Health Insurance Common Claims Formand Supporting Regulations: 42 CFR 414.40, 424.32, 424.44

ICR 200301-0938-008

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 200301-0938-008
Historical Active 200204-0938-007
HHS/CMS
Health Insurance Common Claims Formand Supporting Regulations: 42 CFR 414.40, 424.32, 424.44
Extension without change of a currently approved collection   No
Regular
Approved with change 03/10/2003
Retrieve Notice of Action (NOA) 01/06/2003
This information collection request is approved for an additional three years. However, OMB is not able to lower this collection's burden hours without additional information from the agency. If the agency believes that OMB's burden totals are in error, it must submit an 83-C with an explanation of how its estimate was derived.
  Inventory as of this Action Requested Previously Approved
05/31/2006 05/31/2006 03/31/2003
740,215,135 0 740,215,135
44,189,007 0 44,189,007
0 0 0

Medicare/Medicaid Reimbursement Claims. This form is a standardized form for use in the Medicare/Medicaid programs 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. CMS does not require exclusive use of this form for Medicaid.

None
None


No

1
IC Title Form No. Form Name
Health Insurance Common Claims Formand Supporting Regulations: 42 CFR 414.40, 424.32, 424.44 CMS-1490S, CMS-1490U, 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 740,215,135 740,215,135 0 0 0 0
Annual Time Burden (Hours) 44,189,007 44,189,007 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.
01/06/2003


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