HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS

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
112482	HEALTH INSURANCE COMMON CLAIMS FORM AND INSTRUCTIONS Form	Migrated

ICR Details

OMB Control No: 0938-0008	ICR Reference No: 199109-0938-006
Status: Historical Active	Previous ICR Reference No: 199108-0938-002
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: Approved without change	Conclusion Date: 12/26/1991
	Date Received in OIRA: 09/30/1991
Terms of Clearance: Approved for use through 6/93 under the following conditions: HCFA provides an analysis of the cost of revising the form to display OMB numbers for HCFA, Labor and Defense for immediate use. If the cost analysis demonstrates extreme hardship for HCFA and the regulated industry the next HCFA-1500 submission will: 1) Incorporate OMB Nos. for the Department of Labor and the Department of Defense. These OMB Nos. will be displayed in the top right hand corner of the Form, below the HCFA OMB Control No.; and 2) Amend the burden disclosure statement on the back of the Form so that it only states the average burden per response for all agencie and directs public comments to an agency address contained in agency- specific instructions. Most important, the primary purpose of the standard HCFA-1500 is to reduce administrative burden on providers, suppliers, et.al.. It may become apparent in implementation, however, that the costs of standardizing the systems of States, contractors, and private insurers may exceed these provider administrative savings. OMB encourages participating agencies to closely monitor implementation of the Form and public comment over the next year and to critically reevaluate the cost effectiveness of this standardization approach prior to resubmission for OMB review.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/1993	06/30/1993	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

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Abstract: THIS FORM WILL BECOME A STANDARDIZED FORM FOR USE IN MEDICARE AND 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.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

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

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ICR Summary of Burden

	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	455,826,100	455,826,100	0	0	0	0
Annual Time Burden (Hours)	74,497,169	74,497,169	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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:

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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

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Common Form ICR:  No

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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: 09/30/1991

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