Information Collection

Effective Rate Review Program

IC 212865 under ICR 201408-0938-009 · OMB 0938-1121.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1121 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10380_ERR Determination and Status Questions.pdf Effective Rate Review Determination and Status Questions	IC Document

IC Title:

Effective Rate Review Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 154.301

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 49

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	49	49
Annual IC Time Burden (Hours)	245	245
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Effective Rate Review Determination and Status Questions	CMS-10380_ERR Determination and Status Questions.pdf	08/28/2014

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