View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Other Payer Advanced APM Identification: Payer Initiated Process (see SS-A Table 24)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.1440

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10621	Other Payer Requests for Other Payer Advanced Alternative Payment Model Determinations (Payer Initiated Submission Form)	Appendix H Payer Initiated Submission Form (12-05-19) CLEAN.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Quality Payment Program (QPP), System No. 09–70– 0539	FR Citation: 83 FR 6587

Number of Respondents: 110	Number of Respondents for Small Entity: 110

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 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	110	0	-105	0	0	215
Annual IC Time Burden (Hours)	1,100	0	-1,050	0	0	2,150
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Appendix I Payer Initiated Submission Form Crosswalk (12-05-19).docx	12/10/2019

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