Information Collection

State Notice of Insurance Benefits and Payment Parameters (153.100-153.110)

IC 198548 under ICR 201205-0938-009 · OMB 0938-1155.

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IC Title:

State Notice of Insurance Benefits and Payment Parameters (153.100-153.110)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.100-153.110

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	8,388	8,388
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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

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