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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