Service Level Data Collection for Initial Determinations and Appeals (CMS-10905)

Forms and Documents

Document Name	Status
CMS-10905_Supporting Statement A.docx Supporting Statement A	2025-05-30
CMS Response to Public Comments.docx Supplementary Document	2025-05-29
Crosswalk -CMS-10905.xlsx Supplementary Document	2025-05-29

IC Document Collections

IC ID	Document Title	Status
275516	Service Level Data Collection for Initial Determinations and Appeals Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202505-0938-016
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Service Level Data Collection for Initial Determinations and Appeals (CMS-10905)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/17/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	2,912	0
Time Burden (Hours)	1,456	0
Cost Burden (Dollars)	0	0

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Abstract: The Part C and D Reporting Requirements, as set forth in §§ 422.516(a) and 423.514(a), provide CMS with the ability to collect more granular data related to all plan activities regarding adjudicating requests for coverage and plan procedures related to making service utilization decisions. This includes collecting more timely data with greater frequency or closer in real-time.

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Authorizing Statute(s): US Code: 42 USC 1395w-112 Name of Law: Requirements for and Contracts with Prescription Drug Plan (PDP) Sponsors
   US Code: 42 USC 1395w–27 Name of Law: Contracts with Medicare Choice Organizations
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-112 Name of Law: Requirements for and Contracts with Prescription Drug Plan (PDP) Sponsors
US Code: 42 USC 1395w–27 Name of Law: Contracts with Medicare Choice Organizations

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 65359	08/09/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 23054	05/30/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Service Level Data Collection for Initial Determinations and Appeals

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,912	0	0	2,912	0	0
Annual Time Burden (Hours)	1,456	0	0	1,456	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New collection

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Annual Cost to Federal Government: $300,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/17/2025

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