Information Collection

2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)

IC 245891 under ICR 202101-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)	Form
CMS-10621 Submission Form for Requests for Qualifying Alternative Appendix F1 All-Payer QP Data Submission Form.pdf	Form
CMS-10621 Submission Form for Requests for Qualifying Alternative Appendix F1 All-Payer QP Data Submission Form.pdf	Form

IC Title:

2022 >> Submission of Data for All-Payer QP Determinations under the All-Payer Combination Option (see SS-A Table 27)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	CMS-10621	Submission Form for Requests for Qualifying Alternative Payment Model Participant (QP) Determinations under the All-Payer Combination Option	Appendix F1 All-Payer QP Data 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: 551

Number of Respondents for Small Entity: 551

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	551	551
Annual IC Time Burden (Hours)	2,755	2,755
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.