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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10219 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10219	CMS-10219.2_Effectiveness of Care A_pp 55-111	CMS-10219.2_Effectiveness of Care A_pp 55-111.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.1_General Guidelines_	CMS-10219.1_General Guidelines_to p 54.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.3_Effectiveness of Care B_pp 112-178	CMS-10219.3_Effectiveness of Care B_pp 112-178.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.4_Access-Availability of Care_pp 179-210.	CMS-10219.4_Access-Availability of Care_pp 179-210.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.5_Satisfaction with Care_pp 211-216.	CMS-10219.5_Satisfaction with Care_pp 211-216.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.6_Health Plan Stability_pp 217-220	CMS-10219.6_Health Plan Stability_pp 217-220.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.7_Use of Services A_pp 221-270	CMS-10219.7_Use of Services A_pp 221-270.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.8_Use of Services B_pp 271-302	CMS-10219.8_Use of Services B_pp 271-302.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.9_Cost of Care_pp 303-374	CMS-10219.9_Cost of Care_pp 303-374.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.10_Informed Health Care Choices_pp 375-378	CMS-10219.10_Informed Health Care Choices_pp 375-378.doc	Yes	Yes	Fillable Fileable
Form	CMS-10219	CMS-10219.11_Health Plan Description_pp 379-406	CMS-10219.11_Health Plan Description_pp 379-406.doc	Yes	Yes	Fillable Fileable
Other-Appendices			CMS-10219.12_Appendices 1-2-3-4-5-6-7.doc	Yes	Yes	Fillable Fileable
Instruction			CMS-10219.HEDIS 2007 Vol 2 file list.doc	Yes	Yes	Fillable Fileable
Instruction			CMS-10219.LICENSEAGREEMENT.doc	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 %

	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

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.