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Agency Information Collection Activities: Submission for OMB Review; Comment Request

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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 Start Printed Page 21199furnishing 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​regulations/​pra/​, or e-mail your request, including your address, phone number, OMB number, and CMS document identifier, to, 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.

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Dated: April 15, 2005.

Michelle Short,

Acting Director, CMS Office of Strategic Operations and Regulatory Affairs, Regulations Development Group.

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[FR Doc. 05-8162 Filed 4-22-05; 8:45 am]