Internet-based Self-Service Tool

Transparency in Pricing Information (CMS-10715)

Documents and Forms

Document Name Document Type
Form CMS-10715 Internet-based Self-Service Tool Form and Instruction
CMS-10715 In-network Rate Machine-Readable File Data Elements CMS-10715 (Appendix 2) In-network Rate File Data Elements(clean)_10.07.24.docx Form and Instruction
CMS-10715 APPENDIX 3: The Allowed Amount Machine-Readable File Dat CMS-10715 (Appendix 3) Allowed Amount Machine-Readable File(clean)_10.07.24.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Internet-based Self-Service Tool	Agency IC Tracking Number:	CCIIO-10715

Is this a Common Form? Yes		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 147.211(b)(2)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10715	In-network Rate Machine-Readable File Data Elements	CMS-10715 (Appendix 2) In-network Rate File Data Elements(clean)_10.07.24.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10715	APPENDIX 3: The Allowed Amount Machine-Readable File Data Elements	CMS-10715 (Appendix 3) Allowed Amount Machine-Readable File(clean)_10.07.24.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 836	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: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	836	-144	980
Annual IC Time Burden (Hours)	6,738,160	-16,097,250	22,835,410
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.