Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

Documents and Forms

Document Name Document Type
TriWest CAPDME Request Form_2025.pdf www.tricare-west.com/content/dam/hnfs/tw/prov/resources/pdf/claims/capdme-reimbursement.pdf Other-TRIWEST CAPDME Form
Humana CAPDME Request Form_2025.pdf www.humanamilitary.com/contact/submissions/dme-reimbursement Other-Humana CAPDME Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Diagnosis Related Groups (DRG) Reimbursement (Two Parts)	Agency IC Tracking Number:	0720-0017

Is this a Common Form? No		IC Status: Modified

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
Other-TRIWEST CAPDME Form			TriWest CAPDME Request Form_2025.pdf	https://www.tricare-west.com/content/dam/hnfs/tw/prov/resources/pdf/claims/capdme-reimbursement.pdf	Yes	Yes	Fillable Fileable
Other-Humana CAPDME Form			Humana CAPDME Request Form_2025.pdf	https://www.humanamilitary.com/contact/submissions/dme-reimbursement	Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,600	5,600
Annual IC Time Burden (Hours)	5,600	5,600
Annual IC Cost Burden (Dollars)	283,304	283,304

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.