Information Collection

Mandatory Insurer Reporting (NGHP-Private)

IC 188580 under ICR 202011-0938-013 · OMB 0938-1074.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10625 Mandatory Insurer Reporting (NGHP-Private)	Form and Instruction
CMS-10625 Interim Non-GHP Record Layout 5 NGHP - 271 Health Care Eligibility Benefit Inquiry Companion Guide for Mandatory Report NGHP v5.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10625	Interim Non-GHP Record Layout	5 NGHP - 271 Health Care Eligibility Benefit Inquiry Companion Guide for Mandatory Report NGHP v5.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug System (MARx)

FR Citation: 70 FR 60530

Number of Respondents: 20,111

Number of Respondents for Small Entity: 20,111

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,618,000	1,218,000	2,400,000
Annual IC Time Burden (Hours)	301,500	101,508	199,992
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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