Health Insurance Issuer Submission of the Preliminary Justification

Rate Increase Disclosure and Review Reporting Requirements (CMS-10379)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1141 can be found here:

Documents and Forms

Document Name Document Type
Preliminary Justification Submission Function.docx Other-Microsoft Word
Revised 2017 Unified Rate Review Instructions clean 8.9.16.docx Instruction

Information Collection (IC) Details

IC Title:	Health Insurance Issuer Submission of the Preliminary Justification	Agency IC Tracking Number:	CMS-10379

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Microsoft Word			Preliminary Justification Submission Function.docx		Yes	No	Printable Only
Instruction			Revised 2017 Unified Rate Review Instructions clean 8.9.16.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,243	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: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,665	-3,985	7,650
Annual IC Time Burden (Hours)	41,213	-42,937	84,150
Annual IC Cost Burden (Dollars)	0	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.