Information Collection

Generalized Claims Data Call Submission

IC 226677 under ICR 201401-0938-013 · OMB 0938-1251.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10501 Generalized Claims Data Call Submission Form
Instructions TTP Data Call Submission Process PRA Package 411.docx Instruction
CMS-10501 Data Submission Template Data Submission Template PRA Package 411.docx Form
CMS-10501 - Generic Mini Supporting Statement 6817.docx CMS-10501 - Generic Mini Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Generalized Claims Data Call Submission	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10501	Data Submission Template	Data Submission Template PRA Package 411.docx		No		Fillable Printable
Instruction			Instructions TTP Data Call Submission Process PRA Package 411.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10501 - Generic Mini Supporting Statement	CMS-10501 - Generic Mini Supporting Statement 6817.docx	06/08/2017

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