Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0978 can be found here:

Documents and Forms

Document Name Document Type
PDP-Manual-Chapter 14_dis.pdf Instruction
Final Automated TBT Guidance_dis.pdf Final Automated TBT Guidance_dis IC Document
Instructions SPAP_dis.pdf Instructions SPAP_dis IC Document
crosswalkCOB.doc crosswalkCOB IC Document
Updated Automated TBT Guidance v2_dis.pdf Track Change TBT Guidance IC Document
MDBGpraestimate_COB_5_28.xls MDBGpraestimate_COB_5_28 IC Document

Information Collection (IC) Details

IC Title:	Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.464

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			PDP-Manual-Chapter 14_dis.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56,988	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,153,767,270	2,153,767,270
Annual IC Time Burden (Hours)	1,017,914	1,017,914
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Final Automated TBT Guidance_dis	Final Automated TBT Guidance_dis.pdf	05/21/2009
Instructions SPAP_dis	Instructions SPAP_dis.pdf	05/21/2009
crosswalkCOB	crosswalkCOB.doc	05/27/2009
Track Change TBT Guidance	Updated Automated TBT Guidance v2_dis.pdf	05/21/2009
MDBGpraestimate_COB_5_28	MDBGpraestimate_COB_5_28.xls	05/27/2009

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