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Federal forms, ICRs, and supporting documents

Information Collection Request

Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)

ICR 202309-0938-007 · OMB 0938-1197 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-1500(02-12) CMS-1500 (02-12)/CMS-1490S Form and Instruction Modified Missing upstream
CMS-1500-Supporting-Statement-Part-A.docx Supporting Statement A Uploaded 2023-09-27 Repair queued
Responses to Public Comments_CMS 1500 Form_2023.docx Supplementary Document Uploaded 2023-09-14 Available
IC Document Collections
IC IDCollectionTypeStatusForm
204966 CMS-1500 (02-12)/CMS-1490S Form and Instruction Modified
ICR Details
0938-1197 202309-0938-007
Received in OIRA 201911-0938-017
HHS/CMS OIT
Health Insurance Common Claims Form and Supporting Regulations at 42 CFR Part 424, Subpart C (CMS-1500 and CMS-1490S)
Extension without change of a currently approved collection   No
Regular 09/27/2023
  Requested Previously Approved
36 Months From Approved 10/31/2023
975,664,249 1,033,839,906
17,163,310 18,847,500
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 1395u Name of Law: PROVISIONS RELATING TO THE ADMINISTRATION OF PART B
   US Code: 42 USC 1395k Name of Law: SCOPE OF BENEFITS
   US Code: 42 USC 1395x Name of Law: DEFINITIONS OF SERVICES, INSTITUTIONS, ETC
  
None
Not associated with rulemaking
  88 FR 4082 06/22/2023
88 FR 63579 09/15/2023
Yes
1
IC Title Form No. Form Name
CMS-1500 (02-12)/CMS-1490S CMS-1500(02-12), CMS-1490s, CMS-1490s Claim Form ,   Patient Request for Medical Payment ,   Patient Request for Medical Payment (Spanish)
  Total Request 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 975,664,249 1,033,839,906 0 0 -58,175,657 0
Annual Time Burden (Hours) 17,163,310 18,847,500 0 0 -1,684,190 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
CMS reported decrease in the paper claims processed from the previous reporting period as once again being due to the enforcement of mandatory electronic claim submission requirements. Management records for CY 2022 also indicated that 2,451,781 providers/suppliers were enrolled in Medicare Part B, which is less than what was recorded in the previous year. These changes resulted in a decrease in the collections total hourly burden.
$2,513
No
    Yes
    Yes
No
No
No
No
Stephan McKenzie 410 786-1943 [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.
09/27/2023