View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Counteroffer ICR Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10849				Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

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	40	0	25	0	0	15
Annual IC Time Burden (Hours)	8,170	0	5,106	0	0	3,064
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Redline CMS 10849 NDE Process ICR Forms		11/24/2025
Final 30-day_Redline CMS 10849 NDE Process ICR Forms		01/09/2026

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

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