Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 (CMS-1450)

Forms and Documents

Document Name	Status
Form CMS-1450 (UB04) Fr Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 Form and Instruction	Modified
Supporting Statement - Part A UB04 - Clean 2 7-21-2020v2.docx Supporting Statement A	2020-07-23

IC Document Collections

IC ID	Document Title	Status
43681	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0997	ICR Reference No: 202007-0938-008
Status: Active	Previous ICR Reference No: 201907-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: OIT
Title: Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 (CMS-1450)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/04/2020
	Date Received in OIRA: 07/27/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023	36 Months From Approved	07/31/2021
Responses	214,660,298	0	214,660,298
Time Burden (Hours)	1,797,958	0	1,797,958
Cost Burden (Dollars)	0	0	0

---

Abstract: This standardized form is used in the Medicare/Medicaid program to apply for reimbursement of covered services by all providers that accept Medicare/Medicaid assigned claims and that do not bill Medicare and Medicaid electronically.

---

Authorizing Statute(s): US Code: 42 USC 1395d Name of Law: Scope of benefits
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 15618	04/16/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 34895	07/19/2019
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	CMS-1450 (UB04) Front, CMS-1450 (UB04) Back	Uniform Institutional Providers Form ,   Uniform Institutional Providers Form

---

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	214,660,298	214,660,298	0	0	0	0
Annual Time Burden (Hours)	1,797,958	1,797,958	0	0	0	0
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:

---

Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage:  The form has not changed for CMS' purposes. It is being resubmitted for use as a common form at the request of the Department of Defense.

Approved RCFs using this ICR

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title
DOD/DODOASHA	202008-0720-002CF	Health Insurance Claims Form, UB-04 CMS 1450	Active	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

---

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: 07/27/2020

---