3220-0131

OMB NO. 3220-0131

Justification

Request for Medicare Payment

RRB Form G-740S and CMS-1500

1. Circumstances of information collection - Under Section 7(d) of the Railroad Retirement Act, the Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the railroad retirement system. This collection obtains the information needed by Palmetto GBA, the Medicare carrier for railroad retirement beneficiaries, to pay claims for payments due under Part B of the Medicare program. Authority for collecting the information is 42 CFR 424.32.

2. Purposes of collecting/consequences of not collecting the information -

The forms furnished by the RRB and Palmetto GBA for claiming Medicare payments follow:

Form CMS 1500, Health Insurance Claim Form, is the common claim form from CMS (Centers for Medicare and Medicaid Services) that is used by physicians and suppliers for claiming payment for medical and related services furnished railroad retirement beneficiaries under Medicare (Part B), Medicaid, and other medical insurance programs.

CMS regulations (CMS 42 CFR 424.32) require that most Forms CMS-1500 be submitted electronically. However, physicians and suppliers keep a quantity of paper Forms CMS-1500 on hand for those claims that fall under the exceptions to that requirement. The physicians and suppliers obtain the forms from the Government Printing Office, the American Medical Association or www.cms.hhs.gov/forms/. Form CMS-1500 is designed for self-completion. The completed form is forwarded by the physician or supplier to Palmetto GBA for processing.

Form G-740S, Patient's Request for Medicare Payment, is used by railroad retirement beneficiaries to apply for reimbursement of payments made for medical services under Part B of the Medicare program.

Form G-740S is obtained from Palmetto GBA or an RRB field office, and is designed for self-completion. The completed form is then forwarded by the beneficiary to Palmetto GBA for processing.

The responsible doctors, suppliers, and other Medicare providers are required to submit Medicare claims using Form CMS-1500 for the medical services that they provide to railroad retirement beneficiaries. However, beneficiaries can use Form G-740S in those situations where, for whatever reason, the provider fails to submit a Form CMS-1500 on their behalf.

The format and use of Form G-740S is the same as its counterpart, Form CMS-1490S, OMB No. 0938-0008. Railroad retirement beneficiaries can use either Form G-740S or CMS-1490S.

The RRB proposes the following changes to Form G-740S:

Page 1

• Change reference in the Notice from 42 CFR 405.1678 to 424, Subpart C.

• Address all of the questions, directly to the patient and replace the words “the patient” with “you”

• Move the Palmetto GBA return address to the bottom left of the first page.

• Item 1 – Change “Health Insurance” to “Medicare.”

• Item 4b – Provide a “Yes/No” choice for Item 2, Accident.

• Items 5a/b – Change “Employee Health Plan” with “Employer Health Plan” and then ask if the patient is covered. Remove asking if they are employed.

• Item 5c – Clarify type of insurance by adding “Private” and also adding Medicaid.

• Item 6 –revise the Certification, authorization to release information to the Centers for Medicare and Medicaid Services instead of the Social Security Administration.

Page 2

• Item A, 1-3 and 5 have been made self-explanatory.

• Item 6a, second bullet – Clarify that the user is to attach a brief statement if they are completing the form on behalf of the patient.

• Other minor editorial and cosmetic changes.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – A proposed version of RRB Form G-740S will be available at the Palmetto GBA web-site upon approval.

4. Efforts to identify duplication and other improvements – See previous reference to CMS Form-1490S in item 2.

5. Small business respondents - Respondents can be small businesses. However, participation is voluntary and to the extent determined by the employer.

6. Consequences of less frequent collections - Not applicable since the information is solicited only once for each claim filed.

7. Special circumstances - None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 7275 of the February 13, 2009, Federal Register. No requests for further information or comments were received. Coordination with CMS representatives is an on-going activity.

9. Payments or gifts to respondents – None

10. Confidentiality - Privacy Act System of Records, RRB-3, Medicare: Part B.

11. Sensitive questions - There are no questions of a sensitive nature.

12. Estimate of respondent burden - The RRB uses the information obtained by Forms G-740S and CMS-1500 solely to carry out the requirements of the Centers for Medicare and Medicaid Services (CMS) in the administration of the Medicare program for persons covered by the railroad retirement system. Therefore, the only part of the burden the RRB assumes under its public information collection is a token burden of 1 hour, the burden, in substance, being imposed by CMS. This token 1 hour burden was suggested by OMB originally.

In April 1992, OMB conditioned its approval on the RRB coordinating with CMS to ensure that the burden is being accounted for under HHS OMB Number 0938-0008, since the RRB claims a token burden of only 1 hour for its overall submission.

Monthly, Palmetto GBA submits an electronic workload report which it sends to CMS. This report provides statistical information regarding RRB claims processing activity. This report provides CMS with the data necessary to compute the average number of annual responses. A copy of a recent report is included.

13. Estimate of annual cost burden to respondents or recordkeepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for changes in burden - N.A.

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The G-740S is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests authorization to not display the expiration date on the form.

18. Exceptions to the certification statement - None

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