Information Collection

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

IC 8840 under ICR 201008-0938-009 · OMB 0938-0978.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PDP-Manual-Chapter 14_dis.pdf	Instruction
Instructions SPAP_dis.pdf Instructions SPAP_dis	IC Document
Updated Automated TBT Guidance v2_dis.pdf Updated Automated TBT Guidance v2_dis	IC Document
MDBGpraestimate_COB_2-2010.xls MDBGpraestimate_COB_2-2010	IC Document

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:

table that charts list of 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	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57,227

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	248,018	55,856	-2,153,575,108	2,153,767,270
Annual IC Time Burden (Hours)	754,788	12,858	-275,984	1,017,914
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Instructions SPAP_dis	Instructions SPAP_dis.pdf	08/05/2010
Updated Automated TBT Guidance v2_dis	Updated Automated TBT Guidance v2_dis.pdf	08/05/2010
MDBGpraestimate_COB_2-2010	MDBGpraestimate_COB_2-2010.xls	08/05/2010

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