Information Collection

414.1445 Other Payer Advanced APM Determininations: Medicaid Specific Clinician Initiated Process

IC 229075 under ICR 201810-0938-007 · OMB 0938-1314.

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Information Collection (IC) Details

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IC Title:	414.1445 Other Payer Advanced APM Determininations: Medicaid Specific Clinician Initiated Process	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1445

Information Collection 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: 150	Number of Respondents for Small Entity: 75

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	150	75	75
Annual IC Time Burden (Hours)	1,500	750	750
Annual IC Cost Burden (Dollars)	0	0	0

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