Information Collection

Billing Code Data: 837I Upload

IC 263469 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Document Name Document Type
Form 57.800 Billing Code Data Billing Code Data: 837I Upload Form
57.800 Billing Code Data 57.800 Healthcare Claims Data Template (FACILITY) (OMB version)).xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Billing Code Data: 837I Upload	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.800	Billing Code Data	57.800 Healthcare Claims Data Template (FACILITY) (OMB version)).xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,500	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: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	66,000	44,000	22,000
Annual IC Time Burden (Hours)	5,500	3,667	1,833
Annual IC Cost Burden (Dollars)	0	0	0

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.

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