Information Collection

Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 23)

IC 227509 under ICR 202007-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 23)	Form and Instruction
CMS-10621 Other Payer Requests for Other Payer Advanced Alternativ Appendix D1 Payer Initiated Submission Form.pdf	Form and Instruction
Appendix D2 Payer Initiated Submission Form Crosswalk.pdf Crosswalk: Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Ini	IC Document

IC Title:

Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 23)

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 D1 Payer Initiated Submission Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Quality Payment Program (QPP), System No. 09â70â 0539

FR Citation: 83 FR 6587

Number of Respondents: 80

Number of Respondents for Small Entity: 80

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	80	-30	110
Annual IC Time Burden (Hours)	800	-300	1,100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk: Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix D2 Payer Initiated Submission Form Crosswalk.pdf	08/20/2020

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