View RCF  - OIRA Conclusion

202008-0720-002CF
Active 08/31/2023
DOD/DODOASHA
0938-0997 202007-0938-008
Health Insurance Claims Form, UB-04 CMS 1450
RCF New
 Approved without change   08/28/2020
Retrieve Notice of Action (NOA) 08/28/2020
This information collection is necessary to permit healthcare providers who provide healthcare services and supplies to beneficiaries under the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS)/TRICARE to submit claims for payment to CHAMPUS/TRICARE. This information collection is used by TRICARE/CHAMPUS and their contractors to determine beneficiary (patient) eligibility for TRICARE/CHAMPUS benefits, the extent to which other health insurance may be available to offset TRICARE/CHAMPUS liability, certification that the beneficiary received the care, and that the provider is authorized to receive TRICARE/CHAMPUS payments. The collection instrument, Health Insurance Claim Form (CMS-1450), also more commonly referred to as the UB-04 or 837I for electronic transactions, (hereafter referenced as ‘UB-04/CMS 1450’) will be used by TRICARE/CHAMPUS and its contractors to determine the amount of benefits to be paid to TRICARE/CHAMPUS participating healthcare providers.
US Code: 10 USC 55 Name of Law: Medical and Dental Care
 $796,050
Kira Starks 571 372-4529 [email protected]

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 858,881 7,194 0 Form and Instruction CMS-1450 (UB04) Front Uniform Institutional Providers Form
Form and Instruction CMS-1450 (UB04) Back Uniform Institutional Providers Form

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 858,881 0 0 858,881 0 0
Annual Time Burden (Hours) 7,194 0 0 7,194 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0

Yes
Miscellaneous Actions
No
The Department of Defense, Defense Health Agency previously cleared public burden for form UB-04 CMS 1450 under 0720-0013. The form has been designated as a common form by HHS (CMS) allowing DHA to clear public burden under 0938-0997.