05-12507. Submission for OMB review; Comment Request

AGENCY:

Department of Defense.

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 July 25, 2005.

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

Type of Request: Extension.

Number of Respondents: 7,836.

Responses per Respondent: 268.

Annual Responses: 2,100,000.

Average Burden per Response: 15 minutes

Annual Burden Hours: 525,000.

Needs and Uses: This information collection 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 beneficiary eligibility, other health insurance liability, certification that the beneficiary received 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.

Affected Public: Individuals or households; business or other for-profit; not-for-profit institutions.

Frequency: On occasion.

Respondent's Obligation: Required to obtain or retain benefits

OMB Desk Officer: Mr. John Kraemer.

Written comments and recommendations on the proposed information collection should be sent to Mr. Kraemer at the Office of Management and Budget, Desk Officer for DoD, Room 10236, New Executive Office Building, Washington, DC 20503.

DOD Clearance Officer: Ms.Patricia Toppings.

Written requests for copies of the information collection proposal should be sent to Ms. Toppings, WHS/ESD/Information Management Division, 1225 South Clark Street, Suite 504, Arlington, VA 22202-4326.

Dated: June 15, 2005.

Patricia L.Toppings,

Alternate OSD Federal Register Liaison Officer, Department of Defense.