Information Collection

DDR Quarterly Pricing Data (CMS-367a)

IC 8184 under ICR 202606-0938-019 · OMB 0938-0578.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-376a Quarterly Pricing Data DDR Quarterly Pricing Data (CMS-367a)	Form
CMS-367a Instruction Screenshots_09.2021.pdf	Instruction
CMS-376a Quarterly Pricing Data CMS-367a 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
Form	CMS-376a				Yes	Yes	Fillable Fileable
Instruction					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: 100

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	3,360	88	3,272
Annual IC Time Burden (Hours)	116,928	3,062	113,866
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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