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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
(149.335) - Documentation of Actual Medical Claims Involved
New
2371
208683
0
Form
CMS-10321
ERRP Prima Facie Evidence Cover Sheet
Instruction
(149.35(b)(2)) - Written Agreement with Issuer or Plan
New
1528
1528
0
(149.35(b)(3)) - Procedures to Protect Against Fraud, etc.
New
1528
30560
0
(149.350) Maintenance of Records
New
7500
36660
0
(149.40) - Updating Data in the Application
New
916
916
0
Instruction
Form
CMS-10321
ERRP Application
(149.500 & 149.510) - Requesting Appeals
New
143
1144
0
Instruction
Instruction
(149.600) - Reporting Previous Data Inaccuracies
New
40
3520
0
Instruction
(149.610) - Requesting Reopenings
New
20
160
0
Instruction
(149.700) - Reporting Change of Ownership
New
40
40
0
Early Retiree Reinsurance Program Appeals (Private), for Program Year 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Private), for Program Years 2 and 3
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Public), for Program Year 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Appeals (Public), for Program Years 2 and 3
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Private), for Program Years 2, 3, 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Reopening Requests (Pub lic), for Program Years 2, 3, 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 2
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 3
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Private) Program Year 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 2
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 3
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Early Retiree Reinsurance Program Rerimburement Request Materials and Instructions (Cost Documentation) (Public) Program Year 4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Private Application Update Year 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Private CHOW Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Private Data Inaccuracies Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
ERRP Collection Instrument
Private Fraud and Abuse Procedures Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Private Maintenance of Records Year 2_3_4
Removed
0
0
0
Instruction
Instruction
Private Written Agreement Year 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Public Application Update Year 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Public CHOW Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
ERRP Collection Instrument
Public Data Inaccuracies Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Public Fraud and Abuse Procedures Years 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Public Maintenance of Records Year 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Public Written Agreement Year 2_3_4
Removed
0
0
0
Instruction
Form
CMS-10321
Revised ERRP Collection Instrument
Total burden requested under this ICR:
14086
283211
0
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