Information Collection

Risk Adjustment Data Submission

IC 199936 under ICR 201612-0938-021 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
12_2_9 Companion Guide - Institutional Transaction based on ASC X12 (rev OSORA PRA).pdf	Instruction
12_2_10 Companion Guide - Professional Transaction based on ASC X12 TR3 (rev OSORA PRA).pdf	Instruction
12_2_11 Companion Guide - Durable Medical Equipment (DME) Professional (rev OSORA PRA).pdf	Instruction

IC Title:

Risk Adjustment Data Submission

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:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Instruction	12_2_9 Companion Guide - Institutional Transaction based on ASC X12 (rev OSORA PRA).pdf	No	Fillable Printable
Instruction	12_2_10 Companion Guide - Professional Transaction based on ASC X12 TR3 (rev OSORA PRA).pdf	No	Printable Only
Instruction	12_2_11 Companion Guide - Durable Medical Equipment (DME) Professional (rev OSORA PRA).pdf	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 691

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	769,391,164	252,897,529	516,493,635
Annual IC Time Burden (Hours)	18,817	-15,616	34,433
Annual IC Cost Burden (Dollars)	0	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.