OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

IC 5589 under ICR 202506-0720-004 · OMB 0720-0017.

Documents and Forms
Document Name
Document Type
Other-TRIWEST CAPDME Form
Other-TRIWEST CAPDME Form
Other-Humana CAPDME Form
Other-Humana CAPDME Form
Information Collection (IC) Details

View Information Collection (IC)

Diagnosis Related Groups (DRG) Reimbursement (Two Parts) 0720-0017
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Defense and National Security Operational Defense

 

5,600 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,600 0 5,600 0 0 0
Annual IC Time Burden (Hours) 5,600 0 5,600 0 0 0
Annual IC Cost Burden (Dollars) 283,304 0 283,304 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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