Approved for use
through 6/93 under the following conditions. CHAMPUS will work with
HCFA to determine the feasibility of revising the form immediately
to display OMB control numbers assigned to HCFA, DOD and Labor.
CHAMPUS will work with the other agencies to assure that the next
requests for OMB approval indicate placement of all applicable OMB
control numbers, that the burden disclosure notice indicates
average burden per response for all agencies and directs public
comments to an agency address to be contained within the
agency-specific instructions. The primary purpose of this form is
to reduce administrative burden on providers, suppliers, et. al. It
may become apparent in implementation that the costs of
standardizing the systems of states, contractors, and private
insurers may exceed these administrative savings. OMB encourages
all 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 continued OMB approval.
Inventory as of this Action
Requested
Previously Approved
06/30/1993
06/30/1993
12/31/1991
6,500,000
0
6,500,000
1,625,000
0
3,250,000
0
0
0
THE HCFA 1500 IS A NATIONAL STANDARD
CLAIM FORM APPROVED BY CHAMPUS FOR INDIVIDUAL HEALTH CARE PROVIDERS
AND SUPPLIERS TO FILE FOR REIMBURSEMENT FOR SERVICES OR SUPPLIES
PROVIDED TO CHAMPUS OR CHAMPVA BENEFICIARIES. THE REQUESTED
INFORMATION IS USED TO DETERMINE ELIGIBILITY, APPROPRIATENESS, AND
COST OF CARE AND WHETHER SERVICES RECEIVED ARE BENEFITS.
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.