[Federal Register Volume 68, Number 12 (Friday, January 17, 2003)]
[Notices]
[Pages 2559-2560]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-1055]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare and Medicaid Services

[Document Identifier: CMS-276, CMS-1500, CMS-1490U, CMS-1490S, CMS-
1450, and CMS-R-285, CMS-R-290, and CMS-2744]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

AGENCY: Centers for Medicare and Medicaid Services.
    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Centers for Medicare and Medicaid 
Services (CMS) (formerly known as the Health Care Financing 
Administration (HCFA), 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 functions; (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: Revision of a Currently 
Approved Collection; Title of Information Collection: Prepaid Health 
Plan Cost Report; Form No.: CMS-276 (OMB 0938-0165; Use: These 
forms are needed to establish the reasonable cost of providing covered 
services to the enrolled Medicare population of an HMO in accordance 
with Section 1876 of the Social Security Act.; Frequency: Recordkeeping 
and Reporting on occasion; Affected Public: Business or other for-
profit; Number of Respondents: 45; Total Annual Responses: 225; Total 
Annual Hours: 7,860.

[[Page 2560]]

    (2) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: 
Medicare/Medicaid Health Insurance Common Claim Form, Instructions, and 
Supporting Regulations: 42 CFR 424.32, 424.44; Form No.: CMS-1500, CMS-
1490U, CMS-1490S (OMB 0938-0008); Use: This form is a 
standardized claim form for use in the Medicare/Medicaid programs to 
apply for reimbursement for covered services. Many private insurers 
also use this form. Use of this form reduces cost and administrative 
burdens associated with professional claims because only one format 
needs to be used and maintained. CMS does not require exclusive use of 
this form for Medicaid.; Frequency: On occasion; Affected Public: 
State, Local or Tribal Government, Business or other for-profit, Not-
for-profit institutions; Number of Respondents: 1,216,702; Total Annual 
Responses: 740,215,135; Total Annual Hours: 42,941,276.
    (3) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: 
Medicare Uniform Institutional Provider Bill and Supporting 
Regulations; Form No.: CMS-1450 (OMB 0938-0279); Use: This 
standardized form is used in the Medicare/Medicaid program to apply for 
reimbursement of covered services by all providers that accept 
Medicare/Medicaid assigned claims.; Frequency: On occasion; Affected 
Public: Not for profit institutions and Business or other for profit; 
Number of Respondents: 46,708; Total Annual Responses: 158,603,290; 
Total Annual Hours: 1,666,208.
    (4) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: Request 
for Retirement Benefit Information; Form No.: CMS-R-285 (OMB 
0938-0769); Use: This information is needed to determine 
whether a beneficiary meets the requirements for reduction of Part A 
premium to zero.; Frequency: On occasion; Affected Public:, State and 
Local or Tribal Government; Number of Respondents: 1500; Total Annual 
Responses: 1500; Total Annual Hours: 208.
    (5) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: 
Procedures for Making National Coverage Decisions; Form No.: CMS-R-0290 
(OMB 0938-0776); Use: These information collection 
requirements provide the process CMS will use to make a national 
coverage decision for a specific item or service under sections 1862 
and 1871 of the Social Security Act. This will streamline our decision 
making process and will increase the opportunities for public 
participation in making national coverage decisions; Frequency: Other 
(as needed); Affected Public: Business or other for-profit, Not-for-
profit institutions; Number of Respondents: 200; Total Annual 
Responses: 200; Total Annual Hours: 8,000.
    (6) Type of Information Collection Request: Extension of a 
currently approved collection; Title of Information Collection: End 
Stage Renal Disease Medical Information System ESRD Facility Survey; 
Form No.: CMS-2744 (OMB 0938-0447); Use: The ESRD Facility 
Survey form (CMS-2744) is completed annually by Medicare-approved 
providers of dialysis and transplant services. The CMS-2744 is designed 
to collect information concerning treatment trends, utilization of 
services and patterns of practice in treating ESRD patients.; 
Frequency: Annually; Affected Public:, Business or other for-profit and 
Not-for-profit institutions; Number of Respondents: 4,225; Total Annual 
Responses: 4,225; Total Annual Hours: 33,800.
    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://cms.hhs.gov/regulations/pra/default.asp, 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. 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: Brenda Aguilar, New 
Executive Office Building, Room 10235, Washington, DC 20503.

    Dated: January 9, 2003.
John P. Burke, III,
CMS Reports Clearance Officer, Office of Strategic Operations and 
Regulatory Affairs, Division of Regulations Development and Issuances.
[FR Doc. 03-1055 Filed 1-16-03; 8:45 am]
BILLING CODE 4120-03-P