[Federal Register: December 3, 1999 (Volume 64, Number 232)]
[Notices]               
[Page 67919]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr03de99-97]                         

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[Document Identifier: HCFA-1964]

 
Agency Information Collection Activities: Submission For OMB 
Review; Comment Request

    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, has 
submitted to the Office of Management and Budget (OMB) the following 
proposal for the collection of information. Interested persons are 
invited to send comments regarding the 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 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 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 30 days of this notice directly to the OMB Desk Officer 
designated at the following address:

OMB Human Resources and Housing Branch, Attention: Allison Eydt, New 
Executive Office Building, Room 10235, Washington, D.C. 20503.

    Dated: November 16, 1999.
John Parmigiani,
Manager, HCFA, Office of Information Services, Security and Standards 
Group, Division of HCFA Enterprise Standards.
[FR Doc. 99-31324 Filed 12-2-99; 8:45 am]
BILLING CODE 4120-03-P