Health Insurance Claim Form

Forms and Documents

Document	Type	Status	Availability
Form CMS 1500 Health Insurance Claim Form	Form and Instruction	Modified	Repair queued
CMS 1500 Supporting Statement.doc	Supporting Statement A	Uploaded 2012-08-02	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
5564	Health Insurance Claim Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0720-0001	ICR Reference No: 201207-0720-001
Status: Historical Active	Previous ICR Reference No: 200709-0720-003
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Health Insurance Claim Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/31/2012
	Date Received in OIRA: 07/05/2012
Terms of Clearance: Approved consistent with the following terms of clearance: the DoD shall take care in future submissions to submit requests for extensions in a timely manner in order to avoid violating the Paperwork Reduction Act.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved
Responses	86,000,000	0	0
Time Burden (Hours)	14,333,333	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS 1500 is a national standard claim form approved by TRICARE for individuals health care providers and suppliers of file for reimbursemment for services or supplies provided to TRICARE/CHAMPUS beneficiaries. The requested information is used to determine eligibility, appropriateness and cost of care and whether services are benefits.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: PL: Pub.L. 112 - 81 9999 Name of Law: National Defense Authorization Acts

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 81241	12/27/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25709	05/01/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Health Insurance Claim Form	CMS 1500	Health Insurance Claim From

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ICR Summary of Burden

	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	86,000,000	0	62,000,000	0	0	24,000,000
Annual Time Burden (Hours)	14,333,333	0	8,333,333	0	0	6,000,000
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Increase in number of respondents. Reduced time to respond to 10 minutes. Failure to extend collection in a timely manner, so collection went into violation.

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Annual Cost to Federal Government: $112,884,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/05/2012

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