Information Collection

Prepayment Review of Medical Records

IC 201491 under ICR 202509-0938-008 · OMB 0938-0969.

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Information Collection (IC) Details

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IC Title:	Prepayment Review of Medical Records	Agency IC Tracking Number:	CPI-CMS10417

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 421.200 42 CFR 421.210 42 CFR 421.304

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 489,871	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: 52 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	489,871	4,239	485,632
Annual IC Time Burden (Hours)	244,936	2,120	242,816
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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