Information Collection

(Quality Performance Category) Claims Collection Type (see Table SS-A 10)

IC 221777 under ICR 201812-0938-013 · OMB 0938-1314.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1314 can be found here:

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Information Collection (IC) Details

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IC Title:	(Quality Performance Category) Claims Collection Type (see Table SS-A 10)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1325 and 414.1335

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: 257,260	Number of Respondents for Small Entity: 257,260

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	257,260	-20,779	278,039
Annual IC Time Burden (Hours)	3,653,092	-1,296,002	4,949,094
Annual IC Cost Burden (Dollars)	0	0	0

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