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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.