Information Collection

Medicare: Intermediary Request to Hospitals for Medical Information on Inpatient Claims for Statutorily Excluded Services -- SSA 1862; 42 CFR 411.15; 60 FR 181

IC 7890 under ICR 199611-0938-001 · OMB 0938-0224.

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Information Collection (IC) Details

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IC Title:

Medicare: Intermediary Request to Hospitals for Medical Information on Inpatient Claims for Statutorily Excluded Services -- SSA 1862; 42 CFR 411.15; 60 FR 181

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-9026				No	No

Federal Enterprise Architecture Business Reference Module

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,258

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
Annual Number of Responses for this IC	20,355	20,355
Annual IC Time Burden (Hours)	5,088	5,088
Annual IC Cost Burden (Dollars)	0	0

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