Information Collection

Effective Rate Review Program

IC 212865 under ICR 201609-0938-018 · OMB 0938-1121.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1121 can be found here:

Documents and Forms

Document Name Document Type
CMS-10380_ERR Determination and Status Questions.pdf Effective Rate Review Determination and Status Questions IC Document
CMS-10380 - Effective-Rate-Review-Survey-Instructions.docx ERR - Survey Instructions IC Document
CMS-10380 - Survey Track Change.docx ERR Program - Survey document IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Effective Rate Review Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 154.301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 49	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	49	49
Annual IC Time Burden (Hours)	245	245
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Effective Rate Review Determination and Status Questions	CMS-10380_ERR Determination and Status Questions.pdf	08/28/2014
ERR - Survey Instructions	CMS-10380 - Effective-Rate-Review-Survey-Instructions.docx	09/27/2016
ERR Program - Survey document	CMS-10380 - Survey Track Change.docx	09/27/2016

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