Request for Medicare Payment

ICR 200208-3220-001

OMB: 3220-0131

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
33922 Migrated
ICR Details
3220-0131 200208-3220-001
Historical Active 199906-3220-002
RRB
Request for Medicare Payment
Extension without change of a currently approved collection   No
Regular
Approved without change 10/15/2002
Retrieve Notice of Action (NOA) 08/15/2002
Approved for use through 10/2003 under the condition that the next submission for OMB review reports on RRB's compliance with the HIPAA transaction regulations.
  Inventory as of this Action Requested Previously Approved
10/31/2003 10/31/2003 11/30/2002
1 0 1
1 0 1
0 0 0

The Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the Railroad Retirement System. The collection obtains the information needed by Palmetto GBA, the RRB's carrier, to pay claims for services covered under Part B of the program.

None
None


No

1
IC Title Form No. Form Name
Request for Medicare Payment G-740S, CMS-1500

  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 1 1 0 0 0 0
Annual Time Burden (Hours) 1 1 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.
08/15/2002


© 2024 OMB.report | Privacy Policy