Information Collection

QHP Network and Formulary - Developer Documentation

IC 217257 under ICR 201511-0938-009 · OMB 0938-1284.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1284 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10558 QHP Network and Formulary - Developer Documentation	Form and Instruction
CMS-10558 QHP Network and Formulary - Developer Documentation CMS-10558 - QHP Network and Formulary - Developer Documentation 30 day.pdf	Form and Instruction
CMS-10558 - Developer Documentation Appendix B Index Schema.pdf Appendix B -Developer Documentation	IC Document

IC Title:

QHP Network and Formulary - Developer Documentation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.230(c) 45 CFR 156.122(d)(1)(2)

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-10558	QHP Network and Formulary - Developer Documentation	CMS-10558 - QHP Network and Formulary - Developer Documentation 30 day.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 475

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: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,700	5,700
Annual IC Time Burden (Hours)	98,800	98,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B -Developer Documentation	CMS-10558 - Developer Documentation Appendix B Index Schema.pdf	11/18/2015

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