View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

EOB
 
No Modified
 
Mandatory
 
42 CFR 423.128 42 CFR 422.111(b)(12) 42 CFR 423.104 42 CFR 423.120 42 CFR 422.216

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10453 HMO Monthly Template Appendix A. MA HMO monthly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 HMO Quarterly Template Appendix A. MA HMO quarterly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 MSA Monthly Template Appendix A. MA MSA monthly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 MSA Quarterly Template Appendix A. MA MSA quarterly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10452 PFFS monthly Template Appendix A. MA PFFS monthly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 PFFS quarterly Template Appendix A. MA PFFS quarterly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 PPO Monthly Template Appendix A. MA PPO monthly template.pdf Yes No Fillable Fileable
Form and Instruction CMS-10453 PPO Quarterly Template Appendix A. MA PPO quarterly template.pdf Yes No Fillable Fileable
Instruction Appendix B. CY 2025 Part D EOB Exhibit A.pdf Yes No Printable Only
Instruction Appendix B. CY 2025 Part D EOB Exhibit B.pdf Yes No Fillable Printable
Instruction Appendix B. CY 2025 Part D EOB Exhibit C.pdf Yes No Fillable Printable
Instruction Appendix B. CY 2025 Part D EOB Exhibit D.pdf Yes No Fillable Printable
Instruction Appendix B. CY 2025 Part D EOB Exhibit E.pdf Yes No Fillable Printable
Instruction Appendix B. CY 2025 Part D EOB Exhibit F.pdf Yes No Fillable Printable
Instruction Appendix B. CY 2025 Part D EOB Exhibit G.pdf Yes No Fillable Printable
Form and Instruction CMS-10453 Part D EOB Plan Instructions Appendix B. CY 2025 EOB Plan Instructions.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

1,065 0
   
Individuals or Households
 
   100 %

  Approved 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 1,065 0 -5,703 0 6,768 0
Annual IC Time Burden (Hours) 10,650 0 -87,110 0 97,760 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.