Information Collection

QHP Network and Formulary - Developer Documentation

IC 217257 under ICR 202011-0938-008 · OMB 0938-1284.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1284 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10558 QHP Network and Formulary - Developer Documentation	Form and Instruction
CMS-10558 QHP Provider Formulary CMS-10558-Machine Readable Appendix A-508.pdf	Form and Instruction
CMS-10558 QHP Provider Formulary CMS-10558-Machine Readable Appendix A-508.pdf	Form and Instruction
CMS-10558-Machine Readable Appendix B-508.pdf Appendix B	IC Document
CMS-10558-Machine Readable Appendix B-508.pdf Appendix B	IC Document

IC Title:

QHP Network and Formulary - Developer Documentation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.122(d)(1)(2) 45 CFR 156.230(c)

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-10558	QHP Provider Formulary	CMS-10558-Machine Readable Appendix A-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 376

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,512	-252	4,764
Annual IC Time Burden (Hours)	31,484	-51,092	82,576
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B	CMS-10558-Machine Readable Appendix B-508.pdf	11/27/2020

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