Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)

Part D Coordination of Benefits Data (CMS-10171)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0978 can be found here:

Documents and Forms

Document Name Document Type
Attachment 1_Transaction Facilitation.pdf Instruction
2014 SPAP cover_62613.pdf Instruction
CMS-10171 2017 SPAP Template Attachment 2_2017 SPAP template [rev 02-24-2017 by OSORA PRA].pdf Form

Information Collection (IC) Details

IC Title:	Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers (CMS-10171)	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 423.464

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attachment 1_Transaction Facilitation.pdf	Yes	Yes	Fillable Printable
Form	CMS-10171	2017 SPAP Template	Attachment 2_2017 SPAP template [rev 02-24-2017 by OSORA PRA].pdf	Yes	Yes	Fillable Printable
Instruction			2014 SPAP cover_62613.pdf	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 63,910	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	770,856,393	768,453,811	2,402,582
Annual IC Time Burden (Hours)	938,061	-4,267,067	5,205,128
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.