OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Diagnosis Related Groups (DRG) Reimbursement (Two Parts)

OMB 0720-0017 · DOD/DODOASHA.

OMB 0720-0017

Hospitals subject to the TRICARE DRG-based payment system who wish to be reimbursed for Allowed Capital and Direct Medical Education costs (as outlined in the TRICARE Reimbursement Manual) must submit a request for reimbursement to the appropriate TRICARE/CHAMPUS authorized contractors of Managed Care Support Contracts.

The latest form for Diagnosis Related Groups (DRG) Reimbursement (Two Parts) expires 2029-01-31 and is listed under ICR 202506-0720-004.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
0720-0017_SSA_9.30.2025.docxSupporting Statement A
0720-0017_SSA_9.30.2025.docxSupporting Statement A
Diagnosis Related Groups (DRG) Reimbursement (Two Parts) Other-TRIWEST CAPDME Form

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202506-0720-004 Reinstatement without change of a previously approved collection 2025-11-20
202203-0720-001 Revision of a currently approved collection 2022-03-29 Approved without change
201812-0720-001 Revision of a currently approved collection 2019-01-18 Approved without change
201510-0720-001 Reinstatement with change of a previously approved collection 2015-10-27 Approved without change
201207-0720-004 Reinstatement without change of a previously approved collection 2012-07-05 Approved without change
200708-0720-004 Extension without change of a currently approved collection 2007-08-31 Approved without change
200401-0720-001 Reinstatement without change of a previously approved collection 2004-01-29 Approved with change
199711-0720-001 Existing collection in use without an OMB Control Number 1997-11-10 Approved without change