Information Collection

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

IC 8840 under ICR 201311-0938-015 · OMB 0938-0978.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0978 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PDBM-Chapter 14 08202013.doc	Instruction
2014 SPAP cover_62613.pdf	Instruction
CMS-10171 SPAP Plan to Wrap-Around Part D for CY 2014 2014 SPAPtemplate.pdf	Form
CROSSWALK -- PDBM-Chapter 14.doc Crosswalk	IC Document
MDBGpraestimate_COB_06_17_2013.xls Burden Estimate Table	IC Document

IC Title:

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.464

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
Instruction			PDBM-Chapter 14 08202013.doc	Yes	Yes	Fillable Printable
Form	CMS-10171	SPAP Plan to Wrap-Around Part D for CY 2014	2014 SPAPtemplate.pdf	Yes	Yes	Fillable Printable
Instruction			2014 SPAP cover_62613.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57,116

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,402,582	2,154,564	248,018
Annual IC Time Burden (Hours)	5,205,128	4,450,340	754,788
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CROSSWALK -- PDBM-Chapter 14.doc	11/14/2013
Burden Estimate Table	MDBGpraestimate_COB_06_17_2013.xls	11/14/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.