Information Collection

Payment Error Rate Measurement in Medicaid and the State Children Health Insurance Program

IC 8834 under ICR 201309-0938-009 · OMB 0938-0974.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0974 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10166 Payment Error Rate Measurement in Medicaid and the State Children Health Insurance Program	Form and Instruction
CMS-10166 CAP SHO Letter CAP SHO Letter FINAL to OMB 090407.doc	Form and Instruction
CMS-10166 IPIA IPIA.pdf	Form

IC Title:

Payment Error Rate Measurement in Medicaid and the State Children Health Insurance Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 431.970

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-10166	CAP SHO Letter	CAP SHO Letter FINAL to OMB 090407.doc		No	No	Fillable Fileable
Form	CMS-10166	IPIA	IPIA.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 99 %

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	34	0	34
Annual IC Time Burden (Hours)	56,100	27,540	28,560
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.