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Federal forms, ICRs, and supporting documents

Information Collection

Claim In-Network or Out-of-Network Indicator

IC 254458 under ICR 202412-0938-011 · OMB 0938-1155.

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Information Collection (IC) Details

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Claim In-Network or Out-of-Network Indicator
 
No Modified
 
Mandatory
 
45 CFR 156.130

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability

Health Health Care Services

 

650 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 650 0 0 0 0 650
Annual IC Time Burden (Hours) 2,600 0 0 0 0 2,600
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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