Information Collection

Health Insurance Issuer Submission of the Preliminary Justification

IC 198019 under ICR 201907-0938-002 · OMB 0938-1141.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1141 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10379 - URRT v5.0 Template.xlsm	Other-Microsoft Word
CMS-10379 - URR Instructions 508d.pdf	Instruction

IC Title:

Health Insurance Issuer Submission of the Preliminary Justification

Agency IC Tracking Number:

CMS-10379

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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
Other-Microsoft Word			CMS-10379 - URRT v5.0 Template.xlsm		Yes	No	Printable Only
Instruction			CMS-10379 - URR Instructions 508d.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 589

Number of Respondents for Small Entity: 0

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	589	-3,076	3,665
Annual IC Time Burden (Hours)	20,239	-20,974	41,213
Annual IC Cost Burden (Dollars)	0	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.