HEALTH INSURANCE COMMON CLAIMS FORM "MEDICARE" & "MEDICAID"

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
112476	HEALTH INSURANCE COMMON CLAIMS FORM "MEDICARE" & "MEDICAID" Form	Migrated

ICR Details

OMB Control No: 0938-0008	ICR Reference No: 198906-0938-008
Status: Historical Active	Previous ICR Reference No: 198811-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: HEALTH INSURANCE COMMON CLAIMS FORM "MEDICARE" & "MEDICAID"
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/1989
	Date Received in OIRA: 06/16/1989
Terms of Clearance: end Information and Regulatory Affairs, this submission, (which includes the HCFA-1500, the HCFA-1490S, the HCFA-1490U, the AMA instructions, Medicaid HCPCS coding, and sections of the Carrier's Manual implementing the HCFA-1500), is approved for use through 2/90 under the following conditions: (1) The next submission will include a revised HCFA-1500 which will, to the maximum extent feasible, explicitly incorporate all applicable Medicare and Medicaid federally mandated and sponsored information collection requirements that are currently communicated through separate instructions and the Carrier's Manual. The submission should also include any instructions in the Manual that reiterate or further clarify the requirements on the revised form (2) The Department immediately will issue a Carrier's Manual update which specifies all sections of the Carrier's Manual containing information collection requirements that are now authorized by the OMB control number issued as part of this action. A draft of this update will be sent to OMB for verification prior to its final issuance (3) Future issuances of the Manual will print the respective OMB control number at the beginning of each OMB approved section of the Carrier's Manual as specified pursuant to (2) above (4) continued on next page

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/1990	02/28/1990	08/31/1989
Responses	1	0	1
Time Burden (Hours)	1	0	1
Cost Burden (Dollars)	0	0	0

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Abstract: THIS FORM WILL BECOME A STANDARDIZED FORM FOR USE IN THE MEDICARE/ MEDICAID PROGRAMS TO APPLY FOR REIMBURSEMENT FOR COVERED SERVICES. IN ADDITION, IT WILL REDUCE COSTS AND ADMINISTRATIVE BURDENS ASSOCIATED WITH CLAIMS SINCE ONLY ONE CODING SYSTEM WOULD BE USED AND MAINTAINED.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
HEALTH INSURANCE COMMON CLAIMS FORM "MEDICARE" & "MEDICAID"	HCFA-1500, 1490S, 1490U

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ICR Summary of Burden

	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	1	1	0	0	0	0
Annual Time Burden (Hours)	1	1	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/16/1989

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