[Federal Register Volume 80, Number 200 (Friday, October 16, 2015)]
[Notices]
[Pages 62534-62536]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-26390]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[Document Identifier: CMS-10003, CMS-10467, CMS-1450(UB-04), CMS-
1500(08-05)]


Agency Information Collection Activities: Proposed Collection; 
Comment Request

AGENCY: Centers for Medicare & Medicaid Services, HHS.

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 December 15, 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

[[Page 62535]]

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-10003 Notice of Denial of Medical Coverage (or Payment)
CMS-10467 Evaluation of the Graduate Nurse Education Demonstration 
Program
CMS-1450(UB-04) Medicare Uniform Institutional Provider Bill and 
Supporting Regulations CMS-1500(08-05) Health Insurance Common Claims 
Form and Supporting Regulations

    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: Revision of a currently 
approved collection; Title of Information Collection: Notice of Denial 
of Medical Coverage (or Payment); Use: Medicare health plans, including 
Medicare Advantage plans, cost plans, and Health Care Prepayment Plans, 
are required to issue the CMS-10003 form when a request for either a 
medical service or payment is denied in whole or in part. The notice 
explains why the plan denied the service or payment and informs 
Medicare enrollees of their appeal rights. The notice is also used, as 
appropriate, to explain Medicaid appeal rights to full dual eligible 
individuals enrolled in a Medicare health plan that is also managing 
the individual's Medicaid benefits. To that end, the revised notice 
contains bracketed text the plan will insert if the denial notice is 
being delivered to an enrollee who is a full dual eligible. The text in 
square brackets ``[ ]'' reflects the Federal protections for Medicaid 
managed care enrollees. Since a State may offer additional protections, 
there is also free-text space for inclusion of any State-specific 
protections that exceed the Federal protections. Form Number: CMS-10003 
(OMB control number: 0938-0829). Frequency: Occasionally; Affected 
Public: Private sector (Business or other for-profit and Not-for-profit 
institutions); Number of Respondents: 730; Total Annual Responses: 
33,574,293; Total Annual Hours: 5,593,477. (For policy questions 
regarding this collection contact Staci Paige at 410-786-2045. For all 
other issues call 410-786-1326.)
    2. Type of Information Collection Request: Revision of a currently 
approved information collection; Title of Information Collection: 
Evaluation of the Graduate Nurse Education Demonstration Program; Use: 
The Graduate Nurse Education (GNE) Demonstration is mandated under 
Section 5509 of the Affordable Care Act (ACA) under title XVIII of the 
Social Security Act (42 U.S.C. 1395 et seq.). According to Section 5509 
of the ACA, the five selected demonstration sites receive ``payment for 
the hospital's reasonable costs for the provision of qualified clinical 
training to advance practice registered nurses.'' Section 5509 of the 
ACA also states that an evaluation of the graduate nurse education 
demonstration must be completed no later than October 17, 2017. This 
evaluation includes analysis of the following: (1) Growth in the number 
of advanced practice registered nurses (APRNs) with respect to a 
specific base year as a result of the demonstration; (2) growth for 
each of the following specialties: clinical nurse specialist, nurse 
practitioner, certified nurse anesthetist, certified nurse-midwife; and 
(3) costs to the Medicare program as result of the demonstration.
    All information collected through the Evaluation of the GNE project 
will be used to meet the requirements specified under the ACA Section 
5509. We will also use the information to determine the overall 
effectiveness of the GNE project. The process evaluation seeks to 
understand how the demonstration is implemented overall, how that 
implementation has changed over time, which aspects of the 
demonstration have been successful or unsuccessful, and what plans the 
sites have for the remainder of the implementation and after the 
demonstration formally ends. The process evaluation will answer both 
quantitative and qualitative questions. Form Number: CMS-10467 (OMB 
control number: 0938-1212); Frequency: Annually; Affected Public: 
State, Local, or Tribal Governments; Private sector (Business and other 
for-profit and Not-for-profit institutions); Number of Respondents: 
104; Total Annual Responses: 104; Total Annual Hours: 802. (For policy 
questions regarding this collection contact Pauline Karikari-Martin at 
410-786-1040.)
    3. 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)

[[Page 62536]]

(OMB control number: 0938-0997); Frequency: On occasion; Affected 
Public: Private sector (Business or other for-profit and Not-for-profit 
institutions); 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.)
    4. Type of Information Collection Request: Extension of a currently 
approved collection; Title of Information Collection: Health Insurance 
Common Claims Form and Supporting Regulations at 42 CFR part 424, 
Subpart C; Use: The Form CMS-1500 answers the needs of many health 
insurers. It is the basic form prescribed by CMS for the Medicare 
program for claims from physicians and suppliers. The Medicaid State 
Agencies, CHAMPUS/TriCare, Blue Cross/Blue Shield Plans, the Federal 
Employees Health Benefit Plan, and several private health plans also 
use it; it is the de facto standard ``professional'' claim form.
    Medicare carriers use the data collected on the CMS-1500 and the 
CMS-1490S to determine the proper amount of reimbursement for Part B 
medical and other health services (as listed in section 1861(s) of the 
Social Security Act) provided by physicians and suppliers to 
beneficiaries. The CMS-1500 is submitted by physicians/suppliers for 
all Part B Medicare. Serving as a common claim form, the CMS-1500 can 
be used by other third-party payers (commercial and nonprofit health 
insurers) and other Federal programs (e.g., CHAMPUS/TriCare, Railroad 
Retirement Board (RRB), and Medicaid). However, as the CMS-1500 
displays data items required for other third-party payers in addition 
to Medicare, the form is considered too complex for use by 
beneficiaries when they file their own claims. Therefore, the CMS-1490S 
(Patient's Request for Medicare Payment) was explicitly developed for 
easy use by beneficiaries who file their own claims. The form can be 
obtained from any Social Security office or Medicare carrier. Form 
Number: CMS-1500(08/05), CMS-1490-S (OMB control number: 0938-0999) 
Frequency: On occasion; Affected Public: State, Local, or Tribal 
Governments, Private sector (Business or other-for-profit and Not-for-
profit institutions); Number of Respondents: 1,448,346; Total Annual 
Responses: 988,005,045; Total Annual Hours: 21,418,336. (For policy 
questions regarding this collection contact Shannon Seales at 410-786-
4089.)

    Dated: October 13, 2015.
William N. Parham, III,
Director, Paperwork Reduction Staff, Office of Strategic Operations and 
Regulatory Affairs.
[FR Doc. 2015-26390 Filed 10-15-15; 8:45 am]
 BILLING CODE 4120-01-P