MEDICARE - INFORMATION ON PROVIDER REFUNDS

ICR 198906-0938-014

OMB: 0938-0383

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
166280 Migrated
ICR Details
0938-0383 198906-0938-014
Historical Active 198703-0938-004
HHS/CMS
MEDICARE - INFORMATION ON PROVIDER REFUNDS
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/16/1989
Approved with change 06/16/1989
Retrieve Notice of Action (NOA) 06/16/1989
  Inventory as of this Action Requested Previously Approved
04/30/1990 04/30/1990 04/30/1990
5,500 0 5,500
1,375 0 1,375
0 0 0

WHEN A MEDICARE CLAIM IS DENIED AND THEN PAID AS A RESULT OF A RECONSIDERATION, THERE IS A POSSIBILITY THA THE PROVIDER HAS ALREADY BEEN PAID BY THE BENEFICIARY. THESE QUESTION ON PROVIDER REFUNDS WILL BE USED ON INTERMEDIARY FORMS TO VERIFY THAT THE PROVIDER HAS REFUNDED THE BENEFICIARY'S MONEY.

None
None


No

1
IC Title Form No. Form Name
MEDICARE - INFORMATION ON PROVIDER REFUNDS HCFA-9049

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,500 5,500 0 0 0 0
Annual Time Burden (Hours) 1,375 1,375 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/16/1989


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