Form CMS-10340 CSSC Operations Submitter Authorization Form

CSSC OPERATIONS
AUTHORIZATION FORM

OMB No. 0938-1152
Expires: April 30, 2021

The Authorization Form is used to notify CSSC Operations when a Plan is designating a Third Party submitter to submit and
receive data on their behalf. The following information must be completed by an authorized representative of the Plan.
The completed form may be mailed or sent via email to [email protected].
In the section below, list the Plan Name, Effective Date and all plan numbers applicable to this authorization.
Plan Name ____________________________ Effective Date ____________

Complete the table(s) below for the submission and receipt of Medicare Part C and/or Part D data for the above plan(s).
For Prescription Drug Event (PDE) both the submitter and receiver information tables are required to be completed.
Data Type

Submitter Name

Submitter ID

Receiver Name

Receiver ID

Encounter
Risk Adjustment
Prescription Drug Event

Report Type
PDE Monthly
PDE Monthly

Complete the table(s) below for the submission and receipt of Medicare-Medicaid (FAI) Program data for the above
plan(s). For Prescription Drug Event (PDE) both the submitter and receiver information tables are required to be
completed.
Data Type

Submitter Name

Submitter ID

Receiver Name

Receiver ID

Encounter
Medicaid
National Council
Prescription Drug
Risk Adjustment
Prescription Drug Event

Report Type
PDE Monthly
PDE Monthly

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I am authorized to complete this Authorization Form on behalf of the indicated party and agree to the instructions as
outlined above.

Name

Date

Title

Email Address

Phone
Submitter Authorization Form CSSC
Operations – AG-570
2300 Springdale Drive – Bldg. One
Camden, SC 29020-1728
Phone: (877) 534-2772, Option 2

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1152. The time required to complete this information collection
is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
CMS-10340(04/2021)
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