OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)

IC 217422 under ICR 202606-0938-010 · OMB 0938-1285.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 156.50(d)(2)(ii)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10492 Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment CMS-10492 - Issuer and TPA data elements for FFE adjustment FINAL.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10492 Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services CMS-10492 - TPA Contra UF Instrument.docx Yes Yes Fillable Fileable

Health Health Care Services

 

80 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 80 0 0 0 80 0
Annual IC Time Burden (Hours) 887 0 0 0 887 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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