2012-14673. 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 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: Reinstatement without change of a previously approved collection; Title of Information Collection: Worksheet for Recording Results of Medicare Site Visits of Independent Diagnostic Testing Facilities (IDTFs); Use: The worksheet (form) was developed, approved through the Office of Management and Budget and implemented to allow for CMS to have a standard format to collect and verify information regarding the compliance of independent diagnostic testing facilities (IDTFs) with the performance standards found in 42 CFR 410.33(g). This previously approved form was allowed to expire in error. CMS is now seeking re-instatement of the use of this form.

The worksheet is used to collect and record information obtained on IDTF site visits; the data collected during site visits facilitates the verification of the accuracy and completeness of the information the IDTF furnished on its CMS-855B enrollment application. The worksheet is completed by CMS or its contractors. Some of the answers to the questions/data elements on the worksheet are verbally furnished by the IDTF during the site visit; Form Number: CMS-10221 (OCN 0938-1029); Frequency: Occasionally; Affected Public: Private Sector (Business or other for-profits); Number of Respondents: 2,000; Total Annual Responses: 2,000; Total Annual Hours: 4,000. (For policy questions regarding this collection contact Michael Collett at 410-786-6121. For all other issues call 410-786-1326.)

2. Type of Information Collection Request: Revision of a currently approved collection. Title of Information Collection: Medicare Enrollment Application for Physician and Non-Physician Practitioners. Use: Health care practitioners who wish to enroll in the Medicare program must complete the CMS 855I enrollment application. It is submitted at the time the applicant first requests a Medicare billing number. The application is used by the Medicare Administrative Contractor (MAC), to collect data to assure the applicant has the necessary professional and/or business credentials to provide the health care services for which they intend to bill Medicare including information that allows the MAC to correctly price, process and pay the applicant's claims. It also gathers information that allows the MAC to ensure that the practitioner is not sanctioned from the Medicare program, or debarred, suspended or excluded from any other Federal agency or program. Form Number: CMS-855I (OCN: 0938-0685). Frequency: Once and Occasionally. Affected Public: Private Sector (Business or other for-profit and not-for-profit institutions). Number of Respondents: 345,000. Total Annual Responses: 345,000. Total Annual Hours: 824,000. (For policy questions regarding this collection contact Kimberly McPhillips at 410-786-5374. For all other issues call 410-786-1326.)

3. Type of Information Collection Request: New collection. Title of Information Collection: Medicare Enrollment Application—Reassignment of Medicare Benefits. Use: Health care practitioners who wish to reassign their benefits in the Medicare program must complete the CMS 855R enrollment application. It is submitted at the time the physician or non-physician practitioner first requests reassignment of his/her Medicare benefits to a group practice, as well as any subsequent reassignments or terminations of established reassignments as requested by the physician or non-physician practitioner. The application is used by the Medicare Administrative Contractor (MAC) to collect data to assure the applicant has the necessary information that allows the MAC to correctly establish or terminate the reassignment. Form Number: CMS-855R (OCN: 0938-New). Frequency: Occasionally. Affected Public: Private Sector (Business or other for-profit and not-for-profit institutions). Number of Respondents: 100,000. Total Annual Responses: 100,000. Total Annual Hours: 50,000. (For policy questions regarding this collection contact Kimberly McPhillips at 410-786-5374. 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 Email your request, including your address, phone number, OMB number, and CMS document identifier, to [e-mail], or call the Reports Clearance Office on [phone].

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 July 16, 2012 .

OMB, Office of Information and Regulatory Affairs, Attention: CMS Desk Officer, Fax Number: [phone], Email: [e-mail].

Dated: June 12, 2012.

Martique Jones,

Director, Regulations Development Group, Division B, Office of Strategic Operations and Regulatory Affairs.