Information Collection

Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)

IC 257138 under ICR 202211-0938-011 · OMB 0938-1185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10811 Medicare Part C & D Improper Payment Measure (IPM) (CMS-10811)	Form and Instruction
CMS-10811 CMS-10811. Appendix A_Part C Survey Questions FINAL CMS-10811. Appendix A_Part C Survey Questions FINAL.pdf	Form and Instruction
CMS-10811 CMS-10811. Appendix A_Part C Survey Questions FINAL CMS-10811. Appendix A_Part C Survey Questions FINAL.pdf	Form and Instruction
CMS-10811 CMS-10811. Appendix B_Part D Survey Questions FINAL CMS-10811. Appendix B_Part D Survey Questions FINAL.pdf	Form and Instruction
CMS-10811 CMS-10811. Appendix B_Part D Survey Questions FINAL CMS-10811. Appendix B_Part D Survey Questions FINAL.pdf	Form and Instruction
CMS-10811. GenIC Template (Medicare Part C_D Fast Track).docx CMS-10811. GenIC Template (Medicare Part C_D Fast Track)	IC Document
CMS-10811. GenIC Template (Medicare Part C_D Fast Track).docx CMS-10811. GenIC Template (Medicare Part C_D Fast Track)	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	CMS-10811	CMS-10811. Appendix A_Part C Survey Questions FINAL	CMS-10811. Appendix A_Part C Survey Questions FINAL.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10811	CMS-10811. Appendix B_Part D Survey Questions FINAL	CMS-10811. Appendix B_Part D Survey Questions FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

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: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10811. GenIC Template (Medicare Part C_D Fast Track)	CMS-10811. GenIC Template (Medicare Part C_D Fast Track).docx	11/28/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.