Information Collection

Eob

IC 208197 under ICR 201308-0938-013 · OMB 0938-1228.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1228 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10453 EOB	Form and Instruction
CMS-10453 Example of HMO Monthly Summary Example of populated HMO_monthly summary_06.13.2013.pdf	Form and Instruction
CMS-10453 HMO Quarterly Summary HMO_quarterly summary_06.13.2013.pdf	Form and Instruction
CMS-10453 HMO Monthly HMO_monthly EOB_06.13.2013.pdf	Form and Instruction
CMS-10453 MSA Monthly EOB MSA_monthly EOB_06.13.2013.pdf	Form and Instruction
CMS-10453 MSA Quarterly Summary MSA_quarterly summary_06.13.2013.pdf	Form and Instruction
CMS-10452 PFFS monthly EOB PFFS_monthly EOB_06.13.2013.pdf	Form and Instruction
CMS-10453 PFFS quarterly summary PFFS_quarterly summary_06.13.2013.pdf	Form and Instruction
CMS-10453 PPA Monthly EOB PPO_monthly EOB_06.13.2013.pdf	Form and Instruction
CMS-10453 PPO quarterly summary PPO_quarterly summary_06.13.2013.pdf	Form and Instruction

IC Title:

EOB

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.128 42 CFR 422.111(b)(12) 42 CFR 423.104 42 CFR 423.120 42 CFR 422.216

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10453	Example of HMO Monthly Summary	Example of populated HMO_monthly summary_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	HMO Quarterly Summary	HMO_quarterly summary_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	HMO Monthly	HMO_monthly EOB_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	MSA Monthly EOB	MSA_monthly EOB_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	MSA Quarterly Summary	MSA_quarterly summary_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10452	PFFS monthly EOB	PFFS_monthly EOB_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	PFFS quarterly summary	PFFS_quarterly summary_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	PPA Monthly EOB	PPO_monthly EOB_06.13.2013.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	PPO quarterly summary	PPO_quarterly summary_06.13.2013.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 564

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	6,768	6,768
Annual IC Time Burden (Hours)	97,760	97,760
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.