Request for Medicare Payment

ICR 202209-3220-003

OMB: 3220-0131

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2022-09-20
Supporting Statement B
2019-08-27
IC Document Collections
IC ID
Document
Title
Status
44217 Modified
ICR Details
3220-0131 202209-3220-003
Received in OIRA 201902-3220-005
RRB
Request for Medicare Payment
Extension without change of a currently approved collection   No
Regular 09/21/2022
  Requested Previously Approved
36 Months From Approved 09/30/2022
1 1
1 1
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

  87 FR 42218 07/14/2022
87 FR 57526 09/20/2022
No

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

  Total Request 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
No
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.
09/21/2022


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