Agency Information Collection Activities: Proposed Collection; Comment Request, 66910-66912 [2019-26362]

Download as PDF 66910 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] BILLING CODE 4163–18–P lotter on DSKBCFDHB2PROD with NOTICES 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: VerDate Sep<11>2014 16:11 Dec 05, 2019 Jkt 250001 PO 00000 Frm 00041 Fmt 4703 Sfmt 4703 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 06DEN1 Federal Register / Vol. 84, No. 235 / Friday, December 6, 2019 / Notices lotter on DSKBCFDHB2PROD with NOTICES 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 http:// 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 VerDate Sep<11>2014 16:11 Dec 05, 2019 Jkt 250001 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 PO 00000 Frm 00042 Fmt 4703 Sfmt 4703 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 E:\FR\FM\06DEN1.SGM 06DEN1 lotter on DSKBCFDHB2PROD with NOTICES 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 VerDate Sep<11>2014 16:11 Dec 05, 2019 Jkt 250001 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] BILLING CODE 4120–01–P PO 00000 Frm 00043 Fmt 4703 Sfmt 4703 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 http:// 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]


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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 
http://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