Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Trial Year and Routine Audits Modified 40 31200 0 Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Appeals Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Summary of any pre-audit issues
Form CMS-10630 PACE Supplemental Questionnaire
Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol
Form CMS-10630 Corrective Action Plan (CAP) Process
Form and Instruction CMS-10630 Audit Survey
Form CMS-10630 Service Delivery Request and Appeals Impact Analysis Template
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Grievances Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form and Instruction CMS-10630 Personnel Impact Analysis Template
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Root Cause Analysis Template
Form CMS-10630 Service Delivery Request Impact Analysis Template
Form CMS-10630 Service Delivery Request Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template
Form CMS-10630 Coordination of Care
Form and Instruction CMS-10630 Required Services
Form and Instruction CMS-10630 Special Recommendations
Form and Instruction CMS-10630 Appeal Recognition
Form and Instruction CMS-10630 Appeals Effectuation
Form and Instruction CMS-10630 Arranging Services
Form and Instruction CMS-10630 Grievance Recognition and Notification
Form and Instruction CMS10630 Participant Rights
Form and Instruction CMS-10630 Plan of Care
Form and Instruction CMS-10630 Required Services
Form CMS-10630 Service Determination Request (SDR) Cover Sheet
Form and Instruction CMS-10630 CAP Template
Form and Instruction CMS-10630 Request for Additional Information (RAI)/PO Response
Total burden requested under this ICR: 40 31200 0  
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