Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1490s Patient Request for Medical Payment (Spanish)	Form and Instruction	Modified	Repair queued
Form CMS-1490s Patient Request for Medical Payment	Form and Instruction	Modified	Available
Form CMS-1500(02-12) Claim Form	Form and Instruction	Modified	Available
Form CMS-1500(02-12) CMS-1500 (02-12)/CMS-1490S	Form and Instruction	Modified	Repair queued
CMS-1500-Supporting-Statement-Part-A.docx	Supporting Statement A	Uploaded 2023-09-27	Repair queued
Responses to Public Comments_CMS 1500 Form_2023.docx	Supplementary Document	Uploaded 2023-09-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204966	CMS-1500 (02-12)/CMS-1490S	Form and Instruction	Modified	Patient Request for Medical Payment (Spanish)
204966	CMS-1500 (02-12)/CMS-1490S	Form and Instruction	Modified	Patient Request for Medical Payment
204966	CMS-1500 (02-12)/CMS-1490S	Form and Instruction	Modified	Claim Form
204966	CMS-1500 (02-12)/CMS-1490S	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1197	ICR Reference No: 202309-0938-007
Status: Historical Active	Previous ICR Reference No: 201911-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: OIT
Title: Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/27/2023
Terms of Clearance: Prior to the re-submission of this information collection (IC), CMS will assess linguistic preferences across the respondent population and translate this IC into additional languages as appropriate in order to increase accessibility and reduce health disparities. It is the expectation that CMS will translate this form into more languages that English and Spanish, but the number of additional languages will be based on the agency’s assessment of population needs, but these languages could include both Traditional and Simplified Chinese, Vietnamese, Korean, Tagalog, Arabic, French, and Russian. This request is supported by the principles and priorities set forth in the memorandum titled “Improving Access to Public Benefits Programs Through the Paperwork Reduction Act” (April 13, 2022), the Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” (January 20, 2021), Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency" (August, 11, 2000) and the culturally and linguistically appropriate services (CLAS) standards.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2024	36 Months From Approved	12/31/2023
Responses	975,664,249	0	1,033,839,906
Time Burden (Hours)	17,163,310	0	18,847,500
Cost Burden (Dollars)	0	0	0

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Abstract: Medicare Administrative Contractors use the data collected on the CMS-1500 and the CMS-1490S to determine the proper amount of reimbursement for Part B medical and other health services (as listed in section 1861(s) of the Social Security Act) provided by physicians and suppliers to beneficiaries. The CMS-1500 is submitted by physicians/suppliers for all Part B Medicare. Serving as a common claim form, the CMS-1500 can be used by other third-party payers (commercial and nonprofit health insurers) and other Federal programs (e.g., TRICARE, RRB, and Medicaid).

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Authorizing Statute(s): US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395k Name of Law: SCOPE OF BENEFITS
   US Code: 42 USC 1395x Name of Law: DEFINITIONS OF SERVICES, INSTITUTIONS, ETC
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 4082	06/22/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 63579	09/15/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CMS-1500 (02-12)/CMS-1490S	CMS-1500(02-12), CMS-1490s, CMS-1490s	Claim Form ,   Patient Request for Medical Payment ,   Patient Request for Medical Payment (Spanish)

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ICR Summary of Burden

table that charts list 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	975,664,249	1,033,839,906	0	0	-58,175,657	0
Annual Time Burden (Hours)	17,163,310	18,847,500	0	0	-1,684,190	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: CMS reported decrease in the paper claims processed from the previous reporting period as once again being due to the enforcement of mandatory electronic claim submission requirements. Management records for CY 2022 also indicated that 2,451,781 providers/suppliers were enrolled in Medicare Part B, which is less than what was recorded in the previous year. These changes resulted in a decrease in the collections total hourly burden.

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Annual Cost to Federal Government: $2,513

Does this IC contain surveys, censuses, or employ statistical methods? No

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.     Yes

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.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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: 09/27/2023

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