[Federal Register Volume 70, Number 78 (Monday, April 25, 2005)]
[Notices]
[Pages 21198-21199]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-8162]


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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 [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: 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