MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS

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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
112484	MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS	Form	Migrated

ICR Details

OMB Control No: 0938-0008	ICR Reference No: 199407-0938-002
Status: Historical Active	Previous ICR Reference No: 199309-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM 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: 09/30/1994
	Date Received in OIRA: 07/14/1994
Terms of Clearance: The HCFA-1500 is extended exactly as is through 3/95 with the followin remarks. OMB recognizes that this is a limited extension but believes that HCFA and PHS need this extension period to compile and present mo evidence that collection of E-codes on the HCFA-1500 will produce information that is statistically valid for public health research and policy purposes. This action does not question the coding structure or content. It instead investigates the claim as a vehicle for certai voluntary coding uses. OMB agrees with the Departments' assessment of the policy relevance of E-code data for health research/prevention pur poses. HCFA's supporting statement and the Department's subsequent responses to public comment, however, fail to address how the collection of these data on the HCFA-1500 claim form is an appropriate means of collecting such data while ensuring that it is statistically valid and that future analysis would be based upon a generalizable, representative sample of patients with certain conditions. OMB believes that this particular case is a compelling example of dissonance between statistical objectives and the limitatio of administrative systems. Because OMB supports the Department's research objectives, it recommends that PHS and HCFA staff meet with OMB in the near future in order to delineate the types of supporting analysis and rationales that would be necessary for resubmission pursuant to the Paperwork Reduction Act.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/1995	03/31/1995	09/30/1994
Responses	546,115,406	0	546,115,406
Time Burden (Hours)	73,325,195	0	73,325,195
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. HCFA DOES NOT REQUIRE EXCLUSIVE USE OF THIS FORM FOR MEDICAID.

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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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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	546,115,406	546,115,406	0	0	0	0
Annual Time Burden (Hours)	73,325,195	73,325,195	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: 07/14/1994

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