[Federal Register: April 25, 2005 (Volume 70, Number 78)]
[Notices]
[Page 21198-21199]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr25ap05-41]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: CMS-287, CMS-1771, CMS-R-71, CMS-222]
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 Request: Revision of a currently approved
collection; Title of Information Collection: Home Office Cost Statement
and Supporting Regulations in 42 CFR 413.17 and 413.20; Use: The Home
Office Cost Statement is filed annually by Chain Home Offices to report
the information necessary for the determination of Medicare
reimbursement to components of chain organizations. Many providers of
service participating in Medicare are reimbursed, at least partially,
on the basis of the lesser of reasonable cost or customary services for
services furnished to eligible beneficiaries. When providers obtain
services, supplies or facilities from an organization related to the
provider by common ownership or control, 42 CFR 413.17 requires that
the provider include in its costs, the costs incurred by the related
organization in
[[Page 21199]]
furnishing such services, supplies or facilities. Revisions to this
form include the addition of columns for more detailed reporting and
the elimination of other columns that were deemed unnecessary; Form
Number: CMS-287 (OMB 0938-0202); Frequency: Annually;
Affected Public: Not-for-profit institutions and Business or other for-
profit; Number of Respondents: 1,231; Total Annual Responses: 1,231;
Total Annual Hours: 573,646.
2. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Attending
Physicians Statement and Documentation of a Medicare Emergency and
Supporting Regulations in 42 CFR 424.103; Use: 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; Form Number: CMS-1771 (OMB
: 0938-0023); Frequency: Reporting--On occasion; Affected
Public: Business or other for-profit; Number of Respondents: 200; Total
Annual Responses: 200; Total Annual Hours: 50.
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Quality
Improvement Organization (QIO) Assumption of Responsibilities and
Supporting Regulations in 42 CFR 412.44, 412.46, 431.630, 476.71,
476.73, 476.74, and 476.78; Use: The Peer Review Improvement Act of
1982 amended Title XI of the Social Security Act to create the
Utilization and Quality Control Peer Review Organization (PRO) program
which replaces the Professional Standards Review Organization (PSRO)
program and streamlines peer review activities. The term PRO has been
renamed Quality Improvement Organization (QIO). This collection
describes the review functions to be performed by the QIO. It outlines
relationships among QIOs, providers, practitioners, beneficiaries,
intermediaries, and carriers; Form Numbers: CMS-R-71 (OMB
0938-0445); Frequency: Recordkeeping and Third Party Disclosure, as
needed; Affected Public: Business or other for-profit; Number of
Respondents: 6,036; Total Annual Responses: 6,036; Total Annual Hours:
81,818.
4. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Independent Rural
Health Center/Freestanding Federally Qualified Health Center Cost
Report and Supporting Regulations in 42 CFR 413.20 and 413.24; Use: CMS
is requesting re-approval of a currently approved form, CMS 222 (OMB
No. 0938-0107). The current form implements various provisions of the
Social Security Act including Section 1861(aa) which provides coverage
under Part B of the Medicare program for certain services furnished by
Rural Health Clinics (RHCs) and Freestanding Federally Qualified Health
Clinics (FQHCs), including physician assistant and nurse practitioner
services. The Medicare regulations provide for payment to clinics which
are not part of a hospital (freestanding clinics) under an all-
inclusive rate method designed to pay Medicare's share of the clinics'
incurred reasonable costs for the services provided. Clinics which are
part of a hospital are paid in accordance with the program's hospital
reimbursement methods and principles.; Form Numbers: CMS-222 (OMB
0938-0107); Frequency: Reporting--Annually; Affected Public:
Not-for-profit institutions, Business or other for-profit, and State,
local or tribal government; Number of Respondents: 3000; Total Annual
Responses: 3000; Total Annual Hours: 150,000.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access CMS Web
site address at http://www.cms.hhs.gov/regulations/pra/, or e-mail 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.
Written comments and recommendations for the proposed information
collections must be mailed within 30 days of this notice directly to
the OMB desk officer:
OMB Human Resources and Housing Branch, Attention: Christopher Martin,
New Executive Office Building, Room 10235, Washington, DC 20503.
Dated: April 15, 2005.
Michelle Short,
Acting Director, CMS Office of Strategic Operations and Regulatory
Affairs, Regulations Development Group.
[FR Doc. 05-8162 Filed 4-22-05; 8:45 am]
BILLING CODE 4120-01-P