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 201602-0938-005 · OMB 0938-1197 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-1500(02-12) CMS-1500 (02-12)/CMS-1490S Form and Instruction Modified Available
CMS-1500.Supporting Statement Part A (3-29-17) FINAL.doc Supporting Statement A Uploaded 2017-03-29 Available
IC Document Collections
IC IDCollectionTypeStatusForm
204966 CMS-1500 (02-12)/CMS-1490S Form and Instruction Modified
ICR Details
0938-1197 201602-0938-005
Historical Active 201211-0938-011
HHS/CMS CMS-1500(02-12)
Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C
Extension without change of a currently approved collection   No
Regular
Approved with change 03/29/2017
Retrieve Notice of Action (NOA) 02/25/2016
  Inventory as of this Action Requested Previously Approved
03/31/2020 36 Months From Approved 03/31/2017
1,003,431,991 0 988,005,045
19,818,656 0 21,418,336
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
  80 FR 72998 11/23/2015
81 FR 6277 02/05/2016
No
1
IC Title Form No. Form Name
CMS-1500 (02-12)/CMS-1490S CMS-1500(02-12), CMS-1490s Claim Form ,   Patient Request for Medical Payment
  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 1,003,431,991 988,005,045 0 15,426,946 0 0
Annual Time Burden (Hours) 19,818,656 21,418,336 0 -1,599,680 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Using Information Technology
The 2012 numbers reflect 988,005,045 Reponses and Burden Hours of 21,418,336 and 2016 numbers are for 1,003,431,995 responses and Burden hours of 19,818,656. The total reported Burden hours reported for 2015 decreased from the previous reporting period of 2012 due to the number of electronic claim submissions increased. 2012 reflected: 988,005,045 total number of claims with a total Burden Hours of 21,418,336 2015 reflected: 1,003,431,995 total number of claims with a total Burden Hours of 19,818,656 The total ‘Cost of Forms and Mailing of Forms’ also decreased in 2015. 2012: Total number of claims: 988,005,045 total annual Cost of Forms and Mailing: $90,711,997 2015: Total number of claims: 1,003,431,995 total annual Cost of Forms and Mailing: $87,724,973
$3,514,000,000
No
No
No
No
No
Uncollected
Kayla Williams 410 786-5887 [email protected]
  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.
02/25/2016