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Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
OMB: 0938-0997
IC ID: 43681
OMB.report
HHS/CMS
OMB 0938-0997
ICR 200701-0938-014
IC 43681
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0997 can be found here:
2024-01-02 - RCF Recertification
2023-06-07 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-1450 (UB-04)
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
Form
CMS-1450 (UB-04).Reverse Side-CLEAN DRAFT.doc
Instruction
CMS-1450 (UB-04) Medicare Uniform Institutional Provider Bill
CMS-1450. UB-04 (2006).pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 424.5
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
CMS-1450 (UB-04)
Medicare Uniform Institutional Provider Bill
CMS-1450. UB-04 (2006).pdf
Yes
No
Fillable Fileable
Instruction
CMS-1450 (UB-04).Reverse Side-CLEAN DRAFT.doc
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
53,111
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
99 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
179,489,687
0
-34
0
0
179,489,721
Annual IC Time Burden (Hours)
0
0
-308,237
0
0
308,237
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.