Information Collection

State Exchange Improper Payment Measurement (SEIPM) Data Request Form

IC 251110 under ICR 202201-0938-017 · OMB 0938-1416.

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

View Information Collection (IC)

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.