Health Insurance Claims Form, UB-04 CMS 1450

Forms and Documents

Document	Type	Status	Availability
Form CMS-1450 (UB04) Fr Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	Form and Instruction	New	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
243027	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	Form and Instruction	New

ICR Details

OMB Control No: 0938-0997	ICR Reference No: 202008-0720-002CF
Status: Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Health Insurance Claims Form, UB-04 CMS 1450
Type of Information Collection: RCF New	Common Form ICR:
Type of Review Request:
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/28/2020
	Date Received in OIRA: 08/28/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2023
Responses	858,881	0	0
Time Burden (Hours)	7,194	0	0
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): US Code: 10 USC 55 Name of Law: Medical and Dental Care
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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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

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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	858,881	0	0
Annual Time Burden (Hours)	7,194	0	0	7,194	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The Department of Defense, Defense Health Agency previously cleared public burden for form UB-04 CMS 1450 under 0720-0013. The form has been designated as a common form by HHS (CMS) allowing DHA to clear public burden under 0938-0997.

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Annual Cost to Federal Government: $796,050

Does this IC contain surveys, censuses, or employ statistical methods?

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.    

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.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR: 

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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:

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