Information Collection

Medicare - Intermediary Request To Skilled Nursing Facilities For Medical Information On Claims To Be Processed

IC 113160 under ICR 198803-0938-003 · OMB 0938-0223.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0223 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	MEDICARE - INTERMEDIARY REQUEST TO SKILLED NURSING FACILITIES FOR MEDICAL INFORMATION ON CLAIMS TO BE PROCESSED	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA 9031				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,381	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,381	4,281	3,100
Annual IC Time Burden (Hours)	172,663	155,997	16,666
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.