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

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.