MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS

ICR 199309-0938-001

OMB: 0938-0008

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0008 199309-0938-001
Historical Active 199109-0938-006
HHS/CMS
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 11/05/1993
Retrieve Notice of Action (NOA) 09/08/1993
Approved for use through 9/94. Previous terms of clearance still appl Consistent with Health Care Reform initiatives, HCFA should work with Federal "user agencies" to develop and implement standardized forms, instructions, and standardized electronic submissions.
  Inventory as of this Action Requested Previously Approved
09/30/1994 09/30/1994
546,115,406 0 0
73,325,195 0 0
0 0 0

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. HCFA DOES NOT REQUIRED EXCLUSIVE USE OF THIS FORM FOR MEDICAID.

None
None


No

1
IC Title Form No. Form Name
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS HCFA-1500, HCFA-1490S, HCFA-1490U

  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 546,115,406 0 0 546,115,406 0 0
Annual Time Burden (Hours) 73,325,195 0 0 73,325,195 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
09/08/1993


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