Information Collection

Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)

IC 233582 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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

Document Name Document Type
Form CMS-10621 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26) Form
CMS-10621 Submission Form for Requests for Qualifying Alternative Appendix F All-Payer QP Data Submission Form (version 2).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 26)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1440

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Appendix F All-Payer QP Data Submission Form (version 2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 309	Number of Respondents for Small Entity: 92

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	309	309
Annual IC Time Burden (Hours)	1,545	1,545
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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