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

View Information Collection (IC)

Three-Year Network Adequacy Review for Medicare Advantage Organizations
 
No Modified
 
Mandatory
 
42 CFR 422 Section 112(a)(1)(i) 42 CFR 422 Section 114(a)(3)(ii)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction MA_Network_Adequacy_Guidance_ updated 083022_CMS4192_F_CLEAN.pdf Yes No Printable Only
Form CMS-10636 Provider HSD Table MA_Provider_Table_Template_REVISED (2022 version 2).pdf Yes Yes Fillable Fileable
Form CMS-10636 Facility HSD Table MA_Facility_Table_Template_REVISED (2022 version 2).pdf Yes Yes Fillable Fileable
Form CMS-10636 Exception Request Template MA_Exception_Template_11042021 (2022 version 2).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10636 Partial County Justification Template Partial_County_Justification_Template_11042021 (2022 version 2).pdf Yes Yes Fillable Fileable
Instruction HPMS Network Managment Module.JPG Yes No Printable Only

Health Health Care Services

 

502 0
   
Private Sector Businesses or other for-profits
 
   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 2,753 0 0 258 0 2,495
Annual IC Time Burden (Hours) 27,470 0 0 2,838 0 24,632
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Changes: Network Adequacy Guidance MA_Network_Adequacy_Guidance_ 083022_CMS4192_F_TrackChanges.pdf 09/01/2022
Crosswalk: Network Adequacy Guidance CMS-10636 - CROSSWALK MA Network Adequacy Guidance.pdf 09/01/2022
Track Changes: Provider HSD Table MA_Provider_Table_Template_TC_090922.xlsx 09/06/2022
Crosswalk: Provider HSD Table Provider HSD Crosswalk OMB 0938-1346 090622.xlsx 09/06/2022
Track Changes: Facility HSD Table MA_Facility_Table_Template_TC_090622.xlsx 09/06/2022
Crosswalk: Facility HSD Table Facility HSD Crosswalk OMB 0938-1346 090622.xlsx 09/06/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.