Information Collection

Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt., System Set-up and Administration)

IC 188584 under ICR 200903-0938-009 · OMB 0938-1074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1074 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10265 Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt., System Set-up and Administration) Form and Instruction
CMS-10265 Interim Non-GHP Record Layout NGHPInterim120508[1].pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt., System Set-up and Administration)	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10265	Interim Non-GHP Record Layout	NGHPInterim120508[1].pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Advantage Prescription Drug System (MARx)	FR Citation: 70 FR 60530

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	27	27
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.