Information Collection

Collection of Encounter Data from Medicare Advantage Organizations

IC 199936 under ICR 201410-0938-009 · OMB 0938-1152.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1152 can be found here:

Documents and Forms

Document Name Document Type
Companion Guide - Durable Medical Equipment (DME) Supplier Professional Transaction based on ASC X12 Technical Report Type 3 (TR Instruction
Companion Guide - Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3).pdf Instruction
Companion Guide - Professional Transaction based on ASC X12 Technical Report Type 3 (TR3).pdf Instruction
Instruction - CSSC Operations Submitter Application Form.pdf Instruction
CMS-10340 CSSC Operation Submitter Application (hardcopy) CSSC Operation Submitter Application Form.pdf Form
CMS-10340 CSSC Operation Submitter Authorization Form (hardcopy) CSSC Operations Submitter Authorization Form.pdf Form
CMS-10340 Submitter Authorization (screen shots) Screen Shots - Submitter Application (Third Party and Contract Versions).pdf Form
2011-2014_EDS Companion Guides_Crosswalk_draft_061314.xlsx Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Collection of Encounter Data from Medicare Advantage Organizations	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 422.310

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Companion Guide - Durable Medical Equipment (DME) Supplier Professional Transaction based on ASC X12 Technical Report Type 3 (TR3).pdf	Yes	No	Printable Only
Instruction			Companion Guide - Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3).pdf	Yes	No	Printable Only
Instruction			Companion Guide - Professional Transaction based on ASC X12 Technical Report Type 3 (TR3).pdf	Yes	No	Printable Only
Form	CMS-10340	CSSC Operation Submitter Application (hardcopy)	CSSC Operation Submitter Application Form.pdf	Yes	No	Fillable Printable
Instruction			Instruction - CSSC Operations Submitter Application Form.pdf	Yes	No	Printable Only
Form	CMS-10340	CSSC Operation Submitter Authorization Form (hardcopy)	CSSC Operations Submitter Authorization Form.pdf	Yes	Yes	Fillable Printable
Form	CMS-10340	Submitter Authorization (screen shots)	Screen Shots - Submitter Application (Third Party and Contract Versions).pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 683	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	516,493,635	-324,951	-974,852	517,793,438
Annual IC Time Burden (Hours)	34,433	-22	-65	34,520
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	2011-2014_EDS Companion Guides_Crosswalk_draft_061314.xlsx	10/07/2014

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