Information Collection

?414.1330 and §414.1335 Claims Submission Mechanism

IC 221777 under ICR 201611-0938-002 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10621 ?414.1330 and §414.1335 Claims Submission Mechanism	Form and Instruction
CMS-10621 List of Quality Performance Category Measures MIPS PRA Appendix A- List of Quality Performance Category Measures.doc	Form and Instruction

IC Title:

§414.1330 and §414.1335 Claims Submission Mechanism

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1330 and 414.1335

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-10621	List of Quality Performance Category Measures	MIPS PRA Appendix A- List of Quality Performance Category Measures.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 332,729

Number of Respondents for Small Entity: 332,729

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	332,729	332,729
Annual IC Time Burden (Hours)	6,255,305	6,255,305
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.