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Trial Year and Routine Audits
 
No New
 
Mandatory
 
42 CFR 460.190 42 CFR 460.192

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol PACE_AuditProcess_DataRequest.pdf Yes Yes Fillable Fileable
Form CMS-10630 PACE Supplemental Questions Attachment II-PACE_SupplementalQuestions.pdf Yes Yes Fillable Fileable
Form CMS-10630 Pre-Audit Issue Summary Attachment_III_Pre-AuditIssueSummary.pdf Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Impact Analysis Template Service_Delivery_IA_Template.pdf Yes Yes Fillable Fileable
Form CMS-10630 Appeals Impact Analysis Template Appeal_IA_Template.pdf Yes Yes Fillable Fileable
Form CMS-10630 Grievances Impact Analysis Template Grievance_IA_Template.pdf Yes Yes Fillable Fileable
Form CMS-10630 Root Cause Analysis Template Root_Cause_Template.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Comprehensive Care Impact Analysis Template Clinical_Approp_IA_Template_comp.care.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Emergencies Impact Analysis Template Clinical_Approp_IA_Template_emergency.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for IDT Documentation Impact Analysis Template Clinical_Approp_IA_Template_IDT_doc.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Medical Record Documentation Impact Analysis Template Clinical_Approp_IA_Template_Med_Rec_Doc.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Restraints Impact Analysis Template Clinical_Approp_IA_Template_restraints.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Care Planning Impact Analysis Template Clinical_Approp_IA_Template_Care_Plan.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Assessments Impact Analysis Template Clinical_Approp_IA_Template_Assessments.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Infections Impact Analysis Template Clinical_Approp_IA_Template_Infections.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Providers Impact Analysis Template Clinical_Approp_IA_Template_Providers.pdf Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness for Transportation Impact Analysis Template Clinical_Approp_IA Template_Transportation.pdf Yes Yes Fillable Fileable
Form CMS-10630 Personnel Impact Analysis Template Personnel_IA_Template.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

119 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  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 72 0 72 0 0 0
Annual IC Time Burden (Hours) 17,280 0 17,280 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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