Signature Attestation

Fee-for-Service Recovery Audit Prepayment Review Demonstration and Prior Authorization Demonstration (CMS-10421)

OMB: 0938-1169

IC ID: 202524

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Information Collection (IC) Details

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Signature Attestation
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
42 CFR 421.200, 210, 304, 400

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability

Health Health Care Services

 

4,750 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,750 0 0 0 4,750 0
Annual IC Time Burden (Hours) 1,188 0 0 0 1,188 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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