Information Collection

HEDIS Information Collection Request

IC 181326 under ICR 200707-0938-012 · OMB 0938-1028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1028 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10219 CMS-10219.2_Effectiveness of Care A_pp 55-111 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.1_General Guidelines_ HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.3_Effectiveness of Care B_pp 112-178 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.4_Access-Availability of Care_pp 179-210. HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.5_Satisfaction with Care_pp 211-216. HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.6_Health Plan Stability_pp 217-220 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.7_Use of Services A_pp 221-270 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.8_Use of Services B_pp 271-302 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.9_Cost of Care_pp 303-374 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.10_Informed Health Care Choices_pp 375-378 HEDIS Information Collection Request	Form
Form CMS-10219 CMS-10219.11_Health Plan Description_pp 379-406 HEDIS Information Collection Request	Form
CMS-10219.12_Appendices 1-2-3-4-5-6-7.doc	Other-Appendices
CMS-10219.HEDIS 2007 Vol 2 file list.doc	Instruction
CMS-10219.LICENSEAGREEMENT.doc	Instruction
CMS-10219 CMS-10219.2_Effectiveness of Care A_pp 55-111 CMS-10219.2_Effectiveness of Care A_pp 55-111.doc	Form
CMS-10219 CMS-10219.1_General Guidelines_ CMS-10219.1_General Guidelines_to p 54.doc	Form
CMS-10219 CMS-10219.3_Effectiveness of Care B_pp 112-178 CMS-10219.3_Effectiveness of Care B_pp 112-178.doc	Form
CMS-10219 CMS-10219.4_Access-Availability of Care_pp 179-210. CMS-10219.4_Access-Availability of Care_pp 179-210.doc	Form
CMS-10219 CMS-10219.5_Satisfaction with Care_pp 211-216. CMS-10219.5_Satisfaction with Care_pp 211-216.doc	Form
CMS-10219 CMS-10219.6_Health Plan Stability_pp 217-220 CMS-10219.6_Health Plan Stability_pp 217-220.doc	Form
CMS-10219 CMS-10219.7_Use of Services A_pp 221-270 CMS-10219.7_Use of Services A_pp 221-270.doc	Form
CMS-10219 CMS-10219.8_Use of Services B_pp 271-302 CMS-10219.8_Use of Services B_pp 271-302.doc	Form
CMS-10219 CMS-10219.9_Cost of Care_pp 303-374 CMS-10219.9_Cost of Care_pp 303-374.doc	Form
CMS-10219 CMS-10219.10_Informed Health Care Choices_pp 375-378 CMS-10219.10_Informed Health Care Choices_pp 375-378.doc	Form
CMS-10219 CMS-10219.11_Health Plan Description_pp 379-406 CMS-10219.11_Health Plan Description_pp 379-406.doc	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

HEDIS Information Collection Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Form	CMS-10219	Yes	Yes	Fillable Fileable
Other-Appendices		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 705

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	705	705
Annual IC Time Burden (Hours)	33,840	33,840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].