Information Collection

Effective Rate Review Program

IC 212865 under ICR 201802-0938-006 · OMB 0938-1121.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10380_ERR Determination and Status Questions.pdf Effective Rate Review Determination and Status Questions	IC Document
CMS-10380 - Effective-Rate-Review-Survey-Instructions.docx ERR - Survey Instructions	IC Document
CMS-10380 - Survey Track Change.docx ERR Program - Survey document	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 154.301

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	51	2	49
Annual IC Time Burden (Hours)	255	10	245
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Effective Rate Review Determination and Status Questions	CMS-10380_ERR Determination and Status Questions.pdf	08/28/2014
ERR - Survey Instructions	CMS-10380 - Effective-Rate-Review-Survey-Instructions.docx	09/27/2016
ERR Program - Survey document	CMS-10380 - Survey Track Change.docx	09/27/2016

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