Information Collection

Issuer - Troubleshoot (Small Group)

IC 199282 under ICR 202108-0938-007 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 Issuer - Troubleshoot (Small Group)	Form and Instruction
CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Instruction
CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Instruction
CMS-10320 Appendix D_Data Collection 2017.pdf	Instruction
CMS-10320 Appendix D_Data Collection 2017.pdf	Instruction
CMS-10320 CMS-10320 Issuer - FINAL Instructions and Instruments CMS-10320 Issuer - FINAL Instructions and Instruments.pdf	Form and Instruction
CMS-10320 CMS-10320 Issuer - FINAL Instructions and Instruments CMS-10320 Issuer - FINAL Instructions and Instruments.pdf	Form and Instruction

IC Title:

Issuer - Troubleshoot (Small Group)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	CMS-10320 Issuer - FINAL Instructions and Instruments	CMS-10320 Issuer - FINAL Instructions and Instruments.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Yes	Yes	Paper Only
Instruction			CMS-10320 Appendix D_Data Collection 2017.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

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	500	-200	700
Annual IC Time Burden (Hours)	4,000	-1,600	5,600
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.