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-1500 CMS-1500 sample	Form and Instruction	Modified	Available
Form CMS-1490 English Health Insurance Common Claims Form	Form	Modified	Available
Form CMS-1490S Health Insurance Common Claim Form (Spanish)	Form	Modified	Available
Form CMS-1490S CMS-1500 (02-12)/CMS-1490S	Form	Modified	Repair queued
CMS-1500 and CMS-1490S-Supporting-Statement-Part-A_2024.docx	Supporting Statement A	Uploaded 2024-07-12	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	CMS-1500 sample
204966	CMS-1500 (02-12)/CMS-1490S	Form	Modified	Health Insurance Common Claims Form
204966	CMS-1500 (02-12)/CMS-1490S	Form	Modified	Health Insurance Common Claim Form (Spanish)
204966	CMS-1500 (02-12)/CMS-1490S	Form	Modified

ICR Details

OMB Control No: 0938-1197	ICR Reference No: 202407-0938-004
Status: Active	Previous ICR Reference No: 202309-0938-007
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: 10/27/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/22/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2027	36 Months From Approved	12/31/2024
Responses	998,032,912	0	975,664,249
Time Burden (Hours)	17,329,912	0	17,163,310
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:
	89 FR 32433	04/26/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 56754	07/10/2024
Did the Agency receive public comments on this ICR? No

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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-1490S, CMS-1490 English, CMS-1500	Health Insurance Common Claim Form (Spanish) ,   Health Insurance Common Claims Form ,   CMS-1500 sample

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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	998,032,912	975,664,249	0	22,368,663	0	0
Annual Time Burden (Hours)	17,329,912	17,163,310	0	166,602	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The BLS wage data has been updated and the related calculations have been adjusted accordingly.

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Annual Cost to Federal Government: $1,390

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: 07/22/2024

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