[Federal Register Volume 70, Number 18 (Friday, January 28, 2005)]
[Notices]
[Page 4128]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-1482]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-1771, CMS-R-71 and CMS-222]


Agency Information Collection Activities: Proposed Collection; 
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) 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: Extension of a currently 
approved collection; Title of Information Collection: Attending 
Physicians Statement and Documentation of Medicare Emergency and 
Supporting Regulations in 42 CFR, Section 424.103; Use: Payment may be 
made for certain part A inpatient hospital services and part B 
outpatient provided in a nonparticipating U.S. or foreign hospital when 
services are necessary to prevent the death or serious impairment of 
the health of the individual. This collection is used to document the 
attending physician's statement that the hospitalization was required 
due to an emergency and give clinical support for the claim.; Form 
Number: CMS-1771 (OMB: 0938-0023); Frequency: On Occasion; 
Affected Public: Business or other for-profit; Number of Respondents: 
200; Total Annual Responses: 200; Total Annual Hours: 50.
    2. 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 Sections 412.44, 412.46, 431.630, 
476.71, 476.73, 476.74, 476.78; Form No.: CMS-R-71 (OMB 0938-
0445); Use: This collection describes the review functions to be 
performed by the QIO. It outlines relationships among QIOs, providers, 
practitioners, beneficiaries, intermediaries, and carriers. QIOs assure 
that covered care provided to Medicare patients is reasonable, 
medically necessary, appropriate, and of a quality that meets 
professionally recognized standards of care, and that inpatient 
services could not be more appropriately provided on an outpatient 
basis or in a different type of facility.; Frequency: As Needed; 
Affected Public: Business or other for-profit; Number of Respondents: 
6,036; Total Annual Responses: 6,036; Total Annual Hours: 81,818.
    3. 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, Section 413.20 and 413.24; 
Form No.: CMS-222 (OMB0938-0107); Use: The independent rural 
health clinic/freestanding federally qualified health center cost 
report is the cost report to be used by the mentioned clinics/centers 
to submit annual information. This information is used to achieve a 
settlement of costs for health care services rendered to Medicare 
beneficiaries. Frequency: Annually; Affected Public: Not-for-Profit 
institutions, Business or other for-profit, and State, local or tribal 
government; Number of Respondents: 3,000; Total Annual Responses: 
3,000; Total Annual Hours Requested: 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 [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 60 days of this notice directly to 
the CMS Paperwork Reduction Act Reports Clearance Officer designated at 
the address below: CMS, Office of Strategic Operations and Regulatory 
Affairs, Division of Regulations Development, Attention: Melissa 
Musotto, Room C5-14-03, 7500 Security Boulevard, Baltimore, Maryland 
21244-1850.

    Dated: January 19, 2005.
John P. Burke, III,
CMS Paperwork Reduction Act Reports Clearance Officer, Office of 
Strategic Operations and Regulatory Affairs, Regulations Development 
Group.
[FR Doc. 05-1482 Filed 1-27-05; 8:45 am]
BILLING CODE 4120-03-P