Information Collection

Generalized Claims Data Call Submission

IC 226677 under ICR 201401-0938-013 · OMB 0938-1251.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1251 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10501 Generalized Claims Data Call Submission	Form
Instructions TTP Data Call Submission Process PRA Package 411.docx	Instruction
CMS-10501 Data Submission Template Data Submission Template PRA Package 411.docx	Form
CMS-10501 - Generic Mini Supporting Statement 6817.docx CMS-10501 - Generic Mini Supporting Statement	IC Document

IC Title:

Generalized Claims Data Call Submission

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	CMS-10501	Data Submission Template	Data Submission Template PRA Package 411.docx		No		Fillable Printable
Instruction			Instructions TTP Data Call Submission Process PRA Package 411.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10501 - Generic Mini Supporting Statement	CMS-10501 - Generic Mini Supporting Statement 6817.docx	06/08/2017

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