Information Collection

DDR Quarterly Pricing Data (CMS-367a)

IC 8184 under ICR 202102-0938-016 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-376a DDR Quarterly Pricing Data (CMS-367a)	Form
CMS-367a - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf	Instruction
CMS-367a - Screenshots of MDP Web-Based Instructions_07.2021_508.pdf	Instruction
CMS-376a Quarterly Pricing Data CMS-367a - Screenshots of MDP Online Data Entry_07.2021_508.pdf	Form
CMS-376a Quarterly Pricing Data CMS-367a - Screenshots of MDP Online Data Entry_07.2021_508.pdf	Form
CMS Form-367a_Quarterly Pricing_Crosswalk_07.2021_508.pdf Crosswalk - CMS-367a	IC Document
CMS Form-367a_Quarterly Pricing_Crosswalk_07.2021_508.pdf Crosswalk - CMS-367a	IC Document

IC Title:

DDR Quarterly Pricing Data (CMS-367a)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	CMS-376a	Quarterly Pricing Data	CMS-367a - Screenshots of MDP Online Data Entry_07.2021_508.pdf		Yes	Yes	Fillable Fileable
Instruction			CMS-367a - Screenshots of MDP Web-Based Instructions_07.2021_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: 749

Number of Respondents for Small Entity: 100

Affected Public: Private Sector

Private Sector: 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	Previously Approved
Annual Number of Responses for this IC	2,996	24	2,972
Annual IC Time Burden (Hours)	104,261	835	103,426
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - CMS-367a	CMS Form-367a_Quarterly Pricing_Crosswalk_07.2021_508.pdf	02/26/2021

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