[Federal Register Volume 74, Number 228 (Monday, November 30, 2009)]
[Notices]
[Pages 62575-62577]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-28458]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-304/304a, CMS-1515/1572, CMS-10291, CMS-
10292, CMS-588 and CMS-R-232]


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

[[Page 62576]]

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: 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: Extension without change 
of a currently approved collection; Title of Information Collection: 
Home Health Agency Survey and Deficiencies Report, Home Health 
Functional Assessment Instrument and Supporting Regulations in 42 CFR 
488.26 and 442.30. Use: In order to participate in the Medicare Program 
as a Home Health Agency (HHA) provider, the HHA must meet Federal 
Standards. These forms are used to record information and patients' 
health and provider compliance with requirements and to report the 
information to the Federal Government; Form Number: CMS-1515/1572 
(OMB: 0938-0355); Frequency: Reporting--Yearly; Affected 
Public: Health Care Services; Number of Respondents: 10,078; Total 
Annual Responses: 5,614; Total Annual Hours: 9,821. (For policy 
questions regarding this collection contact Patricia Sevast at 410-786-
8135. For all other issues call 410-786-1326.)
    3. Type of Information Collection Request: Extension without change 
of a currently approved collection; Title of Information Collection: 
Dental Provider and Benefit Information Posted on Insure Kids Now! 
Website; Form Number: CMS-10291 (OMB: 0938-1065); Use: Section 
501 of the Children's Health Insurance Program Reauthorization Act 
(CHIPRA) requires the Secretary to work with States, pediatric 
dentists, and other dental providers to include on the Insure Kids Now 
(IKN) website, a ``current and accurate list of all dentists and 
providers within each State that provide dental services to children 
enrolled in the State plan (or waiver) under Medicaid or the State 
child health plan (or waiver) under CHIP. Section 501 of CHIPRA also 
requires the Secretary to ensure the list is updated at least quarterly 
and includes the description of the dental services provided under 
Medicaid or CHIP and whether the services are provided through a State 
plan or waiver. The Secretary shall also post on the IKN website State 
specific information on available dental benefits. This information 
collection requirement will allow States to collect the information on 
the dental providers and dental benefits in accordance with CHIPRA. 
Frequency: Yearly and Quarterly; Affected Public: State, Tribal and 
Local governments; Number of Respondents: 51; Total Annual Responses: 
255; Total Annual Hours: 9,180. (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: New Collection; Title of 
Information Collection: State Medicaid HIT Plan and Templates for 
Implementation of Section 4201 of ARRA; Form Number: CMS-10292 
(OMB: 0938-NEW); Use: This information is being requested in 
order that States can submit documentation to CMS for review and 
approval in order that States can implement the Medicaid program and 
draw down Federal financial participation. The American Reinvestment 
and Recovery Act of 2009 (ARRA) provides States with the flexibility to 
request funds to develop a health information technology vision and 
road to get to the ultimate goal of meaningful use of certified 
electronic health records technology. We will be sending State Medicaid 
Directors letters and templates for the State Medicaid Hit Plan (SMHP), 
the Planning Advance Planning Document (PAPD) and the Implementation 
Advance Planning Document (IAPD) to States in an effort to request 
these changes if they so choose to make the process as simple as 
possible. Frequency: Yearly, once and/or occasionally; Affected Public: 
State, Tribal and Local governments; Number of Respondents: 56; Total 
Annual Responses: 56; Total Annual Hours: 280. (For policy questions 
regarding this collection contact Donna Schmidt at 410-786-5532. For 
all other issues call 410-786-1326.)
    5. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Electronic Funds Transfer Authorization Agreement; Use: 
Section 1815(a) of the Social Security Act provides the authority for 
the Secretary of Health and Human Services to pay providers/suppliers 
of Medicare services at such time or times as the Secretary determines 
appropriate (but no less frequently than monthly). Under Medicare, CMS, 
acting for the Secretary, contracts with Fiscal Intermediaries and 
Carriers to pay claims submitted by providers/suppliers who furnish 
services to Medicare beneficiaries. Under CMS' payment policy, Medicare 
providers/suppliers have the option of receiving payments 
electronically. Form number CMS-588 authorizes the use of electronic 
fund transfers (EFTs). Form Number: CMS-588 (OMB: 0938-0626); 
Frequency: Reporting--On occasion; Affected Public: Business or other 
for-profit and Not-for-profit institutions; Number of Respondents: 
100,000; Total Annual Responses: 100,000; Total Annual Hours: 100,000. 
(For policy questions regarding this collection contact Kim McPhillips 
at 410-786-5374. For all other issues call 410-786-1326.)
    6. Type of Information Collection Request: Reinstatement without 
change of a currently approved collection; Title of Information 
Collection: Medicare Integrity Program Organizational Conflict of 
Interest Disclosure Certificate and Supporting Regulations at 42 CFR 
421.300-421.316; Use: Section 1893(d)(1) of the Social Security Act 
requires CMS to establish a process for identifying, evaluating, and 
resolving conflicts of interest. CMS proposed a process in Section 
421.310 to mandate submission of pertinent information regarding 
conflicts of interest. The entities providing the information will be 
organizations that have been awarded, or seek award of, a Medicare 
Integrity Program contract. CMS needs this information to assess 
whether contractors who perform, or who seek to perform, Medicare 
Integrity Program functions, such as medical review, fraud review or 
cost audits, have

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organizational conflicts of interest and whether any conflicts have 
been resolved. Form Number: CMS-R-232 (OMB: 0938-0723); 
Frequency: Reporting--On occasion; Affected Public: Business or other 
for-profit; Number of Respondents: 11; Total Annual Responses: 44; 
Total Annual Hours: 2,200. (For policy questions regarding this 
collection contact Joe Strazzire at 410-786-2775. 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 December 30, 
2009.
    OMB, Office of Information and Regulatory Affairs, Attention: CMS 
Desk Officer, Fax Number: (202) 395-6974, E-mail: [email protected].

    Dated: November 20, 2009.
Michelle Shortt,
Director, Regulations Development Group, Office of Strategic Operations 
and Regulatory Affairs.
[FR Doc. E9-28458 Filed 11-27-09; 8:45 am]
BILLING CODE 4120-01-P