[Federal Register Volume 80, Number 182 (Monday, September 21, 2015)]
[Notices]
[Page 56999]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-23528]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifiers: CMS-1771]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare & Medicaid Services.

ACTION: Notice.

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SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is 
announcing an opportunity for the public to comment on CMS' intention 
to collect information from the public. Under the Paperwork Reduction 
Act of 1995 (the PRA), federal agencies are required to publish notice 
in the Federal Register concerning each proposed collection of 
information (including each proposed extension or reinstatement of an 
existing collection of information) and to allow 60 days for public 
comment on the proposed action. Interested persons are invited to send 
comments regarding our burden estimates 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.

DATES: Comments must be received by November 20, 2015.

ADDRESSES: When commenting, please reference the document identifier or 
OMB control number. To be assured consideration, comments and 
recommendations must be submitted in any one of the following ways:
    1. Electronically. You may send 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) that are 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 ____, Room C4-26-05, 7500 Security Boulevard, Baltimore, 
Maryland 21244-1850.
    To obtain copies of a supporting statement and any related forms 
for the proposed collection(s) summarized in this notice, you may make 
your request using one of following:
    1. Access CMS' Web site address at http://www.cms.hhs.gov/PaperworkReductionActof1995.
    2. Email your request, including your address, phone number, OMB 
number, and CMS document identifier, to [email protected].
    3. Call the Reports Clearance Office at (410) 786-1326.

FOR FURTHER INFORMATION CONTACT: Reports Clearance Office at (410) 786-
1326.

SUPPLEMENTARY INFORMATION: 

Contents

    This notice sets out a summary of the use and burden associated 
with the following information collections. More detailed information 
can be found in each collection's supporting statement and associated 
materials (see ADDRESSES).

CMS-1771 Emergency and Foreign Hospital Services

    Under the PRA (44 U.S.C. 3501-3520), federal agencies must obtain 
approval from the Office of Management and Budget (OMB) for each 
collection of information they conduct or sponsor. The term 
``collection of information'' is defined in 44 U.S.C. 3502(3) and 5 CFR 
1320.3(c) and includes agency requests or requirements that members of 
the public submit reports, keep records, or provide information to a 
third party. Section 3506(c)(2)(A) of the PRA requires federal agencies 
to publish a 60-day notice in the Federal Register concerning each 
proposed collection of information, including each proposed extension 
or reinstatement of an existing collection of information, before 
submitting the collection to OMB for approval. To comply with this 
requirement, CMS is publishing this notice.

Information Collection

    1. Type of Information Collection Request: Reinstatement without 
change of a previously approved collection; Title of Information 
Collection: Emergency and Foreign Hospital Services; Use: Section 1866 
of the Social Security Act states that any provider of services shall 
be qualified to participate in the Medicare program and shall be 
eligible for payments under Medicare if it files an agreement with the 
Secretary to meet the conditions outlined in this section of the Act. 
Section 1814(d)(1) of the Social Security Act and 42 CFR 424.100, 
allows payment of Medicare benefits for a Medicare beneficiary to a 
nonparticipating hospital that does not have an agreement in effect 
with the Centers for Medicare and Medicaid Services. These payments can 
be made if such services were emergency services and if CMS would be 
required to make the payment if the hospital had an agreement in effect 
and met the conditions of payment. This form is used in connection with 
claims for emergency hospital services provided by hospitals that do 
not have an agreement in effect under Section 1866 of the Social 
Security Act. As specified in 42 CFR 424.103(b), before a non-
participating 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 and give clinical documentation to support the claim. A 
photocopy of the beneficiary's hospital records may be used in lieu of 
the CMS-1771 if the records contain all the information required by the 
form. Form Number: CMS-1771 (OMB control number: 0938-0023); Frequency: 
Annually; Affected Public: Private sector (Business or other for-
profits and Not-for-profit institutions); Number of Respondents: 100; 
Total Annual Responses: 200; Total Annual Hours: 50. (For policy 
questions regarding this collection contact Shauntari Cheely at 410-
786-1818.)

    Dated: September 15, 2015.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2015-23528 Filed 9-18-15; 8:45 am]
BILLING CODE 4120-01-P