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

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.