State Exchange Improper Payment Measurement (SEIPM) Data Request Form

Estimation of Improper Payments of the Advanced Payment of Premium Tax Credit (APTC) in State Exchanges under the Affordable Care Act (CMS-10794)

Documents and Forms

Document Name Document Type
Form CMS-10794 State Exchange Improper Payment Measurement (SEIPM) Data Request Form Form and Instruction
CMS-10794 State Exchange Improper Payment Measurement Data Request CMS-10794 - SEIPM Data Request Form.xlsx Form and Instruction
CMS-10794 State Exchange Improper Payment Measurement Data Request CMS-10794 - SEIPM Data Request Form.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	State Exchange Improper Payment Measurement (SEIPM) Data Request Form	Agency IC Tracking Number:	CMS - 10794

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 155.1510

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10794	State Exchange Improper Payment Measurement Data Request Form	CMS-10794 - SEIPM Data Request Form.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	12,942	12,942
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.