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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.