[Federal Register Volume 64, Number 180 (Friday, September 17, 1999)]
[Notices]
[Page 50521]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-24269]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[Document Identifier: HCFA-1964]
Agency Information Collection Activities: Proposed Collection;
Comment Request
AGENCY: Health Care Financing Administration.
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 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.
Type of Information Collection Request: Extension of a currently
approved collection;
Title of Information Collection: Request for Review of Part B
Medicare Claim and Supporting Regulations in 42 CFR 405.807;
Form No.: HCFA-1964 (OMB# 0938-0033);
Use: The HCFA-1964 is a form which is used nationally to request
review of an initial determination made on a Part B health insurance
claim. A Medicare beneficiary (or his/her physician/supplier who
accepts assignment) files for Part B benefits using forms HCFA-1490S
(Patient's Request for Medicare Payment), HCFA-1491 (Request for
Medicare Payment--Ambulance), or HCFA-1500 (Health Insurance Claim
Form). If any benefits are denied, the claimant has the right to
request a review of the initial determination by submitting this HCFA-
1964, form.;
Frequency: On occasion;
Affected Public: Individuals or Households, and Not-for-profit
institutions;
Number of Respondents: 5,600,000;
Total Annual Responses: 5,600,000;
Total Annual Hours: 1,400,000.
To obtain copies of the supporting statement and any related forms
for the proposed paperwork collections referenced above, access HCFA's
Web Site address at http://www.hcfa.gov/regs/prdact95.htm, or E-mail
your request, including your address, phone number, OMB number, and
HCFA document identifier, 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
Information Services, Security and Standards Group, Division of HCFA
Enterprise Standards, Attention: Dawn Willinghan, Room N2-14-26, 7500
Security Boulevard, Baltimore, Maryland 21244-1850.
Dated: September 9, 1999.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA Office of Information
Services,Security and Standards Group, Division of HCFA Enterprise
Standards.
[FR Doc. 99-24269 Filed 9-16-99; 8:45 am]
BILLING CODE 4120-03-P
