run PCIP program operates in 23 states plus the
District of Columbia and receives an average of 35,000 enrollment
applications per year. To estimate the number of PCIP applicants and
enrollees who may complete an authorization, we looked at the
percentage of individuals who request an authorization in Medicare as a
baseline. Medicare estimates 3% of its population will submit an
authorization per year. However, since the PCIP program caters to an
exclusive population comprised of individuals who have one or more pre-
existing conditions, we believe it is likely we could receive double
the percentage estimated by Medicare. Accordingly, PCIP estimates 6%
(or 2,100) of its applicants and enrollees may submit an authorization
per year.
It is estimated that up to 2,100 applicants and enrollees may
submit an authorization annually. There is no cost to PCIP
beneficiaries to request, complete, submit, or have the authorization
form processed by PCIP. It should take approximately 15 minutes for a
beneficiary to complete the authorization form. 15 minutes multiplied
by 2,100 beneficiaries equals 525 hours. Form Number: CMS-10428
(OCN: 0938-1161); Frequency: Reporting--Once; Affected Public:
individuals or households; Number of Respondents: 2,100; Total Annual
Responses: 2,100; Total Annual Hours: 525. (For policy questions
regarding this collection contact Laura Dash at 410-786-8623. For all
other issues call 410-786-1326.)
5. Type of Information Collection Request: New 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
[[Page 58560]]
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.
Most recently, the National Uniform Claim Committee (NUCC) has
revised the CMS-1500. The NUCC began revision work on the 1500 Claim
Form, version 02/12 in 2009. The goal of this work was to align the
paper form with some of the changes in the electronic Health Care
Claim: Professional (837), 005010X222 Technical Report Type 3 (5010)
and 005010X222A1 Technical Report Type 3 (5010A1). During the revision
work, consideration was given to different approaches to revising the
form. The NUCC decided to proceed with making ``minor changes'' to the
current form, which was defined as no physical changes to the existing
form lines or underlying layout of the form. Once the CMS-1500 (02/12)
has been approved, the CMS-1500 (08/05) will be discontinued after a
form runoff period during which both the CMS-1500 (08/05) and the CMS-
1500 (02/12) can be used. Form Number: CMS-1500(02/12), CMS-1490-S
(OMB: 0938-New); Frequency: Reporting--On occasion; Affected
Public: State, Local, or Tribal Government, Business or other-for-
profit, 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 Claudette
Sikora at 410-786-5618. For all other issues call 410-786-1326.)
6. Type of Information Collection Request: Reinstatement without
change of a previously approved collection; Title of Information
Collection: Health Insurance Common Claims Form and Supporting
Regulations at 42 CFR Part 424, Subpart C; Form Number: CMS-1500(08/
05), CMS-1490-S (OMB: 0938-0999); 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. Frequency: Reporting--On occasion; Affected Public:
State, Local, or Tribal Government, Business or other-for-profit, 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 Claudette Sikora at 410-
786-5618. 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 address at https://www.cms.hhs.gov/PaperworkReductionActof1995, or
Email 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.
To be assured consideration, comments and recommendations for the
proposed information collections must be received by the OMB desk
officer at the address below, no later than 5 p.m. on October 22, 2012.
OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk
Officer, Fax Number: (202) 395-6974, Email: OIRA_submission@omb.eop.gov.
Dated: September 18, 2012.
Martique Jones,
Director, Regulations Development Group, Division B, Office of
Strategic Operations and Regulatory Affairs.
[FR Doc. 2012-23365 Filed 9-20-12; 8:45 am]
BILLING CODE 4120-01-P
