View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Trial Year and Routine Audits
 
No Modified
 
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 CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template AlertIDT1P14.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Appeals Impact Analysis Template Appeals1P321P661P681P73.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template Assessments1P491P50.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Summary of any pre-audit issues AttachmentIIIPreAuditIssueSummary.xlsx Yes Yes Fillable Fileable
Form CMS-10630 PACE Supplemental Questionnaire AttachmentIIPACESupplementalQuestions.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 PACE Audit Process and Data Request Protocol AttachmentIPACEAuditProtocol.docx Yes Yes Fillable Fileable
Form CMS-10630 Corrective Action Plan (CAP) Process AttachmentVCorrectiveActionPlanProcess.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Audit Survey AttachmentIVAuditSurvey.docx Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request and Appeals Impact Analysis Template Effectuation1P02.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template EmergencyCare1P07.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Grievances Impact Analysis Template Grievances1P311P1031P1041P105.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template HomeCare1P02.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template MedErrors1P02.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Personnel Impact Analysis Template Personnel.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template ProvisionofServices1P02.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template Restraints1P09.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Root Cause Analysis Template RootCauseTemplate.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request Impact Analysis Template SDRIdentification1P76.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Service Delivery Request Impact Analysis Template SDRs1P601P611P85.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template SrvcRestrict1P90.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Clinical Appropriateness and Care Planning Impact Analysis Template WoundCare1P02.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Coordination of Care CoordinationofCare1P95.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Required Services RequiredServices1P931P100.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Special Recommendations RecommendedServices1P94.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Appeal Recognition AppealRecognition1P65.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Appeals Effectuation AppealsEffectuation1P111P30.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Arranging Services ArrangingServices1P101.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Grievance Recognition and Notification GrievanceRecognitionandNotification1P751P77.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS10630 Participant Rights ParticipantRights1P1061P107.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Plan of Care PlanofCare1P151P201P84.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Required Services RequiredServices1P931P100.xlsx Yes Yes Fillable Fileable
Form CMS-10630 Service Determination Request (SDR) Cover Sheet CaseFileCoverSheet.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 CAP Template CAPTemplate.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10630 Request for Additional Information (RAI)/PO Response RequestAdditionalInformationTemplate.docx Yes Yes Fillable Fileable

Health Health Care Services

 

145 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Requested 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 40 0 0 0 0 40
Annual IC Time Burden (Hours) 31,200 0 0 0 0 31,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
WoundCare - Track Change version WoundCare1P02_06022025_tracked.pdf 07/07/2025
CaseFileCoverSheet - Track Change version CaseFileCoverSheet_tracked.pdf 07/07/2025
CAPTemplate - Track Change CAPTemplate_tracked.pdf 07/07/2025
PACEAuditProtocol - Track Change version AttachmentIPACEAuditProtocol_tracked.pdf 07/07/2025
PreAuditIssueSummary - Track Changes version AttachmentIIIPreAuditIssueSummary_tracked.pdf 07/07/2025
PACESupplementalQuestions - Track change version AttachmentIIPACESupplementalQuestions_tracked.pdf 07/07/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.