Information Collection

DDR Monthly Pricing Data (CMS-367b)

IC 222505 under ICR 202203-0938-002 · OMB 0938-0578.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0578 can be found here:

Documents and Forms

Document Name Document Type
CMS-367b Instruction Screenshots_09.2021.pdf Instruction
CMS-367b Instruction Screenshots_09.2021.pdf Instruction
CMS-367b Monthly Pricing Data CMS-367b Data Entry Screenshots_09.2021.pdf Form
CMS-367b Monthly Pricing Data CMS-367b Data Entry Screenshots_09.2021.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DDR Monthly Pricing Data (CMS-367b)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-367b Instruction Screenshots_09.2021.pdf		Yes	Yes	Fillable Fileable
Form	CMS-367b	Monthly Pricing Data	CMS-367b Data Entry Screenshots_09.2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 780	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,360	372	8,988
Annual IC Time Burden (Hours)	419,328	16,665	402,663
Annual IC Cost Burden (Dollars)	0	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.