Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))

Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
CMS-18F5 Interview/SSA Claim System Consolidated Claim Experience (CCE)- Medicare Claim Intake Screen Package_V 3.0.pdf Form and Instruction
CMS-18F5 Interview/SSA Claim System Consolidated Claim Experience (CCE)- Medicare Claim Intake Screen Package_V 3.0.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-18F5	Interview/SSA Claim System	Consolidated Claim Experience (CCE)- Medicare Claim Intake Screen Package_V 3.0.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 515,015	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	515,015	515,015
Annual IC Time Burden (Hours)	85,853	85,853
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.