05-1482. 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 of a currently approved collection; Title of Information Collection: Attending Physicians Statement and Documentation of Medicare Emergency and Supporting Regulations in 42 CFR, Section 424.103; Use: Payment may be made for certain part A inpatient hospital services and part B outpatient provided in a nonparticipating U.S. or foreign hospital when services are necessary to prevent the death or serious impairment of the health of the individual. This collection is used to document the attending physician's statement that the hospitalization was required due to an emergency and give clinical support for the claim.; Form Number: CMS-1771 (OMB#: 0938-0023); Frequency: On Occasion; Affected Public: Business or other for-profit; Number of Respondents: 200; Total Annual Responses: 200; Total Annual Hours: 50.

2. 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 Sections 412.44, 412.46, 431.630, 476.71, 476.73, 476.74, 476.78; Form No.: CMS-R-71 (OMB# 0938-0445); Use: This collection describes the review functions to be performed by the QIO. It outlines relationships among QIOs, providers, practitioners, beneficiaries, intermediaries, and carriers. QIOs assure that covered care provided to Medicare patients is reasonable, medically necessary, appropriate, and of a quality that meets professionally recognized standards of care, and that inpatient services could not be more appropriately provided on an outpatient basis or in a different type of facility.; Frequency: As Needed; Affected Public: Business or other for-profit; Number of Respondents: 6,036; Total Annual Responses: 6,036; Total Annual Hours: 81,818.

3. 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, Section 413.20 and 413.24; Form No.: CMS-222 (OMB#0938-0107); Use: The independent rural health clinic/freestanding federally qualified health center cost report is the cost report to be used by the mentioned clinics/centers to submit annual information. This information is used to achieve a settlement of costs for health care services rendered to Medicare beneficiaries. Frequency: Annually; Affected Public: Not-for-Profit institutions, Business or other for-profit, and State, local or tribal government; Number of Respondents: 3,000; Total Annual Responses: 3,000; Total Annual Hours Requested: 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 http://www.cms.hhs.gov/​regulations/​pra/​,, or E-mail your request, including your address, phone number, OMB number, and CMS document identifier, to [e-mail], or call the Reports Clearance Office on [phone].

Written comments and recommendations for the proposed information collections must be mailed within 60 days of this notice directly to the CMS Paperwork Reduction Act Reports Clearance Officer designated at the address below: CMS, Office of Strategic Operations and Regulatory Affairs, Division of Regulations Development, Attention: Melissa Musotto, Room C5-14-03, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Dated: January 19, 2005.

John P. Burke, III,

CMS Paperwork Reduction Act Reports Clearance Officer, Office of Strategic Operations and Regulatory Affairs, Regulations Development Group.