CMS-10476 MLR Data Form

MLR Data Form for Contract Year 2018

General Information
1. Contract Year
2. Contract Number
3. Organization Name
4. Date MLR Data Form finalized

MLR-2018.1
OMB Approved # 0938-1232
CMS-10476 (OMB exp date 12/31/2021)
2018
6. Adjusted MLR
7. Remittance Amount
01/27/2020

5. Contacts for any questions from CMS regarding this MLR Data Form:
Contact #1
Name, Position
Phone Number
E-mail Address
Contact #2
Name, Position
Phone Number
E-mail Address
According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this
information collection is 0938-1232. The time required to complete this
information collection is estimated to average 36 hours per response,
including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.