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View ICR - OIRA Conclusion

OMB Control No: 0720-0013	ICR Reference No: 201705-0720-002
Status: Historical Active	Previous ICR Reference No: 201201-0720-001
Agency/Subagency: DOW/DODOASHA	Agency Tracking No:
Title: Health Insurance Claims Form, UB-04 CMS 1450
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/14/2017
	Date Received in OIRA: 05/12/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	858,881	0	0
Time Burden (Hours)	41,884	0	0
Cost Burden (Dollars)	715,632	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	858,881	-20,241,119	21,100,000
Annual Time Burden (Hours)	41,884	-483,116	525,000
Annual Cost Burden (Dollars)	715,632	-177,368	893,000

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The data sources used to calculate the number of respondents and the number of responses has changed from the prior submission and therefore there is a significant change in burden. The total number of respondents (hospital institutions) utilizing the form increased from 7,836 to 10,318. The total number of responses has decreased from 2,100,000 to 858,881. In the previous approval, a typo was made and the total number of responses appears as 21,100,000 instead of 2,100,000. The total annual hours requested has decreased from 525,000 to 41,884.

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