Information Collection

Risk Adjustment

IC 206069 under ICR 202604-0938-001 · OMB 0938-1187.

Documents and Forms

Document Name Document Type
Form CMS-10433 Reinsurance and Risk Adjustment Bank Server Risk Adjustment Form and Instruction
CMS-10433 Reinsurance and Risk Adjustment Bank Server F_RA_Programs_Payment_Ops_Data_508.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Risk Adjustment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.220, 410, 540, 610

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Reinsurance and Risk Adjustment Bank Server	F_RA_Programs_Payment_Ops_Data_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 623	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 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	623	-1,777	2,400
Annual IC Time Burden (Hours)	2,025	-5,775	7,800
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.

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