Proposed Collection; Comment Request

DEPARTMENT OF DEFENSE

Office of the Secretary

Proposed Collection; Comment Request

agency: Office of the Assistant Secretary of Defense for Health

Affairs.

action: Notice.

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In accordance with Section 3506(c)(2)(A) of the Paperwork Reduction

Act of 1995, the Office of the Assistant Secretary of Defense for

Health Affairs announces a proposed uniform public information

collection and seeks public comment on the provisions thereof. Comments

are invited on: (a) whether the proposed collection of information is

necessary for the proper performance of the functions of the agency,

including whether the information shall have practical utility; (b) the

accuracy of the agency's estimate of the burden of the proposed

information collection; (c) ways to enhance the quality, utility, and

clarity of the information to be collected; and (d) ways to minimize

the burden of the information collection on respondents, including

through the use of automated collection techniques or other forms of

information technology.

dates: Consideration will be given to all comments received on or

before May 16, 1997.

addresses: Written comments and recommendations on the proposed

information collection should be sent to the Office of the Civilian

Health and Medical Program of the Uniformed Services (OCHAMPUS),

Fitzsimons U.S. Army Garrison, Program Development and Evaluation

Directorate, ATTN: Mr. Joe Rhea, Aurora, CO 80045-6900.

for further information contact: To request more information on this

proposed information collection or to obtain a copy of the proposal and

associated collection instruments, please write to the above address,

or call OCHAMPUS, Program Development and Evaluation Directorate, at

(303) 361-1018.

Title, Associated Form, and OMB Number: TRICARE/CHAMPUS Provider

Enrollment Application, HCFA-855, OMB Number 0938-0685.

Needs and Uses: This information is needed to enroll health care

providers not enrolled by Medicare by identifying them, verifying their

qualifications and eligibility to participate in TRICARE/CHAMPUS, and

to price and pay their claims correctly.

Affected Public: Business or other for-profit; small businesses

organizations, Federal Government.

Annual Burden Hours: 105,000.

Number of Respondents: 70,000.

Responses per Respondent: 1.

Average Burden per Response: 90 minutes.

Frequency: Initial Application.

supplementary information: Application is supported by photocopies of

licensure, certification, and educational qualifications documents on a

selected basis.

Summary of Information Collection

Respondents are health care providers who file claims seeking

reimbursement directly or on behalf of eligible TRICARE/CHAMPUS

beneficiaries for services and supplies which are authorized benefits

of this health care program. The enrollment application and

verification procedures will collect the information from providers

needed to ensure that they can be uniquely identified and enumerated,

and are qualified and eligible to participate in the TRICARE/CHAMPUS

program. The use of the HCFA-855 Provider Enrollment Form makes uniform

the information collection. Providers who have already been enrolled in

Medicare will be required only to sign and submit the Form's

certification statement and submit supplemental agreements for

facsimile signatures and electronic claims submission which may remain

specific and separate for Medicare and TRICARE/CHAMPUS. This

application will implement the enrollment application for all TRICARE/

CHAMPUS providers/suppliers, and collect information necessary to issue

the National Provider Identifier. The National Provider Identifier

(NPI) will be assigned to all current providers and to all incoming

providers as part of the enrollment process. Periodic Re-Verification

of Provider Data will ensure that, once enrolled, all providers/

suppliers remain current under the Conditions of Enrollment.

Dated: March 12, 1997.

Patricia L. Toppings,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

[FR Doc. 97-6645 Filed 3-14-97; 8:45 am]

BILLING CODE 5000-04-M