Information Collection

Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt.)

IC 188581 under ICR 201309-0938-002 · OMB 0938-1074.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1074 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10265 Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt.)	Form and Instruction
CMS-10265 Interim Non-GHP Record Layout NGHPInterim120508[1].pdf	Form and Instruction

IC Title:

Mandatory Insurer Reporting (Non-GHP, State, Local, Tribal Govt.)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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
Form and Instruction	CMS-10265	Interim Non-GHP Record Layout	NGHPInterim120508[1].pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug System (MARx)

FR Citation: 70 FR 60530

Number of Respondents: 100

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,400	1,300	100
Annual IC Time Burden (Hours)	117	109	8
Annual IC Cost Burden (Dollars)	0	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.