View Information Collection Request (ICR) Package
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View Information Collection (IC) List
View Supporting Statement and Other Documents
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:
0938-0997
ICR Reference No:
202007-0938-008
Status:
Historical Active
Previous ICR Reference No:
201907-0938-003
Agency/Subagency:
HHS/CMS
Agency Tracking No:
OIT
Title:
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 (CMS-1450)
Type of Information Collection:
Extension without change of a currently approved collection
Common Form ICR:
Yes
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/04/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/27/2020
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2023
36 Months From Approved
07/31/2021
Responses
214,660,298
0
214,660,298
Time Burden (Hours)
1,797,958
0
1,797,958
Cost Burden (Dollars)
0
0
0
Abstract:
This standardized form is used in the Medicare/Medicaid program to apply for reimbursement of covered services by all providers that accept Medicare/Medicaid assigned claims and that do not bill Medicare and Medicaid electronically.
Authorizing Statute(s):
US Code:
42 USC 1395d
Name of Law: Scope of benefits
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
84 FR 15618
04/16/2019
30-day Notice:
Federal Register Citation:
Citation Date:
84 FR 34895
07/19/2019
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 Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
CMS-1450 (UB04) Front, CMS-1450 (UB04) Back
Uniform Institutional Providers Form
,
Uniform Institutional Providers Form
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
214,660,298
214,660,298
0
0
0
0
Annual Time Burden (Hours)
1,797,958
1,797,958
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
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
Common Form ICR:
Yes
Description/Changes for Common Form Usage:
The form has not changed for CMS' purposes. It is being resubmitted for use as a common form at the request of the Department of Defense.
Approved RCFs using this ICR
Agency/Sub Agency
RCF ID
RCF Title
RCF Status
IC Title
DOD/DODOASHA
202008-0720-002CF
Health Insurance Claims Form, UB-04 CMS 1450
Active
Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5
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:
07/27/2020
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