Connect: Direct Applications for RAPS, Encounter, PDE, and MMP

Collection of Risk Adjustment Data from MA Organizations, Section 1876 Cost HMOS/CMPS, Section 1833 HCPPS, MMPS, and PACE Organizations (CMS-10340)

⚠️ Notice: This information collection may be referencing outdated material.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
12_2_4 RAPS Connect Direct Form with OMB [rev OSORA PRA].docx Instruction
12_2_5 Encounter Connect Direct Form with OMB [rev OSORA PRA].docx Instruction
12_2_6 PDE Connect Direct Form with OMB [rev OSORA PRA].docx Instruction
12_2_7 MMP Connect Direct Form with OMB [rev OSORA PRA].docx Instruction

Information Collection (IC) Details

IC Title:	Connect: Direct Applications for RAPS, Encounter, PDE, and MMP	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	12_2_4 RAPS Connect Direct Form with OMB [rev OSORA PRA].docx	Yes	Yes	Printable Only
Instruction	12_2_5 Encounter Connect Direct Form with OMB [rev OSORA PRA].docx	Yes	Yes	Printable Only
Instruction	12_2_6 PDE Connect Direct Form with OMB [rev OSORA PRA].docx	Yes	Yes	Printable Only
Instruction	12_2_7 MMP Connect Direct Form with OMB [rev OSORA PRA].docx	Yes	Yes	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 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,764	2,764
Annual IC Time Burden (Hours)	320	320
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.