01-31416. Office of the Secretary

ACTION:

Notice.

The Department of Defense has submitted to OMB for clearance, the following proposal for collection of information under the provisions of the Paperwork Reduction Act (44 U.S.C. chapter 35).

DATES:

Consideration will be given to all comments received by January 22, 2002.

Title, Form Number, and OMB Number. Health Insurance Claim Form; HCFA Form 1450 (UB 92); OMB Number 0720-0013.

Type of Request: Reinstatement.

Number of Respondents: 7,836.

Responses Per Respondent: 268 (average).

Annual Responses: 2,100,000.

Average Burden Per Response: 15 minutes.

Annual Burden Hours: 525,000.

Needs and Uses: This information collection requirement is necessary for a medical institution to claim benefits under the Defense Health Program, TRICARE, which includes the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS). The information collected will be used by TRICARE/CHAMPUS to determine beneficially eligibility, other health insurance liability, certification that the beneficiary received the care, and that the provider is authorized to receive TRICARE/CHAMPUS payments. The form will be used by TRICARE/CHAMPUS and its contractors to determine the amount of benefits to be paid to TRICARE/CHAMPUS institutional providers. Use of the UB-92, also known as the HCFA 1450, continues TRICARE/CHAMPUS commitments to use the national standard claim form for reimbursement of medical services/supplies provided by institutional providers.

Affected Public: Individuals or Households; Business or Other For-Profit; Not-For-Profit.

Frequency: On Occasion.

Respondent's Obligation: Required to obtain or retain benefits.

OMB Desk Officer: Mr. Stuart Shapiro.

Written comments and recommendations on the proposed information collection should be sent to Mr. Shapiro at the Office of Management and Budget, Desk Officer for DoD Health Affairs. Room 10235, New Executive Office Building, Washington, DC 20503.

DOD Clearance Officer: Mr. Robert Cushing.

Written requests for copies of the information collection proposal should be sent to Mr. Cushing, WHS/DIOR, 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302.

Dated: December 14, 2001.

Patricia L. Toppings.

Alternate OSD Federal Register Liaison Officer, Department of Defense.