Information Collection

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)

IC 217422 under ICR 201507-0938-006 · OMB 0938-1285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10492 Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction
Form CMS-10492 Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction
CMS-10492 Data Submission Requirements to Receive the Federally-fa CMS-10492 - Issuer and TPA data elements for FFE adjustment.pdf	Form and Instruction
CMS-10492 Third Party Administrators' Submission Requirements for CMS-10492 - Attachment #2 UF_TPAContraceptUFAdjustForm_v3_draft_092915 FINAL.xlsx	Form and Instruction

IC Title:

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)

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 156.50(d)(2)(ii)

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 and Instruction	CMS-10492	Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	CMS-10492 - Issuer and TPA data elements for FFE adjustment.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10492	Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services	CMS-10492 - Attachment #2 UF_TPAContraceptUFAdjustForm_v3_draft_092915 FINAL.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 488

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	488	488
Annual IC Time Burden (Hours)	5,612	5,612
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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