Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C

Forms and Documents

Document Name	Status
Form CMS-1500(08-05) Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C Form and Instruction	Modified
CMS-1500(08-05).Record of Information Clearances.docx Supplementary Document	2012-11-27
CMS-1500(0805)_Supporting_Statement_Part_A.pdf Supporting Statement A	2012-11-27

IC Document Collections

IC ID	Document Title	Status
8856	Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0999	ICR Reference No: 201211-0938-010
Status: Historical Active	Previous ICR Reference No: 200706-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C
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 without change	Conclusion Date: 05/15/2013
	Date Received in OIRA: 11/28/2012
Terms of Clearance: CMS will report this violation in the ICB in 2013.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	988,005,045	0	0
Time Burden (Hours)	21,481,336	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form is a standardized claim form foruse in the Medicare/ Medicaid programs to apply for reimbursement for covered services Many private insurers also use this form. Use of this form reduces cost and administrative burdens associated with professional claims because only one format need be used and maintained.

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Authorizing Statute(s): US Code: 42 USC 1395x Name of Law: DEFINITIONS OF SERVICES, INSTITUTIONS, ETC
   US Code: 42 USC 1395k Name of Law: SCOPE OF BENEFITS
   US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
  

Citations for New Statutory Requirements: None

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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:
	77 FR 31615	05/29/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 58558	09/21/2012
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424 Subpart C	CMS-1500(08-05), CMS-1490-S	Health Insurance Claim Form ,   PATIENT'S REQUEST FOR MEDICAL PAYMENT

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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	988,005,045	0	0	0	17,830,785	970,174,260
Annual Time Burden (Hours)	21,481,336	0	0	0	-11,586,421	33,067,757
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:

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Annual Cost to Federal Government: $3,514,000,000

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: 11/28/2012

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