Supplemental to Form CMS-2552-10: Weighted Median Medicare Advantage Organization Payer- Specific Negotiated Charge Data (CMS-10935)

Forms and Documents

Document Name	Status
Form CMS-10935 Median Payer-Specific Negotiated Charge Data Worksheet Form	New
CMS-10935_ Supporting Statement A_.docx Supporting Statement A	2025-08-01
Weighted Median MAO Payer-Specific Negotiated Charge Data Crosswalk.pdf Supplementary Document	2025-08-01

IC Document Collections

IC ID	Document Title	Status
276834	Median Payer-Specific Negotiated Charge Data Worksheet Form	New

ICR Details

OMB Control No:	ICR Reference No: 202508-0938-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-FFS
Title: Supplemental to Form CMS-2552-10: Weighted Median Medicare Advantage Organization Payer- Specific Negotiated Charge Data (CMS-10935)
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: 08/01/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	3,034	0
Time Burden (Hours)	60,760	0
Cost Burden (Dollars)	0	0

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Abstract: Respondents participating in the Medicare program use Supplemental to Form CMS-2552-10: Median Payer-Specific Negotiated Charge Data Worksheet to report payer-specific negotiated charge data pursuant to the CY 2026 OPPS Proposed Rule (CMS-1834-P) published July 17, 2025. This supplemental form advances the policy goal of increasing healthcare price transparency and promoting market-based approaches in Medicare FFS payments. The form requires hospitals to report, by MS-DRG, the weighted median of the payer-specific charges negotiated with Medicare Advantage organizations. The information reported on the worksheet enables CMS to calculate new IPPS MS-DRG relative weights beginning in FY 2029 and reinforces the administration's commitment to clear, accurate, and actionable healthcare pricing information.

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Authorizing Statute(s): US Code: 42 USC 413.20 Name of Law: Financial data and reports
   US Code: 42 USC 413.24 Name of Law: Adequate cost data and cost finding
   US Code: 42 USC 180 Name of Law: Hospital Price Transparency
  

Citations for New Statutory Requirements: US Code: 42 USC 413.20 Name of Law: Financial data and reports
US Code: 42 USC 413.24 Name of Law: Adequate cost data and cost finding
US Code: 42 USC 180 Name of Law: Hospital Price Transparency

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV51	Proposed rulemaking	90 FR 33476	07/17/2025

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Median Payer-Specific Negotiated Charge Data Worksheet	CMS-10935	Weighted Median MAO Payer-Specific Negotiated Charge Data Form

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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	3,034	0	0	3,034	0	0
Annual Time Burden (Hours)	60,760	0	0	60,760	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: This is a new information collection request.

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Annual Cost to Federal Government: $64,952,905

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: 08/01/2025

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