Information Collection

GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures

IC 236825 under ICR 201708-0938-004 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 #26 GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures	Form
QSSI-MACPro-PRA-AdditionalNotes.pdf	Instruction
QSSI-MACPro-PRA-AQM-MIH-DefOfPopulation.pdf	Instruction
QSSI-MACPro-PRA-CombinedRates.pdf	Instruction
QSSI-MACPro-PRA-DateRange.pdf	Instruction
QSSI-MACPro-PRA-CQM_DefOfPopulation.pdf	Instruction
QSSI-MACPro-PRA-NotReporting.pdf	Instruction
QSSI-MACPro-PRA-OPM.pdf	Instruction
QSSI-MACPro-PRA-StatusOfData.pdf	Instruction
QSSI-MACPro-PRA-TechnicalAssistance.pdf	Instruction
CMS-10434 #26 AQM2017-ABA QSSI-MACPro-PRA-AQM2017-ABA.pdf	Form
CMS-10434 #26 AQM2017-AdminScreen QSSI-MACPro-PRA-AQM2017-AdminScreen.pdf	Form
CMS-10434 #26 AQM2017-AMM QSSI-MACPro-PRA-AQM2017-AMM.pdf	Form
CMS-10434 #26 AQM2017-BCS QSSI-MACPro-PRA-AQM2017-BCS.pdf	Form
CMS-10434 #26 AQM2017-CBP QSSI-MACPro-PRA-AQM2017-CBP.pdf	Form
CMS-10434 #26 AQM2017-CCP QSSI-MACPro-PRA-AQM2017-CCP.pdf	Form
CMS-10434 #26 AQM2017-CCS QSSI-MACPro-PRA-AQM2017-CCS.pdf	Form
CMS-10434 #26 AQM2017-CDF QSSI-MACPro-PRA-AQM2017-CDF.pdf	Form
CMS-10434 #26 AQM2017-CHL QSSI-MACPro-PRA-AQM2017-CHL.pdf	Form
CMS-10434 #26 AQM2017-CPA QSSI-MACPro-PRA-AQM2017-CPA.pdf	Form
CMS-10434 #26 AQM2017-FUA QSSI-MACPro-PRA-AQM2017-FUA.pdf	Form
CMS-10434 #26 AQM2017-FUH QSSI-MACPro-PRA-AQM2017-FUH.pdf	Form
CMS-10434 #26 AQM2017-FVA QSSI-MACPro-PRA-AQM2017-FVA.pdf	Form
CMS-10434 #26 AQM2017-HA1C QSSI-MACPro-PRA-AQM2017-HA1C.pdf	Form
CMS-10434 #26 AQM2017-HPC QSSI-MACPro-PRA-AQM2017-HPC.pdf	Form
CMS-10434 #26 AQM2017-HPCMI QSSI-MACPro-PRA-AQM2017-HPCMI.pdf	Form
CMS-10434 #26 AQM2017-HVL QSSI-MACPro-PRA-AQM2017-HVL.pdf	Form
CMS-10434 #26 AQM2017-IET QSSI-MACPro-PRA-AQM2017-IET.pdf	Form
CMS-10434 #26 AQM2017-MPM QSSI-MACPro-PRA-AQM2017-MPM.pdf	Form
CMS-10434 #26 AQM2017-MSC QSSI-MACPro-PRA-AQM2017-MSC.pdf	Form
CMS-10434 #26 AQM2017-OHD QSSI-MACPro-PRA-AQM2017-OHD.pdf	Form
CMS-10434 #26 AQM2017-PCO1 QSSI-MACPro-PRA-AQM2017-PC01.pdf	Form
CMS-10434 #26 AQM2017-PC03 QSSI-MACPro-PRA-AQM2017-PC03.pdf	Form
CMS-10434 #26 AQM2017-PCR QSSI-MACPro-PRA-AQM2017-PCR.pdf	Form
CMS-10434 #26 AQM2017-PPC QSSI-MACPro-PRA-AQM2017-PPC.pdf	Form
CMS-10434 #26 AQM2017-PQI01 QSSI-MACPro-PRA-AQM2017-PQI01.pdf	Form
CMS-10434 #26 AQM2017-PQI05 QSSI-MACPro-PRA-AQM2017-PQI05.pdf	Form
CMS-10434 #26 AQM2017-PQI08 QSSI-MACPro-PRA-AQM2017-PQI08.pdf	Form
CMS-10434 #26 AQM2017-PQI15 QSSI-MACPro-PRA-AQM2017-PQI15.pdf	Form
CMS-10434 #26 AQM2017-SAA QSSI-MACPro-PRA-AQM2017-SAA.pdf	Form
CMS-10434 #26 AQM2017-SSD QSSI-MACPro-PRA-AQM2017-SSD.pdf	Form
CMS-10434 #26 AQM2018-ABA QSSI-MACPro-PRA-AQM2018-ABA.pdf	Form
CMS-10434 #26 AQM2018-AdminScreen QSSI-MACPro-PRA-AQM2018-AdminScreen.pdf	Form
CMS-10434 #26 AQM2018-AMM QSSI-MACPro-PRA-AQM2018-AMM.pdf	Form
CMS-10434 #26 AQM2018-AMR QSSI-MACPro-PRA-AQM2018-AMR.pdf	Form
CMS-10434 #26 AQM2018-BCS QSSI-MACPro-PRA-AQM2018-BCS.pdf	Form
CMS-10434 #26 AQM2018-CBP QSSI-MACPro-PRA-AQM2018-CBP.pdf	Form
CMS-10434 #26 AQM2018-CCP QSSI-MACPro-PRA-AQM2018-CCP.pdf	Form
CMS-10434 #26 AQM2018-CCS QSSI-MACPro-PRA-AQM2018-CCS.pdf	Form
CMS-10434 #26 AQM2018-CCW QSSI-MACPro-PRA-AQM2018-CCW.pdf	Form
CMS-10434 #26 AQM2018-CHL QSSI-MACPro-PRA-AQM2018-CHL.pdf	Form
CMS-10434 #26 AQM2018-COB QSSI-MACPro-PRA-AQM2018-COB.pdf	Form
CMS-10434 #26 AQM2018-CPA QSSI-MACPro-PRA-AQM2018-CPA.pdf	Form
CMS-10434 #26 AQM2018-FUA FUM QSSI-MACPro-PRA-AQM2018-FUA_FUM.pdf	Form
CMS-10434 #26 AQM2018-FUH QSSI-MACPro-PRA-AQM2018-FUH.pdf	Form
CMS-10434 #26 AQM2018-FVA QSSI-MACPro-PRA-AQM2018-FVA.pdf	Form
CMS-10434 #26 AQM2018-HA1C QSSI-MACPro-PRA-AQM2018-HA1C.pdf	Form
CMS-10434 #26 AQM2018-HPC QSSI-MACPro-PRA-AQM2018-HPC.pdf	Form
CMS-10434 #26 AQM2018-HPCMI QSSI-MACPro-PRA-AQM2018-HPCMI.pdf	Form
CMS-10434 #26 AQM2018-HVL QSSI-MACPro-PRA-AQM2018-HVL.pdf	Form
CMS-10434 #26 AQM2018-IET QSSI-MACPro-PRA-AQM2018-IET.pdf	Form
CMS-10434 #26 AQM2018-MPM AD QSSI-MACPro-PRA-AQM2018-MPM-AD.pdf	Form
CMS-10434 #26 AQM2018-MSC QSSI-MACPro-PRA-AQM2018-MSC.pdf	Form
CMS-10434 #26 AQM2018-OHD QSSI-MACPro-PRA-AQM2018-OHD.pdf	Form
CMS-10434 #26 AQM2018-PC01 AD QSSI-MACPro-PRA-AQM2018-PC01-AD.pdf	Form
CMS-10434 #26 AQM2018-PC03 AD QSSI-MACPro-PRA-AQM2018-PC03-AD.pdf	Form
CMS-10434 #26 AQM2018-PCR AD QSSI-MACPro-PRA-AQM2018-PCR-AD.pdf	Form
CMS-10434 #26 AQM2018-PPC AD QSSI-MACPro-PRA-AQM2018-PPC-AD.pdf	Form
CMS-10434 #26 AQM2018-PQI01 QSSI-MACPro-PRA-AQM2018-PQI01.pdf	Form
CMS-10434 #26 AQM2018-PQI05 QSSI-MACPro-PRA-AQM2018-PQI05.pdf	Form
CMS-10434 #26 AQM2018-PQI08 QSSI-MACPro-PRA-AQM2018-PQI08.pdf	Form
CMS-10434 #26 AQM2018-PQI15 QSSI-MACPro-PRA-AQM2018-PQI15.pdf	Form
CMS-10434 #26 AQM2018-SSA AD QSSI-MACPro-PRA-AQM2018-SAA-AD.pdf	Form
CMS-10434 #26 AQM2018-SSD AD QSSI-MACPro-PRA-AQM2018-SSD-AD.pdf	Form
CMS-10434 #26 CQM2017-ADD QSSI-MACPro-PRA-CQM2017-ADD.pdf	Form
CMS-10434 #26 CQM2017-AdminScreen QSSI-MACPro-PRA-CQM2017-AdminScreen.pdf	Form
CMS-10434 #26 CQM2017-AMB QSSI-MACPro-PRA-CQM2017-AMB.pdf	Form
CMS-10434 #26 CQM2017-APC QSSI-MACPro-PRA-CQM2017-APC.pdf	Form
CMS-10434 #26 CQM2017-APP QSSI-MACPro-PRA-CQM2017-APP.pdf	Form
CMS-10434 #26 CQM2017-AUD QSSI-MACPro-PRA-CQM2017-AUD.pdf	Form
CMS-10434 #26 CQM2017-AWC QSSI-MACPro-PRA-CQM2017-AWC.pdf	Form
CMS-10434 #26 CQM2017-BHRA QSSI-MACPro-PRA-CQM2017-BHRA.pdf	Form
CMS-10434 #26 CQM2017-CAP QSSI-MACPro-PRA-CQM2017-CAP.pdf	Form
CMS-10434 #26 CQM2017-CHL QSSI-MACPro-PRA-CQM2017-CHL.pdf	Form
CMS-10434 #26 CQM2017-CIS QSSI-MACPro-PRA-CQM2017-CIS.pdf	Form
CMS-10434 #26 CQM2017-CLABSI QSSI-MACPro-PRA-CQM2017-CLABSI.pdf	Form
CMS-10434 #26 CQM2017-CPC QSSI-MACPro-PRA-CQM2017-CPC.pdf	Form
CMS-10434 #26 CQM2017-DEV QSSI-MACPro-PRA-CQM2017-DEV.pdf	Form
CMS-10434 #26 CQM2017-FPC QSSI-MACPro-PRA-CQM2017-FPC.pdf	Form
CMS-10434 #26 CQM2017-FUH QSSI-MACPro-PRA-CQM2017-FUH.pdf	Form
CMS-10434 #26 CQM2017-IMA QSSI-MACPro-PRA-CQM2017-IMA.pdf	Form
CMS-10434 #26 CQM2017-LBW QSSI-MACPro-PRA-CQM2017-LBW.pdf	Form
CMS-10434 #26 CQM2017-MMA QSSI-MACPro-PRA-CQM2017-MMA.pdf	Form
CMS-10434 #26 CQM2017-PC02 QSSI-MACPro-PRA-CQM2017-PC02.pdf	Form
CMS-10434 #26 CQM2017-PDENT QSSI-MACPro-PRA-CQM2017-PDENT.pdf	Form
CMS-10434 #26 CQM2017-PPC QSSI-MACPro-PRA-CQM2017-PPC.pdf	Form
CMS-10434 #26 CQM2017-SEAL QSSI-MACPro-PRA-CQM2017-SEAL.pdf	Form
CMS-10434 #26 CQM2017-SRA QSSI-MACPro-PRA-CQM2017-SRA.pdf	Form
CMS-10434 #26 CQM2017-StateSpecific QSSI-MACPro-PRA-CQM2017-StateSpecific.pdf	Form
CMS-10434 #26 CQM2017-W15 QSSI-MACPro-PRA-CQM2017-W15.pdf	Form
CMS-10434 #26 CQM2017-W34 QSSI-MACPro-PRA-CQM2017-W34.pdf	Form
CMS-10434 #26 CQM2017-WCC QSSI-MACPro-PRA-CQM2017-WCC.pdf	Form
CMS-10434 #26 CQM2018-ADD-CH QSSI-MACPro-PRA-CQM2018-ADD-CH.pdf	Form
CMS-10434 #26 CQM2018-AdminScreen QSSI-MACPro-PRA-CQM2018-AdminScreen.pdf	Form
CMS-10434 #26 CQM2018-AMB-CH QSSI-MACPro-PRA-CQM2018-AMB-CH.pdf	Form
CMS-10434 #26 CQM2018-AMR-CH QSSI-MACPro-PRA-CQM2018-AMR-CH.pdf	Form
CMS-10434 #26 CQM2018-APC-CH QSSI-MACPro-PRA-CQM2018-APC-CH.pdf	Form
CMS-10434 #26 CQM2018-APP-CH QSSI-MACPro-PRA-CQM2018-APP-CH.pdf	Form
CMS-10434 #26 CQM2018-AUD-CH QSSI-MACPro-PRA-CQM2018-AUD-CH.pdf	Form
CMS-10434 #26 CQM2018-AWC-CH QSSI-MACPro-PRA-CQM2018-AWC-CH.pdf	Form
CMS-10434 #26 CQM2018-CAP-CH QSSI-MACPro-PRA-CQM2018-CAP-CH.pdf	Form
CMS-10434 #26 CQM2018-CCP-CH QSSI-MACPro-PRA-CQM2018-CCP-CH.pdf	Form
CMS-10434 #26 CQM2018-CCW-CH QSSI-MACPro-PRA-CQM2018-CCW-CH.pdf	Form
CMS-10434 #26 CQM2018-CDF-CH QSSI-MACPro-PRA-CQM2018-CDF-CH.pdf	Form
CMS-10434 #26 CQM2018-CHL-CH QSSI-MACPro-PRA-CQM2018-CHL-CH.pdf	Form
CMS-10434 #26 CQM2018-CIS-CH QSSI-MACPro-PRA-CQM2018-CIS-CH.pdf	Form
CMS-10434 #26 CQM2018-CLABSI-CH QSSI-MACPro-PRA-CQM2018-CLABSI-CH.pdf	Form
CMS-10434 #26 CQM2018-CPC-CH QSSI-MACPro-PRA-CQM2018-CPC-CH.pdf	Form
CMS-10434 #26 CQM2018-DEV-CH QSSI-MACPro-PRA-CQM2018-DEV-CH.pdf	Form
CMS-10434 #26 CQM2018-FUH-CH QSSI-MACPro-PRA-CQM2018-FUH-CH.pdf	Form
CMS-10434 #26 CQM2018-IMA-CH QSSI-MACPro-PRA-CQM2018-IMA-CH.pdf	Form
CMS-10434 #26 CQM2018-LBW-CH QSSI-MACPro-PRA-CQM2018-LBW-CH.pdf	Form
CMS-10434 #26 CQM2018-PC02-CH QSSI-MACPro-PRA-CQM2018-PC02-CH.pdf	Form
CMS-10434 #26 CQM2018-PDENT-CH QSSI-MACPro-PRA-CQM2018-PDENT-CH.pdf	Form
CMS-10434 #26 CQM2018-PPC-CH QSSI-MACPro-PRA-CQM2018-PPC-CH.pdf	Form
CMS-10434 #26 CQM2018-SEAL-CH QSSI-MACPro-PRA-CQM2018-SEAL-CH.pdf	Form
CMS-10434 #26 CQM2018-W15-CH QSSI-MACPro-PRA-CQM2018-W15-CH.pdf	Form
CMS-10434 #26 CQM2018-W34-CH QSSI-MACPro-PRA-CQM2018-W34-CH.pdf	Form
CMS-10434 #26 CQM2018-WCC-CH QSSI-MACPro-PRA-CQM2018-WCC-CH.pdf	Form
26 - Supporting Statement (2019 version 2).docx Generic Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

GenIC #26 (Transfer from 0938-1148) - Medicaid Adult and Child Core Set Measures

Agency IC Tracking Number:

CMCS

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 #26	AQM2017-ABA	QSSI-MACPro-PRA-AQM2017-ABA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-AdminScreen	QSSI-MACPro-PRA-AQM2017-AdminScreen.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-AMM	QSSI-MACPro-PRA-AQM2017-AMM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-BCS	QSSI-MACPro-PRA-AQM2017-BCS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CBP	QSSI-MACPro-PRA-AQM2017-CBP.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CCP	QSSI-MACPro-PRA-AQM2017-CCP.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CCS	QSSI-MACPro-PRA-AQM2017-CCS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CDF	QSSI-MACPro-PRA-AQM2017-CDF.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CHL	QSSI-MACPro-PRA-AQM2017-CHL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-CPA	QSSI-MACPro-PRA-AQM2017-CPA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-FUA	QSSI-MACPro-PRA-AQM2017-FUA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-FUH	QSSI-MACPro-PRA-AQM2017-FUH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-FVA	QSSI-MACPro-PRA-AQM2017-FVA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-HA1C	QSSI-MACPro-PRA-AQM2017-HA1C.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-HPC	QSSI-MACPro-PRA-AQM2017-HPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-HPCMI	QSSI-MACPro-PRA-AQM2017-HPCMI.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-HVL	QSSI-MACPro-PRA-AQM2017-HVL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-IET	QSSI-MACPro-PRA-AQM2017-IET.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-MPM	QSSI-MACPro-PRA-AQM2017-MPM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-MSC	QSSI-MACPro-PRA-AQM2017-MSC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-OHD	QSSI-MACPro-PRA-AQM2017-OHD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PCO1	QSSI-MACPro-PRA-AQM2017-PC01.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PC03	QSSI-MACPro-PRA-AQM2017-PC03.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PCR	QSSI-MACPro-PRA-AQM2017-PCR.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PPC	QSSI-MACPro-PRA-AQM2017-PPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PQI01	QSSI-MACPro-PRA-AQM2017-PQI01.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PQI05	QSSI-MACPro-PRA-AQM2017-PQI05.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PQI08	QSSI-MACPro-PRA-AQM2017-PQI08.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-PQI15	QSSI-MACPro-PRA-AQM2017-PQI15.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-SAA	QSSI-MACPro-PRA-AQM2017-SAA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2017-SSD	QSSI-MACPro-PRA-AQM2017-SSD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-ABA	QSSI-MACPro-PRA-AQM2018-ABA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-AdminScreen	QSSI-MACPro-PRA-AQM2018-AdminScreen.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-AMM	QSSI-MACPro-PRA-AQM2018-AMM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-AMR	QSSI-MACPro-PRA-AQM2018-AMR.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-HPC	QSSI-MACPro-PRA-AQM2018-HPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-HPCMI	QSSI-MACPro-PRA-AQM2018-HPCMI.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-HVL	QSSI-MACPro-PRA-AQM2018-HVL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-IET	QSSI-MACPro-PRA-AQM2018-IET.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-MPM AD	QSSI-MACPro-PRA-AQM2018-MPM-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-MSC	QSSI-MACPro-PRA-AQM2018-MSC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-OHD	QSSI-MACPro-PRA-AQM2018-OHD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PC01 AD	QSSI-MACPro-PRA-AQM2018-PC01-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PC03 AD	QSSI-MACPro-PRA-AQM2018-PC03-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PCR AD	QSSI-MACPro-PRA-AQM2018-PCR-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PPC AD	QSSI-MACPro-PRA-AQM2018-PPC-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PQI01	QSSI-MACPro-PRA-AQM2018-PQI01.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PQI05	QSSI-MACPro-PRA-AQM2018-PQI05.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-BCS	QSSI-MACPro-PRA-AQM2018-BCS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CBP	QSSI-MACPro-PRA-AQM2018-CBP.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CCP	QSSI-MACPro-PRA-AQM2018-CCP.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CCS	QSSI-MACPro-PRA-AQM2018-CCS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CCW	QSSI-MACPro-PRA-AQM2018-CCW.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CHL	QSSI-MACPro-PRA-AQM2018-CHL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-COB	QSSI-MACPro-PRA-AQM2018-COB.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-CPA	QSSI-MACPro-PRA-AQM2018-CPA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-FUA FUM	QSSI-MACPro-PRA-AQM2018-FUA_FUM.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-FUH	QSSI-MACPro-PRA-AQM2018-FUH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-FVA	QSSI-MACPro-PRA-AQM2018-FVA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-HA1C	QSSI-MACPro-PRA-AQM2018-HA1C.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-AUD	QSSI-MACPro-PRA-CQM2017-AUD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-AWC	QSSI-MACPro-PRA-CQM2017-AWC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-BHRA	QSSI-MACPro-PRA-CQM2017-BHRA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-CAP	QSSI-MACPro-PRA-CQM2017-CAP.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-CHL	QSSI-MACPro-PRA-CQM2017-CHL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-CIS	QSSI-MACPro-PRA-CQM2017-CIS.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-CLABSI	QSSI-MACPro-PRA-CQM2017-CLABSI.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-CPC	QSSI-MACPro-PRA-CQM2017-CPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-DEV	QSSI-MACPro-PRA-CQM2017-DEV.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-FPC	QSSI-MACPro-PRA-CQM2017-FPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-FUH	QSSI-MACPro-PRA-CQM2017-FUH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-IMA	QSSI-MACPro-PRA-CQM2017-IMA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-LBW	QSSI-MACPro-PRA-CQM2017-LBW.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-MMA	QSSI-MACPro-PRA-CQM2017-MMA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-PC02	QSSI-MACPro-PRA-CQM2017-PC02.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-PDENT	QSSI-MACPro-PRA-CQM2017-PDENT.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-PPC	QSSI-MACPro-PRA-CQM2017-PPC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-SEAL	QSSI-MACPro-PRA-CQM2017-SEAL.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-SRA	QSSI-MACPro-PRA-CQM2017-SRA.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-StateSpecific	QSSI-MACPro-PRA-CQM2017-StateSpecific.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-W15	QSSI-MACPro-PRA-CQM2017-W15.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-W34	QSSI-MACPro-PRA-CQM2017-W34.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-WCC	QSSI-MACPro-PRA-CQM2017-WCC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-ADD-CH	QSSI-MACPro-PRA-CQM2018-ADD-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-AdminScreen	QSSI-MACPro-PRA-CQM2018-AdminScreen.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-AMB-CH	QSSI-MACPro-PRA-CQM2018-AMB-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-AMR-CH	QSSI-MACPro-PRA-CQM2018-AMR-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-APC-CH	QSSI-MACPro-PRA-CQM2018-APC-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-APP-CH	QSSI-MACPro-PRA-CQM2018-APP-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-AUD-CH	QSSI-MACPro-PRA-CQM2018-AUD-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-AWC-CH	QSSI-MACPro-PRA-CQM2018-AWC-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CAP-CH	QSSI-MACPro-PRA-CQM2018-CAP-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CCP-CH	QSSI-MACPro-PRA-CQM2018-CCP-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CCW-CH	QSSI-MACPro-PRA-CQM2018-CCW-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CDF-CH	QSSI-MACPro-PRA-CQM2018-CDF-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CHL-CH	QSSI-MACPro-PRA-CQM2018-CHL-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CIS-CH	QSSI-MACPro-PRA-CQM2018-CIS-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CLABSI-CH	QSSI-MACPro-PRA-CQM2018-CLABSI-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-CPC-CH	QSSI-MACPro-PRA-CQM2018-CPC-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-DEV-CH	QSSI-MACPro-PRA-CQM2018-DEV-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-FUH-CH	QSSI-MACPro-PRA-CQM2018-FUH-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-IMA-CH	QSSI-MACPro-PRA-CQM2018-IMA-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-LBW-CH	QSSI-MACPro-PRA-CQM2018-LBW-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-PC02-CH	QSSI-MACPro-PRA-CQM2018-PC02-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-PDENT-CH	QSSI-MACPro-PRA-CQM2018-PDENT-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-PPC-CH	QSSI-MACPro-PRA-CQM2018-PPC-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-SEAL-CH	QSSI-MACPro-PRA-CQM2018-SEAL-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-W15-CH	QSSI-MACPro-PRA-CQM2018-W15-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-W34-CH	QSSI-MACPro-PRA-CQM2018-W34-CH.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2018-WCC-CH	QSSI-MACPro-PRA-CQM2018-WCC-CH.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-AdditionalNotes.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-AQM-MIH-DefOfPopulation.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-CombinedRates.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-DateRange.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-CQM_DefOfPopulation.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-NotReporting.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-OPM.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-StatusOfData.pdf	Yes	Yes	Fillable Fileable
Instruction			QSSI-MACPro-PRA-TechnicalAssistance.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PQI08	QSSI-MACPro-PRA-AQM2018-PQI08.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-PQI15	QSSI-MACPro-PRA-AQM2018-PQI15.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-SSA AD	QSSI-MACPro-PRA-AQM2018-SAA-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	AQM2018-SSD AD	QSSI-MACPro-PRA-AQM2018-SSD-AD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-ADD	QSSI-MACPro-PRA-CQM2017-ADD.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-AdminScreen	QSSI-MACPro-PRA-CQM2017-AdminScreen.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-AMB	QSSI-MACPro-PRA-CQM2017-AMB.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-APC	QSSI-MACPro-PRA-CQM2017-APC.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10434 #26	CQM2017-APP	QSSI-MACPro-PRA-CQM2017-APP.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	224	224
Annual IC Time Burden (Hours)	8,960	8,960
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	26 - Supporting Statement (2019 version 2).docx	07/11/2019

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