```

[Federal Register Volume 80, Number 20 (Friday, January 30, 2015)]
[Notices]
[Pages 5094-5095]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2015-01793]

=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF DEFENSE

Office of the Secretary

[Docket ID DoD-2015-HA-0008]

Proposed Collection; Comment Request

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

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: 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.

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

ADDRESSES: You may submit comments, identified by docket number and 
title, by any of the following methods:
     Federal eRulemaking Portal: http://www.regulations.gov. 
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 http://www.regulations.gov 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 http://www.regulations.gov for submitting comments. 
Please submit comments on any given form identified by docket number, 
form number, and title.

FOR FURTHER INFORMATION CONTACT: 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.

SUPPLEMENTARY INFORMATION:
    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

[[Page 5095]]

reimbursement 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.

    Dated: January 27, 2015.
Aaron Siegel,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2015-01793 Filed 1-29-15; 8:45 am]
BILLING CODE 5001-06-P
```