Information Collection

?414.1440 Other Payer Advanced APM Identification: Other Payer Initiated Process

IC 227509 under ICR 201711-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10621 ?414.1440 Other Payer Advanced APM Identification: Other Payer Initiated Process Form and Instruction
CMS-10621 Clinician Initiated Submission Form Appendix D Clinician Initiated Submission Form.pdf Form and Instruction
CMS-10621 Payer Initiated Submission Form Appendix E Payer Initiated Submission Form.pdf Form and Instruction
Crosswalk_Payer Submission Form_Amended.docx Crosswalk Payer Submission Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	§414.1440 Other Payer Advanced APM Identification: Other Payer Initiated Process	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1440

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10621	Payer Initiated Submission Form	Appendix E Payer Initiated Submission Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10621	Clinician Initiated Submission Form	Appendix D Clinician Initiated Submission Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 300

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	3,000	3,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk Payer Submission Form	Crosswalk_Payer Submission Form_Amended.docx	01/08/2018

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