Agency Information Collection Activities: Proposed Collection; Comment Request, 66910-66912 [2019-26362]
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Federal Register / Vol. 84, No. 235 / Friday, December 6, 2019 / Notices
understand the interests, attributes and
needs of different populations and
persons in that community. Formative
research occurs before a program is
designed and implemented, or while a
program is being conducted.
At CDC, formative research is
necessary for developing new programs
or adapting programs that deal with the
complexity of behavior, social context,
cultural identity, and health care that
underlie the epidemiology of diseases
and conditions in the U.S. CDC
conducts formative research to develop
public-sensitive communication
messages and user friendly tools prior to
developing or recommending
interventions, or care. Sometimes these
studies are entirely behavioral but most
often they are cycles of interviews and
focus groups designed to inform the
development of a product. Products
from these formative research studies
will be used for prevention of disease.
Findings from these studies may also be
presented as evidence to diseasespecific National Advisory Committees,
to support revisions to recommended
prevention and intervention methods, as
well as new recommendations.
Much of CDC’s health communication
takes place within campaigns that have
fairly lengthy planning periods—
timeframes that accommodate the
standard Federal process for approving
data collections. Short term qualitative
interviewing and cognitive research
techniques have previously proven
invaluable in the development of
scientifically valid and populationappropriate methods, interventions, and
instruments.
This request includes studies
investigating the utility and
acceptability of proposed sampling and
recruitment methods, intervention
contents and delivery, questionnaire
domains, individual questions, and
interactions with project staff or
electronic data collection equipment.
These activities will also provide
information about how respondents
answer questions, and ways in which
question response bias and error can be
reduced.
This request also includes collection
of information from public health
programs to assess needs related to
initiation of a new program activity or
expansion or changes in scope or
implementation of existing program
activities to adapt them to current
needs. The information collected will be
used to advise programs and provide
capacity-building assistance tailored to
identify needs.
Overall, these development activities
are intended to provide information that
will increase the success of the
surveillance or research projects
through increasing response rates and
decreasing response error, thereby
decreasing future data collection burden
to the public. The studies that will be
covered under this request will include
one or more of the following
investigational modalities: (1)
Structured and qualitative interviewing
for surveillance, research, interventions
and material development, (2) cognitive
interviewing for development of specific
data collection instruments, (3)
methodological research (4) usability
testing of technology-based instruments
and materials, (5) field testing of new
methodologies and materials, (6)
investigation of mental models for
health decision-making, to inform
health communication messages, and (7)
organizational needs assessments to
support development of capacity.
Respondents who will participate in
individual and group interviews
(qualitative, cognitive, and computer
assisted development activities) are
selected purposively from those who
respond to recruitment advertisements.
In addition to utilizing advertisements
for recruitment, respondents who will
participate in research on survey
methods may be selected purposively or
systematically from within an ongoing
surveillance or research project.
Participation of respondents is
voluntary. There is no cost to
participants other than their time. The
total estimated annual burden is 20,000
hours.
ESTIMATED ANNUALIZED BURDEN HOURS
Number of
respondents
Type of respondent
Form name
General public and health care providers ...............................
Screener ................................
Interview .................................
Focus Group Interview ...........
Survey ....................................
Jeffrey M. Zirger,
Lead, Information Collection Review Office,
Office of Scientific Integrity, Office of Science,
Centers for Disease Control and Prevention.
[FR Doc. 2019–26369 Filed 12–5–19; 8:45 am]
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–379, CMS–
10242, CMS–1771, CMS–10180 and CMS–
R–199]
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Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
The Centers for Medicare &
Medicaid Services (CMS) is announcing
an opportunity for the public to
SUMMARY:
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16:11 Dec 05, 2019
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10,000
5,000
5,000
5,000
Number of
responses
per
respondent
Average
hours per
response
1
1
1
1
15/60
1
2
30/60
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
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
E:\FR\FM\06DEN1.SGM
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Federal Register / Vol. 84, No. 235 / Friday, December 6, 2019 / Notices
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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 must be received by
February 4, 2020.
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 https://
www.regulations.gov. Follow the
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 ll 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’ website address at
website address at https://www.cms.gov/
Regulations-and-Guidance/Legislation/
PaperworkReductionActof1995/PRAListing.html.
2. Email your request, including your
address, phone number, OMB number,
and CMS document identifier, to
Paperwork@cms.hhs.gov.
3. Call the Reports Clearance Office at
(410) 786–1326.
FOR FURTHER INFORMATION CONTACT:
William N. Parham at (410) 786–4669.
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–379 Financial Statement of Debtor
CMS–10242 Emergency and NonEmergency Ambulance Transports
and Beneficiary Signature
Requirements
CMS–1771 Attending Physicians
Statement and Documentation of
Medicare Emergency
CMS–10180 Children’s Health
Insurance Program (CHIP) Report on
Payables and Receivables
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16:11 Dec 05, 2019
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CMS–R–199 Medicaid Report on
Payables and Receivables
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: Extension of a currently
approved collection; Title of
Information Collection: Financial
Statement of Debtor; Use: Section
1893(f)(1) of the Social Security Act and
42 CFR 401.607 provides the authority
for collection of this information.
Section 42 CFR 405.607 requires that,
CMS recover amounts of claims due
from debtors including interest where
appropriate by direct collections in
lump sums or in installments. In
addition, the DOJ Final Rule, the
Federal Claims Collection Standards,
which was published as 32 CFR parts
900–904, on November 22, 2000, in the
Federal Register, Section 32 CFR 900.1
stipulates that, ‘‘. . . standards for
Federal agency use in the administrative
collection, offset, compromise, and the
suspension or termination of collection
activity . . .’’ Section 32 CFR 901.8(a)
states that, ‘‘Agencies should obtain
financial statements from debtors who
represent that they are unable to pay the
debt in one lump sum.’’ Form Number:
CMS–379 (OMB control number: 0938–
0270); Frequency: Yearly; Affected
Public: Private Sector; Business or other
for-profits; Number of Respondents:
500; Total Annual Responses: 500; Total
Annual Hours: 1,000. (For policy
questions regarding this collection
contact Anita Crosier at (410) 786–
0217.)
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Emergency and
Non-Emergency Ambulance Transports
and Beneficiary Signature
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66911
Requirements; Use: The statutory
authority requiring a beneficiary’s
signature on a claim submitted by a
provider is located in section 1835(a)
and in 1814(a) of the Social Security Act
(the Act), for Part B and Part A services,
respectively. The authority requiring a
beneficiary’s signature for supplier
claims is implicit in sections
1842(b)(3)(B)(ii) and in 1848(g)(4) of the
Act. Federal regulations at 42 CFR
424.32(a)(3) state that all claims must be
signed by the beneficiary or on behalf of
the Beneficiary (in accordance with
424.36). Section 424.36(a) states that the
beneficiary’s signature is required on a
claim unless the beneficiary has died or
the provisions of 424.36(b), (c), or (d)
apply. For emergency and
nonemergency ambulance transport
services, where the beneficiary is
physically or mentally incapable of
signing the claim (and the beneficiary’s
authorized representative is unavailable
or unwilling to sign the claim), that it
is impractical and infeasible to require
an ambulance provider or supplier to
later locate the beneficiary or the person
authorized to sign on behalf of the
beneficiary, before submitting the claim
to Medicare for payment. Therefore, an
exception was created to the beneficiary
signature requirement with respect to
emergency and nonemergency
ambulance transport services, where the
beneficiary is physically or mentally
incapable of signing the claim, and if
certain documentation requirements are
met. Thus, we added subsection (6) to
paragraph (b) of 42 CFR 424.36. The
information required in this ICR is
needed to help ensure that services were
in fact rendered and were rendered as
billed. Form Number: CMS–10242
(OMB control number: 0938–1049);
Frequency: Yearly; Affected Public:
Private Sector; Business or other forprofits, Not-for-profit Institutions;
Number of Respondents: 10,229; Total
Annual Responses: 13,318,440; Total
Annual Hours: 1,110,757. (For policy
questions regarding this collection
contact Martha Kuespert at (410) 786–
4605.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Attending
Physicians Statement and
Documentation of Medicare Emergency;
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
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66912
Federal Register / Vol. 84, No. 235 / Friday, December 6, 2019 / Notices
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. 42 CFR
424.103(b) requires that before a nonparticipating 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 (42
CFR 424.101 attached) 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: Yearly;
Affected Public: Private Sector; Business
or other for-profits, 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: Revision of a currently
approved collection; Title of
Information Collection: Children’s
Health Insurance Program (CHIP) Report
on Payables and Receivables; Use:
Section 2105 of the Social Security Act
(Title XXI) requires the Secretary to
estimate the amount each State should
be paid at the beginning of each quarter.
This amount is based on a report filed
by the State. Section 2105 of the Social
Security Act authorizes the Secretary to
pay the amount estimated, reduced or
increased to the extent of any
overpayment or underpayment for any
prior quarter. Section 3515 of the CFO
Act requires government agencies to
produce auditable financial statements
in accordance with Office of
Management and Budget guidelines on
Form and Content. The Government
Management and Reform Act of 1994
requires that all offices, bureaus and
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16:11 Dec 05, 2019
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associated activities of the 24 CFO Act
agencies must be covered in an agencywide, audited financial statement.
Collection of CHIP data and the
calculation of the CHIP Incurred But
Not Reported (IBNR) estimate are
pertinent to CMS’ financial audit. The
CHIP Report on Payables and
Receivables will provide the
information needed to calculate the
CHIP IBNR. Failure to collect this
information could result in noncompliance with the law. Form Number:
CMS–10180 (OMB control number:
0938–0988); Frequency: Yearly; Affected
Public: State, Local, or Tribal
Governments; Number of Respondents:
56; Total Annual Responses: 56; Total
Annual Hours: 504. (For policy
questions regarding this collection
contact Beverly Boher at (410) 786–
7806.)
5. Type of Information Collection
Request: Revision of a currently
approved collection; Title of
Information Collection: Medicaid Report
on Payables and Receivables; Use:
Section 1903(b)(d)(1) of the Social
Security Act requires the Secretary to
estimate the amount each State should
be paid at the beginning of each quarter.
This amount is to be based on a report
filed by the State. Section
1903(b)(d)(2)(A) of the Social Security
Act authorizes the Secretary to pay the
amount estimated, reduced or increased
to the extent of any overpayment or
underpayment for any prior quarter.
Section 3515 of CFO Act requires
government agencies to produce
auditable financial statements in
accordance with Office of Management
and Budget guidelines on Form and
Content. The Government Management
and Reform Act of 1994 requires that all
offices, bureaus and associated activities
of the 24 CFO Act agencies must be
covered in an agency. Form Number:
CMS–R–199 (OMB control number:
0938–0697); Frequency: Yearly; Affected
Public: State, Local, or Tribal
Governments; Number of Respondents:
56; Total Annual Responses: 56; Total
Annual Hours: 504. (For policy
questions regarding this collection
contact Beverly Boher at (410) 786–
7806.)
Dated: December 3, 2019.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office
of Strategic Operations and Regulatory
Affairs.
[FR Doc. 2019–26362 Filed 12–5–19; 8:45 am]
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DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–10717]
Agency Information Collection
Activities: Proposed Collection;
Comment Request
Centers for Medicare &
Medicaid Services, HHS.
ACTION: Notice.
AGENCY:
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
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 must be received by
February 4, 2020.
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 https://
www.regulations.gov. Follow the
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 ll, Room C4–26–05,
7500 Security Boulevard, Baltimore,
Maryland 21244–1850.
To obtain copies of a supporting
statement and any related forms for the
SUMMARY:
E:\FR\FM\06DEN1.SGM
06DEN1
]]>Agencies
[Federal Register Volume 84, Number 235 (Friday, December 6, 2019)]
[Notices]
[Pages 66910-66912]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-26362]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: CMS-379, CMS-10242, CMS-1771, CMS-10180 and CMS-
R-199]
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 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
[[Page 66911]]
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 must be received by February 4, 2020.
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
https://www.regulations.gov. Follow the 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' website address at website address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
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: William N. Parham at (410) 786-4669.
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-379 Financial Statement of Debtor
CMS-10242 Emergency and Non-Emergency Ambulance Transports and
Beneficiary Signature Requirements
CMS-1771 Attending Physicians Statement and Documentation of Medicare
Emergency
CMS-10180 Children's Health Insurance Program (CHIP) Report on Payables
and Receivables
CMS-R-199 Medicaid Report on Payables and Receivables
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: Extension of a currently
approved collection; Title of Information Collection: Financial
Statement of Debtor; Use: Section 1893(f)(1) of the Social Security Act
and 42 CFR 401.607 provides the authority for collection of this
information. Section 42 CFR 405.607 requires that, CMS recover amounts
of claims due from debtors including interest where appropriate by
direct collections in lump sums or in installments. In addition, the
DOJ Final Rule, the Federal Claims Collection Standards, which was
published as 32 CFR parts 900-904, on November 22, 2000, in the Federal
Register, Section 32 CFR 900.1 stipulates that, ``. . . standards for
Federal agency use in the administrative collection, offset,
compromise, and the suspension or termination of collection activity .
. .'' Section 32 CFR 901.8(a) states that, ``Agencies should obtain
financial statements from debtors who represent that they are unable to
pay the debt in one lump sum.'' Form Number: CMS-379 (OMB control
number: 0938-0270); Frequency: Yearly; Affected Public: Private Sector;
Business or other for-profits; Number of Respondents: 500; Total Annual
Responses: 500; Total Annual Hours: 1,000. (For policy questions
regarding this collection contact Anita Crosier at (410) 786-0217.)
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Emergency and
Non-Emergency Ambulance Transports and Beneficiary Signature
Requirements; Use: The statutory authority requiring a beneficiary's
signature on a claim submitted by a provider is located in section
1835(a) and in 1814(a) of the Social Security Act (the Act), for Part B
and Part A services, respectively. The authority requiring a
beneficiary's signature for supplier claims is implicit in sections
1842(b)(3)(B)(ii) and in 1848(g)(4) of the Act. Federal regulations at
42 CFR 424.32(a)(3) state that all claims must be signed by the
beneficiary or on behalf of the Beneficiary (in accordance with
424.36). Section 424.36(a) states that the beneficiary's signature is
required on a claim unless the beneficiary has died or the provisions
of 424.36(b), (c), or (d) apply. For emergency and nonemergency
ambulance transport services, where the beneficiary is physically or
mentally incapable of signing the claim (and the beneficiary's
authorized representative is unavailable or unwilling to sign the
claim), that it is impractical and infeasible to require an ambulance
provider or supplier to later locate the beneficiary or the person
authorized to sign on behalf of the beneficiary, before submitting the
claim to Medicare for payment. Therefore, an exception was created to
the beneficiary signature requirement with respect to emergency and
nonemergency ambulance transport services, where the beneficiary is
physically or mentally incapable of signing the claim, and if certain
documentation requirements are met. Thus, we added subsection (6) to
paragraph (b) of 42 CFR 424.36. The information required in this ICR is
needed to help ensure that services were in fact rendered and were
rendered as billed. Form Number: CMS-10242 (OMB control number: 0938-
1049); Frequency: Yearly; Affected Public: Private Sector; Business or
other for-profits, Not-for-profit Institutions; Number of Respondents:
10,229; Total Annual Responses: 13,318,440; Total Annual Hours:
1,110,757. (For policy questions regarding this collection contact
Martha Kuespert at (410) 786-4605.)
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Attending
Physicians Statement and Documentation of Medicare Emergency; 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
[[Page 66912]]
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. 42 CFR
424.103(b) requires that 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 (42 CFR 424.101 attached) 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: Yearly;
Affected Public: Private Sector; Business or other for-profits, 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: Revision of a currently
approved collection; Title of Information Collection: Children's Health
Insurance Program (CHIP) Report on Payables and Receivables; Use:
Section 2105 of the Social Security Act (Title XXI) requires the
Secretary to estimate the amount each State should be paid at the
beginning of each quarter. This amount is based on a report filed by
the State. Section 2105 of the Social Security Act authorizes the
Secretary to pay the amount estimated, reduced or increased to the
extent of any overpayment or underpayment for any prior quarter.
Section 3515 of the CFO Act requires government agencies to produce
auditable financial statements in accordance with Office of Management
and Budget guidelines on Form and Content. The Government Management
and Reform Act of 1994 requires that all offices, bureaus and
associated activities of the 24 CFO Act agencies must be covered in an
agency-wide, audited financial statement. Collection of CHIP data and
the calculation of the CHIP Incurred But Not Reported (IBNR) estimate
are pertinent to CMS' financial audit. The CHIP Report on Payables and
Receivables will provide the information needed to calculate the CHIP
IBNR. Failure to collect this information could result in non-
compliance with the law. Form Number: CMS-10180 (OMB control number:
0938-0988); Frequency: Yearly; Affected Public: State, Local, or Tribal
Governments; Number of Respondents: 56; Total Annual Responses: 56;
Total Annual Hours: 504. (For policy questions regarding this
collection contact Beverly Boher at (410) 786-7806.)
5. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Medicaid Report
on Payables and Receivables; Use: Section 1903(b)(d)(1) of the Social
Security Act requires the Secretary to estimate the amount each State
should be paid at the beginning of each quarter. This amount is to be
based on a report filed by the State. Section 1903(b)(d)(2)(A) of the
Social Security Act authorizes the Secretary to pay the amount
estimated, reduced or increased to the extent of any overpayment or
underpayment for any prior quarter. Section 3515 of CFO Act requires
government agencies to produce auditable financial statements in
accordance with Office of Management and Budget guidelines on Form and
Content. The Government Management and Reform Act of 1994 requires that
all offices, bureaus and associated activities of the 24 CFO Act
agencies must be covered in an agency. Form Number: CMS-R-199 (OMB
control number: 0938-0697); Frequency: Yearly; Affected Public: State,
Local, or Tribal Governments; Number of Respondents: 56; Total Annual
Responses: 56; Total Annual Hours: 504. (For policy questions regarding
this collection contact Beverly Boher at (410) 786-7806.)
Dated: December 3, 2019.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and
Regulatory Affairs.
[FR Doc. 2019-26362 Filed 12-5-19; 8:45 am]
BILLING CODE 4120-01-P
