Medicare/Medicaid Health Insurance Common Claim Form, Instructions, and Supporting Regulations -- 42 CFR 424.32 and 42 CFR 414.40

ICR 199708-0938-005

OMB: 0938-0008

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0008 199708-0938-005
Historical Active 199701-0938-005
HHS/CMS
Medicare/Medicaid Health Insurance Common Claim Form, Instructions, and Supporting Regulations -- 42 CFR 424.32 and 42 CFR 414.40
Extension without change of a currently approved collection   No
Emergency 09/01/1997
Approved without change 08/27/1997
Retrieve Notice of Action (NOA) 08/20/1997
Approved for use through 2/98 pursuant to the attached conditions dated 6/30/95.
  Inventory as of this Action Requested Previously Approved
02/28/1998 02/28/1998 08/31/1997
644,802,413 0 644,802,423
46,797,008 0 46,797,008
0 0 0

This form is a standardized form for use in the Medicare/Medicaid programs and to apply for reimbursement for covered services. In addition, it reduces cost and administrative burdens associated with claims, since only one coding system is 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, Instructions, and Supporting Regulations -- 42 CFR 424.32 and 42 CFR 414.40 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 644,802,413 644,802,423 0 -10 0 0
Annual Time Burden (Hours) 46,797,008 46,797,008 0 0 0 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.
08/20/1997


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