Information Collection

DDR Quarterly Pricing Data Specifications (CMS-367a)

IC 8184 under ICR 201912-0938-003 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-367_Instructions_to_Labelers_August 2019_Final.pdf	Instruction
CMS-376a Quarterly Pricing Data 367a_August 2019_Final.pdf	Form
367a_August 2019_Track Changes.docx CMS-367a - Track Changes	IC Document
Form Record Specification Crosswalk 367a_August 2019.xlsx CMS-367a - Crosswalk	IC Document
Form Record Specification Crosswalk of Instructions Document December 2019.xlsx Instructions - Crosswalk	IC Document
CMS-367_Instructions_to_Labelers_August 2019_Track Changes.docx Instructions - Track Changes	IC Document

IC Title:

DDR Quarterly Pricing Data Specifications (CMS-367a)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction			CMS-367_Instructions_to_Labelers_August 2019_Final.pdf		Yes	Yes	Fillable Fileable
Form	CMS-376a	Quarterly Pricing Data	367a_August 2019_Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 743

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,972	532	2,440
Annual IC Time Burden (Hours)	103,426	18,514	84,912
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-367a - Track Changes	367a_August 2019_Track Changes.docx	12/12/2019
CMS-367a - Crosswalk	Form Record Specification Crosswalk 367a_August 2019.xlsx	12/12/2019
Instructions - Crosswalk	Form Record Specification Crosswalk of Instructions Document December 2019.xlsx	12/12/2019
Instructions - Track Changes	CMS-367_Instructions_to_Labelers_August 2019_Track Changes.docx	12/12/2019

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