3220-0131

OMB NO. 3220-0131

Justification

Request for Medicare Payment

RRB Form G-740S and CMS-1500

1. Circumstances of information collection - Under Section 7(d) of the Railroad Retirement Act, the Railroad Retirement Board (RRB) (45 U.S.C. 231f) administers the Medicare program for persons covered by the railroad retirement system. This collection obtains the information needed by Palmetto GBA, the Medicare carrier for railroad retirement beneficiaries, to pay claims for payments due under Part B of the Medicare program. Authority for collecting the information is 42 CFR 424.32.

2. Purposes of collecting/consequences of not collecting the information – This collection is required in order for RRB beneficiaries and medical providers to transmit the necessary claims to the Medicare carrier, Palmetto GBA. The forms furnished by the RRB and Palmetto GBA for claiming Medicare payments follow.

Form CMS-1500, Health Insurance Claim Form, is the common claim form from CMS (Centers for Medicare & Medicaid Services) that is used by physicians and suppliers for claiming payment for medical and related services furnished to railroad retirement beneficiaries under Medicare (Part B), Medicaid, and other medical insurance programs.

CMS regulation 42 CFR 424.32 requires that most Forms CMS-1500 be submitted electronically. However, physicians and suppliers keep a quantity of paper Forms CMS-1500 on hand for those claims that fall under the exceptions to that requirement. The physicians and suppliers obtain the forms from the Government Printing Office, the American Medical Association, or https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1500.pdf.

Form CMS-1500 is designed for self-completion. The completed form is forwarded by the physician or supplier to Palmetto GBA for processing.

Form G-740S, Patient's Request for Medicare Payment, is used by railroad retirement beneficiaries to apply for reimbursement of payments made for medical services under Part B of the Medicare program.

Form G-740S is obtained from Palmetto GBA or an RRB field office and is designed for self-completion. The completed form is then forwarded by the beneficiary to Palmetto GBA for processing.

The responsible doctors, suppliers, and other Medicare providers are required to submit Medicare claims using Form CMS-1500 for the medical services that they provide to railroad retirement beneficiaries. However, beneficiaries can use Form G-740S in those situations where, for whatever reason, the provider fails to submit a Form CMS-1500 on their behalf.

The RRB proposes no changes to Form G‑740S.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – Due to agency technology limitations, this information collection does not allow for electronic submission of Form G-740S as described in the Government Paperwork Elimination Act (GPEA). However, we will reevaluate electronic signatures after the completion of our IT Modernization project.

4. Efforts to identify duplication and other improvements - The format and use of Form G-740S is the same as its counterpart, Form CMS-1490S (OMB Control Number 0938-1202). Although railroad retirement beneficiaries can use either Form G-740S or CMS-1490S, Form G-740S is specific for railroad retirement beneficiaries, as it contains the name and address of the sole RRB Medicare contractor to whom claims are to be submitted Form CMS-1490S contains a table of listing of contractors by states, which could be misleading to railroad retirement beneficiaries.

5. Small business respondents - Respondents can be small businesses. However, participation is voluntary and to the extent determined by the employer.

6. Consequences of less frequent collections - Not applicable since the information is solicited only once for each claim filed.

7. Special circumstances - N.A.

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 42218, of the July 14, 2022, Federal Register. No requests for further information or comments were received. Coordination with CMS representatives is an on-going activity.

9. Payments or gifts to respondents - N.A.

10. Confidentiality - Privacy Act System of Records, RRB-3, Medicare: Part B. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The RRB uses the information obtained by Forms G‑740S and CMS-1500 solely to carry out the requirements of the Centers for Medicare & Medicaid Services (CMS) in the administration of the Medicare program for persons covered by the railroad retirement system. Therefore, the only part of the burden the RRB assumes under its public information collection is a token burden of 1 hour, the burden, in substance, being imposed by CMS. This token 1 hour burden was suggested by OMB originally.

In April 1992, OMB conditioned its approval on the RRB coordinating with CMS to ensure that the burden is being accounted for HCFA-1500 under HHS OMB Control Number 0938-0008, since the RRB claims a token burden of only 1 hour for its overall submission.

Monthly, Palmetto GBA submits an electronic workload report which it sends to CMS. This report provides statistical information regarding the RRB’s claims processing activity and provides CMS with the data necessary to compute the average number of annual responses. A copy of a recent report is included.

13. Estimate of annual cost burden to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for changes in burden - N.A.

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The RRB started an extensive multi-year IT Modernization Initiative at the beginning of Fiscal Year 2019 to transform our operations into the 21^st Century using multiple contractor services to improve mission performance, expand service capabilities, and strengthen cybersecurity. We provided OMB with a consolidated project timeline.

Given that the forms in this collection are seldom revised; the costs associated with redrafting, reprinting, and distributing forms in order to keep the appropriate OMB expiration date in place; and our desire to reevaluate after the completion of the modernization project, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to the certification statement - None

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