Information Collection

Health Insurance Issuer Submission of the Preliminary Justification

IC 198019 under ICR 201403-0938-012 · OMB 0938-1141.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1141 can be found here:

Documents and Forms

Document Name Document Type
Preliminary Justification Submission Function.docx Other-Microsoft Word

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Issuer Submission of the Preliminary Justification	Agency IC Tracking Number:	CMS-10379

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Microsoft Word			Preliminary Justification Submission Function.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 65	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	163	-1,038	1,201
Annual IC Time Burden (Hours)	1,793	-11,418	13,211
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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