Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

ICR 202403-0938-009

OMB: 0938-1152

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10340 Submitter Authorization Form Form	Modified
Form CMS-10340 Submitter Application and Instructions Form and Instruction	Modified
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form	Unchanged
10340 - Supporting Statement A_Encounter Data.docx Supporting Statement A	2024-03-28
DENTAL PRA RESPONSE Final.docx Supplementary Document	2024-03-14
CMS-10340 Dental PRA Crosswalk.pdf Supplementary Document	2024-03-28
SSN Justification.pdf Supplementary Document	2017-08-29

IC Document Collections

IC ID	Document Title	Status
247095	Complete Certification	Unchanged
246826	Reviewing Encounter Data Submission Guidance Instruction	Modified
225029	Connect: Direct Applications for RAPS, Encounter, PDE, and MMP Instruction	Modified
225027	Submitter Authorization Form Form	Modified
225026	Submitter Application and Instructions Form and Instruction	Modified
225025	Electronic Data Interchange (EDI) Agreement Form	Unchanged
199936	Encounter Data Submission Instruction	Modified