Information Collection

Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

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

Documents and Forms

Documents and forms in this information collection
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
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
Humana CAPDME Request Form_2025.pdf www.humanamilitary.com/contact/submissions/dme-reimbursement	Other-Humana CAPDME Form

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-TRIWEST CAPDME Form				https://www.tricare-west.com/content/dam/hnfs/tw/prov/resources/pdf/claims/capdme-reimbursement.pdf	Yes	Yes	Fillable Fileable
Other-Humana CAPDME Form				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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	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

table that charts IC Documents
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.

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