Information Collection

2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)

IC 245881 under ICR 202107-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 30)	Form and Instruction
CMS-10621 2022 Submission Form for Other Payer Requests for Other Appendix D1 2022 Payer Initiated Submission Form.pdf	Form and Instruction
CMS-10621 2022 Submission Form for Other Payer Requests for Other Appendix D1 2022 Payer Initiated Submission Form.pdf	Form and Instruction
Appendix D2 2022 Payer Initiated Submission Form Crosswalk.pdf CROSSWALK (Appendix D2) 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determi	IC Document
Appendix D2 2022 Payer Initiated Submission Form Crosswalk.pdf CROSSWALK (Appendix D2) 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determi	IC Document

IC Title:

2022 >> Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 30)

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	2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix D1 2022 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: 15

Number of Respondents for Small Entity: 15

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	15	-65	80
Annual IC Time Burden (Hours)	150	-650	800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CROSSWALK (Appendix D2) 2022 Submission Form for Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix D2 2022 Payer Initiated Submission Form Crosswalk.pdf	09/01/2021

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