Information Collection

Request For Medical Review Of Part B Intermediary Outpatient Therapy Claims

IC 113181 under ICR 199211-0938-007 · OMB 0938-0227.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0227 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FOR MEDICAL REVIEW OF PART B INTERMEDIARY OUTPATIENT THERAPY CLAIMS

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA 700				No	No
Form	701 & 702				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 33,630

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,100,000	1,650,000	450,000
Annual IC Time Burden (Hours)	2,437,415	2,324,915	112,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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