Regulatory Collection Filing

Health Insurance Claims Form, UB-04 CMS 1450

RCF 202008-0720-002CF · Host ICR 202007-0938-008 · OMB 0938-0997

RCF Summary

Request for correction metadata
Host OMB Control No.	0938-0997
Host ICR Reference No.	202007-0938-008
Agency/Subagency	DOD/DODOASHA
Status	Active
Type of RCF	RCF New
OIRA Conclusion Action	Approved without change
Date Received in OIRA	2020-08-28
Conclusion Date	2020-08-28
Related Links	OMB 0938-0997 · ICR 202007-0938-008 · Retrieve Notice of Action (NOA)

RCF Details

View RCF - OIRA Conclusion

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RCF ID: 202008-0720-002CF	Previous RCF ID:
Status: Active	Expiration Date: 08/31/2023
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Host OMB Control No: 0938-0997	Host ICR Reference No: 202007-0938-008

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Title: Health Insurance Claims Form, UB-04 CMS 1450

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Type of RCF: RCF New
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/28/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/28/2020
Terms of Clearance:

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Description of Agency Usage: 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 âUB-04/CMS 1450â) will be used by TRICARE/CHAMPUS and its contractors to determine the amount of benefits to be paid to TRICARE/CHAMPUS participating healthcare providers.

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Authorizing Statute(s): US Code: 10 USC 55 Name of Law: Medical and Dental Care

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Annual Cost to Federal Government: $796,050
Agency Contact: Kira Starks 571 372-4529 [email protected]

Common Form Information Collections (IC) in this RCF:

table that charts list of ICs
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
		858,881	7,194	0	Form and Instruction	CMS-1450 (UB04) Back	Uniform Institutional Providers Form

RCF Summary of Burden:

table that charts list of burden
	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	858,881	858,881
Annual Time Burden (Hours)	7,194	7,194
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.