View Information Collection (IC)

View Information Collection (IC)

IC Title:	QHP Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.1065 45 CFR 156.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10433	Data Template Administrative	A1 Administrative.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Medical Essential Community Providers	A2.1 Medical ECP.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Dental Essential Community Provider	A2.2 Dental ECP.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	URAC Application	A3.1 URAC.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	NCQA Template	A3.2 NCQA.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	AAAHC	A3.3 AAAHC.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Network Adequacy	A4 NetworkAdequacy.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Program Attestations	A5 Program Attestations.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10433	Accreditation Attestations	A6 Accreditation Attestation.pdf		Yes	Yes	Fillable Fileable
Form	CMS-10433	Plan and Benefit	B1 Plan and Benefits.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Prescription Drugs Template	B2 Prescription_Drugs_Template.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Service Area	B3 ServiceArea.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Network ID	B4 NetworkID.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Rates Table	C1 RatesTable.xlsm		Yes	Yes	Fillable Fileable
Form	CMS-10433	Business Rules	C2 Business Rules.xlsm		Yes	Yes	Fillable Fileable
Instruction			CMS-10433_Appendix D RI RA Banking and Edge Server ( 7-23-14) clean(2).pdf		Yes	Yes	Fillable Fileable

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: 975	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, 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	975	0	0	0	0	975
Annual IC Time Burden (Hours)	182,325	0	0	0	0	182,325
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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