Form CMS-10398 #55 CMS-10398 #55 State Fee Schedule Drop

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Overview

State Submission
PRA disclosure

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Sheet 1: State Submission

State Fee Schedule Drop
State:
HCPCS CODE	HCPCS Description	Modifier 1	Modifier 2	Payment Rate	Claim Volume	Medicare Area Code (if available)

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Sheet 2: PRA disclosure

PRA Disclosure Statement  According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #55). The time required to complete this information collection is estimated to average 8 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850