Request for Medicare Payment

ICR 201902-3220-005

OMB: 3220-0131

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement B
2019-08-27
Supplementary Document
2019-04-30
Supporting Statement A
2019-08-27
IC Document Collections
IC ID
Document
Title
Status
44217 Modified
ICR Details
3220-0131 201902-3220-005
Active 201603-3220-007
RRB
Request for Medicare Payment
Revision of a currently approved collection   No
Regular
Approved with change 09/03/2019
Retrieve Notice of Action (NOA) 04/30/2019
Upon resubmission RRB should either calculate the burden or coordinate with CMS to integrate the form into CMS’ collection.
  Inventory as of this Action Requested Previously Approved
09/30/2022 06/30/2019 08/31/2019
1 0 1
1 0 1
0 0 0

The Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the Railroad Retirement System. The collection obtains the information needed by Palmetto GBA, the RRB's carrier, to pay claims for services covered under Part B of the program.

US Code: 45 USC 231f(d) Name of Law: Railroad Retirement Act
  
None

Not associated with rulemaking

  84 FR 5734 02/22/2019
84 FR 18097 04/29/2019
No

1
IC Title Form No. Form Name
Request for Medicare Payment G-740S (03-13), G-740S (06-18), CMS-1500 (02-12) Patient's Request for Medicare Payment ,   Patient's Request for Medicare Payment ,   Health Insurance Claim Form

  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 1 1 0 0 0 0
Annual Time Burden (Hours) 1 1 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
    Yes
    Yes
No
No
No
Uncollected
Brian Foster 312 751-4826 [email protected]

  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.
04/30/2019


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