[Federal Register Volume 74, Number 113 (Monday, June 15, 2009)]
[Notices]
[Pages 28249-28250]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-13944]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-304/304a, CMS-10288, CMS-10289 and CMS-1450 
(UB-04)]


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 without change 
of a currently approved collection; Title of Information Collection: 
Reconciliation of State Invoice and Prior Quarter Adjustment Statement; 
Use: Section 1927 of the Social Security Act requires drug 
manufacturers to enter into and have in effect a rebate agreement with 
CMS in order for States to receive funding for drugs dispensed to 
Medicaid recipients. Drug manufacturers must complete and submit to 
States the 304 form (the Reconciliation of State Invoice Form) to 
explain any rebate payment adjustments for the current quarter, and 
complete and submit the 304A form (the Prior Quarter Adjustment 
Statement Form) to States to explain rebate payment adjustments to any 
prior quarters. Both forms are used to reconcile drug rebate payments 
made by manufacturers with the State invoices of rebates due. Form 
Number: CMS-304/304a (OMB: 0938-0676); Frequency: Reporting--
Quarterly; Affected Public: Private Sector: Business or other for 
profits; Number of Respondents: 570; Total Annual Responses: 3820; 
Total Annual Hours: 141,080. (For policy questions regarding this 
collection contact Cindy Bergin at 410-786-1176. For all other issues 
call 410-786-1326.)
    2. Type of Information Collection Request: New Collection; Title of 
Information Collection: State Plan Pre-Print to Implement Required 
Dental Benefits Pursuant of Children's Health Insurance Program 
Reauthorizing Act (CHIPRA) 2009; Use: Section 501 of CHIPRA 2009 amends 
XXI and requires that ``child health assistance provide to a targeted 
low-income child shall include coverage of dental services necessary to 
prevent disease and promote oral health, restore oral structures to 
health and function, and treat emergency conditions.'' States that 
provide coverage in a separate Children's Health Insurance Program may 
choose between two methods of providing the dental services required in 
Section 501. The State may define the

[[Page 28250]]

services in the dental benefit package and demonstrate that it includes 
all the required services. Alternatively, the State may provide a 
dental benefit package that is equivalent to one of the three benchmark 
packages described in the statute. In order to implement one of these 
options and comply with the statute, States must amend their State Plan 
using the State Plan pre-print. Form Number: CMS-10288 (OMB : 
0938--NEW); Frequency: Reporting One-time; Affected Public: State, 
Local, or Tribal Governments; Number of Respondents: 51; Total Annual 
Responses: 51; Total Annual Hours: 1530. (For policy questions 
regarding this collection contact Nancy Goetschius at 410-786-0707. For 
all other issues call 410-786-1326.)
    3. Type of Information Collection Request: New Collection; Title of 
Information Collection: Optional Dental-only Supplemental Coverage 
State Plan Amendment Template; Use: CHIPRA 2009 provides States with an 
option to provide supplemental dental-only coverage to children who 
would be eligible to enroll in the State's Children's Health Insurance 
Program (CHIP), except that they already have health insurance 
coverage, either through a group health plan or employer sponsored 
insurance. If the health insurance plan the child is enrolled in does 
not provide dental benefits, the State may provide the child with the 
same State-defined dental package or benchmark benefit plan provided to 
children who are eligible for the entire CHIP benefit package. The 
child will only be entitled to the dental services provided to other 
CHIP children.
    In order to choose this option, State must comply with all other 
requirements of the statute regarding cost sharing, income eligibility 
level, absence of a waiting list for their entire CHIP program (not 
just for dental coverage), and not providing more favorable treatment 
to children eligible for the supplemental dental benefit under this 
option. In order to implement this option States must amend their State 
Plan using the Supplemental Dental Benefits State Plan Amendment 
Template. Form Number: CMS-10289 (OMB: 0938--NEW); Frequency: 
Reporting One-time; Affected Public: State, local, or Tribal 
Governments; Number of Respondents: 51; Total Annual Responses: 51; 
Total Annual Hours: 1020. (For policy questions regarding this 
collection contact Nancy Goetschius at 410-786-0707. For all other 
issues call 410-786-1326.)
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Medicare Uniform 
Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5; 
Use: Section 42 CFR 424.5(a)(5) requires providers of services to 
submit a claim for payment prior to any Medicare reimbursement. Charges 
billed are coded by revenue codes. The bill specifies diagnoses 
according to the International Classification of Diseases, Ninth 
Edition (ICD-9-CM) code. Inpatient procedures are identified by ICD-9-
CM codes, and outpatient procedures are described using the CMS Common 
Procedure Coding System (HCPCS). These are standard systems of 
identification for all major health insurance claims payers. Submission 
of information on the CMS-1450 permits Medicare intermediaries to 
receive consistent data for proper payment. Form Numbers: CMS-1450 (UB-
04) (OMB: 0938-0997); Frequency: Reporting--On occasion; 
Affected Public: Not-for-profit institutions, Business or other for-
profit; Number of Respondents: 53,111; Total Annual Responses: 
181,909,654; Total Annual Hours: 1,567,455. (For policy questions 
regarding this collection contact Matt Klischer at 410-786-7488. 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 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.
    In commenting on the proposed information collections please 
reference the document identifier or OMB control number. To be assured 
consideration, comments and recommendations must be submitted in one of 
the following ways by August 14, 2009:
    1. Electronically. You may submit your comments electronically to 
http://www.regulations.gov. Follow the instructions for ``Comment or 
Submission'' or ``More Search Options'' to find the information 
collection document(s) accepting comments.
    2. By regular mail. You may mail written comments to the following 
address: CMS, Office of Strategic Operations and Regulatory Affairs, 
Division of Regulations Development, Attention: Document Identifier/OMB 
Control Number (CMS-10078), Room C4-26-05, 7500 Security Boulevard, 
Baltimore, Maryland 21244-1850.

    Dated: June 5, 2009.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. E9-13944 Filed 6-12-09; 8:45 am]
BILLING CODE 4120-01-P