[Federal Register Volume 61, Number 128 (Tuesday, July 2, 1996)]
[Notices]
[Pages 34437-34438]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-16844]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Health Care Financing Administration, HHS.
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Health Care Financing
Administration (HCFA), Department of Health and Human Services, is
publishing the following summaries 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: Reinstatement, without
change, of previously approved collection for which approval has
expired; Title of Information Collection: Information Collection
Requirements in 42 CFR 473.18 (a) and (b), 473.34 (a) and (b), 473.36
(a) and (b), and 473.42 (a), Peer Review Organization (PRO)
Reconsideration and Appeals; Form No.: HCFA-R-72; Use: These
regulations contain procedures for PRO's to use in reconsideration of
initial determinations. The information requirements contained in these
regulations are on PROs to provide information to parties requesting a
reconsideration review. These parties will use the information as
guidelines for appeal rights in instances where issues are still in
dispute; Frequency: On occasion; Affected Public: Business or other for
profit; Number of Respondents: 53; Total Annual Responses: 15,670;
Total Annual Hours: 3,578.
2. Type of Information Collection Request: Reinstatement, without
change, of previously approved collection for
[[Page 34438]]
which approval has expired; Title of Information Collection: Request
for Enrollment in Supplementary Medical Insurance; Form No.: HCFA-4040;
Use: The HCFA-4040 is used to establish entitlement to Supplementary
Medical Insurance by Beneficiaries not eligible under Part A of Title
XVIII or Title II of the Social Security Act. The HCFA-4040SP is the
Spanish edition of this form; Frequency: One time only; Affected
Public: Individuals and households, Federal government, State, local,
or tribal governments; Number of Respondents: 10,000; Total Annual
Responses: 10,000; Total Annual Hours: 2,500.
3. Type of Information Collection Request: Extension of a currently
approved collection; Title of Information Collection: Request for
Certification as a Rural Health Clinic, Rural Health Clinic Survey
Report Form; Form No.: HCFA-29, 30; Use: The form HCFA-29 ``Request for
Certification as a Rural Health Clinics'' is used by facilities to
apply to participate in the Medicare program. The form HCFA-30 ``Rural
Health Clinic Survey Report Form, is used by State survey agencies to
record data needed to determine compliance with the Federal
requirements; Frequency: Annually; Affected Public: State, local or
tribal governments; Number of Respondents: 390; Total Annual Responses:
390; Total Annual Hours: 682.
4. Type of Information Collection Request: Reinstatement, without
change, of previously approved collection for which approval has
expired; Title of Information Collection: Quarterly Showing; Form No.:
HCFA-R-41; Use: This form is used by State Medicaid agencies to list
participating health care facilities and the dates the State agencies
reviewed the facilities. The lists are required to assure the existence
of an effective utilization (of services) control program, as required
by law and regulation, to avoid a penalty; Frequency: Quarterly;
Affected Public: State, local or tribal governments; Number of
Respondents: 47; Total Annual Responses: 188; Total Annual Hours:
9,212.
5. Type of Information Collection Request: Reinstatement, without
change, of previously approved collection for which approval has
expired; Title of Information Collection: Quarterly Showing Validation
Survey; Form No.: HCFA-9050; Use: Reporting entities may be required to
submit lists of Medicaid beneficiaries residing in a select number of
institutions. State Medicaid agencies may also be required to submit
procedures for conducting inspection of care reviews and other
documentation necessary to validate the Quarterly Showing reports. The
listings are required to determine those patients for which the State
is currently responsible for their care. This part of the operation to
determine that states have an effective utilization control program;
Frequency: Annually; Affected Public: State, local or tribal
governments; Number of Respondents: 47; Total Annual Responses: 8;
Total Annual Hours: 376.
6. Type of Information Collection Request: Reinstatement, with
change, of previously approved collection for which approval has
expired; Title of Information Collection: Medicare Managed Care
Disenrollment Form; Form No.: HCFA-566; Use: This form is used to
process a beneficiaries request of disenrollment action from a health
maintenance organization or competitive medical plan and to update the
beneficiaries' health insurance master record; Frequency: On occasion;
Affected Public: Individuals and households, Business or other for
profit, not for profit institutions, Federal government, State, local,
or tribal governments; Number of Respondents: 24,000; Total Annual
Responses: 24,000; Total Annual Hours: 792.
7. Type of Information Collection Request: New collection; Title of
Information Collection: ``Maximizing the Effective Use of Telemedicine:
A study of the Effects, Cost Effectiveness and Utilization Patterns of
Consultations via Telemedicine.''; Form No.: HCFA-R-197; Use: The major
objective of this study is to evaluate the medical and cost
effectiveness of three different categories of telemedicine services;
Frequency: Other (periodically); Affected Public: Individuals and
households, Business or other for profit, not for profit institutions;
Number of Respondents: 1819; Total Annual Responses: 11,095; Total
Annual Hours: 1,564.
8. Type of Information Collection Request: Revision of a currently
approved collection; Title of Information Collection: Business Proposal
Formats for Utilization and Quality Control Peer Review Organizations
(PROs); Form No.: HCFA-718-721; Use: Submission of proposal information
by current PROs and other bidders, according to the business proposal
instructions, will satisfy HCFA's need for consistent, and verifiable
data with which to validate contract proposals; Frequency: Other (Tri-
annually); Affected Public: Business or other for profit, not for
profit institutions; Number of Respondents: 20; Total Annual Responses:
23; Total Annual Hours: 450.
9. Type of Information Collection Request: Reinstatement, without
change, of a previously approved collection for which approval has
expired; Title of Information Collection: Request for Accelerated
Payments; Form No.: HCFA-9042; Use: These forms are used by fiscal
intermediaries to access a provider's eligibility for accelerated
payments. Such payment is granted if there is an unusual delay in
processing bills. Frequency: On occasion; Affected Public: Business or
other for-profit and Not for-profit institutions; Number of
Respondents: 854; Total Annual Responses: 854; Total Annual Hours
Requested: 427.
To obtain copies of the supporting statement for the proposed
paperwork collections referenced above, access HCFA's WEB SITE ADDRESS
at http://www.hcfa.gov , or to obtain the supporting statement and any
related forms, E-mail your request, including your address and phone
number, to Paperwork@hcfa.gov, or call the Reports Clearance Office on
(410) 786-1326. Written comments and recommendations for the proposed
information collections must be mailed within 60 days of this notice
directly to the HCFA Paperwork Clearance Officer designated at the
following address: HCFA, Office of Financial and Human Resources,
Management Planning and Analysis Staff, Attention: John Burke, Room C2-
26-17, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Dated: June 25, 1996.
Kathleen B. Larson,
Director, Management Planning and Analysis Staff, Office of Financial
and Human Resources, Health Care Financing Administration.
[FR Doc. 96-16844 Filed 7-1-96; 8:45 am]
BILLING CODE 4120-03-P
