Response to Terms of Clearance

February 16, 2007

NOTE TO: Martique S. Jones

Director, Division of Regulation Developlment-B

SUBJECT: Requesting OMB Re-Approval for CMS-460 Form (OMB #0938-0373)

Attached is the electronic package that my staff has put together to request OMB approval of the CMS-460 form. In June 2006, OMB approved the form for one year with the stipulation that CMS would provide a web-based form that can be filled out and submitted electronically (including the electronic signature functionality). The form is set to expire in October 2007.

In order to meet the terms of clearance requested by OMB, we have taken the necessary action to make the form interactive on the CMS Web site and on the CD that is mailed to all physicians each November. Physicians can complete the form (except for a signature) via the internet or CD. However, since CMS does not yet have a policy in place for E-signature, physicians will have to print the completed form and sign it before mailing to the local carrier.

The electronic package is being sent to you for OSORA’s necessary action to begin the clearance process for obtaining OMB approval of the CMS-460 form for an additional 3 years. We will be doing another mass mailing of CDs to all physicians this coming November and we need to get OMB approval for the CMS-460 in time to be able to include the interactive form on the CD. Without approval of this form, physicians will not have the appropriate form to use to change their non-participation status during the participation open enrollment period which runs each November 15 through December 31.

Questions on the electronic package can be directed to Melvia Page-Lasowski of my staff on 6427 or Patricia gill on 61297.

Susan Myers

Director

Division of Practitioner Claims Processing

OMB Terms of Clearance for CMS-460—(OMB#0938-0373)

OMB approved the CMS-460 form for one year until October 2007 with the following terms of clearance:

Prior to resubmission, the agency will provide a web-based form that can

be filled out and submitted electronically (including the electronic signature functionality).

We have partially complied with the above terms as the CMS-460 is an interactive form that can be completed on line (except for signing). The form is available on the CMS Web site. An interactive version of the CMS-460 is also on the CD-ROM that is mailed to all physicians each November as part of the participation enrollment period. Carriers conduct an open enrollment period from November 15 until December 31 to give physicians the opportunity to make any changes in their participation status. In order to do this, Medicare carriers perform a mass mailing of CDs to all physicians in early November. The CD contains a variety of educational information on the Medicare program in addition to an interactive CMS-460 form that physicians can complete if they choose to become participating.

We cannot at this time require physicians to electronically sign the CMS-460 and submit it electronically as the Department of HHS and CMS has not yet established a policy on electronic signature, and, therefore, CMS does not have the ability to accept electronic signatures. Until a CMS policy is in place, physicians will be able to complete the form on line but must download and sign the form before submitting it to their local carrier.

Questions can be directed to: Patricia Gill, 410-786-1297

Technical Advisor

CMS/CMM/PGB/DPCP