Prepaid Health Plan Cost Report (HCPPS)

Prepaid Health Plan Cost Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0165 can be found here:

Documents and Forms

Document Name Document Type
CMS-276.Cost Report Instructions .pdf Instruction
CMS-276 CMS-276.4th Quarter Report CMS-276.4th Quarter Report.xls Form
CMS-276 CMS-276.Budget Forecast CMS-276.Budget Forecast.pdf Form
CMS-276 CMS-276.Final Cost Report CMS-276.Final Cost Report.xls Form
CMS-276 CMS-276.Interim report CMS-276.Interim report.xls Form

Information Collection (IC) Details

IC Title:	Prepaid Health Plan Cost Report (HCPPS)	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 417.810 42 CFR 417.808

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-276.Cost Report Instructions .pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	CMS-276.4th Quarter Report	CMS-276.4th Quarter Report.xls	Yes	Yes	Fillable Fileable
Form	CMS-276	CMS-276.Budget Forecast	CMS-276.Budget Forecast.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	CMS-276.Final Cost Report	CMS-276.Final Cost Report.xls	Yes	Yes	Fillable Fileable
Form	CMS-276	CMS-276.Interim report	CMS-276.Interim report.xls	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 85 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	36	-189	225
Annual IC Time Burden (Hours)	960	-6,900	7,860
Annual IC Cost Burden (Dollars)	0	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.