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Proposed Collection; Comment Request

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Office of the Assistant Secretary of Defense for Health Affairs, DoD.




In compliance with the Paperwork Reduction Act of 1995, the Office of the Assistant Secretary of Defense for Health Affairs announces a proposed public information collection and seeks public comment on the provisions thereof. Comments are invited on: (a) whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information shall have practical utility; (b) the accuracy of the agency's estimate of the burden of the proposed information collection; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the information collection on respondents, including through the use of automated collection techniques or other forms of information technology.


Consideration will be given to all comments received by March 31, 2015.


You may submit comments, identified by docket number and title, by any of the following methods:

  • Federal eRulemaking Portal: Follow the instructions for submitting comments.
  • Mail: Federal Docket Management System Office, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100.

Instructions: All submissions received must include the agency name, docket number and title for this Federal Register document. The general policy for comments and other submissions from members of the public is to make these submissions available for public viewing on the Internet at as they are received without change, including any personal identifiers or contact information.

Any associated form(s) for this collection may be located within this same electronic docket and downloaded for review/testing. Follow the instructions at for submitting comments. Please submit comments on any given form identified by docket number, form number, and title.

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To request more information on this proposed information collection or to obtain a copy of the proposal and associated collection instruments, please write to Defense Health Agency, Performance Evaluation & Transition Management Branch, ATTN: Ann Fazzini, 16401 E. Centretech Parkway, Aurora, CO 80011-9066, telephone 303-676-3613.

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Title; Associated Form; and OMB Number: Health Insurance Claim Form, UB-04 CMS.1450, OMB Number 0720-0013.

Needs and Uses: The 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 beneficiary 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 by TRICARE/CHAMPUS to institutional providers.

Affected Public: Business or other for profit; Not-for-profit institutions.

Annual Burden Hours: 135,000.

Number of Respondents: 540,000.

Responses per Respondent: 1.

Average Burden per Response: 15 minutes.

Frequency: On occasion.

This collection instrument is for use by medical institutions filing for Start Printed Page 5095reimbursement with the Defense Health Program, TRICARE, which includes the Civilian Health and Medical Program of the Uniformed Services (TRICARE/CHAMPUS). TRICARE/CHAMPUS is a health benefits entitlement program for the dependents of active duty members of the Uniformed Services, and deceased sponsors, retirees and their dependents, of the Department of Homeland Security (Coast Guard) sponsors and certain North Atlantic Treaty Organization, National Oceanic and Atmospheric Administration, and Public Health Service eligible beneficiaries. Use of the UB-04/CMS-1450 continues TRICARE/CHAMPUS commitments to use the national standard claim form for reimbursement of medical services/supplies provided by institutional providers.

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Dated: January 27, 2015.

Aaron Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 2015-01793 Filed 1-29-15; 8:45 am]