Information Collection

Collection of Encounter Data from Medicare Advantage Organizations

IC 199936 under ICR 201605-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10340 Collection of Encounter Data from Medicare Advantage Organizations Form and Instruction
CMS-10340 Contract and Contact Verification Form Screen Shot - Sample PRS Contract and Contact Verification Form.docx Form and Instruction

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10340	Contract and Contact Verification Form	Screen Shot - Sample PRS Contract and Contact Verification Form.docx		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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	516,493,635	516,493,635
Annual IC Time Burden (Hours)	34,433	34,433
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.