HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
112481	HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS	Form	Migrated

ICR Details

OMB Control No: 0938-0008	ICR Reference No: 199108-0938-002
Status: Historical Inactive	Previous ICR Reference No: 199009-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 09/12/1991
	Date Received in OIRA: 08/29/1991
Terms of Clearance: Withdrawn pursuant to the request of the Department of Health and Human Services' Office of the Secretary.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1991	12/31/1991	12/31/1991
Responses	455,826,100	0	455,826,100
Time Burden (Hours)	74,497,169	0	74,497,169
Cost Burden (Dollars)	0	0	0

---

Abstract: THIS FORM WILL BECOME A STANDARDIZED FORM FOR USE IN THE MEDICARE MEDICAID PROGRAMS TO APPLY FOR REIMBURSEMENT FOR COVERED SERVICES. IN ADDITION, IT WILL REDUCE COSTS AND ADMINISTRATION BURDENS ASSOCIATED WITH CLAIMS SINCE ONLY ONE CODING SYSTEM WOULD BE USED AND MAINTAINED.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS	HCFA-1500, HCFA-1490S, HCFA-1490U

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/29/1991

---