Agency Information Collection Activities: Proposed Collection; Comment Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

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: End Stage Renal Disease

(ESRD) Application and Survey and Certification Report Form; Form No.:

HCFA-3427; Use: This form is a facility identification and screening

measurement tool used to initiate the certification and recertification

of ESRD facilities. The form is also completed by the Medicare/Medicaid

State survey agency to determine facility compliance with ESRD

conditions for coverage; Frequency: Annually; Affected Public: State,

local or tribal governments; Number of Respondents: 2,640; Total Annual

Hours: 2,376.

2. Type of Information Collection Request: Reinstatement, without

change, of previously approved collection for which approval has

expired; Title of Information Collection: Withholding Medicare Payments

to Recover Medicaid Overpayments; Form No.: HCFA-R-21; Use: Medicaid

providers who have received overpayments may terminate or substantially

reduce their participation in Medicaid to avoid the State's effort to

recover the amounts due. This provision establishes a mechanism for

State agencies to recoup the overpayments by withholding Medicare

payments to these providers; Frequency: On occasion; Affected Public:

State, local or tribal governments; Number of Respondents: 54; Total

Annual Hours: 81.

3. 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 HSQ-110, Acquisition, Protection and Disclosure of Peer

Review Organization (PRO) Information--42 CFR 476.104, 476.105,

476.116, and 476.134; Form No.: HCFA-R-70; Use: ``Medicare Disclosure

Information, Regulatory'' The Peer Review Improvement Act of 1982

authorizes PRO's to acquire information necessary to fulfill their

duties and functions and places limits on disclosure of the

information. These requirements are on the PRO to provide notices to

the affected parties when disclosing information about them. These

requirements serve to protect the rights of the affected parties;

Frequency: On occasion; Affected Public: Business or other for profit;

Number of Respondents: 53; Total Annual Hours: 30,577.

4. Type of Information Collection Request: Extension of a currently

approved collection; Title of Information Collection: Survey report

Form (CLIA); Form No.: HCFA-1557; Use: Clinical Laboratory

Certification and Recertification: This survey form is an instrument

used by the State agency to record data collected in order to determine

compliance with CLIA; Frequency: Biennially; Affected Public: Business

or other for profit, not for profit institutions, Federal government

and State, local or tribal governments; Number of Respondents: 30,225;

Total Annual Hours: 16,322.

5. Type of Information Collection Request: Extension of a currently

approved collection; Title of Information Collection: Laboratory

Personnel Report (CLIA); Form No.: HCFA-209; Use: This form is used by

the State agency to determine a laboratory's compliance with personnel

qualifications under CLIA. This information is needed for a

laboratory's CLIA certification and recertification;

[[Page 29407]]

Frequency: Biennially; Affected Public: Business or other for profit,

not for profit institutions, Federal, State , local or tribal

governments; Number of Respondents: 26,250; Total Annual Hours: 13,125.

6. Type of Information Collection Request: Reinstatement, without

change, of previously approved collection for which approval has

expired; Title of Information Collection: Prepaid Health Plan Cost

Report; Form No.: HCFA-276; Use: These forms are needed to establish

the reasonable cost providing covered services to the enrolled Medicare

population of an HMO in accordance with Section 1876 of the Social

Security Act; Frequency: Quarterly, Annually; Affected Public: Business

or other for profit; Number of Respondents: 82; Total Annual Hours:

9,934.

7. Type of Information Collection Request: Reinstatement, without

change, of previously approved collection for which approval has

expired; Title of Information Collection: Medicare Credit Balance

Reporting Requirements; Form No.: HCFA-838; Use: The collection of

credit balance information is needed to ensure that millions of dollars

in improper program payments are collected. Approximately 37,600 health

care providers will be required to submit a quarterly credit balance

report that indicates the amount of improper payments they received

that are due to Medicare. The intermediaries will monitor the reports

to ensure these funds are collected; Frequency: Quarterly; Affected

Public: Not for profit institutions; Number of Respondents: 37,600;

Total Annual Hours: 902,400.

8. Type of Information Collection Request: Revision of a currently

approved collection; Title of Information Collection: Statement of

Deficiencies and Plan of Correction; Form No.: HCFA-2567-A; Use: This

Paperwork package provides information regarding deficiencies for Organ

Procurement Organizations (OPO) as well as deficiencies noted during

periodic facility and laboratory certification surveys. This

information is used to make decisions concerning OPO redesignation,

certification/recertification of health care facilities participating

in the Medicare/Medicaid Programs, and laboratories regulated by CLIA.

Frequency: Annually and Biennially; Affected Public: State, Local or

Tribal Governments, Business or other for-profit, Not-for-profit

institutions, Federal Government; Number of Respondents: 49,200; Total

Annual Responses: 98,400; Total Annual Hours Requested: 196,800.

9. Type of Information Collection Request: Revision of a currently

approved collection; Title of Information Collection: Medicare/Medicaid

Hospital Survey Report Form; Form No.: HCFA-1537; Use: Section 1861(e)

of the Social Security ACT provides that hospitals participating in

Medicare must meet specific requirements. These requirements are

presented as conditions of Participation. State agencies must determine

compliance with these conditions through the use of this report form;

Frequency: Annually; Affected Public: State, Local or Tribal

Governments; Number of Respondents: 1,322; Total Annual Hours

Requested: 4,296.50.

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 P[email protected], 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 3, 1996.

Kathleen B. Larson,

Director, Management Planning and Analysis Staff, Office of Financial

and Human Resources, Health Care Financing Administration.

[FR Doc. 96-14479 Filed 6-7-96; 8:45 am]

BILLING CODE 4120-03-P