Approved for use through 12/2002 under the condition that the next submission for OMB review reflects implementation of HIPAA, and the burden estimate is adjusted accordingly. In addition, no later than 8/2002, CMS must submit to OMB a correction work sheet reflecting the requested burden reduction due to increased electronic transmission and a more detailed explanation of the data and underlying assumptions behind this burden reduction estimate.
Inventory as of this Action
Requested
Previously Approved
12/31/2002
12/31/2002
06/30/2002
740,215,135
0
714,391,083
44,189,007
0
44,189,007
0
0
0
This form is a standardized claim form for use in the Medicare/Medicaid programs to apply for reimbursement for covered services. Many private insuers also use this form. Use of this form reduces costa nd administrative burdens associated with professional claims because only one format need be used and maintained. CMS does not require exclusive use of this form for Medicaid.
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.
Medicare/Medicaid Health Insurance Common Claim Form, Instructions, and Supporting Regulations: 42 CFR 414.40, 424.32, 424.44