Information Collection

Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)

IC 227509 under ICR 201907-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)	Form and Instruction
CMS-10621 Other Payer Requests for Other Payer Advanced Alternativ Appendix H Payer Initiated Submission Form (7-8-19).docx	Form and Instruction

IC Title:

Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)

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 and Instruction	CMS-10621	Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix H Payer Initiated Submission Form (7-8-19).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 110

Number of Respondents for Small Entity: 110

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	110	-105	215
Annual IC Time Burden (Hours)	1,100	-1,050	2,150
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.