OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C

ICR 201211-0938-011 · OMB 0938-1197 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-1490S CMS-1500 (02-12)/CMS-1490S Form and Instruction New Available
CMS Response to Public Comments Received for CMS15000212.docx Supplementary Document Uploaded 2012-11-27 Repair queued
CMS-1500(02-12)-Supporting_StatementPart_A.pdf Supporting Statement A Uploaded 2012-11-27 Available
IC Document Collections
IC IDCollectionTypeStatusForm
204966 CMS-1500 (02-12)/CMS-1490S Form and Instruction New
ICR Details
0938-1197 201211-0938-011
Historical Active
HHS/CMS
Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 06/10/2013
Retrieve Notice of Action (NOA) 11/28/2012
  Inventory as of this Action Requested Previously Approved
06/30/2016 36 Months From Approved
988,005,045 0 0
21,418,336 0 0
0 0 0
Medicare Administrative Contractors use the data collected on the CMS-1500 and the CMS-1490S to determine the proper amount of reimbursement for Part B medical and other health services (as listed in section 1861(s) of the Social Security Act) provided by physicians and suppliers to beneficiaries. The CMS-1500 is submitted by physicians/suppliers for all Part B Medicare. Serving as a common claim form, the CMS-1500 can be used by other third-party payers (commercial and nonprofit health insurers) and other Federal programs (e.g., TRICARE, RRB, and Medicaid).
US Code: 42 USC 1395k Name of Law: SCOPE OF BENEFITS
   US Code: 42 USC 1395x Name of Law: DEFINITIONS OF SERVICES, INSTITUTIONS, ETC
   US Code: 42 USC 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
  
None
Not associated with rulemaking
  77 FR 31615 05/29/2012
77 FR 58558 09/21/2012
Yes
1
IC Title Form No. Form Name
CMS-1500 (02-12)/CMS-1490S CMS-1490S, CMS-1500(02-12) PATIENT'S REQUEST FOR MEDICAL PAYMENT ,   Claim 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 988,005,045 0 0 988,005,045 0 0
Annual Time Burden (Hours) 21,418,336 0 0 21,418,336 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new information collection request. It is a new version of the form submitted under 0938-0999. Once both forms are approved, there will be a run-off period before only the form associated with this submission, the 1500(02-12) is acceptable for claims submission.
$3,514,000,000
No
No
No
No
No
Uncollected
William Parham 4107864669
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/28/2012