Form CMS-10515 Monthly Data Submission Accuracy Certification Form

Submission Certification Instructions

(1) Complete the information highlighted in lines 5 through 14 below. (2) Retain a signed copy of this certification tab on file to be provided to CMS upon request. Note: Certifications are only required with the submission of a data workbook. If data is not being submitted via the workbook, certification is not required.

The Financial Authority Contact (FAC) (CEO, CFO or authorized delegate), inserted in type print below has reviewed the information in this Enrollment and Payment Data Workbook as submitted to the Centers for Medicare & Medicaid Services (CMS) and certified to the following: I certify that to the best of my knowledge, information, and belief, the information provided is accurate. The information provided as of the submission date is a good faith estimate. If this submission includes a restatement for any month’s data that was submitted previously, the latest restatement is the official statement to serve as the basis for payments during that particular month. The information included in this submission will be the basis for the calculation of the amount to be paid to, or collected from, my organization, if any, for the payment month specified in this workbook during this interim payment process. This amount will be reconciled by the Federal government once the regular payment process is fully implemented. This certification applies to this month’s submission, including any restatements provided in this submission. I further certify that a copy of my above certification including signature is available on file and will be provided to CMS, upon request.

Certification Information (Please populate B5-B14)

5-Digit Issuer ID:

Financial Authority Contact (or authorized delegate):

Title:

Date:

Organization:

Telephone:

Email Address:

Workbook Contact Name:

Workbook Contact Phone #:

Workbook Contact Email:

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1217. The purpose of this information collection is to collect enrollment and payment data from Exchange issuers via a manual template for the APTC program while the issuers are transitioning to State-based exchanges. The time required to complete this information collection is estimated to average 10 minutes per response. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.