Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
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
Retrieve Notice of Action (NOA)
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
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.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
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
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:
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
Common Form ICR:
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:
(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
An official website of the United States government
The .gov means it's official.
The site is secure.
