Information Collection

TPAs

IC 250668 under ICR 202112-0938-006 · OMB 0938-1407.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1407 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10788.RxDC Section 204 Reporting Instructions 11-23-21 (final).docx	Instruction
CMS-10788.RxDC Section 204 Reporting Instructions 11-23-21 (final).docx	Instruction

IC Title:

TPAs

Agency IC Tracking Number:

CCIIO - 10788

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 149.730 45 CFR 149.720 45 CFR 149.740

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
Instruction			CMS-10788.RxDC Section 204 Reporting Instructions 11-23-21 (final).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 92

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	416,970	416,970
Annual IC Cost Burden (Dollars)	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.