Health Insurance Claims Form, UB-04 CMS 1450

Forms and Documents

Document Name	Status
Form CMS-1450 UB-04 For Health Insurance Claims Form, UB-04 CMS 1450 Form	Modified
CFR-2011-title32-vol2-sec199-14.pdf Supplementary Document	2017-05-12
CFR-2011-title32-vol2-sec199-7.pdf Supplementary Document	2017-05-12
OMB Supporting Statement Part A_0720-0013.doc Supporting Statement A	2017-05-12

IC Document Collections

IC ID	Document Title	Status
5581	Health Insurance Claims Form, UB-04 CMS 1450 Form	Modified

ICR Details

OMB Control No: 0720-0013	ICR Reference No: 201705-0720-002
Status: Historical Active	Previous ICR Reference No: 201201-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Health Insurance Claims Form, UB-04 CMS 1450
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/14/2017
	Date Received in OIRA: 05/12/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	858,881	0	0
Time Burden (Hours)	41,884	0	0
Cost Burden (Dollars)	715,632	0	0

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Abstract: This information collection requirement is necessary for a medical institution to claim benefit under the Defense Health Agency, TRICARE, which includes the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The information collected will be used by CHAMPUS/TRICARE contractors to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary received the care and that the provider is authorized to receive CHAMPUS/TRICARE payments.

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Authorizing Statute(s): US Code: 10 USC chapter 55 Name of Law: null
  

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:
	81 FR 32736	05/24/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 22127	05/12/2017
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 Claims Form, UB-04 CMS 1450	CMS-1450 UB-04 Form	Health Insurance Claim Form

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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	858,881	0	0	-20,241,119	0	21,100,000
Annual Time Burden (Hours)	41,884	0	0	-483,116	0	525,000
Annual Cost Burden (Dollars)	715,632	0	0	-177,368	0	893,000

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The data sources used to calculate the number of respondents and the number of responses has changed from the prior submission and therefore there is a significant change in burden. The total number of respondents (hospital institutions) utilizing the form increased from 7,836 to 10,318. The total number of responses has decreased from 2,100,000 to 858,881. In the previous approval, a typo was made and the total number of responses appears as 21,100,000 instead of 2,100,000. The total annual hours requested has decreased from 525,000 to 41,884.

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Annual Cost to Federal Government: $796,050

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: 05/12/2017

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