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

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-10492 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

Information Collection (IC) Details

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:

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 %

	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

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.