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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:
199407-0938-002
Status:
Historical Active
Previous ICR Reference No:
199309-0938-001
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS
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:
09/30/1994
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/14/1994
Terms of Clearance:
The HCFA-1500 is extended exactly as is through 3/95 with the followin remarks. OMB recognizes that this is a limited extension but believes that HCFA and PHS need this extension period to compile and present mo evidence that collection of E-codes on the HCFA-1500 will produce information that is statistically valid for public health research and policy purposes. This action does not question the coding structure or content. It instead investigates the claim as a vehicle for certai voluntary coding uses. OMB agrees with the Departments' assessment of the policy relevance of E-code data for health research/prevention pur poses. HCFA's supporting statement and the Department's subsequent responses to public comment, however, fail to address how the collection of these data on the HCFA-1500 claim form is an appropriate means of collecting such data while ensuring that it is statistically valid and that future analysis would be based upon a generalizable, representative sample of patients with certain conditions. OMB believes that this particular case is a compelling example of dissonance between statistical objectives and the limitatio of administrative systems. Because OMB supports the Department's research objectives, it recommends that PHS and HCFA staff meet with OMB in the near future in order to delineate the types of supporting analysis and rationales that would be necessary for resubmission pursuant to the Paperwork Reduction Act.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/1995
03/31/1995
09/30/1994
Responses
546,115,406
0
546,115,406
Time Burden (Hours)
73,325,195
0
73,325,195
Cost Burden (Dollars)
0
0
0
Abstract:
THIS FORM WILL BECOME A STANDARDIZED FORM FOR USE IN MEDICARE AND MEDICAID PROGRAMS TO APPLY FOR REIMBURSEMENT FOR COVERED SERVICES. IN ADDITION, IT WILL REDUCE COSTS AND ADMINISTRATION BURDENS ASSOCIATED WITH CLAIMS SINCE ONLY ONE CODING SYSTEM WOULD BE USED AND MAINTAINED. HCFA DOES NOT REQUIRE EXCLUSIVE USE OF THIS FORM FOR MEDICAID.
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
MEDICARE/MEDICAID HEALTH INSURANCE COMMON CLAIM FORM AND INSTRUCTIONS
HCFA-1500, HCFA-1490S, HCFA-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
546,115,406
546,115,406
0
0
0
0
Annual Time Burden (Hours)
73,325,195
73,325,195
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:
07/14/1994
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