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_4205-F_CLEAN.pdf
Yes
No
Printable Only
Form
CMS-10636
Provider HSD Table
MA_Provider_Table_Template NEW 508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10636
Facility HSD Table
MA_Facility_Table_Template NEW 508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10636
Exception Request Template
MA_Exception_Template_REVISED.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10636
Partial County Justification Template
Partial_County_Justification_Template_(2022 version) NO CHANGES 508.pdf
Yes
Yes
Fillable Fileable
Form
CMS-10636
HPMS Web Based Application: NMM
Telehealth NMM Page Proposed Changes.pdf
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
Redline: Network Adequacy Guidance
MA_Network_Adequacy_Guidance_4205-F_Track changes_03062024.pdf
12/17/2024
Crosswalk: Provider HSD Table
Provider HSD Table Crosswalk 508.pdf
12/17/2024
Crosswalk: Facility HSD Table Template
Facility HSD Table Crosswalk 508.pdf
12/17/2024
Crosswalk: Exception Request Template
Exception Request Template Crosswalk.pdf
12/17/2024
Crosswalk: Network Management Module (NMM)
HPMS NMM Crosswalk.pdf
12/17/2024
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.
The site is secure.
