Information Collection

Median Payer-Specific Negotiated Charge Data Worksheet

IC 276834 under ICR 202512-0938-006 · OMB 0938-1486.

Documents and Forms

Document Name Document Type
Form CMS-10935 Median Payer-Specific Negotiated Charge Data Worksheet Form
Form CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Data Form Median Payer-Specific Negotiated Charge Data Worksheet Form
Weighted Median MAO Payer-Specific Negotiated Charge Data Instructions.docx Instruction
Weighted Median MAO Payer-Specific Negotiated Charge Data Instructions.docx Instruction
CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Dat Weighted Median MAO Payer-Specific Negotiated Charge Data Form.xlsx Form
CMS-10935 Weighted Median MAO Payer-Specific Negotiated Charge Dat Weighted Median MAO Payer-Specific Negotiated Charge Data Form.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Median Payer-Specific Negotiated Charge Data Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 413.24(f)(4)(ii)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10935	Weighted Median MAO Payer-Specific Negotiated Charge Data Form	Weighted Median MAO Payer-Specific Negotiated Charge Data Form.xlsx		Yes	Yes	Fillable Fileable
Instruction			Weighted Median MAO Payer-Specific Negotiated Charge Data Instructions.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,034	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,034	3,034
Annual IC Time Burden (Hours)	60,760	60,760
Annual IC Cost Burden (Dollars)	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.

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