Information Collection

DDR Monthly Pricing Data (CMS-367b)

IC 222505 under ICR 202606-0938-019 · OMB 0938-0578.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-367b Monthly Pricing Data DDR Monthly Pricing Data (CMS-367b)	Form
CMS-367b Instruction Screenshots_09.2021.pdf	Instruction
CMS-367b Monthly Pricing Data CMS-367b Data Entry Screenshots_09.2021.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Fillable Fileable
Form	CMS-367b				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 840

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,080	264	9,816
Annual IC Time Burden (Hours)	451,584	11,827	439,757
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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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