Information Collection

State Children's Health Insurance Program (SCHIP) Report on Payables and Receivables (CMS-10180)

IC 43677 under ICR 202002-0938-008 · OMB 0938-0988.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
IBNRSUserGuide_v1.7_3-2014 - Copy.pdf	Instruction
CMS-10180 Validation Letter_2020_508.pdf	Instruction
CMS-10180 CHIP INCURRED BUT NOT REPORTED (IBNR) SURVEY CMS-10180 Form_508_10-22-19.pdf	Form
CMS-10180 System Crosswalk_508_10-11-19.pdf Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

OFM

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			IBNRSUserGuide_v1.7_3-2014 - Copy.pdf	No		Fillable Fileable
Form	CMS-10180	CHIP INCURRED BUT NOT REPORTED (IBNR) SURVEY	CMS-10180 Form_508_10-22-19.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS-10180 Validation Letter_2020_508.pdf	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	1,792	1,400	392
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	CMS-10180 System Crosswalk_508_10-11-19.pdf	02/14/2020

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