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Intermediary Benefit Payment Report
INTERMEDIARY BENEFIT PAYMENT REPORT
OMB: 0938-0371
IC ID: 113573
OMB.report
HHS/CMS
OMB 0938-0371
ICR 198705-0938-002
IC 113573
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0371 can be found here:
1993-03-16 - Revision of a currently approved collection
1991-10-24 - Reinstatement with change of a previously approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
INTERMEDIARY BENEFIT PAYMENT REPORT
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
HCFA-456
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
62
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
62
0
0
0
0
62
Annual IC Time Burden (Hours)
22,320
0
0
0
0
22,320
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.