Information Collection

Eob

IC 208197 under ICR 202312-0938-004 · OMB 0938-1228.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10453 EOB	Form and Instruction
Form CMS-10453 HMO Monthly Template EOB	Form and Instruction
Form CMS-10453 HMO Quarterly Template EOB	Form and Instruction
Form CMS-10453 MSA Monthly Template EOB	Form and Instruction
Form CMS-10453 MSA Quarterly Template EOB	Form and Instruction
Form CMS-10452 PFFS monthly Template EOB	Form and Instruction
Form CMS-10453 PFFS quarterly Template EOB	Form and Instruction
Form CMS-10453 PPO Monthly Template EOB	Form and Instruction
Form CMS-10453 PPO Quarterly Template EOB	Form and Instruction
Form CMS-10453 Part D EOB Plan Instructions EOB	Form and Instruction
Appendix B. CY 2025 Part D EOB Exhibit A.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit A.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit B.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit B.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit C.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit C.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit D.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit D.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit E.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit E.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit F.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit F.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit G.pdf	Instruction
Appendix B. CY 2025 Part D EOB Exhibit G.pdf	Instruction
CMS-10453 HMO Monthly Template Appendix A. MA HMO monthly template.pdf	Form and Instruction
CMS-10453 HMO Monthly Template Appendix A. MA HMO monthly template.pdf	Form and Instruction
CMS-10453 HMO Quarterly Template Appendix A. MA HMO quarterly template.pdf	Form and Instruction
CMS-10453 HMO Quarterly Template Appendix A. MA HMO quarterly template.pdf	Form and Instruction
CMS-10453 MSA Monthly Template Appendix A. MA MSA monthly template.pdf	Form and Instruction
CMS-10453 MSA Monthly Template Appendix A. MA MSA monthly template.pdf	Form and Instruction
CMS-10453 MSA Quarterly Template Appendix A. MA MSA quarterly template.pdf	Form and Instruction
CMS-10453 MSA Quarterly Template Appendix A. MA MSA quarterly template.pdf	Form and Instruction
CMS-10452 PFFS monthly Template Appendix A. MA PFFS monthly template.pdf	Form and Instruction
CMS-10452 PFFS monthly Template Appendix A. MA PFFS monthly template.pdf	Form and Instruction
CMS-10453 PFFS quarterly Template Appendix A. MA PFFS quarterly template.pdf	Form and Instruction
CMS-10453 PFFS quarterly Template Appendix A. MA PFFS quarterly template.pdf	Form and Instruction
CMS-10453 PPO Monthly Template Appendix A. MA PPO monthly template.pdf	Form and Instruction
CMS-10453 PPO Monthly Template Appendix A. MA PPO monthly template.pdf	Form and Instruction
CMS-10453 PPO Quarterly Template Appendix A. MA PPO quarterly template.pdf	Form and Instruction
CMS-10453 PPO Quarterly Template Appendix A. MA PPO quarterly template.pdf	Form and Instruction
CMS-10453 Part D EOB Plan Instructions Appendix B. CY 2025 Part D EOB Plan Instructions.pdf	Form and Instruction
CMS-10453 Part D EOB Plan Instructions Appendix B. CY 2025 EOB Plan Instructions.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

EOB

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.128 42 CFR 422.111(b)(12) 42 CFR 423.104 42 CFR 423.120 42 CFR 422.216

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10452	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Form and Instruction	CMS-10453	Yes	No	Fillable Fileable
Instruction		Yes	No	Printable Only
Instruction		Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Instruction		Yes	No	Fillable Printable
Form and Instruction	CMS-10453	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,065

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,065	-5,703	6,768
Annual IC Time Burden (Hours)	10,650	-87,110	97,760
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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