Information Collection Request

Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

ICR 202302-0938-015 · OMB 0938-1152 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1152 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10340 Submitter Authorization Form Form	Unchanged
Form CMS-10340 Submitter Authorization Form Form	Unchanged
Form CMS-10340 Submitter Application and Instructions Form and Instruction	Unchanged
Form CMS-10340 Submitter Application and Instructions Form and Instruction	Unchanged
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form	Unchanged
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form	Unchanged
Non-sub Change Request Memo_ED PRA_022223.docx Justification for No Material/Nonsubstantive Change	2023-02-22
Non-sub Change Request Memo_ED PRA_022223.docx Justification for No Material/Nonsubstantive Change	2023-02-22
CMS-10340 - Supporting Statement A_Encounter Data PRA_022223.docx Supporting Statement A	2023-02-22
CMS-10340 - Supporting Statement A_Encounter Data PRA_022223.docx Supporting Statement A	2023-02-22
United BCBSA_Response to Public Comments - CMS-10340_final.pdf Supplementary Document	2021-04-30
United BCBSA_Response to Public Comments - CMS-10340_final.pdf Supplementary Document	2021-04-30
PRA Forms Revisions - Crosswalk_021723.xlsx Supplementary Document	2023-02-22
PRA Forms Revisions - Crosswalk_021723.xlsx Supplementary Document	2023-02-22
SSN Justification.pdf Supplementary Document	2017-08-29
SSN Justification.pdf Supplementary Document	2017-08-29

IC Document Collections

IC ID	Document Title	Status
247095	Complete Certification	Unchanged
246826	Reviewing Encounter Data Submission Guidance Instruction	Unchanged
225029	Connect: Direct Applications for RAPS, Encounter, PDE, and MMP Instruction	Modified
225027	Submitter Authorization Form Form	Unchanged
225027	Submitter Authorization Form Form	Unchanged
225026	Submitter Application and Instructions Form and Instruction	Unchanged
225026	Submitter Application and Instructions Form and Instruction	Unchanged
225025	Electronic Data Interchange (EDI) Agreement Form	Unchanged
225025	Electronic Data Interchange (EDI) Agreement Form	Unchanged
199936	Encounter Data Submission Instruction	Unchanged

ICR Details

Status	Active
Agency/Subagency	HHS/CMS
OMB Control No	0938-1152
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202104-0938-010
Agency Tracking No	CM-CPC
Date Submitted to OIRA	2023-02-22
Requested Expiration Date	1969-12-31