Information Collection

Health Insurance Issuer Submission of the Preliminary Justification

IC 198019 under ICR 202408-0938-033 · OMB 0938-1141.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10379 - Unified_Rate_Review_Template v6.0 - 08-08-24.xlsm	Other-Microsoft Word
CMS-10379 - Unified_Rate_Review_Template v6.0 - 08-08-24.xlsm	Other-Microsoft Word
2024 PY URR instructions clean - 8-8-24.docx	Instruction
2024 PY URR instructions clean - 8-8-24.docx	Instruction

IC Title:

Agency IC Tracking Number:

CMS-10379

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Other-Microsoft Word					Yes	No	Printable Only
Instruction					Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 573

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
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	573	-16	589
Annual IC Time Burden (Hours)	17,533	-2,706	20,239
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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