Medicare/Medicaid Health Insurance Common Claim Form and Instructions

ICR 199505-0938-003

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 199505-0938-003
Historical Active 199407-0938-002
HHS/CMS
Medicare/Medicaid Health Insurance Common Claim Form and Instructions
Revision of a currently approved collection   No
Regular
Approved without change 06/30/1995
Retrieve Notice of Action (NOA) 05/10/1995
Approved for use through 9/96 pursuant to the attached conditions dated 6/30/95.
  Inventory as of this Action Requested Previously Approved
09/30/1996 09/30/1996 06/30/1995
614,967,982 0 0
52,139,385 0 73,325,195
0 0 0

This form will become a stanardized form for use in the Medicare/Medicaid programs to apply for reimbursement for covered services. In addition, it will reduce costs and administrative burdens associated with claims since only one coding system will be used and maintained. HCFA does not require 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-1490U, HCFA-1490S

  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 614,967,982 0 0 0 614,967,982 0
Annual Time Burden (Hours) 52,139,385 73,325,195 0 0 -21,185,810 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
05/10/1995


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