Supporting Statement – Part A
Supporting Regulations Contained in 42 CFR 424.5 for the Uniform Institutional Providers Form
(CMS-1450 (UB-04); OMB-0938-0997)
All paper claims processed by Part-A Medicare Administrative Contractors (MACs) must be submitted on the UB-04 CMS-1450 after May 23, 2007. Data fields in the X12 837 data set are consistent with the UB-04 CMS-1450 data set. The Centers for Medicare and Medicaid Services (CMS) is requesting an OMB extension request with no changes to the currently approved collection for an additional three years.
The basic authorities which allow providers of service to bill for services on behalf of the beneficiary are section 1812 (42 USC 1395d - http://www.gpo.gov/fdsys/granule/USCODE-2009title42/USCODE-2009-title42-chap7-subchapXVIII-partA-sec1395d) (a) (1), (2), (3), (4) and 1833 (2) (B) of the Social Security Act). Also, section 1835 (42 USC 1395n) requires that payment for services furnished to an individual may be made to providers of services only when a written request for payment is filed in such form as the Secretary may prescribe by regulations. Section 42 CFR 424.5(a)(5) requires providers of services to submit a claim for payment prior to any Medicare reimbursement. Charges billed are coded by revenue codes. The bill specifies diagnoses according to the International Classification of Diseases, Tenth Edition (ICD-10) code. Inpatient procedures are identified by ICD-10 codes, and outpatient procedures are described using the CMS Common Procedure Coding System (HCPCS). These are standard systems of identification for all major health insurance claims payers. Submission of information on the UB-04 CMS-1450 permits Medicare Part A MACs to receive consistent data for proper payment.
The UB-04 CMS-1450 is managed by the National Uniform Billing Committee (NUBC), sponsored by the American Hospital Association. Most payers are represented on this body, and the UB-04 is widely used in the industry. Medicare receives 99.97 percent of the Part A claims submitted by institutional providers electronically. Because of the number of small and rural providers who do not submit claims electronically, it is not possible to achieve total electronic submission at this time. Medicare Part A MACs use the information on the UB-04 CMS-1450 to determine whether to make Medicare payment for the services provided, the payment amount, and whether or not to apply deductibles to the claim. The same method is also used by other payers. CMS is also a secondary user of data. CMS uses the information to develop a database, which is used to update, and revise established payment schedules and other payment rates for covered services. CMS also uses the information to conduct studies and reports.
Medicare receives over 99.98 percent of the claims submitted by institutional providers
electronically. CMS only accepts electronic claims in the Accredited Standards Committee (ASC) Health Insurance Portability and Accountability Act (HIPAA) 837 format for institutional providers unless the provider meets CMS requirements to submit paper claims. With the uniform bill, we have been able to achieve a more uniform and a more automated bill processing system for Medicare institutional and providers. This form is consistent with the CMS electronic billing specifications, i.e., all coding data element specifications are identical. This has promoted and eased the conversion to electronic billing. Provider billing costs have decreased as a result of standardization of bill preparation, related training and other activities.
Is this collection currently available for completion electronically? Yes. Medicare receives over 99.98 percent of the claims submitted by institutional providers electronically. - Does this collection require a signature from the respondent(s)? No.
If CMS had the capability of accepting electronic signature(s), could this collection be made available electronically? N/A.
If this collection is not currently electronic but will be made electronic in the future, please give a date (month & year) as to when this will be available electronically and explain why it cannot be done sooner. N/A.
If this collection cannot be made electronic or if it is not cost beneficial to make it electronic, please explain. N/A.
Most hospitals participate in both Medicare and many other insurance programs and, without use of the UB-04 CMS-1450, would have to maintain distinct and duplicate billing systems to handle the billing form, and the diagnostic coding systems for the many programs. The purpose of the requirements in this package is to eliminate this duplication. There is no one form that can accommodate as much information as the UB-04 CMS-1450 does; nor is there another that can handle a variety of services the way the uniform bill does. The UB-04 CMS-1450 is managed by the National Uniform Billing Committee, a standard’s body sponsored by the American Hospital Association.
Burden can be minimized by providing training materials and by obtaining assistance from the uniform bill coordinator designated by each CMS regional office.
There will always be a very small percentage of institutional providers that need to submit paper claims to Medicare for reimbursement of services rendered to patients who are covered under the Medicare Program. Therefore, the form must continue to be available for use. Form usage has declined significantly since the last collection.
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study,
Use a statistical data classification that has not been reviewed and approved by OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
8. Federal Register/Outside Consultation
The 60-day Federal Register Notice published in the Federal Register on 3/14/2023 (88 FR 15726).
No comments received
The 30-day Federal Register Notice published in the Federal Register on TBD (88 FR).
The UB-04 CMS-1450 must be used to receive payment for the provision of the institutional health care claims. The use of the form itself does not convey payments or gifts to respondents; many conditions must be met before payment can be made.
Privacy Act requirements have already been addressed under a Notice Systems of Record entitled "Intermediary Medicare Claims Record" system number 09-70-0503, DHHS/CMS/OIS. Note that OIS has been renamed to the Office of Information Technology (OIT).
11. Sensitive Questions
No questions of a sensitive nature are asked.
To derive average costs, we used data from the U.S. Bureau of Labor Statistics’ May 2021
National Occupational Employment and Wage Estimates for all salary estimates
(www.bls.gov/oes/current/oes_nat.htm). In this regard, the following table presents the mean hourly wage, a 100% increase to account for fringe benefits, and the adjusted hourly wage.
Occupation Title |
Occupation Code |
Mean Hourly Wage ($/hour) |
Fringe Benefit ($/hour) |
Adjusted Hourly Wage ($/hour) |
Office Clerks |
43-9061 |
$18.75 |
$18.75 |
$37.50 |
2022 Institutional Claim Data pulled from the MAC/CMS Data Exchange (MDX) Portal.
Estimated Annual Burden Hours
2022 Institutional Claim Data |
Total number of claims |
Percentage |
Time to process a Claim |
Total Burden Hours |
Billed Electronically |
193,506,219 |
99.98% |
0.5 minutes |
1,612,552 |
Billed on Paper |
29,722 |
0.02% |
9 minutes |
4,458 |
Total |
|
|
|
1,617,010 |
4,458 Paper burden hours
1,617,010 Total burden hours
Cost Estimate to process institutional paper claims
2022 Institutional Claim Data |
Total number of claims |
Total hours to process the claims |
Mean Hourly Wage |
Fringe Benefit |
Adjusted Hourly Wage |
Total Labor Costs |
Billed on Paper |
29,722 |
4,458 |
$18.75 |
$18.75 |
$37.50 |
$167,175.00 |
13. Capital Costs
There is no capital or operational costs associated with this collection.
The calculations for OIT employees’ hourly salary was obtained from the OPM website, with an additional 100% to account for fringe benefits.
Hourly Wage: $62.83 + 100% fringe benefits = 125.66 per hour.
Task |
Estimated Cost |
Acquiring and Preparing the Required Data and Oversight |
|
1 GS-13: 1 x $125.66 x 20 hours |
$2513.20 |
Total Costs to Government |
$2513.20 |
The reported decrease in the paper claims processed from the previous reporting period is once again due to the enforcement of mandatory electronic claim submission requirements, which are part of the Administrative Simplification Compliance Act (ASCA). Section 3 of the ASCA, PL107-105, and the implementing regulation at 42 CFR 424.32, requires providers, with limited exceptions, to submit all initial claims for reimbursement under Medicare electronically. Consequently, unless a provider fits one of the approved exceptions, any paper claims submitted to Medicare will not be paid.
The burden changes reported are due to the cost per hour wages have increased from the previous reporting period CY 2018 to CY 2022 used in this package. This estimate takes into account labor and resource cost based on the Bureau of Labor and Statistics (BLS) Occupational and Employment Data for Category 43-9061 Office Clerks. To account for fringe and overhead, we added 100% of the hourly mean hourly labor wage to get an adjusted cost burden of $37.50 ($18.75 + $18.75) per hour.
The purpose of this data collection is payment to providers for Medicare services rendered. We do not employ statistical methods to collect this information, but rather all Medicare institutional providers generate this billing information subsequent to the delivery of services. Generalized claims data is made public by CMS.
The UB-04 CMS-1450 is maintained by the National Uniform Billing Committee (NUBC). The current version of the form is 2007. The form is clearly marked that it was approved by the NUBC and there have been no changes to the UB-04 CMS-1450 since 2007.
The UB-04 CMS-1450 is used widely throughout the healthcare industry by commercial, state Medicaid’s, workers’ compensation, property and casualty insurance plans, in addition to federal health plans. While OMB approval is needed for the form to be used by federal programs, it is not necessary for other health plans that use the form. Requiring the OMB expiration date on the UB04 CMS-1450 would impact a large sector of non-federal health plan users of the form.
The Administrative Simplification and Compliance Act permits institutional providers with less than 25 FTE (as defined by 1861(u) of the Social Security Act) or fewer than 10 FTE institutional providers that is not otherwise a provider under section 1861(u) to submit paper UB-04 CMS1450 claims to Medicare, recognizing the potential cost that electronic billing systems may present to small providers. Since these facilities would presumably not have the overhead to adopt an electronic billing platform, an expiration date on a stock of forms could have a particularly burdensome impact on the resources of these facilities. When considering such an impact, it is important to recognize that the UB-04 form is not exclusive to hospitals, but rather is used across institutional providers, many of which are more likely to have fewer than 25 FTE, including: Community mental health centers, Comprehensive outpatient rehabilitation facilities, End-stage renal disease facilities, Histocompatibility laboratories, Home health agencies, Hospices, Indian Health Services facilities, Organ procurement organizations, Outpatient physical therapy organizations, Occupational therapy facilities and Speech pathology facilities.
The UB-04 CMS-1450 cannot be printed for use by institutional providers, the form must be purchased from print vendors. The majority of UB-04 CMS-1450 claims sent to Medicare Administrative Contractors (MACs) are scanned using Optical Character Recognition (OCR) technology. Provider printed forms and photocopies cannot be scanned therefore the claim form must be purchased from print vendors. The only acceptable claim forms are those printed in specific Flint OCR red, J6983, (or exact match) ink, not black.
The UB-04 CMS-1450 forms are usually packaged in packs as small as 100 and up to packs of 15,000 with a cost range from $15.99 up to $335.70 depending on the size of the package of claim forms purchased.
Regardless of how frequently they are used, any physician practice, other group practice, hospital, other facility, supplier, and other user of the UB-04 CMS-1450 could be required to purchase new forms with the OMB expiration date included on it. Purchases of new forms would be required every three years with each OMB renewal because of an updated expiration date only.
Per the American Hospital Association, there are 6,146 hospitals in the U.S. If 6,000 hospitals had to replace a modest number of forms, such as 1,000, the cost would be (1 package of 1,000 x $44 x 6,000) $264,000.
The supportive information stated here, attests that the UB-04 CMS-1450 form is to be exempt from requiring an expiration date.
The electronic version of the UB-04 CMS-1450 is the Health Care Claim: Institutional (837i). The
837i is a statutory electronic claim that is adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA allows for updates to the 837i. When the 837i is updated via the Federal rulemaking process, the effective date of the updated 837i is contained in the Final Rule. The effective date for the updated 837i version, by reference, establishes the expiration date of the prior version.
There are no exceptions to the certification statement.
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