ADA Dental Claim Form (CMS-10883)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10883 ADA Dental Claim Form	Form and Instruction	New	Available
Form CMS-10883 Paper Submission	Form and Instruction	New	Available
Form CMS-10883 ADA Dental Claim Form	Form and Instruction	New	Available
Form CMS-10883 Electronic Submission	Form and Instruction	New	Repair queued
CMS-10883.Supporting Statement Part A (3-28-24).docx	Supporting Statement A	Uploaded 2024-03-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
266388	Paper Submission	Form and Instruction	New	ADA Dental Claim Form
266388	Paper Submission	Form and Instruction	New
266385	Electronic Submission	Form and Instruction	New	ADA Dental Claim Form
266385	Electronic Submission	Form and Instruction	New

ICR Details

OMB Control No: 0938-1471	ICR Reference No: 202403-0938-016
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: OIT
Title: ADA Dental Claim Form (CMS-10883)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/30/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/04/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2027	36 Months From Approved
Responses	360,000	0	0
Time Burden (Hours)	17,667	0	0
Cost Burden (Dollars)	44,000	0	0

---

Abstract: Medicare Administrative Contractors (MACs) will use the data collected on the ADA Dental Claim Form to determine the proper amount of reimbursement for Part B dental services (as listed in section 1861(s) of the Social Security Act) provided by dental providers to beneficiaries. The ADA Dental Claim Form is submitted by dental providers for Part B Medicare.

---

Authorizing Statute(s): US Code: 42 USC 1395l Name of Law: Social Security Act
   US Code: 42 USC 1395d Name of Law: Social Security Act
  

Citations for New Statutory Requirements: US Code: 42 USC 1395d Name of Law: Social Security Act
US Code: 42 USC 1395l Name of Law: Social Security Act

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 88622	12/22/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 21254	03/27/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Electronic Submission	CMS-10883	ADA Dental Claim Form
Paper Submission	CMS-10883	ADA Dental Claim Form

---

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	360,000	0	360,000	0	0	0
Annual Time Burden (Hours)	17,667	0	17,667	0	0	0
Annual Cost Burden (Dollars)	44,000	0	44,000	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: This is a new information collection request.

---

Annual Cost to Federal Government: $2,584

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.     No

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

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

---

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: 04/04/2024

---