View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Three-Year Network Adequacy Review for Medicare Advantage Organizations
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 422 Section 114(a)(3)(ii)
42 CFR 422 Section 112(a)(1)(i)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Instruction
MA_Network_Adequacy_Guidance_4201-F_CLEAN_03072023.docx
Yes
No
Printable Only
Form
CMS-10636
Provider HSD Table
MA_Provider_Table_Template_(2022 version 2).pdf
Yes
Yes
Fillable Fileable
Form
CMS-10636
Facility HSD Table
MA_Facility_Table_Template_(2022 version 2).pdf
Yes
Yes
Fillable Fileable
Form
CMS-10636
Exception Request Template
MA_Exception_Template_REVISED_03072023.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
Other-Screen Shot: HPMS Web Based Application
HPMS Network Managment Module.JPG
Yes
Yes
Fillable Fileable
Other-Screen Sot: LOI Upload Page
LOI Upload Page NMM HPMS.jpg
Yes
Yes
Fillable Fileable
Form
CMS-10636
LOI Group to NPI Matrix Template
LOI Group to NPI matrix template.xlsx
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:
502
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
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
2,753
0
0
0
0
2,753
Annual IC Time Burden (Hours)
27,470
0
0
0
0
27,470
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Exception Request Template (Track Change)
MA_Exception_Template_TC_03072023.pdf
09/22/2023
Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance (Track Change)
MA_Network_Adequacy_Guidance_4201-F_TC_03072023.docx
09/22/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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The .gov means it's official.
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