[Federal Register Volume 75, Number 237 (Friday, December 10, 2010)]
[Notices]
[Pages 76987-76988]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-31075]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifier: 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: Reinstatement 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
[[Page 76988]]
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: 1,048,243; Total Annual Responses:
991,160,925; Total Annual Hours: 23,815,541. (For policy questions
regarding this collection contact Brian Reitz at 410-786-5001. 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 http://www.cms.hhs.gov/PaperworkReductionActof1995, or
e-mail your request, including your address, phone number, OMB number,
and CMS document identifier, to [email protected], 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 January 10, 2011.
OMB, Office of Information and Regulatory Affairs.
Attention: CMS Desk Officer.
Fax Number: (202) 395-6974.
E-mail: [email protected].
Dated: December 6, 2010.
Michelle Shortt,
Director, Regulations Development Group Office of Strategic Operations
and Regulatory Affairs.
[FR Doc. 2010-31075 Filed 12-9-10; 8:45 am]
BILLING CODE 4120-01-P