Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

ICR 202302-0938-015

OMB: 0938-1152

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-10340 Submitter Authorization Form Form	Unchanged
Form CMS-10340 Submitter Authorization Form Form	Unchanged
Form CMS-10340 Submitter Application and Instructions Form and Instruction	Unchanged
Form CMS-10340 Submitter Application and Instructions Form and Instruction	Unchanged
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form	Unchanged
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form	Unchanged
Non-sub Change Request Memo_ED PRA_022223.docx Justification for No Material/Nonsubstantive Change	2023-02-22
Non-sub Change Request Memo_ED PRA_022223.docx Justification for No Material/Nonsubstantive Change	2023-02-22
CMS-10340 - Supporting Statement A_Encounter Data PRA_022223.docx Supporting Statement A	2023-02-22
CMS-10340 - Supporting Statement A_Encounter Data PRA_022223.docx Supporting Statement A	2023-02-22
United BCBSA_Response to Public Comments - CMS-10340_final.pdf Supplementary Document	2021-04-30
United BCBSA_Response to Public Comments - CMS-10340_final.pdf Supplementary Document	2021-04-30
PRA Forms Revisions - Crosswalk_021723.xlsx Supplementary Document	2023-02-22
PRA Forms Revisions - Crosswalk_021723.xlsx Supplementary Document	2023-02-22
SSN Justification.pdf Supplementary Document	2017-08-29
SSN Justification.pdf Supplementary Document	2017-08-29

IC Document Collections

IC ID	Document Title	Status
247095	Complete Certification	Unchanged
246826	Reviewing Encounter Data Submission Guidance Instruction	Unchanged
225029	Connect: Direct Applications for RAPS, Encounter, PDE, and MMP Instruction	Modified
225027	Submitter Authorization Form Form	Unchanged
225027	Submitter Authorization Form Form	Unchanged
225026	Submitter Application and Instructions Form and Instruction	Unchanged
225026	Submitter Application and Instructions Form and Instruction	Unchanged
225025	Electronic Data Interchange (EDI) Agreement Form	Unchanged
225025	Electronic Data Interchange (EDI) Agreement Form	Unchanged
199936	Encounter Data Submission Instruction	Unchanged